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75–441 PS 2001

S. Hrg. 107–142

FEMA’S ROLE IN MANAGING BIOTERRORIST ATTACKS AND THE IMPACT OF PUBLIC HEALTH

CONCERNS ON BIOTERRORISM PREPAREDNESS

HEARING

BEFORE THE

INTERNATIONAL SECURITY, PROLIFERATION AND

FEDERAL SERVICES SUBCOMMITTEE

OF THE

COMMITTEE ON

GOVERNMENTAL AFFAIRS

UNITED STATES SENATE

ONE HUNDRED SEVENTH CONGRESS

FIRST SESSION

JULY 23, 2001

Printed for the use of the Committee on Governmental Affairs

(

(II)

COMMITTEE ON GOVERNMENTAL AFFAIRS

JOSEPH I. LIEBERMAN, Connecticut, Chairman

CARL LEVIN, Michigan

DANIEL K. AKAKA, Hawaii

RICHARD J. DURBIN, Illinois

ROBERT G. TORRICELLI, New Jersey

MAX CLELAND, Georgia

THOMAS R. CARPER, Delaware

JEAN CARNAHAN, Missouri

MARK DAYTON, Minnesota

FRED THOMPSON, Tennessee

TED STEVENS, Alaska

SUSAN M. COLLINS, Maine

GEORGE V. VOINOVICH, Ohio

PETE V. DOMENICI, New Mexico

THAD COCHRAN, Mississippi

ROBERT F. BENNETT, Utah

JIM BUNNING, Kentucky

JOYCE A. RECHTSCHAFFEN, Staff Director and Counsel

HANNAH S. SISTARE, Minority Staff Director and Counsel

DARLA D. CASSELL, Chief Clerk

INTERNATIONAL SECURITY, PROLIFERATION AND FEDERAL SERVICES

SUBCOMMITTEE

DANIEL K. AKAKA, Hawaii, Chairman

CARL LEVIN, Michigan

ROBERT G. TORRICELLI, New Jersey

MAX CLELAND, Georgia

THOMAS R. CARPER, Delaware

JEAN CARNAHAN, Missouri

MARK DAYTON, Minnesota

THAD COCHRAN, Mississippi

TED STEVENS, Alaska

SUSAN M. COLLINS, Maine

GEORGE V. VOINOVICH, Ohio

PETE V. DOMENICI, New Mexico

ROBERT F. BENNETT, Utah

Richard J. Kessler, Staff Director

Mitchel B. Kugler, Minority Staff Director

Brian D. Rubens, Chief Clerk

(III)

C O N T E N T S

Opening statement: Page

Senator Akaka .................................................................................................. 1

Senator Cochran ............................................................................................... 20

Prepared statement:

Senator Cleland ................................................................................................ 3

WITNESSES

MONDAY, JULY 23, 2001

Bruce Baughman, Director, Planning and Readiness, Federal Emergency

Management Agency (FEMA) ............................................................................. 3

Scott R. Lillibridge, M.D., Special Assistant to the Secretary, Department

of Health and Human Services for National Security and Emergency Management, Washington, DC ................................................................................... 5

Tara J. O’Toole, M.D., M.P.H., Johns Hopkins Center for Civilian Biodefense

Studies .................................................................................................................. 10

Dan Hanfling, M.D., FACEP, Chairman, Disaster Preparedness Committee,

Inova Fairfax Hospital, Falls Church, Virginia ................................................. 15

ALPHABETICAL LIST OF WITNESSES

Baughman, Bruce:

Testimony .......................................................................................................... 3

Prepared statement .......................................................................................... 25

Hanfling, Dan, M.D., FACEP:

Testimony .......................................................................................................... 15

Prepared statement .......................................................................................... 52

Lillibridge, Scott R., M.D.:

Testimony .......................................................................................................... 5

Prepared statement .......................................................................................... 33

O’Toole, Tara J., M.D., M.P.H.:

Testimony .......................................................................................................... 10

Prepared statement .......................................................................................... 43

APPENDIX

Questions and responses for the record from:

Mr. Baughman .................................................................................................. 59

Dr. Lillibridge ................................................................................................... 63

Dr. OToole ......................................................................................................... 66

Dr. Hanfling ...................................................................................................... 70

(1)

FEMA’S ROLE IN MANAGING BIOTERRORIST

ATTACKS AND THE IMPACT OF PUBLIC

HEALTH CONCERNS ON BIOTERRORISM

PREPAREDNESS

MONDAY, JULY 23, 2001

U.S. SENATE,

SUBCOMMITTEE ON INTERNATIONAL SECURITY,

PROLIFERATION, AND FEDERAL SERVICES,

OF THE COMMITTEE ON GOVERNMENTAL AFFAIRS,

Washington, DC.

The Subcommittee met, pursuant to notice, at 2 p.m., in room

SD–342, Dirksen Senate Office Building, Hon. Daniel K. Akaka,

Chairman of the Subcommittee, presiding.

Present: Senators Akaka and Cochran.

OPENING STATEMENT OF SENATOR AKAKA

Senator AKAKA. The Committee will please come to order. I want

to thank our witnesses—will you please be seated—Bruce

Baughman of the Federal Emergency Management Agency and Dr.

Scott Lillibridge of the Department of Health and Human Services,

for being with us today. I want to also welcome Dr. Tara O’Toole

of the Johns Hopkins Center for Civilian Biodefense Studies, and

Dr. Dan Hanfling from Inova Fairfax Hospital.

According to Committee rules, it is required that all witnesses be

under oath while testifying. So, at this time, I would like the witnesses to please stand and remain standing. Raise your right hand.

Do you solemnly swear to tell the truth, the whole truth, and nothing but the truth, so help you, God?

Mr. BAUGHMAN. I do.

Dr. LILLIBRIDGE. I do .

Dr. O’TOOLE. I do.

Dr. HANFLING. I do .

Senator AKAKA. Thank you. You may be seated. I look forward

to this hearing and to hear from FEMA and HHS describe what

the Federal Government is doing to prepare our local communities

for bioterrorism.

I am also eager to hear from our other witnesses, who will tell

us what their concerns are and how effective our Federal programs

have been. We have two agencies represented here, but there are

many Federal stakeholders and many programs that address unconventional terrorism. For example, we have national medical response teams, the Metropolitan Medical Response System, FEMA

urban search and rescue task forces, National Guard RAID teams,

2

and domestic preparedness training through the Department of

Justice. I want to commend these and all terrorism-response efforts.

Across the country, States and communities are also working to

develop terrorism-response plans. I offer the statewide terrorism

preparedness efforts in Hawaii, which have been hailed by HHS as,

‘‘exemplary,’’ as a national model of Federal, State and local coordination and cooperation. President Bush directed FEMA to create

an Office of National Preparedness, to coordinate anti-terrorism

programs among all these stakeholders. HHS and its Centers for

Disease Control and Prevention, with their expertise and experience, are the lead implementing agencies for bioterrorism response

programs.

Bioterrorism is different from other forms of terrorism. A bioterrorist attack will not be preceded by a large explosion. First responders will be the physicians and nurses in our local hospitals

and emergency rooms, who may not realize that there has been an

attack for days or weeks. Preparing for biological events should not

be limited to worst-case scenarios, where thousands of Americans

die from an intentional release of anthrax or smallpox. A simple

and perhaps more likely hostile act of infecting a population with

food poisoning would also overwhelm most area hospitals. Naturally-occurring emergency infectious diseases can do just as much

damage.

We must ensure that hospitals and medical professionals are

equipped to deal with these threats. As former Secretary of Health

and Human Services Donna Shalala once said, ‘‘Bioterrorism is

perhaps the first time in American history in which the public

health system is integrated directly into the national security system.’’ Therefore, problems and concerns within the public health

system directly affect our ability to plan and respond to acts of bioterrorism. Similarly, efforts to improve our preparedness for bioterrorism also improve our health and medical communities.

There are three things we must do to deal with a biological

event: (1) continuous surveillance so that an unusual event can be

recognized, (2) active investigation for a quick and decisive diagnosis, and (3) an emergency response. These are the areas that

local and State planners concentrate on while preparing their own

response plans. These are also the areas where the Federal Government can help. But how much are Federal programs that are

designed to help local communities prepare for biological events, in

fact, helping? Are they addressing local planners primary concerns

and needs?

