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[Senate Hearing 107-700]
[From the U.S. Government Publishing Office]

                                                        S. Hrg. 107-700
 
 DEPARTMENT OF VETERANS' AFFAIRS FOURTH MISSION: CARING FOR VETERANS, 
     SERVICE MEMBERS, AND THE PUBLIC FOLLOWING CONFLICTS AND CRISES
=======================================================================

                                HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS
                          UNITED STATES SENATE

                      ONE HUNDRED SEVENTH CONGRESS

                             FIRST SESSION

                               __________

                            OCTOBER 16, 2001

                               __________

      Printed for the use of the Committee on Veterans' Affairs

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                     COMMITTEE ON VETERANS' AFFAIRS

            JOHN D. ROCKEFELLER IV, West Virginia, Chairman

BOB GRAHAM, Florida                  ARLEN SPECTER, Pennsylvania
JAMES M. JEFFORDS (I), Vermont       STROM THURMOND, South Carolina
DANIEL K. AKAKA, Hawaii              FRANK H. MURKOWSKI, Alaska
PAUL WELLSTONE, Minnesota            BEN NIGHTHORSE CAMPBELL, Colorado
PATTY MURRAY, Washington             LARRY E. CRAIG, Idaho
ZELL MILLER, Georgia                 TIM HUTCHINSON, Arkansas
E. BENJAMIN NELSON, Nebraska         KAY BAILEY HUTCHISON, Texas

                     William E. Brew, Chief Counsel

      William F. Tuerk, Minority Chief Counsel and Staff Director

                                  (ii)

                            C O N T E N T S

                              ----------                              

                            October 16, 2001

                                SENATORS

                                                                   Page
Miller, Hon. Zell, U.S. Senator from Georgia, prepared statement.    10
Rockefeller, Hon. John D. IV, U.S. Senator from West Virginia, 
  prepared statement.............................................     3
    Statements for the record from:
        Backhus, Stephen P., Director, Health Care-Veterans' and 
          Military Health Care Issues, U.S. General Accounting 
          Office.................................................     4
        Garrick, Jacqueline, CSW, ACSW, CTS, Deputy Director, 
          Health Care, National Veterans Affairs and 
          Rehabilitation Commission, The American Legion.........    53
        Hayden, Paul A. Associate Director, National Legislative 
          Service, Veterans of Foreign Wars of the United States.    51

                               WITNESSES

Allen, Claude A., Deputy Secretary, Department of Health and 
  Human Services.................................................    33
    Prepared statement...........................................    34
Baughman, Bruce P., Director, Planning and Readiness Division, 
  Readiness, Response, and Recovery Directorate, Federal 
  Emergency Management Agency....................................    42
    Prepared statement...........................................    43
Chu, David, Ph.D., Under Secretary of Defense for Personnel and 
  Readiness......................................................    37
    Prepared statement...........................................    39
Principi, Hon. Anthony J., Secretary, Department of Veterans 
  Affairs........................................................    12
    Prepared statement...........................................    13
    Response to written questions submitted by Hon. John D. 
      Rockefeller IV.............................................    20

                                 (iii)

 DEPARTMENT OF VETERANS' AFFAIRS FOURTH MISSION: CARING FOR VETERANS, 
     SERVICE MEMBERS, AND THE PUBLIC FOLLOWING CONFLICTS AND CRISES

                              ----------                              

                       TUESDAY, OCTOBER 16, 2001

                                       U.S. Senate,
                            Committee on Veterans' Affairs,
                                                    Washington, DC.
    The committee met, pursuant to notice, at 2:46 p.m., in 
room 418, Russell Senate Office Building, Hon. John D. 
Rockefeller IV (chairman of the committee) presiding.
    Present: Senators Rockefeller, Jeffords, Wellstone, Miller, 
Nelson, and Specter.
    Chairman Rockefeller. My apologies to my colleagues and to 
all. Particularly, I think some of you--Tony, I do not know if 
you are one of them, but some of you have White House 
appointments so that you are time constrained and so I am even 
more embarrassed than usual.
    I want to make this opening statement. Obviously, the world 
has desperately changed. When we gathered last in this hearing 
room, it was to discuss legislation that would help VA fill its 
hospitals with qualified nurses, and that was and is a terribly 
important subject. Other things have overtaken it. The question 
now really is what happens with the VA if there is a large 
national catastrophe, domestically as well as with deployed 
National Guard and troops, and the military cannot take care of 
everything.
    I do not think anybody would make any mistake that caring 
for the men and women who serve this Nation remains VA's 
primary responsibility to our veterans. However, VA may be 
called upon to play a much larger role. We must be sure that VA 
has the support it needs to fulfill its duties toward military 
personnel and civilians, should conflicts and crises arise, 
without sacrificing the veterans part.
    VA shares the Federal responsibility for preserving public 
health during domestic crises. As a partner in the National 
Disaster Medical System, VA coordinates medical resources and 
shares staff and supplies with local health providers during 
public health emergencies. VA also works with other Federal 
agencies and the Red Cross, as well, as part of the Federal 
Response Plan to disasters. And, if necessary, they would offer 
direct patient care to assist communities overwhelmed by large 
numbers of patients. FEMA coordinates this plan, and the 
Secretary of Health and Human Services directs the public 
health care responses.
    In the past few weeks, I have heard a great deal about the 
problems that arise when multiple Federal, State, and local 
agencies work together--what happens when they do that and 
respond to disasters. I saw one example of this in my own State 
of West Virginia following this year's devastating floods. 
Local health care givers found themselves scrambling for 
medicines and supplies for West Virginians. The VA had at least 
one mobile health clinic ready to travel to the area and other 
clinics would have been available had the State officially 
requested them.
    As you may know, when the VA goes in without an official 
request, they can treat only veterans; hence, a problem. Due to 
the lack of information and communication between the VA and 
State agencies, that official request never came. I am not 
blaming anybody. It just never happened. The Beckley VA Medical 
Center staff took one of their own vans, staffed it with their 
own people on their own time, did a wonderful job providing 
care to veterans who were afflicted by floods in these 
destroyed communities.
    As Congress focuses on preventing and preparing for 
terrorism, we have heard again and again that we must include 
the medical community when we plan for emergencies. As the 
largest health care system in the Nation, the VA can offer 
invaluable services during a public health care emergency. This 
is a huge system with a lot of capacity and the VA has an 
enormous responsibility walking into times in which we know not 
what will happen. That may be terrorism, that may be a natural 
disaster, but we are certainly faced with the possibility of 
those right now.
    By no means am I asking the VA to serve as the first line 
of defense against terrorism. Secretary Principi, you know 
that. Other agencies have resources to address these needs and 
we must not force new missions upon a VA medical system which 
is already strained to the limit and is being underfunded for 
the 20th consecutive year.
    However, since managed care--not one of my favorite 
subjects--has eroded the national capacity to deal with large 
numbers of patients and VA has proved itself capable of 
preparing for and responding to emergencies, I am resolved that 
VA's existing resources should be used as efficiently as 
possible.
    In 1982, Congress created VA's so-called fourth mission: 
serving as the primary medical backup to the Department of 
Defense during times of conflict. The events of the past week 
remind us that we must protect VA's capacity for this mission, 
especially in light of the rapidly shrinking military health 
care system. I look forward to hearing about what is needed to 
preserve VA's ability to accept military casualties as well as 
the question beyond that of civilian casualties and National 
Guard casualties, should that happen.
    Interestingly--and Senator Jeffords and Senator Miller and 
Senator Wellstone may be interested in this--in 1998, we passed 
here something called the Veterans' Program Enhancement Act, 
which is one of those typically marvelous titles that we give 
to things. This Act directed VA to contract with the National 
Academy of Sciences to plan for a national center to 
understand, to prevent, and to treat illnesses related to 
biological, chemical, and other battlefield exposures. The 
National Academy of Sciences recommended that the VA and the 
Department of Defense and HHS work together to create an 
interagency National Center for Military Health and Deployment 
Readiness, guided by a board representing the three Federal 
agencies and the independent research and veterans' 
communities.
    However, nothing has happened. Nothing has happened. The 
bill was passed in 1998 and progress seems to rely primarily 
upon VA and DoD programs. The governing board has never 
convened. It has never been convened, and I just want to say 
that I am curious about that. We cannot know whether that could 
have been helpful, but I am not prepared to say that it could 
not have been.
    I will end up by saying, in brief, that accurate 
recordkeeping--as we learned during the Gulf War, when it was 
not done in spite of claims that it was--is essential if VA is 
to provide appropriate medical care to returning troops and 
veterans, conduct research, and all the rest of it.
    [The prepared statement of Senator Rockefeller follows:]

