```

[Senate Hearing 107-142]
[From the U.S. Government Publishing Office]

                                                        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

                   U.S. GOVERNMENT PRINTING OFFICE
75-441                     WASHINGTON : 2001

----------------------------------------------------------------------------
For Sale by the Superintendent of Documents, U.S. Government Printing Office
Internet: bookstore.gpr.gov  Phone: toll free (866) 512-1800; (202) 512�091800  
Fax: (202) 512�092250 Mail: Stop SSOP, Washington, DC 20402�090001

                   COMMITTEE ON GOVERNMENTAL AFFAIRS

               JOSEPH I. LIEBERMAN, Connecticut, Chairman
CARL LEVIN, Michigan                 FRED THOMPSON, Tennessee
DANIEL K. AKAKA, Hawaii              TED STEVENS, Alaska
RICHARD J. DURBIN, Illinois          SUSAN M. COLLINS, Maine
ROBERT G. TORRICELLI, New Jersey     GEORGE V. VOINOVICH, Ohio
MAX CLELAND, Georgia                 PETE V. DOMENICI, New Mexico
THOMAS R. CARPER, Delaware           THAD COCHRAN, Mississippi
JEAN CARNAHAN, Missouri              ROBERT F. BENNETT, Utah
MARK DAYTON, Minnesota               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                 THAD COCHRAN, Mississippi
ROBERT G. TORRICELLI, New Jersey     TED STEVENS, Alaska
MAX CLELAND, Georgia                 SUSAN M. COLLINS, Maine
THOMAS R. CARPER, Delaware           GEORGE V. VOINOVICH, Ohio
JEAN CARNAHAN, Missouri              PETE V. DOMENICI, New Mexico
MARK DAYTON, Minnesota               ROBERT F. BENNETT, Utah
                   Richard J. Kessler, Staff Director
               Mitchel B. Kugler, Minority Staff Director
                      Brian D. Rubens, Chief Clerk

                            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

 
 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, 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 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, 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.
---------------------------------------------------------------------------
    \1\ The prepared statement of Mr. Baughman appears in the Appendix 
on page 00.
---------------------------------------------------------------------------
    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 
Preparedness. 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.
---------------------------------------------------------------------------
    \1\ The prepared statement of Dr. Lillibridge appears in the 
Appendix on page 00.
---------------------------------------------------------------------------
    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 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 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 people 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, 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.
---------------------------------------------------------------------------
    \1\ The prepared statement of Dr. O'Toole appears in the Appendix 
on page 00.
---------------------------------------------------------------------------
    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. Chairman, 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 
hospital 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 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 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.

 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.
---------------------------------------------------------------------------
    \1\ The prepared statement of Dr. Hanfling appears in the Appendix 
on page 00.
---------------------------------------------------------------------------
    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 exclusively 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 
community-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 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 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 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 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 well-organized 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.
    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 
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 curricula, 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.]

                            A P P E N D I X

                              ----------                              

[GRAPHIC] [TIFF OMITTED] T5441.001

[GRAPHIC] [TIFF OMITTED] T5441.002

[GRAPHIC] [TIFF OMITTED] T5441.003

[GRAPHIC] [TIFF OMITTED] T5441.004

[GRAPHIC] [TIFF OMITTED] T5441.005

[GRAPHIC] [TIFF OMITTED] T5441.006

[GRAPHIC] [TIFF OMITTED] T5441.007

[GRAPHIC] [TIFF OMITTED] T5441.008

[GRAPHIC] [TIFF OMITTED] T5441.009

[GRAPHIC] [TIFF OMITTED] T5441.010

[GRAPHIC] [TIFF OMITTED] T5441.011

[GRAPHIC] [TIFF OMITTED] T5441.012

[GRAPHIC] [TIFF OMITTED] T5441.013

[GRAPHIC] [TIFF OMITTED] T5441.014

[GRAPHIC] [TIFF OMITTED] T5441.015

[GRAPHIC] [TIFF OMITTED] T5441.016

[GRAPHIC] [TIFF OMITTED] T5441.017

[GRAPHIC] [TIFF OMITTED] T5441.018

[GRAPHIC] [TIFF OMITTED] T5441.019

[GRAPHIC] [TIFF OMITTED] T5441.020

[GRAPHIC] [TIFF OMITTED] T5441.021

[GRAPHIC] [TIFF OMITTED] T5441.022

[GRAPHIC] [TIFF OMITTED] T5441.023

[GRAPHIC] [TIFF OMITTED] T5441.024

[GRAPHIC] [TIFF OMITTED] T5441.025

[GRAPHIC] [TIFF OMITTED] T5441.026

[GRAPHIC] [TIFF OMITTED] T5441.027

[GRAPHIC] [TIFF OMITTED] T5441.028

[GRAPHIC] [TIFF OMITTED] T5441.029

[GRAPHIC] [TIFF OMITTED] T5441.030

[GRAPHIC] [TIFF OMITTED] T5441.031

[GRAPHIC] [TIFF OMITTED] T5441.032

[GRAPHIC] [TIFF OMITTED] T5441.033

[GRAPHIC] [TIFF OMITTED] T5441.034

[GRAPHIC] [TIFF OMITTED] T5441.035

[GRAPHIC] [TIFF OMITTED] T5441.036

[GRAPHIC] [TIFF OMITTED] T5441.037

[GRAPHIC] [TIFF OMITTED] T5441.038

[GRAPHIC] [TIFF OMITTED] T5441.039

[GRAPHIC] [TIFF OMITTED] T5441.040

[GRAPHIC] [TIFF OMITTED] T5441.041

[GRAPHIC] [TIFF OMITTED] T5441.042

[GRAPHIC] [TIFF OMITTED] T5441.043

[GRAPHIC] [TIFF OMITTED] T5441.044

[GRAPHIC] [TIFF OMITTED] T5441.045

[GRAPHIC] [TIFF OMITTED] T5441.046

[GRAPHIC] [TIFF OMITTED] T5441.047

[GRAPHIC] [TIFF OMITTED] T5441.048


```