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75–758CC 2002

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

2

COMMITTEE ON ENERGY AND COMMERCE

W.J. ‘‘BILLY’’ TAUZIN, Louisiana, Chairman

MICHAEL BILIRAKIS, Florida

JOE BARTON, Texas

FRED UPTON, Michigan

CLIFF STEARNS, Florida

PAUL E. GILLMOR, Ohio

JAMES C. GREENWOOD, Pennsylvania

CHRISTOPHER COX, California

NATHAN DEAL, Georgia

STEVE LARGENT, Oklahoma

RICHARD BURR, North Carolina

ED WHITFIELD, Kentucky

GREG GANSKE, Iowa

CHARLIE NORWOOD, Georgia

BARBARA CUBIN, Wyoming

JOHN SHIMKUS, Illinois

HEATHER WILSON, New Mexico

JOHN B. SHADEGG, Arizona

CHARLES ‘‘CHIP’’ PICKERING, Mississippi

VITO FOSSELLA, New York

ROY BLUNT, Missouri

TOM DAVIS, Virginia

ED BRYANT, Tennessee

ROBERT L. EHRLICH, Jr., Maryland

STEVE BUYER, Indiana

GEORGE RADANOVICH, California

CHARLES F. BASS, New Hampshire

JOSEPH R. PITTS, Pennsylvania

MARY BONO, California

GREG WALDEN, Oregon

LEE TERRY, Nebraska

JOHN D. DINGELL, Michigan

HENRY A. WAXMAN, California

EDWARD J. MARKEY, Massachusetts

RALPH M. HALL, Texas

RICK BOUCHER, Virginia

EDOLPHUS TOWNS, New York

FRANK PALLONE, Jr., New Jersey

SHERROD BROWN, Ohio

BART GORDON, Tennessee

PETER DEUTSCH, Florida

BOBBY L. RUSH, Illinois

ANNA G. ESHOO, California

BART STUPAK, Michigan

ELIOT L. ENGEL, New York

TOM SAWYER, Ohio

ALBERT R. WYNN, Maryland

GENE GREEN, Texas

KAREN MCCARTHY, Missouri

TED STRICKLAND, Ohio

DIANA DEGETTE, Colorado

THOMAS M. BARRETT, Wisconsin

BILL LUTHER, Minnesota

LOIS CAPPS, California

MICHAEL F. DOYLE, Pennsylvania

CHRISTOPHER JOHN, Louisiana

JANE HARMAN, California

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

CLIFF STEARNS, Florida

PAUL E. GILLMOR, Ohio

STEVE LARGENT, Oklahoma

RICHARD BURR, North Carolina

ED WHITFIELD, Kentucky

Vice Chairman

CHARLES F. BASS, New Hampshire

W.J. ‘‘BILLY’’ TAUZIN, Louisiana

(Ex Officio)

PETER DEUTSCH, Florida

BART STUPAK, Michigan

TED STRICKLAND, Ohio

DIANA DEGETTE, Colorado

CHRISTOPHER JOHN, Louisiana

BOBBY L. RUSH, Illinois

JOHN D. DINGELL, Michigan,

(Ex Officio)

(II)

3

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)

(1)

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

2

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,

3

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 MiamiDade Counties. And, you know, we understand—and the Secretary

of HHS has been on television on several occasions since last

4

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

5

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

6

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

7

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

8

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.

9

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.

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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

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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 nec- essary...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

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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 bioterrorism 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,

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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.

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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.

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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

16

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

17

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.

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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.

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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 authorVerDate 11-MAY-2000 12:38 Apr 08, 2002 Jkt 010199 PO 00000 Frm 00023 Fmt 6633 Sfmt 6621 E:\HEARINGS\75758 pfrm09 PsN: 75758
20

ity. 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

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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 11⁄2 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

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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 longstanding warnings of the Institute of Medicine and the World Health Organization

and adjusting their course offerings, requirements, and other professional activities

accordingly.

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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 communitywide 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.

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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 nonFEMA 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

25

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:

• 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.

• 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.

• 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.

• 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.

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• 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.

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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.

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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 dayto-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

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(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.

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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.

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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 realtime 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.

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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

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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

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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.

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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

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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 thirtysix 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.

• Ensure that significant funding goes directly to localities so we can have the flexibility to plan our response based on our unique needs

• Enable local health and public safety agencies to work together with hospitals to

coordinate a response

• Coordinate among agencies at the federal level to ensure unified interagency guidance, materials and funding.

• 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

37

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 hosVerDate 11-MAY-2000 12:38 Apr 08, 2002 Jkt 010199 PO 00000 Frm 00041 Fmt 6633 Sfmt 6621 E:\HEARINGS\75758 pfrm09 PsN: 75758
38

pitals, 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

• New programs should include a lessons learned format, with concrete references

and examples to help localities plan.

• New programs should be planned to 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, police and fire personnel.

• 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.

39

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

40

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

41

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

42

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:

43

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

44

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 preVerDate 11-MAY-2000 12:38 Apr 08, 2002 Jkt 010199 PO 00000 Frm 00048 Fmt 6633 Sfmt 6621 E:\HEARINGS\75758 pfrm09 PsN: 75758
45

pared 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:

• 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.

• 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.

• 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.

• 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.

• 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.

• 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

46

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.

47

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 opVerDate 11-MAY-2000 12:38 Apr 08, 2002 Jkt 010199 PO 00000 Frm 00051 Fmt 6633 Sfmt 6602 E:\HEARINGS\75758 pfrm09 PsN: 75758
48

erations 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 communitywide 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 decVerDate 11-MAY-2000 12:38 Apr 08, 2002 Jkt 010199 PO 00000 Frm 00052 Fmt 6633 Sfmt 6602 E:\HEARINGS\75758 pfrm09 PsN: 75758
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ades, 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 PhysiciansAmerican 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.