 Prepared Statement of Hon. John D. Rockefeller IV, U.S. Senator From 
                             West Virginia

    Good afternoon. I do not have to tell you that we meet 
today in a world desperately changed. When the Committee last 
gathered in this hearing room, it was to discuss legislation 
that would help VA fill its hospitals with qualified nurses, 
improve educational benefits, assist homeless veterans, and 
ensure that the rising cost of living does not erode veterans' 
benefits, among many other important issues. Since then, the 
tragic events of September 11 have absorbed the Nation and 
Congress, as we confront fear and loss and forge a new resolve.
    Make no mistake--caring for the men and women who served 
this Nation remains VA's primary mission. However, in light of 
recent events, VA may be called upon to play a larger role. We 
must be sure that VA has the support it needs to fulfill its 
duties toward military personnel and civilians during conflicts 
and crises, without sacrificing its obligation to provide 
health care and benefits for veterans.
    VA shares the Federal responsibility for preserving public 
health during domestic crises. As a partner in the National 
Disaster Medical System, VA coordinates medical resources and 
shares staff and supplies with local health care providers 
during public health emergencies. VA also works with other 
Federal agencies and the Red Cross as part of the Federal 
Response Plan to disasters, supplying personnel, supplies, 
facilities, and--if necessary--direct patient care to assist 
communities overwhelmed by large numbers of patients. FEMA 
coordinates this plan, and the Secretary of Health and Human 
Services directs the public health care responses.
    In the past few weeks, I have heard a great deal about the 
problems that arise when multiple Federal, State, and local 
agencies work together to plan for, and respond to, disasters. 
I saw one example of this in my own state of West Virginia, 
following this year's devastating floods. Local health care 
givers found themselves scrambling for medicines and supplies 
for West Virginians. VA had at least one mobile health clinic 
ready to travel to the area, and other clinics would have been 
available had the state ``officially'' requested them. As you 
may know, when VA goes in without an official request, they can 
treat only veterans. Due to a lack of information and 
communication between VA and state agencies, that official 
request never came. The Beckley VA Medical Center staff took 
out one of their own vans, staffed with their own staff, and 
did a wonderful job of providing care to veterans in the 
destroyed communities the only care VA was allowed to offer.
    As Congress focuses on preventing and preparing for 
terrorism, we have heard again and again that we must include 
the medical community when we plan for emergencies. As the 
largest health care system in the Nation, VA can offer 
invaluable services during a public health care emergency, 
whether that emergency is terrorism or a natural disaster.
    By no means am I asking VA to serve as the first line of 
defense against terrorism. Other agencies have resources to 
address these needs, and we must not force new missions upon a 
VA medical system already struggling with limited resources. 
However, since managed care has eroded the national capacity to 
deal with large numbers of patients, and VA has proved itself 
capable of preparing for and responding to emergencies, I am 
resolved that VA's existing resources should be used as 
efficiently as possible.
    In 1982, Congress created VA's Fourth Mission: serving as 
the primary medical back up to the Department of Defense during 
times of conflict. The events of the past weeks remind us that 
we must protect VA's capacity for this mission, especially in 
light of the rapidly shrinking military health care system. I 
look forward to hearing about what is needed to preserve VA's 
ability to accept military casualties while continuing to care 
for veterans, especially if the many reservists who work within 
VA should be called up.
    If VA is to perform this Fourth Mission of caring for 
active duty military casualties during a conflict--and its 
primary mission of caring for veterans--we must not ignore the 
lessons learned so painfully in the wake of the Gulf War. All 
of our efforts to link battlefield exposures to the symptoms 
reported by returning troops have been compromised by poor 
medical surveillance and incomplete records.
    Accurate record keeping is essential if VA is to provide 
appropriate medical care to returning troops and veterans, 
conduct research, and identify health conditions that are 
likely to be connected to military service. As our Nation 
prepares for war, the American people deserve assurances that 
the service branches have corrected previous shortcomings in 
military public health, not only to assist returning 
servicemembers in seeking health care and benefits, but to 
preserve the readiness and trust of our forces. I have asked 
GAO to prepare testimony on challenges faced by the Department 
of Defense in establishing a medical surveillance system, and I 
ask that this testimony be entered into the record.
    I look forward to hearing about the best ways to encourage 
this interagency coordination and communication to shape a 
seamless medical response to emergencies. I welcome all of the 
witnesses.

    Chairman Rockefeller. I have asked the GAO to prepare 
testimony on challenges faced by the Department of Defense in 
establishing a medical surveillance system and I hereby put 
that in the record.
    [The information referred to follows:]
    Prepared Statement of Stephen P. Backhus, Director, Health Care-
  Veterans' and Military Health Care Issues, U.S. General Accounting 
                                 Office