Last year, the TOPOFF exercise simulated an outbreak of plague

in Colorado. Another exercise, Dark Winter, was performed to simulate a possible U.S. reaction to the deliberate introduction of

smallpox in three States. Have we begun to apply the lessons

learned from TOPOFF and Dark Winter? Are we in better position

to handle a bioterrorist attack today, a year after TOPOFF or 6

years after the world learned of the Aum Shinrikyo cult and their

attempts to master biological agents?

Once again, I welcome our witnesses and look forward to an interesting and educational discussion. I am glad you are here as our

witnesses. I thank you very much, and Senator Cleland regrets

3

1The prepared statement of Mr. Baughman appears in the Appendix on page 00.

that he is unable to be here today. He has asked that his comments

be submitted for the record.

[The prepared statement of Senator Cleland follows:]

PREPARED STATEMENT OF SENATOR CLELAND

Thank you, Senator Akaka and Subcommittee members, for conducting today’s hearing on managing and preparing for acts of bioterrorism. One of today’s most serious potential threats to U.S. national security is bioterrorism. I want to commend

Sam Nunn and the Johns Hopkins’ sponsored Dark Winter small pox bioterrorism

exercise conducted at Andrews Air Force Base on June 22–23, 2001. This exercise

dramatically illustrates that our response to date is woefully inadequate to deal

with a domestic bioterrorist event and that a reconsideration both of strategy and

organizational structure are needed. There is, as yet, no agreed upon comprehensive

national strategy or plan to deal with bioterrorism. The United States has just

begun to act on many of the needed biodefense programs.

During the last session of Congress, we passed P.L. 106–505. This law authorizes

crucial provisions for protection against public health threats and to build a national

biodefense plan. There is widespread agreement that we face a significant potential

for a domestic bioterrorist attack, yet for fiscal year 2001, we appropriated only $1

million instead of the $99 million needed. Fully funding P.L. 106–505 is vital because it also recognizes the role of private industry partnerships with Federal agencies and State and local public health programs as the foundation of an effective

national strategy for bioterrorism preparedness and response.

I am very proud to have the Centers for Disease Control and Prevention (CDC)

in my State of Georgia. The CDC is and must be a major and integral part of homeland defense, because of its ability to expeditiously identify, classify, and recommend

courses of action in dealing with biological and chemical threats. Since January

1999, CDC has been tasked by the Secretary of Health and Human Services to develop national, State, and local public health capacities to effectively respond to acts

of biological and chemical terrorism. Yet it was just this past year that Congress

began to appropriate funds to assist leading Federal agencies, including the CDC,

in meeting this challenge. The CDC also has a critical supportive role to the Department of Defense Rapid Assessment and Initial Detection (RAID) in preventing and

preparing for the possibility of bioterrorism. Additionally, CDC’s research and development in areas of Gulf War Syndrome and the current anthrax threats are of critical importance to our military.

The problems with vaccine production and distribution encountered during the

Dark Winter exercise parallel the current difficulties with Anthrax and adenovirus

vaccines. My question is, ‘‘do we have clear procedures defining State and Federal

responsibilities and on the use and distribution of the national stockpile of vaccines?’’ If the answer is no, then why not?

For all of the attention that missile defense has received in Congress and the Executive Branch, it is undeniably true that the use of weapons of mass destruction,

in the form of biological or chemical agents delivered by terrorists, is a far more

immediate and real threat to the people of the United States. We must, I repeat

must, set our priorities accordingly. I thank you, Mr. Chairman and the Members

of the Subcommittee, for the opportunity to offer my comments on this crucial issue.

Senator AKAKA. I am expecting Senator Cochran soon.

Mr. Baughman, we welcome any opening statement or comments

you may have, so you may begin.

TESTIMONY OF BRUCE BAUGHMAN,1 DIRECTOR, PLANNING

AND READINESS, FEDERAL EMERGENCY MANAGEMENT

AGENCY (FEMA)

Mr. BAUGHMAN. Thank you, Mr. Chairman. I am Bruce

Baughman, Director of Planning and Readiness Division at the

Federal Emergency Management Agency. Director Joe Allbaugh regrets that he is unable to attend this session today. It is my pleasure to represent him at this important hearing on bioterrorism. I

will briefly describe today how FEMA works with other agencies,

4

what our approach is to bioterrorism, and the role of the new Office

of National Preparedness. FEMA’s mission is to reduce the loss of

life and property and to protect our Nation’s critical infrastructure

from all types of hazards. As staffing goes, FEMA is a small agency. Our success depends upon our ability to organize and lead a

community of local, State and Federal agencies and volunteer organizations.

We provide a management framework, a funding source. The

Federal response plan is the heart of that framework. It reflects

the labors of interagency groups that meet in Washington and all

10 of our FEMA regions to develop the Federal capability to respond to any emergency as a team. That team is made up of 26

departments and agencies, along with the American Red Cross.

Since 1992, the Federal response plan has been the proven framework for managing major disasters and emergencies, regardless of

cost. It works. The reason is it is simple. The plan organizes agencies into functions based upon their existing authorities and expertise.

Now, we recognize that a biological scenario presents unique

challenges. The worst-case scenarios begin undetected and play out

as epidemics. That means that response begins in the public health

and medical community. Initial requests for Federal assistance will

probably come through the health and medical channels to the

Centers for Disease Control and prevention, or CDC. At some

point, the situation would escalate into a national emergency. As

an element of HHS, the CDC 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 HHS as the primary agency for

the health and medical function under the Federal response plan.

We rely on HHS to bring the experts to the table when the Federal

response plan agencies need to meet to discuss a biological scenario. As a result of these efforts, we are learning more about the

threat, how it spreads, and the resources and techniques that will

be needed to control it. We are making progress. Exercise TOPOFF

in May 2000 involves two concurrent terrorism scenarios in two

metropolitan areas of the United States. One of these scenarios

was bioterrorism. We are still working on the lessons learned from

that exercise. It takes time and resources to identify, develop and

incorporate changes into the system.

Exercises, when conducted properly and in moderation, are critical to helping us prepare for the various scenarios we may be confronted with by a weapon of mass destruction. In January 2001,

the FBI and FEMA published the U.S. Government’s Interagency

Domestic Terrorism Concept of Operations, or CON plan. With the

coordination of HHS and other key departments and agencies, we

pledged to continue the planning process to develop specific procedures for different scenarios, including bioterrorism. The Federal

response plan and the framework it can provide for managing disasters can also be used to manage a bioterrorism event.

Now, let me take a few minutes to talk about our Office of National Preparedness. On May 8, 2001, President Bush asked the director of FEMA, Joe Allbaugh, to create an Office of National PreVerDate 11-MAY-2000 12:44 Oct 05, 2001 Jkt 000000 PO 00000 Frm 00008 Fmt 6633 Sfmt 6601 75441.TXT SAFFAIRS PsN: SAFFAIRS
5

1The prepared statement of Dr. Lillibridge appears in the Appendix on page 00.

paredness. This office will do the following: One, coordinate all Federal programs dealing with weapons of mass destruction consequence management; this office is not intended to take over any

individual agency program or function; two, solicit input from first

responders at the State and local and emergency management organizations, and how to continue to build and sustain a national

capability; three, support the collective effort to design a balanced

national program that involves planning, training, exercises, equipment, and other elements as required; and, fourth, identify shortfalls and duplications existing in Federal programs and make recommendations on how to address these areas.

FEMA established this office earlier this month with an initial

staffing element. As the structure and activities of the office evolve,

staffing will be augmented with personnel from other departments

and agencies, State and local organizations. Mr. Chairman, you

convened this hearing to ask about our approach to bioterrorism.

It is FEMA’s responsibility to ensure that the Federal response

plan is adequate to respond to the consequences of catastrophic

emergencies and disasters, regardless of cause. Bioterrorism presents tremendous challenges. We rely on HHS to lead the health

and medical community in addressing the health and medical aspects of this problem. They need support to strengthen their detection and reporting supporting capabilities, and their operating capacity in emergency medicine. We need support to ensure that the

national system has the tools to gather information, set priorities,

and deploy resources in a biological scenario.

FEMA and the Federal response plan have a successful history

of coordinating Federal, State and local consequence management

efforts before, during and after emergencies. This track record provides a strong foundation for the new Office of National Preparedness. Thank you Mr. Chairman. I would be happy to answer any

questions.

Senator AKAKA. Thank you very much, Mr. Baughman.

At this time, I would like to tell the witnesses that we will include all of your statements, full statements, in the record. Dr.

Lillibridge, we invite you to make an opening statement now.