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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

51

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

52

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. • 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. • 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.

• 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.

• 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.

• Issues of national supplies and their disbursement need to be evaluated and resolved. Determinations as to how much vaccine, pharmaceuticals, medical equipVerDate 11-MAY-2000 12:38 Apr 08, 2002 Jkt 010199 PO 00000 Frm 00056 Fmt 6633 Sfmt 6621 E:\HEARINGS\75758 pfrm09 PsN: 75758
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ment 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. • 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.

54

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 hosVerDate 11-MAY-2000 12:38 Apr 08, 2002 Jkt 010199 PO 00000 Frm 00058 Fmt 6633 Sfmt 6602 E:\HEARINGS\75758 pfrm09 PsN: 75758
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pital 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:]

56

1D.R. Franz et al. Clinical Recognition and management of patients exposed to biological warfare agents, JAMA 278: 399-411

PREPARED STATEMENT OF FRANK E. YOUNG, FORMER DIRECTOR, OFFICE OF EMER- GENCY PREPAREDNESS, NATIONAL DISASTER MEDICAL SYSTEM, VICE PRESIDENT RE- FORMED 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 1.1 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’’. 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 10μ 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 approVerDate 11-MAY-2000 12:38 Apr 08, 2002 Jkt 010199 PO 00000 Frm 00060 Fmt 6633 Sfmt 6621 E:\HEARINGS\75758 pfrm09 PsN: 75758
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2J. Miller, S. Engelberg and W. Broad Germs, Biological Weapons and America’s Secret War

Simon and Schuster, New York 2001, pg151-152

priate 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.2 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

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medical emergency responders to be able to address successfully biological and

chemical terrorism.

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.

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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:

• Augmentation of the medical systems in the National Guard to enable them

to rapidly deploy to the disaster site.

• 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

• Support training of individuals capable to manage the medical consequences

of weapons of mass destruction both in the military and civilian sectors.

• 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

• Develop a similar civilian training program for all hazards

• 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.

• Augment the containment facilities in hospitals to ensure that the hospital

will not be rendered useless through needless contamination.

• Ensure that the emergency response teams can be protected through proper

equipment and protective clothing. One recent development is a shirt develVerDate 11-MAY-2000 12:38 Apr 08, 2002 Jkt 010199 PO 00000 Frm 00063 Fmt 6633 Sfmt 6621 E:\HEARINGS\75758 pfrm09 PsN: 75758
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oped 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 • 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

61

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—

62

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.

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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

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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.

65

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 inVerDate 11-MAY-2000 12:38 Apr 08, 2002 Jkt 010199 PO 00000 Frm 00069 Fmt 6633 Sfmt 6602 E:\HEARINGS\75758 pfrm09 PsN: 75758
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formation, 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

67

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 sucVerDate 11-MAY-2000 12:38 Apr 08, 2002 Jkt 010199 PO 00000 Frm 00071 Fmt 6633 Sfmt 6602 E:\HEARINGS\75758 pfrm09 PsN: 75758
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ceeds 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.

69

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.

70

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

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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 citybased 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

72

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

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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

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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 comVerDate 11-MAY-2000 12:38 Apr 08, 2002 Jkt 010199 PO 00000 Frm 00078 Fmt 6633 Sfmt 6602 E:\HEARINGS\75758 pfrm09 PsN: 75758
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ment 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?

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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.

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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.

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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

79

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.

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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.

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came 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?

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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.]

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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.

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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

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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 incorVerDate 11-MAY-2000 12:38 Apr 08, 2002 Jkt 010199 PO 00000 Frm 00089 Fmt 6633 Sfmt 6621 E:\HEARINGS\75758 pfrm09 PsN: 75758
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porate 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:

• A well trained, well staffed, fully prepared public health workforce;

• Laboratory capacity to produce timely and accurate results for diagnosis and investigation;

• Epidemiology and surveillance, which provide the ability to rapidly detect heath

threats;

• Secure, accessible information systems which are essential to communicating rapidly, analyzing and interpreting health data, and providing public access to

health information;

• Communication systems that provide a swift, secure, two-way flow of information

to the public and advice to policy-makers in public health emergencies;

• Effective policy and evaluation capability to routinely evaluate and improve the

effectiveness of public health programs; and

• 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:

• Improving the public health infrastructure remains a critical focus of the bioterrorism preparedness and response efforts.

• Local health care systems should expand their health care capacity rapidly in the

face of mass casualties.

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• Local communities will need assistance with the distribution of stockpile medications and will greatly benefit from additional planning related to epidemic response. • 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.

• 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. • 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. • 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. • 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. • 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.

• 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.

• 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.

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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

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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:]

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PREPARED STATEMENT OF BRUCE P. BAUGHMAN, DIRECTOR, PLANNING AND READI- NESS 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

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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

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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-train- er’’ 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 firetraining 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 41⁄2 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

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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 terrorismrelated 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.

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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

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ticular 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

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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 HomeVerDate 11-MAY-2000 12:38 Apr 08, 2002 Jkt 010199 PO 00000 Frm 00100 Fmt 6633 Sfmt 6602 E:\HEARINGS\75758 pfrm09 PsN: 75758
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land 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 inVerDate 11-MAY-2000 12:38 Apr 08, 2002 Jkt 010199 PO 00000 Frm 00101 Fmt 6633 Sfmt 6602 E:\HEARINGS\75758 pfrm09 PsN: 75758
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vestigation 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——

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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

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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

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rorism 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——

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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

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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.

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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’ ThreeYear Domestic Preparedness Strategies.

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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 ThreeYear 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 Pro- gram, 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

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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 NunnLugar-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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