                       VA AND DEFENSE HEALTH CARE

   progress and challenges dod faces in executing a military medical 
                          surveillance system
    Mr. Chairman and Members of the Committee:
    We are pleased to submit this statement for the record on the 
Department of Defense's (DOD) efforts to establish a medical 
surveillance system that enables DOD--along with the Department of 
Veterans Affairs (VA)--to respond to the health care needs of our 
military personnel and veterans. A medical surveillance system involves 
the ongoing collection and analysis of uniform information on 
deployments, environmental health threats, disease monitoring, medical 
assessments, and medical encounters. It is also important that this 
information be disseminated in a timely manner to military commanders, 
medical personnel, and others. DOD is responsible for developing and 
executing this system and needs this information to help ensure the 
deployment of healthy forces and the continued fitness of those forces. 
VA also needs this information to fulfill its missions of providing 
health care to veterans, backing up DOD in contingencies, and 
adjudicating veterans' claims for service-connected disabilities. 
Scientists at VA, DOD, and other organizations also use this 
information to conduct epidemiological studies and research.\1\
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    \1\ Epidemiology is the scientific study of the incidence, 
distribution, and control of disease in a population.
---------------------------------------------------------------------------
    Given our current military actions responding to the events of 
September 11, you asked us to describe the challenges DOD faces in 
establishing a reliable medical surveillance system, based on what has 
been reported about DOD's medical surveillance activities during the 
Gulf War and Operation Joint Endeavor.\2\ This statement focuses on 
reports GAO,\3\ the Institute of Medicine (IOM), the Presidential 
Advisory Committee on Gulf War Veterans' Illnesses,\4\ and others have 
issued over the past several years. This statement is also based on 
interviews we held over the past 2 weeks with various Defense Health 
Program officials, including officials from the Army Surgeon General's 
Office.\5\
---------------------------------------------------------------------------
    \2\ United States and allied nations deployed peacekeeping forces 
to Bosnia beginning in December 1995 in support of Operation Joint 
Endeavor, the NATO-led Bosnian peacekeeping force.
    \3\ See list of related GAO products at the end of this statement.
    \4\ The President established this committee in May 1995 to conduct 
independent, open, and comprehensive examinations of health care 
concerns related to Gulf War service. The committee consisted of 
physicians, scientists, and Gulf War veterans.
    \5\ The Secretary of the Army is responsible for medical 
surveillance for POD deployments, consistent with DOD's medical 
surveillance policy.
---------------------------------------------------------------------------
    In summary, GAO, the Institute of Medicine, and others have 
reported extensively on weaknesses in DOD's medical surveillance 
capability and performance during the Gulf War and Operation Joint 
Endeavor and the challenges DOD faces in implementing a reliable 
medical surveillance system. Investigations into the unexplained 
illnesses of Gulf War veterans uncovered many deficiencies in DOD's 
ability to collect, maintain, and transfer accurate data describing the 
movement of troops, potential exposures to health risks, and medical 
incidents during deployment. DOD improved its medical surveillance 
system under Operation Joint Endeavor, which provided useful 
information to military commanders and medical personnel. However, we 
and others reported a number of problems with this system. For example, 
information related to service members' health and deployment status--
data critical to an effective medical surveillance system--was 
incomplete or inaccurate. DOD's numerous databases, including those 
that capture health information, are currently not linked, which 
further challenges the department's efforts to establish a single, 
comprehensive electronic system to document, archive, and access 
medical surveillance data.
    DOD has several initiatives under way to improve the reliability of 
deployment information and to enhance its information technology 
capabilities, as we and others have recommended, though some 
initiatives are several years away from full implementation. 
Nonetheless, these efforts reflect a commitment by DOD to establish a 
comprehensive medical surveillance system. The ability of VA to fulfill 
its role in serving veterans and providing backup to DOD in times of 
war will be enhanced as DOD increases its medical surveillance 
capability.
                               background
    An effective military medical surveillance system needs to collect 
reliable information on (1) the health care provided to service members 
before, during, and after deployment; (2) where and when service 
members were deployed; (3) environmental and occupational health 
threats or exposures during deployment (in theater) and appropriate 
protective and counter measures; and (4) baseline health status and 
subsequent health changes.
    This information is needed to monitor the overall health condition 
of deployed troops, inform them of potential health risks, as well as 
maintain and improve the health of service members and veterans.
    In times of conflict, a military medical surveillance system is 
particularly critical to ensure the deployment of a fit and healthy 
force and to prevent disease and injuries from degrading force 
capabilities. DOD needs reliable medical surveillance data to determine 
who is fit for deployment; to prepare service members for deployment, 
including providing vaccinations to protect against possible exposure 
to environmental and biological threats; and to treat physical and 
psychological conditions that resulted from deployment. DOD also uses 
this information to develop educational measures for service members 
and medical personnel to ensure that service members receive 
appropriate care.
    Reliable medical surveillance information is also critical for VA 
to carry out its missions. In addition to VA's better known missions--
to provide health care and benefits to veterans and medical research 
and education--VA has a fourth mission: to provide medical backup to 
DOD in times of war and civilian health care backup in the event of 
disasters producing mass casualties. As such, VA needs reliable medical 
surveillance data from DOD to treat casualties of military conflicts, 
provide health care to veterans who have left active duty, assist in 
conducting research should troops be exposed to environmental or 
occupational hazards, and identify service-connected disabilities and 
adjudicate veterans' disability claims.
 medical recordkeeping and surveillance during the gulf war was lacking
    Investigations into the unexplained illnesses of service members 
and veterans who had been deployed to the Gulf uncovered the need for 
DOD to implement an effective medical surveillance system to obtain 
comprehensive medical data on deployed service members, including 
Reservists and National Guardsmen. Epidemiological and health outcome 
studies to determine the causes of these illnesses have been hampered 
due to incomplete baseline health data on Gulf War veterans, their 
potential exposure to environmental health hazards, and specific health 
data on care provided before, during, and after deployment. The 
Presidential Advisory Committee on Gulf War Veterans' Illnesses' and 
IOM's 1996 investigations into the causes of illnesses experienced by 
Gulf War veterans confirmed the need for more effective medical 
surveillance capabilities.\6\
---------------------------------------------------------------------------
    \6\ Health Consequences of Service During the Persian Gulf War 
Recommendations for Research and Information Systems, Institute of 
Medicine, Medical Follow-up Agency (Washington, D.C.: National Academy 
Press, 1996); Presidential Advisory Committee on Gulf War Veterans' 
Illnesses. Interim Report (Washington, D.C.: U.S. Government Printing 
Office, Feb. 1996); Presidential Advisory Committee on Gulf War 
Veterans' Illnesses: Final Report (Washington, D.C.: U.S. Government 
Printing Office, Dec. 1996).
---------------------------------------------------------------------------
    The National Science and Technology Council, as tasked by the 
Presidential Advisory Committee, also assessed the medical surveillance 
system for deployed service members. In 1998, the council reported that 
inaccurate recordkeeping made it extremely difficult to get a clear 
picture of what risk factors might be responsible for Gulf War 
illnesses.\7\ It also reported that without reliable deployment and 
health assessment information, it was difficult to ensure that 
veterans' service-related benefits claims were adjudicated 
appropriately. The council concluded that the Gulf War exposed many 
deficiencies in the ability to collect, maintain, and transfer accurate 
data describing the movement of troops, potential exposures to health 
risks, and medical incidents in theater. The council reported that the 
government's recordkeeping capabilities were not designed to track 
troop and asset movements to the degree needed to determine who might 
have been exposed to any given environmental or wartime health hazard. 
The council also reported major deficiencies in health risk 
communications, including not adequately informing service members of 
the risks associated with countermeasures such as vaccines. Without 
this information, service members may not recognize potential side 