TESTIMONY OF SCOTT R. LILLIBRIDGE,1 M.D., SPECIAL ASSISTANT TO THE SECRETARY, DEPARTMENT OF HEALTH

AND HUMAN SERVICES FOR NATIONAL SECURITY AND

EMERGENCY MANAGEMENT, WASHINGTON, DC

Dr. LILLIBRIDGE. Thank you, Mr. Chairman and Members of the

Subcommittee. Thank you for inviting me here today to discuss the

activities of the Department of Health and Human Services in responding to bioterrorism, other emergencies and acts of terrorism.

I am Scott Lillibridge, Special Assistant to the Secretary of HHS

for National Security and Emergency Management. On July 10,

Secretary Tommy Thompson appointed me to this position and directed me to develop a unified HHS preparedness and response

system to deal with these important issues. I would like to discuss

that effort with you, highlighting some of the areas in which HHS

works with the Federal Emergency Management Agency.

6

Bioterrorism has unique characteristics, as you mentioned in

your opening statement, that set it apart from other acts of terrorism. Biologic agents are easy to conceal, potentially contagious

in nature, and, in the most worrisome scenario, the first responders

are likely to be health professionals in emergency rooms, outpatient clinics and public health settings. HHS is the primary

agency responsible for health and medical response under FEMA’s

Federal response plan. HHS also coordinates and provides health

leadership to the National Disaster Medical System, NDMS. This

is a partnership that brings together HHS, the Department of Defense, FEMA, the Department of Veterans Affairs, and the private

sector.

NDMS was developed to provide medical response, patient evacuation, and definitive medical care for mass-casualty events. This

system addresses both disaster situations and military contingencies. I would like to talk a little bit about bioterrorism preparedness and response—and begin with how HHS provides technical assistance to the FBI during bioterrorism threats and then

discuss other issues associated with crisis management. FEMA is

the lead agency in charge of consequence management. The broad

goals of a national response to bioterrorism or any epidemic involving a large population will simply be to detect the problem, control

the epidemic spread in the population, and to treat the victims.

The Department’s approach to this challenge has been to strengthen the public health infrastructure and to hone our emergency

health and medical response capacities at the Federal, State and

local level.

In an emergency, HHS is able to mobilize NDMS resources, CDC

disease experts and the national pharmaceutical stockpile. In addition, disaster teams of the Office of Emergency Preparedness, the

Public Health Services Commissioned Corps Readiness Force, and

the support of other Federal agencies can be mobilized. Since fiscal

year 1995, HHS, through the Office of Emergency Preparedness,

has been developing Metropolitan Medical Response Systems,

MMRS. This initiative enhances the existing local and city system’s

capability to respond to a chemical or biologic incident, and provides for triage and medical treatment. These city systems have

been developed to help address the medical needs of victims of terrorism and to facilitate the transport of patients to hospitals.

In the area of training, HHS has used classroom training, distance learning and hands-on training activities to prepare the

health and medical community for contingencies such as bioterrorism. Expansion of the bioterrorism training component of Nobel

Training Center and Hospital at Fort McClellan, Alabama, is a

high priority for HHS. We will continue our strong linkage with the

adjacent Department of Justice Office of Justice Programs training

facility for first responders and its National Domestic Preparedness

Consortium.

The recent FEMA–CDC initiative to expand the scope of FEMA’s

integrated emergency management course will serve as a vehicle to

integrate emergency management and the health community response efforts in a way that has not been possible in the past. It

is clear that these communities can best respond together if they

are able to train together. Our priorities for HHS? Well, through

7

CDC, we need to expand our cooperative agreements to health departments and to enhance State and local preparedness for bioterrorism.

In the near future, as part of its responsibility associated with

the National Disaster Medical System, HHS must begin to broaden

its perspectives to address issues related to health facility preparedness in civilian communities. It is also time to review the

roles and responsibilities between NDMS partners, to see how they

match against the new threats facing our Nation. In conclusion, the

Department of Health and Human Services is committed to ensuring the health and medical care of our citizens. We are prepared

to quickly mobilize the professionals required to respond to a disaster anywhere in the United States and its territories, and we are

actively preparing for the challenge posed by acts of bioterrorism.

At the end of my second week at this new post, it is clear that

close ties between HHS, FEMA, and the Department of Justice will

be paramount in addressing the consequences of bioterrorism and

other terrorist incidents. Mr. Chairman, that concludes my prepared remarks and I would be pleased to answer your questions at

this time.

Thank you.

Senator AKAKA. Thank you very much, Dr. Lillibridge. I find the

amount of work being done within both your agencies in response

to this threat to be very impressive. I do have a few questions for

both of you. Mr. Baughman, an Office of National Preparedness

section is being created at FEMA headquarters and in each of the

10 regional offices. Will these offices be staffed by new personnel

or by existing staff who will have additional responsibilities?

Mr. BAUGHMAN. They are going to be staffed really by three sets

of individuals: There will be existing FEMA personnel, there will

be personnel from other agencies, and then there will be State and

local personnel also staffing these offices.

Senator AKAKA. These personnel from other agencies, are they

going to be just coordinating with you from their agencies?

Mr. BAUGHMAN. I think initially that they will be resident at our

agency until we can map out the strategy that we have been asked

to work with the White House on, and then after that we will have

to see how things play out. If things are well-coordinated, then I

think that perhaps they could go back to their home agencies. But

I think initially our intent is to have those personnel at our agency.

Senator AKAKA. You mentioned in your written testimony the

Emergency Management Institute Comprehensive Course on Public

Health Concerns. This sounds like just the sort of program that is

needed to foster cooperation and heighten awareness to the issues

surrounding bioterrorism. My question is how do communities and

participants become involved? Do you find interest in these courses

uniform across the country or are some States and regions very active, while others are less so?

Mr. BAUGHMAN. Senator, our Office of Training could answer

that better than I could. I can provide you a response to that for

the record.

Senator AKAKA. Please do. Please provide it.

Dr. Lillibridge, the key to minimizing the consequences of a biological event, whether a naturally-occurring epidemic or an overt

8

terrorist attack, is to notice that it is an event as soon as possible.

My question is what is your office doing to help communities know

if an unusual event is occurring? For example, can you tell them

what an abnormal number of cases would be for a certain disease

or illness?

Dr. LILLIBRIDGE. Fair enough. Mr. Chairman, we are working on

a number of avenues, primarily through the Centers for Disease

Control, to develop and enhance local surveillance systems at the

State and local level. These systems help cross over early clues of

awareness—like 911 calls and health service utilization—and help

build that public service infrastructure to give us that early warning. There is more that we could be doing in this area, and we are

working through training and several other grant mechanisms to

develop this activity in virtually all States.

Senator AKAKA. Dr. Lillibridge, the Emergency Medical Treatment and Labor Act of 1986 establishes the general requirements

for emergency rooms. For example, a hospital that operates an

emergency department must comply to any medical examination

request. Also, if an individual comes to the hospital with an emergency medical condition, the hospital must provide treatment. The

question is, this act requires emergency care to be provided to anyone who needs treatment, regardless of their insurance status or

ability to pay. Does this law have an impact on planning bioterrorism response?

Dr. LILLIBRIDGE. Mr. Chairman, I think that law relates to several of our planning efforts. One way the law relates is that we

look at our preparedness and response activities to involve planning at the most local level. This includes the regulation or movement of patients, the collective act of moving certain patients to

certain hospitals, and involves most facets or nearly all facets of

planning at the local level. We have also given consideration to this

in terms of our planning grants through CDC and through our

MMRS activity at the local level.

It is something that we have to consider as an extremely important part of our planning process, but does not stop us from doing

the essential things in epidemic control.

Senator AKAKA. Dr. Baughman, we have heard from Dr.

Lillibridge about the National Disaster Medical System, which was

designed for responding to natural disasters. In it, member hospitals are required to accept patients from other hospitals in the

event of a crisis. Tell me, how will this work during a bioterrorist

attack? Would a remote hospital whose participation in a system

is voluntary be willing to accept contagious patients suffering from

plague? Could FEMA require them to do so?

Mr. BAUGHMAN. Mr. Chairman, we cannot require them to do so,

and it is voluntary, so it may be problematic, and maybe Dr.

Lillibridge can maybe lend a little bit more to that.

Senator AKAKA. Would you?

Dr. LILLIBRIDGE. Mr. Chairman, in our recent exercises with

TOPOFF last year and recently with Dark Winter, it was clear that

even, over and above the Federal Government, that governors have

extraordinary powers during emergencies, during State emergencies, that would include epidemics or an act of bioterrorism.

There may be issues where they will restrict the movement of peoVerDate 11-MAY-2000 12:44 Oct 05, 2001 Jkt 000000 PO 00000 Frm 00012 Fmt 6633 Sfmt 6601 75441.TXT SAFFAIRS PsN: SAFFAIRS
9

ple in their State. They may close businesses. They may even order

the movement of patients or closure of certain facilities.

Many of these issues are being considered at that level of planning with the governors. At the recent Governors Association Meeting, issues of bioterrorism were the focus of nearly 2 days of discussions.

Senator AKAKA. Dr. Lillibridge, many veterinarians are familiar

with diseases that affect both animals and humans. Several of

these diseases are potential bioterrorism agents, such as anthrax

and plague. Some diseases, such as the West Nile virus, generally

affect animals before humans. These factors make communication

between veterinarians, medical doctors and public health officials

very important. How does the CDC communicate with local and

State veterinarians? Do you have a senior level official who is in

regular contact with the animal health community?

Dr. LILLIBRIDGE. Yes, sir. We have communication with the veterinary community through a number of fora. As a matter of fact,

in the bioterrorism program at CDC, essentially half of the staff in

our surveillance office are veterinarians—for that very reason, for

the crossover. It became clear during West Nile and other activities

related to preparedness for bioterrorism that consideration for

crossing over the human health and the veterinary health link was

extremely important. We have embodied that concept in the surveillance activities that we are working on—and in some of our

partnerships with the Department of Justice and the Department

of Defense—as we work on bioterrorism preparedness research and

response activities.

Senator AKAKA. Dr. Lillibridge, I agree with your plans to

strengthen surveillance networks beyond public health departments. You mentioned how detailed information on emergency department visits, 911 calls, health service usage, and pharmacy

sales would be useful for timely and effective detecting and reporting of disease outbreaks. Do you think that also including veterinarians in this network would be useful? What resources would a

community require to get all of this information?

Dr. LILLIBRIDGE. Mr. Chairman, we think that would be extremely useful. We have embarked on a pilot project to begin looking at linking animal and human health through surveillance, and

it is clear that there is going to be—if there is a bioterrorism attack

in the human population—some intrusion perhaps into the animal

population. That is going to be extremely important from the veterinary side. The West Nile virus showed us that early attention

to cases in animals could precede cases in humans, and those will

expand over time. Through linkage with the veterinary associations, our colleagues in the research and veterinary communities,

we are beginning to forge those links.

In the Office of Bioterrorism Activities at the Centers for Disease

Control, there is deliberate consideration for active engagement

and expansion of those kinds of networks.

Senator AKAKA. I am sure my colleagues will have questions for

you, so I will keep the record open, of this Subcommittee so that

other questions may be placed into the record.

Dr. Baughman and Dr. Lillibridge, I want to thank you again

being here this afternoon and for your cooperation. This, I think,

10

1The prepared statement of Dr. O’Toole appears in the Appendix on page 00.

will be the beginning of some interesting planning for the future,

but there is no question that we must take the time to do critical

planning in case something like this happens to our communities.

Thank you very much.

Mr. BAUGHMAN. Thank you, sir.

Senator AKAKA. So you may be excused.

Dr. LILLIBRIDGE. Thank you, Mr. Chairman.

Senator AKAKA. Thank you. And now, we invite Dr. Tara O’Toole

of the Johns Hopkins Center for Civilian Biodefense Studies and

Dr. Dan Hanfling of Department of Emergency Medicine at Inova

Fairfax Hospital. I invite you to come to the witness table, and as

soon as you are ready, we will proceed with the hearing.

Dr. O’Toole, I know both of you have taken the oath already, so

we will continue. Dr. O’Toole, we welcome any opening statement

or comments that you may have, and as I said, your full statement

will be placed in the record.

TESTIMONY OF TARA O’TOOLE,1 M.D., M.P.H., JOHNS HOPKINS

CENTER FOR CIVILIAN BIODEFENSE STUDIES

Dr. O’TOOLE. Thank you, Mr. Chairman. Thank you for the opportunity to be here today and to make remarks on this very important topic. I want to emphasize at the beginning that in my

view and that of my colleagues at Johns Hopkins, FEMA is a government organization success story and has brought vital help and

comfort to millions of Americans through a whole array of disasters

over the past decade and more. Likewise, CDC is world-renowned

as an expert in epidemic management and in public health, and

there is no doubt about either its reputation or its expertise.

That said, it is my belief that in the context of responding to a

biological weapons attack on U.S. civilians, FEMA and CDC are

likely to find themselves called upon to facilitate decisions and actions which are unfamiliar, unpracticed and highly controversial

within the decision making circles. They are also going to be asked

to coordinate a medical and public health response, which is not

only complex, and time sensitive, but will depend critically on institutions and infrastructures which we believe are very fragile and

may well become dysfunctional or collapse altogether in the face of

a sudden surge in patient demand. I am talking here particularly

about the medical service infrastructure. Hospitals, in particular,

have very little elasticity or ability to respond to sudden surges in

patient demand. Second, the public health infrastructure, which

has been neglected financially and, in terms of political attention,

for decades cannot handle the demands an epidemic would impose.

It is clear that Secretary Thompson has put bioterrorism very

high on his agenda. I think the appointment of Dr. Lillibridge to

be his special assistant is an extremely positive move. I also think

that Director Allbaugh’s designation of a new Office of National

Preparedness is very encouraging. There is no question that the

Federal Government—Congress and the administration together—

have made progress in bioterrorism response in the past several

years. But I am going to focus today on your question, Mr. ChairVerDate 11-MAY-2000 12:44 Oct 05, 2001 Jkt 000000 PO 00000 Frm 00014 Fmt 6633 Sfmt 6601 75441.TXT SAFFAIRS PsN: SAFFAIRS
11

man, are the current Federal programs really meeting local needs,

and what could we do to meet those needs more effectively?

I am going to take a glass-half-empty approach here, with the

appropriate caveat beforehand that I think we have made progress.

I am going to suggest four recommendations which I will run

through right now. First of all, I think we have to get hospitals and

hospital leadership much more engaged in bioterrorism response

planning. That is going to take attention from the appropriate Federal agencies, but also money from Congress, and I will come back

to that.

Second, I think we have to really assess by means of independent

studies that are beyond reproach, the actual capacity of the National Disaster Medical System, the VA hospital system, and other

institutions that the Federal response plan now says, are going to

be there if we need them to treat sick people in the midst of epidemic.

Third, I think we need to do a lot more to design, assess and encourage drills, exercises such as TOPOFF, that would include not

only the usual responder communities, including hospitals and

public health officials, but would also include decisionmakers themselves, members of Congress, members of the cabinet and the National Security Council, and so forth, so that the issues that they

are going to be confronting if—God forbid, there is a bioterrorist attack—are more familiar and the options are also perhaps more lucidly understood.

So that is where I am going to end up. Let me go back to my

analysis of why those recommendations are, in my view, necessary.

You have already outlined, Mr. Chairman, how a bioterrorist

attack would differ from natural disasters or even other kinds of

catastrophic terrorism. It is going to cause an epidemic. The awareness of the epidemic will likely build slowly as people die

inexplicably or large numbers of people become ill and report to the

medical care system. Hopefully, early on, physicians and clinicians

will alert the public health system that something strange is happening. That does not now happen, as a matter of course.

When the first two cases of West Nile virus were called in to the

New York City Department of Health, there were already a dozen

cases of encephalitis in hospitals in New York City. Encephalitis is

a legally-reportable disease, but none of the physicians caring for

those patients had called them in. There is a lot of data to support

that this is usually the case. It is also the case that most health

departments do not have the resources to man phone lines 24

hours a day, 7 days a week. So in many States, even if the physician were to call some suspicions in, he or she may not get an answer on the other end of the line for a day or more.

The U.S. medical care system has been under tremendous financial stress for at least a decade, and one of its responses to these

financial pressures has been to cut out excess capacity. Hospitals

in virtually every town in this country, whether it is the Johns

Hopkins Medical Center or a small rural hospital, are basically

now functioning on ‘‘just-in-time’’ models. The number of nurses

that are going to be working at Hopkins tomorrow are based upon

the number of patients in the hospital today; likewise for supplies,

for antibiotics, for what have you. It is very difficult for any hosVerDate 11-MAY-2000 12:44 Oct 05, 2001 Jkt 000000 PO 00000 Frm 00015 Fmt 6633 Sfmt 6601 75441.TXT SAFFAIRS PsN: SAFFAIRS
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pital to ramp up quickly in response to a sudden surge in demand,

as we find out every flu season.