effects of these countermeasures and promptly take precautionary 
actions, including seeking medical care.
---------------------------------------------------------------------------
    \7\ National Science and Technology Council Presidential Review 
Directive 5 (Washington, D.C.: Executive Office of the President, 
Office of Science and Technology Policy, Aug. 1998).
---------------------------------------------------------------------------
 medical surveillance under operation joint endeavor improved but was 
                           not comprehensive
    In response to these reports, DOD strengthened its medical 
surveillance system under Operation Joint Endeavor when service members 
were deployed to Bosnia-Herzegovina, Croatia, and Hungary. In addition 
to implementing departmentwide medical surveillance policies, DOD 
developed specific medical surveillance programs to improve monitoring 
and tracking environmental, and biomedical threats in theater. While 
these efforts represented important steps, a number of deficiencies 
remained.
    On the positive side, the Assistant Secretary of Defense (Health 
Affairs) issued a health surveillance policy for troops deploying to 
Bosnia.\8\ This guidance stressed the need to (1) identify health 
threats in theater, (2) routinely and uniformly collect and analyze 
information relevant to troop health, and (3) disseminate this 
information in a timely manner. DOD required medical units to develop 
weekly reports on the incidence rates of major categories of diseases 
and injuries during all deployments. Data from these reports showed 
theaterwide illness and injury trends so that preventive measures could 
be identified and forwarded to the theater medical command regarding 
abnormal trends or actions that should be taken.
---------------------------------------------------------------------------
    \8\ Health Affairs Policy 96-019 (DOD Assistant Secretary of 
Defense Memorandum, Jan. 4, 1996).
---------------------------------------------------------------------------
    DOD also established the U.S. Army Center for Health Promotion and 
Preventive Medicine--a major enhancement to DOD's ability to perform 
environmental monitoring and tracking. For example, the center operates 
and maintains a repository of service members' serum samples for 
medical surveillance and a system to integrate, analyze, and report 
data from multiple sources relevant to the health and readiness of 
military personnel. This capability was augmented with the 
establishment of the 520th Theater Army Medical Laboratory--a 
deployable public health laboratory for providing environmental 
sampling and analysis in theater. The sampling results can be used to 
identify specific preventive measures and safeguards to be taken to 
protect troops from harmful exposures and to develop procedures to 
treat anyone exposed to health hazards. During Operation Joint 
Endeavor, this laboratory was used in Tuzla, Bosnia, where most of the 
U.S. forces were located, to conduct air, water, soil, and other 
environmental monitoring.
    Despite the department's progress, we and others have reported on 
DOD's implementation difficulties during Operation Joint Endeavor and 
the shortcomings in DOD's ability to maintain reliable health 
information on service members. Knowledge of who is deployed and their 
whereabouts is critical for identifying individuals who may have been 
exposed to health hazards while deployed. However, in May 1997, we 
reported that the inaccurate information on who was deployed and where 
and when they were deployed--a problem during the Gulf War--continued 
to be a concern during Operation Joint Endeavor.\9\ For example, we 
found that the Defense Manpower Data Center (DMDC) database--where 
military services are required to report deployment information--did 
not include records for at least 200 Navy service members who were 
deployed. Conversely, the DMDC database included Air Force personnel 
who were never actually deployed. In addition, we reported that DOD had 
not developed a system for tracking the movement of service members 
within theater. IOM also reported that the location of service members 
during the deployments were still not systematically documented or 
archived for future use.\10\
---------------------------------------------------------------------------
    \9\ Defense Health Care: Medical Surveillance Improved Since Gulf 
War, but Mixed Results in Bosnia (GAO/NSIAD-97-136, May 13, 1997).
    \10\ See Institute of Medicine, Protecting Those Who Serve. 
Strategies to Protect the Health of Deployed U.S. Forces (Washington, 
D.C., National Academy Press, 2000).
---------------------------------------------------------------------------
    We also reported in May 1997 that for the more than 600 Army 
personnel whose medical records we reviewed, DOD's centralized database 
for postdeployment medical assessments did not capture 12 percent of 
those assessments conducted in theater and 52 percent of those 
conducted after returning home.\11\ These data are needed by 
epidemiologists and other researchers to assess at an aggregate level 
the changes that have occurred between service members' pre- and 
postdeployment health assessments. Further, many service members' 
medical records did not include complete information on in--theater 
postdeployment medical assessments that had been conducted. The Army's 
European Surgeon General attributed missing in-theater health 
information to DOD's policy of having service members hand carry paper 
assessment forms from the theater to their home units, where their 
permanent medical records were maintained. The assessments were 
frequently lost en route.
---------------------------------------------------------------------------
    \11\ In many cases, we found that these assessments were not 
conducted in a timely manner or were not conducted at all. For example, 
of the 618 personnel whose records we reviewed, 24 percent did not 
receive in-theater postdeployment medical assessments and 21 percent 
did not receive home station postdeployment medical assessments. Of 
those who did receive home station postdeployment medical assessments, 
the assessments were on average conducted nearly 100 days after they 
left theater--instead of within 30 days, as DOD requires.
---------------------------------------------------------------------------
    We have also reported that not all medical encounters in theater 
were being recorded in individual records. Our 1997 report identified 
that this problem was particularly common for immunizations given in 
theater. Detailed data on service members' vaccine history are vital 
for scheduling the regimen of vaccinations and boosters and for 
tracking individuals who received vaccinations from a specific lot in 
the event health concerns about the vaccine lot emerge. We found that 
almost one-fourth of the service members' medical records that we 
reviewed did not document the fact that they had received a vaccine for 
tick-borne encephalitis. In addition, in its 2000 report, IOM cited 
limited progress in medical recordkeeping for deployed active duty and 
reserve forces and emphasized the need for records of immunizations to 
be included in individual medical records.
          current policies and programs not fully implemented
    Responding to our and others' recommendations to improve 
information on service members' deployments, in-theater medical 
encounters, and immunizations, DOD has continued to revise and expand 
its policies relating to medical surveillance, and the system continues 
to evolve. In addition, in 2000, DOD released its Force Health 
Protection plan, which presents its vision for protecting deployed 
forces.\12\ This vision emphasizes force fitness and health 
preparedness and improving the monitoring and surveillance of health 
threats in military operations. However, IOM criticized DOD's progress 
in implementing its medical surveillance program and the failure to 
implement several recommendations that IOM had made. In addition, IOM 
raised concerns about DOD's ability to achieve the vision outlined in 
the Force Health Protection plan. We have also reported that some of 
DOD's programs designed to improve medical surveillance have not been 
fully implemented.
---------------------------------------------------------------------------
    \12\ Joint Staff, Medical Readiness Division, Force Health 
Protection (2000).
---------------------------------------------------------------------------
   recent iom report concludes slow progress by dod in implementing 
                            recommendations
    IOM's 2000 report presented the results of its assessment of DOD's 
progress in implementing recommendations for improving medical 
surveillance made by IOM and several others. IOM stated that, although 
DOD generally concurred with the findings of these groups, DOD had made 
few concrete changes at the field level. For example, medical 
encounters in theater were still not always recorded in individuals' 
medical records, and the locations of service members during 
deployments were still not systematically documented or archived for 
future use. In addition, environmental and medical hazards were not yet 
well integrated in the information provided to commanders.
    The IOM report notes that a major reason for this lack of progress 
is no single authority within DOD has been assigned responsibility for 
the implementation of the recommendations and plans. IOM said that 
because of the complexity of the tasks involved and the overlapping 
areas of responsibility involved, the single authority must rest with 
the Secretary of Defense.
    In its report, IOM describes six strategies that in its view demand 
further emphasis and require greater efforts by DOD:
     Use a systematic process to prospectively evaluate non-
battle-related risks associated with the activities and settings of 