Staff shortages are chronic. They are not just in nursing, which

is the most famous source of shortages right now, but they cover

virtually all of the functions of the hospital: Respiratory technicians, lab technicians, pharmacists and so on, and these staff shortages are expected to worsen. If we are in the midst of an epidemic,

particularly a lethal epidemic or one that is contagious, one has to

wonder if health care staff are going to report to work. Some are

going to have to be home caring for their own families. Others may

be sick. Others may be fearful of bringing contagion home. So these

staff shortages may worsen, just at the time we have great need

for people working in hospitals in dealing with patients.

Few, if any, hospitals in America today could handle 100 patients

suddenly demanding care. The Secretary of Health in Maryland did

a study a year ago, after a fire in a high-rise building which luckily

caused no serious injuries, to see if Baltimore or, indeed, Maryland,

home to two medical schools, could handle 100 patients suddenly

needing ventilator assistance. We could not. There is no way, and

this is a State with over 50 hospitals in it. There is no metropolitan

area, no geographically-contiguous area, that could handle 1,000

people suddenly needing advanced medical care in this country

right now.

There is no surge capacity in the medical care system. This is

most serious in the hospital sector, but it also pertains to doctors’ officers and clinics. That is a big problem. We need to deal with

that fact. It is also the case that hospitals are not now engaged in

bioterrorism planning. The Office of Emergency Preparedness at

HHS has tried to get hospitals engaged, as has FEMA, to a lesser

extent. Hospitals are not interested. We had a meeting with over

30 CEOs of hospitals of all shapes and sizes last year, and they

told us the following: We are so busy trying to keep our heads

above water on a day-to-day basis that we are not going to put

aside any resources for bioterrorism planning unless two things

happen: (1) the highest levels of government have got to tell us

that this is a priority and that we are expected to play a vital role,

and (2) they have got to send money. Hospitals today do not feel

that they can divert any of their precious resources, even to what

it takes to plan for a bioterrorism response. That lack of engagement of the hospital sector in planning is a big problem for us.

Moving on to the public health infrastructure, Dr. Lillibridge

talked about the vital work that CDC is doing to try and improve

the public health infrastructure at the State and local level. When

Secretary Thompson testified in May before the combined Senate

committees, he affirmed that improving the public health infrastructure is possibly the most important task ahead of HHS, in improving bioterrorism response. I would agree, but we are spending

less than $50 million a year on what the Secretary of HHS—two

Secretaries of HHS—have now said is the most vital component of

bioterrorism response. This is a piddling amount for so crucial a

feature of our capacity to protect people from epidemic disease.

I think we have to spend less attention asking the question who

is in charge and more time and attention thinking about what are

we going to do and what information decisionmakers are going to

13

need to make informed decisions. During the Dark Winter exercise,

which was a fictional smallpox scenario that asked a panel of

former high-level government officials to act as members of the National Security Council, the participants were continually asking

for more information, more data: What about this? What is the

story here? How many people are sick here? How many more can

we expect to get ill?

We could not answer those questions, and, in fact, these participants had more information than they would in the real world.

Once we know we are under attack, once we know we have an epidemic underway, it is the public health officials who have to answer the question: How many people are sick? Where are they?

What do they have in common? How many other people are likely

to become ill? Where are the supplies that we need in order to protect people or to give them effective treatment and so forth. If the

State health departments are not able to answer those questions,

there will be very little that FEMA or CDC can do.

CDC itself is quite small. There are fewer than 150 people in the

Epidemic Intelligence Service, which is, in the normal course of

small natural outbreaks, who you would call upon to augment

State and local health departments. Now, CDC could probably, in

a dire emergency, put in the field 1,000 or so people who have some

background in epidemic control, but CDC itself has a very small office of bioterrorism. Most of the people working in it are matrixed

to other responsibilities, and they could use some more resources

in this important endeavor.

I mentioned that there are vulnerabilities in decisionmaking

structures. This is reflected, I think, in Congress’ continuing worries about who is in charge of bioterrorism response, and also

showed up in many different guises in the TOPOFF exercise. We

found, in our analysis of TOPOFF, which we agree was an enormously valuable drill that we ought to consider repeating in many

different ways—we found that there were several different joint operation centers. We found that hospital leaders had no idea who

was in charge or who to call for information or to get more supplies. It appeared that the law-enforcement operations and the

health-care operations were running on separate tracks. The public

health and the medical people were meeting in one place and making their own sets of decisions, and the law-enforcement folks were

going about their business. There was not actual conflict between

these two hubs, but there did not seem to be a lot of collaboration

or crosstalk. I think that would be an unrealistic way to go in the

midst of an actual attack on the United States.

We also found that key participants could not really tell you

what decisions had been made. For example, people who were in

the throes of things had very different ideas about whether or not

it had been decided to actually quarantine Denver and Colorado.

That is a key decision, and yet there was dispute about whether

it had been made or not. We found in Dark Winter and also in the

course of conversations with many different officials at both the

State and Federal level that there is a preoccupation with imposing

quarantines, particularly if the disease is contagious. There is an

array of public health measures beyond quarantine, before quarantine, that are likely to be much more beneficial, that are much

14

easier to employ, and that ought to be considered long before anybody starts talking about closing down Baltimore, Washington, DC,

or New York City. Yet these different public health measures, I

think because they are unfamiliar to governors and to Senators

and to national security officials, have gotten very little discussion

or attention. Also, for these measures to be put in place, certain

preparatory actions have to be considered.

So all of these vulnerabilities in the decisionmaking structures,

in addition to the ones Congress has already noted—46 different

agencies, the national security crowd and the law-enforcement

crowd and the public health crowd all trying to be coordinated and

collaborative—I think deserve intense attention and discussion.

Finally, we need more effective vaccines and medicines. Some of

the most effective and important bioterrorism response tools are

not going to be there unless they are gotten ready long before an

attack occurs. We now have drugs or effective vaccines for only

about a dozen of the 50 pathogens thought to be most likely used

as biological weapons.

We are going to be asking FEMA and CDC to lead a response

to an epidemic without having sufficient supplies of effective medicines and vaccines. This is like asking firefighters to respond to a

12-alarm blaze without water or foam. It is crazy. We really need

to give serious consideration in this country to a major biomedical

R&D program that would, first of all, target the likely bioweapons

pathogens and create effective medicines and vaccines for those organisms, and second that would delve into the causes and means

of preventing and treating infectious diseases, generally. I do not

see any way around this.

As biology progresses, which it is doing at a prodigious pace, both

the power and the diversity of biological weapons is going to increase. That is where the trajectory of science is going. We have to

keep up with it. We can do this, and we can shift the advantage

from the offense to the defense, if we invest the tremendous talent

in R&D and biomedical areas that exist in this country appropriately, but we have to get going on this.

So, to end, Mr. Chairman, my recommendations again are: First,

engage hospitals and their leadership and get them involved in

planning and responding to bioterrorism. Congress must lead in

this. They must signal to hospitals that they have an important

role to play, and also spend money so that hospitals can show up.

Second, we should assess the real capacity of the National Disaster

Medical System and the VA hospital system via independent analyses of our current institutional capabilities and plans to care for

the sick, and find out if that really is a solid pillar of the Federal

response plan. Third, we should mount a substantial research and

development program that involves biomedical talent in the private

sector and the universities. Fourth, I would encourage FEMA, in

particular, to design, assess and use drills that might reveal the

vulnerabilities and inspire coordination and improve awareness of

the issues and options that a biological weapons attack would

present to decisionmakers.

Thank you.

Senator AKAKA. Thank you very much, Dr. O’Toole.We will now

hear from Dr. Hanfling.

15

1The prepared statement of Dr. Hanfling appears in the Appendix on page 00.

TESTIMONY OF DAN HANFLING,1 M.D., FACEP, CHAIRMAN, DISASTER PREPAREDNESS COMMITTEE, INOVA FAIRFAX HOSPITAL, FALLS CHURCH, VIRGINIA

Dr. HANFLING. Mr. Chairman, thank you very much for inviting

me here this afternoon to discuss issues that I think are of great

importance to the well-being of our Nation. I am Dan Hanfling, a

board-certified emergency physician with extensive experience in

the practice of out-of-hospital emergency care. As an ‘‘ER doc’’ working in the trenches of Inova Fairfax Hospital, a teeming, bustling emergency department and trauma center located just across

the river in northern Virginia, as medical director of one of the

best-respected fire and rescue services in the country, and as a veteran of the urban search-and-rescue disaster environment, I can

tell you that I have seen pain, suffering and devastation that is,

at times, unimaginable. But the consequences of a surreptitious release of a biological agent in our midst, or the effects of an as-yet

unconsidered, newly-emerging, infectious pathogen would make

what I see daily pale by comparison.

I would like to discuss briefly the ability of emergency departments to handle the aftermath of a bioterrorist attack. Conventional pre-hospital and hospital disaster plans prepare for events

that may result in the transport of tens or possibly hundreds of

patients to local community emergency departments and trauma

centers. Even these extenuating circumstances would place a significant burden on most local communities, as Dr. O’Toole just

mentioned. Emergency department overcrowding, nursing staff

shortages, hospital financial burdens and other constraints on our

existing health care system make rendering such care difficult.

These conditions contribute to impediments that hamper local disaster planning and preparedness.

Across the country, hospitals are so full that ambulance crews

are often rerouted or diverted from where they usually deliver their

patients. In northern Virginia, this is what we call circling the beltway. Facing the difficulties that we face now, how are we to manage the number of patients that will require care in the aftermath

of a bioterrorist attack? Emergency departments and in-hospital

patient bed availability will be a major issue, so, too, the ability to

encourage trained personnel to remain to treat patients. Razor-thin

inventories of pharmaceutical and medical equipment will be quickly exhausted. Effective communication links will be crucial, and yet

only a handful of communities have invested the money to creating

a system that works in a crisis. And all these become issues only

after the deluge has struck.

I would now like to discuss the local impact of Federal agencies.

We have come a long way towards improving the role of Federal

agencies in community-oriented disaster mitigation, and it is in

large part due to the tremendous efforts of the agencies that were

represented here before us today. However, disaster mitigation

must be accomplished using local resources and by the local community. Successful local disaster-planning efforts must be predicated on the fact that the calvary is not coming, at least not right

away. I must emphasize that the issue of bioterrorism is not excluVerDate 11-MAY-2000 12:44 Oct 05, 2001 Jkt 000000 PO 00000 Frm 00019 Fmt 6633 Sfmt 6601 75441.TXT SAFFAIRS PsN: SAFFAIRS
16

sively a large, urban, traditional first-responder event, as you have

heard mentioned many times already this afternoon.

This will affect all types of communities, urban, suburban and

rural, and it will be the medical and public health communities

that are up to bat first. So this is where we must focus our efforts.

Federal support of local and regional planning efforts, taking an

all-hazards approach, but geared towards bioterrorism preparedness, is what is greatly needed. How can this be effected? First, invest in restoring our medical infrastructure to be the strongest possible. We must focus attention on the issue of hospital and emergency department overcrowding. Second, support the development

of a meaningful partnership between the medical and public health

communities. Even without shooting for pie-in-the-sky information

system capabilities, funding must be made available now to pay for

the time required to conduct drop-in surveillance, such as was performed in the metro Washington, DC area during the past Presidential inauguration. Finally, promote disaster preparedness at the

local level specifically by funding educational, training and planning initiatives.

This process has already begun. The Department of Health and

Human Services and the American College of Emergency Physicians recently released a report, that was funded by the HHS Office of Emergency Preparedness, on the current state of training for

civilian emergency medical responders. That includes paramedics,

firefighters, emergency physicians and nurses. This report evaluated current training programs, analyzed barriers to implementing

training, and established objectives, content and competencies for

the training of these individuals. This represents a very important

first step in the right direction, because it is clear that we must

begin by creating a cadre of knowledgeable health care responders.

I want to be more specific. Federal funding for bioterrorism preparedness must be made available to hospitals, and a framework

for hospital and community-wide planning, in fact, already exists.

Guidelines of the Joint Commission on the Accreditation of Hospital Organizations are carefully followed by hospitals that wish to

achieve and maintain coveted accreditation status. However, they

receive no funding to implement such guidelines, and these guidelines specify the following: Establishing community and hospital

linkage by integrating the hospital with community-wide response

agencies; identifying alternative care treatment facilities; establishing backup external and internal communication systems; providing an ongoing orientation and education program; and conducting drills each year. Please, Mr. Chairman, help us fund these

important steps.

In March 1992, patients from the first documented anthrax hoax

were treated in Inova Fairfax Hospital. Three years prior to that,

Ebola virus decimated a stock of laboratory rhesus monkeys in Reston, Virginia, and again it was Inova Fairfax Hospital in the eye

of the storm. Each episode involved few patients and the lethality

of each infectious agent was not an issue, so we breathed a sigh

of relief. But now, almost 10 years later, emergency departments,

hospitals and the health care community are not organized to treat

victims of a bioterrorist attack. Meaningful discussion on the issue

of domestic preparedness must focus on the development of commuVerDate 11-MAY-2000 12:44 Oct 05, 2001 Jkt 000000 PO 00000 Frm 00020 Fmt 6633 Sfmt 6601 75441.TXT SAFFAIRS PsN: SAFFAIRS
17

nity-wide endeavors to meet this tremendous challenge. In order to

be truly effective, the planned Federal efforts to improve domestic

preparedness will require substantial additional resources and

funding at the local level.

With 20/20 hindsight, one can say that ‘‘duck-and-cover’’ represented a somewhat ludicrous civil preparedness stance in the

face of nuclear attack. I hope that as emergency planners of the future look back on our discussions of today, they do not chuckle the

way that some of us do now.

Mr. Chairman, I truly appreciate the opportunity to be here and,

of course, I am willing to take any questions.

Senator AKAKA. Thank you very much, Dr. Hanfling. I appreciate

your statements. You have certainly identified the huge problem

that this will bring, as well as to mention some of the resources

and maybe how we can bring it together, including resources and

money, possibly, from Congress. But, Dr. O’Toole, the Department

of Justice is the lead agency and in sole command of an incident

while in the crisis management phase. FEMA, as we have heard,

is responsible for all consequence-management activities.

The question is do you find this division between crisis and consequence management useful in combatting and responding to biological terrorism?

Dr. O’TOOLE. No.

Senator AKAKA. Can you expand on that?

Dr. O’TOOLE. Well, there will be no crisis in a bioterrorist event,

as it is traditionally understood. If it is an announced attack, then

perhaps there will be some prelude during which people try to figure out how to mobilize a response. But it is likely going to creep

up on us, and it will be the medical and public health community,

not the intelligence community, not the law-enforcement community, that gets the first inkling that something is up. So there will

not be that initial crisis response, as there was, for example, in the

Oklahoma City bombing. It is going to have very different flavor.

It is going to have a very different pace than other sorts of disasters.

I do not think the distinction between crisis and consequence

management is helpful. I am not sure it is a problem. I think the

FBI obviously would be involved very early on, at the first suspicion that this was a deliberate epidemic, and I think they will

have their job to do. I do think it would be very useful to deepen

the coordination and collaboration between the FBI and public

health at the local level. One FBI agent in New York told me that

they would have at least 200 to 500 people on the ground within

24 hours after a major bioterrorist attack. As a public health professional, I was very envious of that operational capability. Public

health cannot do that. Even if we had the full force of CDC behind

us I do not think we could do that in 24 hours.

Early on, the FBI and the public health officials are going to

want answers to virtually the same questions: Where were you?

What were you doing? Who have you been in contact with? If everybody is holding the same set of questions on palm pilots that get

coordinated, maybe the FBI and the public health could share their

expertise and resources in very constructive ways. So this crisis

consequence management division, I think, is not very helpful. It

18

is basically not going to exist as even an imaginary line in a bioterrorism event.

Senator AKAKA. Dr. O’Toole, you stated that the medical and hospital communities need to be included in bioterrorism preparedness

and response planning. Are there other groups that are routinely

left out of the biological terrorism discussion, and if you know, if

so, why?