deployments.
     Collect and manage environmental data and personnel 
location, biological samples, and activity data to facilitate analysis 
of deployment exposures and to support clinical care and public health 
activities.
     Develop the risk assessment, risk management, and risk 
communications skills of military leaders at all levels.
     Accelerate implementation of a health surveillance system 
that completely spans an individual's time in service.
     Implement strategies to address medically unexplained 
symptoms in populations that have deployed.
     Implement a joint computerized patient record and other 
automated recordkeeping that meets the information needs of those 
involved with individual care and military public health.
    our work also indicates some dod programs for improving medical 
                 surveillance are not fully implemented
    DOD guidance established requirements for recording and tracking 
vaccinations and automating medical records for archiving and recalling 
medical encounters. While our work indicates that DOD has made some 
progress in improving its immunization information, the department 
faces numerous challenges in implementing an automated medical record.
    In October 1999, we reported that DOD's Vaccine Adverse Event 
Reporting System, which relies on medical personnel or service members 
to provide needed vaccine data, may not have included information on 
adverse reactions because DOD did not adequately inform personnel on 
how to provide this information.\13\
---------------------------------------------------------------------------
    \13\ Medical Readiness: DOD Faces Challenges in Implementing Its 
Anthrax Vaccine Immunization Program (GAO/NSIAD-00-36, Oct. 22, 1999).
---------------------------------------------------------------------------
    Additionally, in April 2000, we testified that vaccination data 
were not consistently recorded in paper records and in a central 
database, as DOD requires.\14\ For example, when comparing records from 
the database with paper records at four military installations, we 
found that information on the number of vaccinations given to service 
members, the dates of the vaccinations, and the vaccine lot numbers 
were inconsistent at all four installations. At one installation, the 
database and records did not agree 78 to 92 percent of the time. DOD 
has begun to make progress in implementing our recommendations, 
including ensuring timely and accurate data in its immunization 
tracking system.
---------------------------------------------------------------------------
    \14\ Medical Readiness: DOD Continues to Face Challenges in 
Implementing Its Anthrax Vaccine Immunization Program (GAO/T-NSIAD-00-
157, Apr. 13, 2000).
---------------------------------------------------------------------------
    The Gulf War revealed the need to have information technology play 
a bigger role in medical surveillance to ensure that the information is 
readily accessible to DOD and VA. In August 1997, DOD established 
requirements that called for the use of innovative technology, such as 
an automated medical record device for documenting inpatient and 
outpatient encounters in all settings and that can archive the 
information for local recall and format it for an injury, illness, and 
exposure surveillance database.\15\ Also, in 1997, the President, 
responding to deficiencies in DOD's and VA's data capabilities for 
handling service members' health information, called for the two 
agencies to start developing a comprehensive, lifelong medical record 
for each service member. As we reported in April 2001, DOD's and VA's 
numerous databases and electronic systems for capturing mission-
critical data, including health information, are not linked and 
information cannot be readily shared.\16\
---------------------------------------------------------------------------
    \15\ DOD Directive 6490.2, ``Joint Medical Surveillance'' (Aug. 30, 
1997).
    \16\ Computer-Based Patient Records: Better Planning and Oversight 
by VA, DOD, and IHS Would Enhance Health Data Sharing (GAO-01-459, Apr. 
30, 2001).
---------------------------------------------------------------------------
    DOD has several initiatives under way to link many of its 
information systems--some with VA. For example, in an effort to create 
a comprehensive, lifelong medical record for service members and 
veterans and to allow health care professionals to share clinical 
information, DOD and VA, along with the Indian Health Service 
(IHS),\17\ initiated the Government Computer-Based Patient Record 
(GCPR) project in 1998. GCPR is seen as yielding a number of potential 
benefits, including improved research and quality of care, and clinical 
and administrative efficiencies. However, our April 2001 report 
describes several factors--including planning weaknesses, competing 
priorities, and inadequate accountability--that made it unlikely that 
DOD and VA would accomplish GCPR or realize its benefits in the near 
future. To strengthen the management and oversight of GCPR, we made 
several recommendations, including designating a lead entity with a 
clear line of authority for the project and creating comprehensive and 
coordinated plans for sharing meaningful, accurate, and secure patient 
health data.
---------------------------------------------------------------------------
    \17\ IHS was included in the effort because of its population-based 
research expertise and its long-standing relationship with VA.
---------------------------------------------------------------------------
    For the near term, DOD and VA have decided to reconsider their 
approach to GCPR and focus on allowing VA to view DOD health data. 
However, under the interim effort, physicians at military medical 
facilities will not be able to view health information from other 
facilities or from VA--now a potentially critical information source 
given VA's fourth mission to provide medical backup to the military 
health system in times of national emergency and war.
    Recent meetings with officials from the Defense Health Program and 
the Army Surgeon General's Office indicate that the department is 
working on issues we have reported on in the past, including the need 
to improve the reliability of deployment information and the need to 
integrate disparate health information systems. Specifically, these 
officials informed us that DOD is in the process of developing a more 
accurate roster of deployed service members and enhancing its 
information technology capabilities. For example, DOD's Theater Medical 
Information Program (TMIP) is intended to capture medical information 
on deployed personnel and link it with medical information captured in 
the department's new medical information system, now being field 
tested.\18\ Developmental testing for TMIP is about to begin and field 
testing is expected to begin next spring, with deployment expected in 
2003. A component system of TMIP--Transportation Command Regulating and 
Command and Control Evacuation System--is also under development and 
aims to allow casualty tracking and provide in-transit visibility of 
casualties during wartime and peacetime. Also under development is the 
Global Expeditionary Medical System, which DOD characterizes as a 
stepping stone to an integrated biohazard surveillance and detection 
system.
---------------------------------------------------------------------------
    \18\ Composite Health Care System H (CHCS II) is expected to 
capture information on immunizations; allergies; outpatient encounters, 
such as diagnostic and treatment codes; patient hospital admission and 
discharge; patient medications; laboratory results; and radiology. CHCS 
II is expected to support best business practices, medical 
surveillance, and clinical research.
---------------------------------------------------------------------------
                        concluding observations
    Clearly, the need for comprehensive health information on service 
members and veterans is very great, and much more needs to be done. 
However, it is also a very difficult task because of uncertainties 
about what conditions may exist in a deployed setting, such as 
potential military conflicts, environmental hazards, and frequency of 
troop movements. While progress is being made, DOD will need to 
continue to make a concerted effort to resolve the remaining 
deficiencies in its surveillance system. Until such a time that some of 
the deficiencies are overcome, VA's ability to perform its missions 
will be affected.
                      contact and acknowledgments
    For further information, please contact Stephen P. Backhus. 
Individuals making key contributions to this testimony included Ann 
Calvaresi Barr, Karen Sloan, and Keith Steck.
                          related gao products
    Computer-Based Patient Records. Better Planning and Oversight by 
VA, DOD, and IHS Would Enhance Health Data Sharing (GAO-01459, Apr. 30, 
2001).
    Medical Readiness: DOD Continues to Face Challenges in Implementing 
Its Anthrax Vaccine Immununization Program (GAO/T-NSIAD-00-157, Apr. 
13, 2000).
    Medical Readiness: DOD Faces Challenges in Implementing Its Anthrax 
Vaccine Immunization Program (GAO/NSIAD-00-36, Oct. 22, 1999).
    Chemical and Biological Defense: Observations on DOD's Plans to 
Protect U.S. Forces (GAO/T-NSIAD-98-83, Mar. 17, 1998).
    Gulf War Veterans. Incidence of Turnors Cannot Be Reliably 
Determined From Available Data (GAO/NSIAD-98-89, Mar. 3, 1998).
    Gulf War Illnesses: Federal Research Strategy Needs Reexamination 
(GAO-T-NSIAD-98-104, Feb. 24, 1998).
    Gulf War Illnesses: Research, Clinical Monitoring and Medical 
Surveillance (GAO/T-NSIAD-98-88, Feb. 5, 1998).
    Defense Health Care: Medical Surveillance Improved Since Gulf War, 
but Mixed Results in Bosnia (GAO/NSIAD-97-136, May 13, 1997).