Dr. O’TOOLE. Well, I think you touched on the veterinarians, who

are also very important. You could envelop the entire world in bioterrorism response and were, Lord forbid, there to be an epidemic,

we will envelop the entire world very quickly, because it will affect

transportation. It will affect trade. It will affect virtually every aspect of human activity. But if we are setting priorities in terms of

increasing awareness and fostering engagement, my list right now

is, (1) the hospital community, because they are the core of the

medical community, institutionally speaking; and (2) would be the

governors, who I think have an enormous amount at stake and are

in a position similar to hospital CEOs. They say, ‘‘Look, I have an

enormous amount going on. I have daily fires I have to take care.

I have major priorities for my State that I want to accomplish.’’ National security is not usually within the purview of governors, and

they do not consider it to be their business. I think it would be very

helpful if the governors were awakened to the implications of bioterrorism and started applying their own insights, as well as their

political muscle and influence, to the problem.

Senator AKAKA. You also mentioned that there are other public

health measures that can be used instead of quarantine. Can you

tell me what they are and how can we make these known to policy

makers and planners?

Dr. O’TOOLE. Well, there has been a lot of discussion about this

lately within public health circles and also at Dark Winter. Quarantine is a concept that actually comes from the Middle Ages, when

they forced ships to lay off at one corner of the harbor for 40 days,

to try and prevent the introduction of diseases into the port. Sometimes it worked, sometimes it did not, but it became a historical

fact. Quarantining a major metropolitan city is all but impossible,

as we discovered in TOPOFF. They tried to impose a quarantine

on Denver initially, when they realized they had a contagious disease abroad and they did not have enough antibiotics to protect everyone from the disease. That is the first problem.

If you have the vaccines and you have the prophylactic antibiotics, you do not have to worry about quarantine. You can give

people the protective medicines and they can go on about their

way. The second problem is that by the time you know you have

got an epidemic on your hands, people who are infected are probably going to be all over the world, and calling them back and gathering them together in one place is basically going to be impossible.

Another method beyond appropriate medicines and vaccines is to

limit the interaction of people in ways that are less Draconian than

quarantine. So, for example, you can forbid congregate gatherings.

You can cancel sporting events and so forth. You can limit, for example, the transportation of people without completely forbidding

the movement of cargo and food, so you do not find the problem

19

they did in TOPOFF. Three days into the quarantine, they realized

Denver was out of food.

Probably the most important thing one needs to do is enlist the

help of the public at-large. This is a constantly-neglected priority.

I neglected it in my testimony today, partly because the notion of

engaging the public in a cooperative enterprise aimed at stopping

the spread of disease or protecting whole populations seems to be

so hard.

But we do need to think through how we would communicate effectively with people and tell them how best to protect themselves

and their families. People do not panic in catastrophic situations,

history shows. They actually do very reasonable things, and if you

give them reasonable options, they will pursue them. If you tell

them, on the other hand, there is a deadly plague abroad in your

city, your kids may die, there are not enough medicines to go

around, this city is running out of medicines and we are about to

close all exit routes out of the city, they are probably going to pack

up their kids and try to get someplace where there are still medicines or at least less of a danger.

So I think enlisting the public in cooperative measures that are

not coercive is probably one of the most important things that we

could do.

Senator AKAKA. Dr. Hanfling, are the physicians and nurses in

your hospital trained to watch for unusual clusters of symptoms or

cases that are indicative of bioterrorist activity, and would you explain the chain of command on such cases?

Dr. HANFLING. To answer the first question first, with respect to

the training and capabilities of our emergency physicians, nurses

and other health professionals, there has been very limited formal

training of these staffs on these issues. A handful of physicians and

a few nurses have had the opportunity to attend some of the hospital preparedness training that came about as a result of the

Nunn-Lugar-Domenici Domestic Preparedness Program. But, as

you know and have probably heard in testimony previously to this

Subcommittee, there was very little attention focused on the hospital portion and inpatient treatment, diagnostic, and therapeutic

modalities during that curricula. Most of it was actually focused on

the traditional first-responder community.

During the Presidential inauguration this past January, we actually implemented as part of a State of Virginia Department of

Health project, a ‘‘drop-in’’ surveillance program where, for the 2

weeks preceding the inauguration and the 2 weeks following the

inauguration, we were looking at every emergency department patient with respect to one of a number of symptoms that they presented with. Unfortunately, because of the constraints that I mentioned earlier in my testimony, this was very difficult to effect and,

in fact, we had to have the health department supply their own

personnel to review each and every one of our charts. We see up

to 250 patients in a 24-hour period, and to do the paperwork that

was required was onerous and difficult, on top of all of the other

requirements for patient care.

To answer your second question, with respect to chain of command, the chain of command is very loose within the hospital organizations. There has been a lot of effort put forth—in fact, this has

20

been championed in the State of California, in the Office of Emergency Preparedness, or whatever their title is, in developing a hospital incident command system. This is a formal application of a

framework that addresses the issue of chain of command, and this

is beginning to catch on in the hospital communities. But, again,

without funding for support of these endeavors, it is very hard to

put these in place.

So when we talk about our current chain of command, it involves

the chairman of the emergency department, it involves the chairman of the disaster preparedness committee, it involves the chief

administrator of the hospital, it will, at some point, involve the fire

chief or his designate and the police chief and his designate, but

I can tell you I do not think any of us have ever sat down at a table

together. So it has never really been tested.

Senator AKAKA. In his testimony, Dr. Hanfling, Dr. Lillibridge

stated that one of the lessons learned from the TOPOFF exercise

was the importance to link emergency management services and

health decision making at the State and local level. He gave the

example of training to help workers to understand emergency management tools, like the incident command system. In your opinion,

how big a task is this? Do you feel that health care workers will

welcome this training?

Dr. HANFLING. Well, I would like to comment on some of what

Dr. Lillibridge mentioned in his response to that question of yours.

Primarily, the efforts of training that come from the Federal level

have been designated towards the traditional first-responder community. So this really ends up falling in the laps of our pre-hospital

fire and rescue services providers. There has been very little engagement of the folks that I mentioned in my testimony from the

hospital community and, as Dr. O’Toole mentioned, in the public

health community, in these same sorts of emergency management

curricula.

To get our emergency physicians and nurses, our paramedics and

firefighters, to do the sort of reporting that they are required to do

today as part of their day-to-day work is an onerous and difficult

task enough, and that is, I think, the challenge of providing yet additional curricula and additional requirements. We need to find a

way to incentivize these efforts, to make it worth their while and,

at the same time, not make it yet another additional requirement

that might be viewed as a burden for additional work.

Senator AKAKA. Thank you, Dr. Hanfling.

Let me ask my friend and colleague, Senator Cochran, for any

statement that you may have and questions that you may have.

OPENING STATEMENT OF SENATOR COCHRAN

Senator COCHRAN. Thank you very much, Mr. Chairman. I appreciate the fact that you have organized this hearing. I think it

is a timely subject to discuss. I was pleased to see the administration assume some responsibilities earlier this year, and try to set

up a framework for coordinating and examining the capabilities we

have to deal with these threats. I am hopeful that that will focus

attention, as obviously attention is being focused by this Subcommittee today, on the subject and how serious it can be and how

21

it could stretch our resources and also be a threat to the lives and

health of our American citizens.

So we want to be sure that we are getting it right, that we understand the facts, and that we understand what the improvements

are that can be made to deal with this very serious situation.

Thank you very much, Mr. Chairman. I have some questions, but

I do not want to interfere with your—— Senator AKAKA. Well, you are welcome to—— Senator COCHRAN. Well, I will ask Dr. O’Toole—I see that you

are at the Johns Hopkins Center for Civilian Biodefense Studies— what your impression is of these new suggestions that we are hearing regarding coordination? There had been some suggestion that

the Department of Health and Human Services was not very wellorganized to handle this job, and this administration has suggested

that a new position of special assistant to the secretary would help

increase the coordination of the department’s anti-bioterrorism efforts. Do you agree with that?

Dr. O’TOOLE. Yes, very strongly, Senator. I think Secretary

Thompson’s appointment of Dr. Lillibridge to be his special assistant on bioterrorism is a very good idea. As the Chairman remarked

earlier, HHS is not normally in the room when national security

issues are being discussed, and yet bioterrorism preparedness requires a sustained, collaborative effort here in Washington and

around the country amongst many different agencies, including

HHS. So having someone who is in a position to run to meetings,

which the NSC often calls at the last-minute, as you know, and to

present the medical point of view, I think, is an enormously important step forward. I think Secretary Thompson’s testimony at the

May hearings also evidences that he is very aware of bioterrorism

as a high-priority issue and intends to grab hold of it.