    Chairman Rockefeller. I welcome everybody. Secretary 
Principi, there may be several other Senators who wish to make 
a statement. I would welcome their doing so if they want to, 
and again apologize for my own inexcusable lateness.
    Senator Jeffords?
    Senator Jeffords. Thank you. I want to commend you on the 
tremendous work you did on September 11 and the beds that were 
provided. It was just amazing, an excellent job.
    I am anxious to hear your remarks, but let me again first 
say that in New England, we are really proud of your work on 
VISN 1 and throughout the White River Junction VA in 
particular. But I believe we owe it to those dedicated 
professionals on the front lines to clarify a few things for 
them.
    First of all, we need to allay their fears that the 
resources will be there to cover these expenditures, and just 
being prepared costs money.
    Second, I believe guidance is needed on how to balance 
these competing demands in the event of an emergency, and we 
also need to make sure that we are not double-counting the same 
beds for different purposes.
    And finally, I hear concern that while both the VA and the 
municipalities are well prepared for traditional types of 
disaster, there is much that needs to be done to properly 
respond to an emergency involving hazardous materials and 
biological, et cetera, and I am concerned there is insufficient 
training and equipment in this area.
    So once again, I appreciate what you are doing and hope you 
can give us some reassurance in some of these areas. Thank you 
very much.
    Chairman Rockefeller. Senator Miller?
    Senator Miller. I have a statement, but I would like to ask 
that it be made part of the record and I will just skip giving 
it.
    Chairman Rockefeller. Thank you, Senator.
    [The prepared statement of Senator Miller follows:]