Senator COCHRAN. I think the President has also asked the Vice

President to undertake a high-level review, to be sure that we do

what we can to focus and increase the Federal Government’s ability

to respond government-wide to a biological weapons attack. Do you

agree that that is a step in the right direction, as well?

Dr. O’TOOLE. I think the more light we shed on this, the better

off we are, and I think the President initiating those kind of discussions at the highest levels is very important, substantively and also

as a signal that he intends that the government take this matter

very seriously.

Senator COCHRAN. Dr. Hanfling, I noticed that FEMA and CDC,

the Centers for Disease Control, have entered into an agreement

to conduct a course for emergency management and health community personnel to improve their ability to respond to a bioterrorism

attack. Do you think that may be a step in the right direction, too,

to generate more interest in the health community and awareness?

Dr. HANFLING. Yes, Senator. I think that these efforts to improve

education, especially focused on the State and, most certainly, at

the local level, will be steps in the right direction. To put it in perspective, though, in order to get those emergency managers and

those personnel involved in the day-to-day care of their communities away, to be able to attend courses that might be a week in

time, may require travel, etc., requires the sort of support that is

not always available in the local communities.

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I would also make another point, which is that it is often the

best and the brightest who have the opportunity to attend those

sorts of courses and curricula, and I think that the model that the

Federal agencies have used in the past, which is a train-the-trainer

model, is a successful way to impart that information. But those

may not be the folks who are manning the helm when the proverbial event happens. So we have got to allow this information to

trickle down to all levels of providers.

Senator COCHRAN. Thank you, Mr. Chairman.

Senator AKAKA. Thank you for your questions. I have a few more

questions I would like to continue with.

Dr. Hanfling, I asked Dr. Lillibridge about the Emergency Medical Treatment and Labor Act of 1986, which guarantees emergency

room care to anyone who seeks treatment. As someone who works

in an emergency room, how do you see this law impacting bioterrorism response?

Dr. HANFLING. I commend you on asking that question, because

I do think that this is an important issue that needs some attention. As an emergency physician, I view the EMTALA, or Emergency Medical Treatment and Labor Act, as really providing the

legal framework that creates a safety net for providing care across

our country for those who have no other place to turn. So I am very

supportive of this act, in supporting the efforts that I try to achieve

each and every day. But in the context of a bioterrorism attack, I

think we have to consider the utility of such a law, which requires

medical attention and more than just triage. It actually requires a

medical screening exam for each patient who comes to the hospital,

and I think Dr. O’Toole is more the expert in terms of looking at

some of the strategies that might be put into place, to enact treatment in out-of-hospital environments, but one such endeavor might

be to sequester patients who are sick or patients who have not

been exposed in facilities far away from the community that is impacted, and yet those patients may initially present to the local

community hospital seeking care.

So I think we have to consider appropriate amendments of acts

such as EMTALA in the setting of a catastrophic event such as bioterrorism, that would change the structure in which we are practicing medicine and delivering all of our social services day-to-day.

Does that answer your question?

Senator AKAKA. Yes. Thank you very much for that response.

You stated, Dr. Hanfling, that relationships between Federal agencies and State officials have improved, but are still limited on the

local level. Are there steps that we can take to improve these relationships?

Dr. HANFLING. I think that attention has been focused appropriately here this afternoon on the role of governors and the important power that the governors wield in such crisis situations. It is

clear that the Federal response plan is put in place and designates

lead agencies in crisis and consequence management, but the fact

is that these disasters occur at the local level, and that in occurring

in that manner, at least initially, the State governors have some

ownership and authority of those efforts. So I think that there

ought to be some attention focused at the State level to really making the sorts of meaningful relationships come into play, to allow

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community preparedness to occur, as a part of regional preparedness, and State preparedness, all fitting into the national picture.

Senator AKAKA. You also mentioned the barriers between traditional first responders and hospital communities. Do you think that

long-term plans by FEMA and HHS, as described by Mr. Baughman and Dr. Lillibridge, will help either of these concerns?

Dr. HANFLING. I do believe that, in the long-term, these gentlemen understand that this is a matter that is not going to be solved

at the Federal level, and that these are issues that really require

effective preparedness at the local level in order to mitigate them

properly. I think that FEMA has taken tremendous steps in the

last decade to prove that it is able to do that, but bioterrorism is

different than a hurricane or an earthquake, and so we really have

to focus, I think, at the local level, enhancing the local infrastructure, and really allowing the health-care community—that includes

the medical community and the public health community—to be

able to stand alone until those Federal assets are available, and we

know that might take some time.

Senator AKAKA. A question to both of you: Some say one of the

barriers for training for bioterrorism first-responders, mainly emergency room physician, nurses and emergency medical technicians,

is that existing medical and nursing school training programs are

so full, and time is limited. The question is how can we persuade

medical and nursing schools that bioterrorism preparedness justifies dedicating resources and time to course curricula? Would you

substitute bioterrorism training over other areas to ensure awareness?

Dr. O’Toole.

Dr. O’TOOLE. Well, health professionals learn all the time. I

mean, it is part of their job, and I would target first not medical

schools or nursing schools, because I think it is very difficult to get

new curriculum subjects introduced into medical schools and nursing schools. I would target practicing physicians, and provide

enough seed money to create some reliable continuing medical education credits for both physicians and nurses through their professional societies, which is how health professionals learn, and I

think with that seed money, the Infectious Disease Society of

America and the nursing associations and so forth will take it upon

themselves to proliferate the original curriculum.

We have been having discussions—I know CDC has been having

discussions—with professional groups. I know OEP has been talking to the emergency physicians’ professional societies, and the

problem with all of these groups is the initial seed money to develop the first core curriculum, but then everybody can go out and

share, whether it is in San Francisco or Mississippi. So I think

monies for professional curriculums and putting them in the hands

of the appropriate professional societies would be the way to go. I

think that training component is very important.

Dr. HANFLING. I think I would echo what Dr. O’Toole has stated.

In the context of the American College of Emergency Physicians’ evaluation of this very issue, they found that funding and time constraints were the biggest barriers to getting effective training curricula to the designated health-care professionals. I think that certainly in the context of the existing medical and nursing school curVerDate 11-MAY-2000 12:44 Oct 05, 2001 Jkt 000000 PO 00000 Frm 00027 Fmt 6633 Sfmt 6601 75441.TXT SAFFAIRS PsN: SAFFAIRS
24

ricula, which are already so chock-full of absolute requirements, it

might be hard to carve additional time out of what is already a robust schedule. But certainly those who begin to practice would be

the appropriate group of folks to target this information. One additional means of making that information attractive and imperative,

would also be to focus on hospital CEOs and administrators, who

do have a certain impact on the medical staffs of their respective

institutions, and get them to champion these as important issues

for the safety, not only of their hospitals and the well-being of their

health systems, but also of the communities in which they serve.

Senator AKAKA. Thank you very much.

Senator Cochran, would you have any more questions or comments to make?

Senator COCHRAN. Mr. Chairman, I do not, except to thank you

for convening the hearing. I think it is a very important subject for

us to consider, particularly in light of the new initiatives the administration is pushing to try to get better control over the way we

are organized, to deal with and respond to these problems, to understand them, and having the vaccines in the quantities that we

need to deal with some of these emergency situations. I think we

are moving in the right direction.

Senator AKAKA. Thank you. I think so, too. I would like to thank

our witnesses, Dr. O’Toole and Dr. Hanfling, and I want to thank

my friend and colleague, Senator Cochran, for being here this afternoon and for your cooperation in this effort. Today’s testimony has

given us much to think about and consider. I have heard three underlying concerns that need to be met to properly prepare for bioterrorism: First, the medical and hospital community needs to be

more engaged in bioterrorism planning; second, the partnership between medical and public health professionals needs to be strengthened; and, third, hospitals must have the resources to develop

surge capabilities. The first two concerns can be addressed through

a coordinated national terrorism policy, as being developed by

FEMA. The last concern is more complicated and will require substantial changes to our health care system. I look forward to working with all the different stakeholders in their efforts to prepare

our communities for an act of bioterrorism.

I do not have any further questions. However, Members of this

Subcommittee may submit questions in writing for any of the witnesses. We would appreciate a timely response to those questions.

The record will remain open for these questions and for further

statements by my colleagues. I would like to express my sincere appreciation once again to all the witnesses for their time and for

sharing their insights with us this afternoon. This hearing is adjourned.

[Whereupon, at 3:28 p.m., the Subcommittee was adjourned.]

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