   Prepared Statement of Hon. Zell Miller, U.S. Senator From Georgia

    Thank you Mr. Chairman, and I commend you for convening a 
hearing to examine this very important subject. The events of 
September 11th, coupled with the continuing threat of terrorist 
attacks, demand that we be prepared for the possibility of mass 
casualties that require immediate medical attention. As we 
know, such casualties could be military, civilian, or both. For 
the VA to be an effective assisting agency in these large-scale 
emergencies, we must ensure that interagency and 
intergovernmental coordination is thoroughly planned 
beforehand. I know that this coordination already exists on 
some level, and we must determine if it is sufficient to handle 
thousands, rather than hundreds of patients. To that end, 
Secretary Principi has formed a senior level working group to 
assess the VA's ability in managing a multi-scenario crisis, 
and I look forward to seeing those results.
    It is imperative that this complete and honest assessment 
of the VA's ability to assist with such national emergencies is 
done with the primary mission of quality service to veterans in 
mind. If more resources are needed in the areas of facilities, 
equipment, or manpower, we need to identify those deficiencies 
and act on them before a disaster arrives.
    We have seen that combating terrorism and safeguarding our 
citizens is an expensive endeavor. I anticipate that the VA's 
responsibility in preserving public health during a domestic 
crisis will be no exception. In order for the VA to be viable 
in this ``Fourth Mission,'' we must realistically identify the 
requirements, fund any deficiencies, implement an expeditious 
plan of action, and conduct realistic training. We all hope 
that this kind of contingency preparation will never be needed, 
but the cost of not being fully prepared could be staggering. 
Therefore, we must fulfill our obligation of providing 
emergency healthcare service to veterans, service members, and 
when necessary, civilians.
    I would also like to recognize and thank the distinguished 
panelists appearing here today for imparting their thoughts and 
expertise on this most important issue.

    Chairman Rockefeller. Senator Wellstone?
    Senator Wellstone. I would rather go forward with the 
testimony. My apology to the Secretary. I have a markup I have 
to go to, Mr. Chairman, so I will just get to hear the 
beginning and then I will read the full statement. I do want to 
say to Secretary Principi, I think the veterans' community has 
a great deal of affection for him and really trusts and 
believes in him and I thank him for his leadership.
    Chairman Rockefeller. Senator Nelson?
    Senator Nelson. Thank you, Mr. Chairman. I do not want to 
extend the timeframe. I am anxious to get to the Secretary's 
comments, as well, but I would like to begin by thanking you 
for holding this hearing to address the role and responsibility 
of the Veterans' Affairs Department in coordinating emergency 
medical responses. Fortunately, we have never had one in 
Nebraska. We have never had to call on your agency. But it is 
reassuring to know that if we did have that need, that it would 
be there to be responded to.
    I would like to thank you for our conversation this morning 
on an entirely different matter and for being responsive to the 
needs of our veterans in not only a professional but a caring 
way. I look forward to your comments today. Thank you.
    Chairman Rockefeller. Thank you, Senator Nelson.
    Senator Specter has arrived and we would welcome any words 
from him.
    Senator Specter. Well, thank you very much, Mr. Chairman. I 
regret being late. Let me pick up on the flow of action and 
perhaps have a question or two when I catch up a little. Good 
morning, Mr. Secretary.
    Chairman Rockefeller. Spoken like a skilled lawyer.
    Senator Specter. It is better than speaking like an 
unskilled lawyer. [Laughter.]
    Chairman Rockefeller. Or not being one at all. [Laughter.]
    Secretary Principi, we are delighted to have you here. Your 
full statement is a part of the record and we welcome whatever 
you have to say.

STATEMENT OF HON. ANTHONY J. PRINCIPI, SECRETARY, DEPARTMENT OF 
  VETERANS' AFFAIRS, ACCOMPANIED BY FRAN MURPHY, DEPUTY UNDER 
     SECRETARY FOR HEALTH, DEPARTMENT OF VETERANS' AFFAIRS

    Mr. Principi. Thank you, Mr. Chairman, Senator Specter, 
members of the committee. It is always a privilege to appear 
before you, especially on an issue of such critical importance 
to all Americans in the aftermath of this crisis.
    I am very pleased to be joined by Dr. Fran Murphy, our 
Deputy Under Secretary of Health, who has a great deal of 
expertise in emergency preparedness, and I am pleased she is 
with me, as well as my two colleagues one from HHS and one from 
the Department of Defense who will be testifying shortly.
    I think it is so terribly important, as I indicated 
yesterday before the House, that we break down the barriers in 
government and stress the importance of cooperation across all 
levels of government today to respond to the enormous tragedy 
that befell America. I will be very, very brief.
    I believe that VA has played a very, very important role in 
emergency management throughout its history, and certainly over 
the past 20 years, as we look at the natural disasters that 
have hit America. From Hurricane Hugo, Hurricane Andrew, the 
Northern California earthquake, the devastating floods in the 
Midwest, and as you indicated, Mr. Chairman, in West Virginia, 
and more recently in Houston, VA has been present and responded 
to legislation that was passed creating the VA-DoD Contingency 
Hospital System, the National Disaster Medical System, and to 
various Presidential directives. These have made VA a partner, 
along with FEMA, HHS, and DoD in responding to crises in 
America.
    Clearly on September 11, I am very, very proud of the way 
VA people responded in New York at all levels. At our health 
care system, they were there literally taking people in off the 
street with their injuries. Our regional office benefits 
counselors were there at the family assistance center on 94th 
Street at the pier, assisting families with benefits 
counseling. Our PTSD counselors from various parts of the 
country convened in New York to assist, again, not only 
veterans but families of veterans, fire fighters, and police 
deal with the trauma of the aftermath of the crisis.
    At all levels, our plans and people worked well, in 
treatment, in sharing our inventory of pharmaceuticals and 
supplies, in benefits counseling, and in providing for the 
expeditious memorial services at our national cemetery in New 
York. I think all of us can be very, very proud of the way our 
people performed.
    But you know, Mr. Chairman and members of the committee, 
regrettably, 6,000 young men and women, for the most part, died 
in that tragedy. There were not many survivors, relatively few, 
unfortunately. Had there been more seriously wounded people, I 
question--and I only speak for my Department--whether we would 
have had the capability to respond adequately to treatment of 
the seriously wounded if there had been thousands, maybe tens 
of thousands if that strike would have occurred later in the 
day when there were 50,000 people in the World Trade Center as 
opposed to maybe 10,000 or 12,000 in the relatively early 
morning hours of Wall Street. What would have happened in that 
case? I believe that collectively we would have been 
overwhelmed, quite honestly, and I think that is something that 
we all have to consider in the aftermath of this tragedy.
    A mission in statute is our words, in my view. It is kind 
of like pacing the word ``Humvee'' on the side of a Chevrolet 
and trying to believe that it would be a mountain terrain 
vehicle. It is still a Chevrolet.
    So I think that VA does have a fourth mission as a backup 
and also in cases of emergency to care for civilians, and to do 
that, we need to be prepared. We need to be fully funded, and I 
am not here asking for money, but I do think that we have a 
responsibility, all of us in the executive branch of 
government, to identify what our requirements are, what are 
reasonable levels of risk and vulnerability that we want to be 
prepared to deal with, and to ensure that those requirements 
are well understood. We can, by working with Congress, balance 
capacity and dollars and make the policy decisions as to what 
it is going to take to ensure that we have the resources, we 
have the bed capacity, we have the staffing, we have the 
training, we have the pharmaceuticals and medical supplies, and 
we are ready to address matters during an event.
    I convened a task force, an emergency preparedness task 
force, shortly after September 11 to take a look at where we 
needed to improve. We did identify that we need to improve 
dealing with multiple scenario crises, with call-up reserve and 
Guard personnel, with our training, protective equipment. So 
there are many, many areas that we have to work on.
    I am pleased the President has established the Office of 
Homeland Security so that the principal players in emergency 
preparedness in responding to crises, be they manmade or 
natural, weapons of mass destruction, will know what needs to 
be done and that we can ask Congress for the resources 
necessary to respond to them. Thank you.
    Chairman Rockefeller. Thank you, Secretary Principi.
    [The prepared statement of Mr. Principi follows:]
 Prepared Statement of Hon. Anthony J. Principi, Secretary, Department 
                          of Veterans Affairs
    Mr. Chairman, I thank you for the opportunity to testify before the 
committee on VA's preparedness to perform its missions under the 
conditions of military conflict abroad and terrorist attacks at home. I 
am accompanied by Dr. Frances Murphy, VA's Deputy Under Secretary for 
Health.
    My testimony will cover four significant areas:
     how VA responded on, and in the days following, September 
11;
     VA's emergency response missions;
     the challenges facing VA; and
     the actions we are taking in response to those challenges.
    Mr. Chairman, I will take this opportunity to again thank all VA 
employees for their efforts--whether they have been directly involved 
or have been a part of local VA and community efforts--in responding to 
the needs of victims and their families in New York, Washington, and 
Pennsylvania. I particularly want to commend VA staff in the immediate 
areas for their efforts to continue serving veterans in very difficult 
circumstances and beyond this--to support community family and victim 
assistance efforts in New York, New Jersey, and at the Pentagon.
    VA operates the largest integrated national health care system in 
the country and with our 1200 sites nationwide, provides direct care 
benefits and memorial services in every state. We expect that this 
national resource will be called on to provide significant assistance 
should mass casualty situations arise. We have responded well in this 
circumstance and are prepared to provide assistance to the Department 
of Defense should the need arise. We are reexamining our plans and will 
be taking steps to strengthen them. We also stand ready to assist 
Governor Ridge and our other federal partners in the weeks ahead as 
they strengthen the Nation's ability to prevent and respond to any 
future terrorist attack.
              va's response to the events of september 11
Veterans Health Administration
    VA reacted very quickly to the events of September 11, 2001. 
Immediately following the second aircraft crash into the World Trade 
Center, the VA Continuity of Operations Plan (COOP) was activated. 
Alternate sites, which serve as command centers and give VA leadership 
the ability to manage a crisis in the event VA's headquarters is closed 
down, were operational and key personnel were deployed within a few 
hours.
    While staff in the Central Office assured the continuity of 
operations, the Veterans Integrated Service Networks (VISN) 3 and 5 
command centers were activated. VISN 4 provided support to the response 
following the downed aircraft in Pennsylvania. VA staff supported the 
special security mission during the President's address to the Nation.
    In New York, VA was dealing with the greatest national tragedy to 
touch our shores in a very immediate way, caring for patients, managing 
emergent situations, heightening security, deploying staff, sharing 
inventory, assuring continuous communications, all very close to ground 
zero. It should be noted that in New York nearly every person in the VA 
family has been affected in some personal way by the tragedy. Some VA 
staff work so close to where the World Trade Centers stood that they 
watched the entire catastrophe unfold before their eyes. Some staff had 
loved ones and close friends in the towers who haven't come home.
    While the wounded were few, they were significant, and VA 
facilities in New York provided much needed supplies to the emergency 
workers and the National Guard to help them carry out their jobs in the 
immediate aftermath. VA continues to provide medical support to 3,000 
members of the National Guard who are providing security to the city 
and its critical infrastructure. The Network's centralized kitchen and 
laundry operations worked miracles in keeping food and clean linens 
stocked at all of our medical centers in New York and New Jersey, 
fighting bridge and tunnel closures, rigorous inspection stops and 
using VA Police escorts to get around town and into the suburbs. 
Whereas many businesses and hospitals in the city were without 
telephone communications, our team had telephones continuously up and 
working.
    Since the tragedy, VA outreach teams have been staffing family and 
victim assistance centers around the city and in New Jersey. We are now 
gearing up for the emotional and traumatic impact this event is likely 
to generate in the weeks and months ahead. The mental health team 
across the network is reaching out to those who are at risk.
    As a part of VA's support of civilian emergencies under the Federal 
Response Plan, two VA critical care burn nurses were deployed to 
Cornell Medical Center Burn Unit and four critical care burn nurses 
were deployed to the Washington Hospital Center Burn Unit in 
Washington, DC to augment their staffs.
    On the Saturday following the terrorist attacks, staff from VA's 
National Center for PTSD arrived in Virginia to assist DoD in its 
relief efforts at the Pentagon. They provided education for counselors 
and debriefing and psychoeducational support for relief staff that 
included Red Cross personnel and DoD Casualty Assistance Officers. 
Among the tools they created for assisting the relief workers were a 
Debriefing Facilitators Manual, an evaluation questionnaire for 
Casualty Assistance Officers, and a computerized self-assessment for 
the Army Community Support Center staff.
    Within days following the event, VA broadcast the Department of 
Defense-sponsored series on ``Medical Management of Biological and 
Chemical Casualties'', throughout the VA system using the VA's 
Knowledge Satellite Network. In addition, a nationwide satellite 
videoconference on ``Medical Response to Chemical and Biological Agent 
Exposure'' will be broadcast to VA facilities on October 16, 2001, 
followed by ``Medical Response to Radiological Agent Exposure'' in 
November.
Veterans Benefits Administration
    The Veterans Benefits Administration (VBA) has had an active role 
in administering benefits to veterans and their families affected by 
the events of September 11. The New York Regional Office (NYRO) has 
been very involved in helping the survivors and family members affected 
by the World Trade Center disaster, while the Washington Regional 
Office (WRO) and personnel from VBA Headquarters have been supporting 
the Department of Defense in providing assistance to family members of 
the victims of the attack on the Pentagon.
    On September 17, VBA established an information, assistance, and 
on-site processing unit at DoDs Family Assistance Center. The 
Washington Regional Office, along with VA headquarters staff, are 
providing the coverage for this unit and VA's Insurance Center in 
Philadelphia and each of the benefits programs within VBA are 
supporting them.
    The New York Regional Office (NYRO) established a team of employees 
who are providing help at the New York City Family Assistance Center, 
located at Pier 94. Vocational Rehabilitation and Employment, Loan 
Guaranty, and Veterans Benefits and Services Divisions developed 
alternate plans to provide counseling, to close home loans, and to 
interview veterans at off-site locations. Telephone calls about 
benefits issues were rerouted to other Regional Offices until the NYRO 
toll-free service was restored.
    In an effort to ensure control and efficient, effective service to 
the survivors of this terrible tragedy we issued a letter to each of 
our field stations outlining procedures for handling all claims related 
to the attack. All claims processing for this initiative has been 
centralized to our Compensation and Pension Service at Headquarters.
    We have also established a toll-free telephone number for the 
survivors, families of the victims, and DoD Casualty Assistance 
Officers to obtain information about benefits and services offered by 
VA. They are being notified of this special number in a letter that VBA 
is sending to each of the affected families. In addition, VA's web site 
offers information on benefits and services available to the survivors.
    We have streamlined the claims process as much as possible in an 
effort to be as supportive as possible of the families at this 
difficult time. Working with DoD, we have obtained direct online access 
to the Defense Eligibility and Entitlement Records System (DEERS) to 
obtain data on dependents allowing us to conduct on-site claims 
processing. We are faxing claims for Servicemembers Group Life 
Insurance (SGLI) directly to the Office of SGLI in Newark where the 
claims are processed within 24 hours. We have also implemented similar 
procedures for processing burial claims and headstone or marker 
applications.
    I am pleased to say that both DoD and the families have indicated 
appreciation for the support and services we have been able to offer in 
this very difficult time.
National Cemetery Administration
    The National Cemetery Administration (NCA) was quick to respond to 
the events of September 11, 2001. After news of the terrorist attacks 
was received and the alternate site was activated, the NCA Continuity 
Of Operations (COOP) team was there to participate fully in 
guaranteeing that VA was able to continue meeting its missions.
    As long as the COOP was activated, NCA was an active participant in 
the One VA effort to guarantee that key functions were carried out. For 
NCA, this included making decisions concerning burials for victims of 
the attacks. NCA remained sensitive to the needs of their families 
during this crisis, making accommodations wherever possible. All VA 
national cemeteries were directed to treat all VA burials resulting 
from this tragedy as high priority, and to honor requests for weekend 
burials and to extend hours, if necessary.
    All national cemeteries remained operational with the exception of 
Ft. Rosecrans and Barrancas National Cemeteries, which, because of the 
attacks, were temporarily closed for burials. This was a result of the 
proximity of the cemeteries to military bases with restricted access. 
This interruption in service lasted only a short time and all burials 
scheduled before the attacks were successfully rescheduled and 
completed.
    It was reported that there had been cancellations of military 
funeral honors by the Department of Defense. Cemetery Directors were 
urged to seek alternate honors approaches, including the use of 
cemetery representatives and/or other employees or additional Veteran 
Service Organization assistance if possible.
    NCA has provided or scheduled burials for 15 victims in its 
national cemeteries, with three additional requests having been made 
but services not yet scheduled. We immediately began providing 
Presidential Memorial Certificates (PMC) to the families of the active-
duty personnel and veterans killed on September 11. PMCs bear the 
President's signature and commemorate a person's honorable service to 
the Nation. NCA has begun to provide a headstone or marker for several 
victims. In those cases where remains are unrecoverable, we will be 
able to provide a memorial marker in lieu of an actual burial.
    NCA will continue to meet the burial needs of the victims of this 
horrendous act in a compassionate manner.
    In short, VA's response to the attacks was swift, orderly, and 
effective. And that response is consistent with VA's history of being 
there in times of great need.
         the interagency planning process for the frp and ndms
    Mr. Chairman, the Committee asked specifically how VA functions 
within the federal system under the Federal Response Plan (FRP). The 
FRP establishes the plan for interagency response to disasters. The FRP 
organizes interagency response into 12 ``Emergency Support Functions'' 
(ESFs). Each ESF is led by a Primary Agency that serves as the Federal 
executive agent to accomplish the ESF mission. Each ESF also has a 
number of Support Agencies that provide support to the Primary Agency 
in order to accomplish the ESF mission. VA is a Support Agency in the 
following four ESFs: (1) ESF #3, Public Works and Engineering; (2) ESF 
#6, Mass Care; (3) ESF #7, Resource Support; and (4) ESF #8, Health and 
Medical Services. VA may receive mission assignments from the Primary 
Agencies in charge of those four ESFs, most frequently from the 
Department of Health and Human Services, the Primary Agency for ESF #8. 
The mission assignments are the mechanisms FEMA uses to task other 
Federal agencies, with or without reimbursement, to provide services 
under the FRP. VA employee salaries remain the responsibility of VA 
(i.e., they are not reimbursed).
    The four National Disaster Medical System (NDMS) partner agencies 
(VA, DoD, FEMA and Public Health Service) review and update plans via 
monthly meetings of the NDMS Directorate Staff. There is an NDMS Senior 
Policy Group (SPG), which sets major policy direction. The Under 
Secretary for Health represents VA at SPG meetings. An annual NDMS 
Conference is also conducted by the four partner agencies.
How FEMA Engages HHS and VA in Preparing for the Most Efficient 
        Responses to Public Healthcare Emergencies
    FEMA uses the FRP structure to engage HHS and VA in providing for 
health care in emergencies. The FRP includes an Emergency Support 
Function #8 for Health and Medical Services. As noted above, HHS is the 
Primary Agency for ESF #8 and VA is a Support Agency. Therefore, VA 
receives mission assignments from HHS to support health emergencies.
    VA works closely with the Federal Emergency Management Agency to 
ensure continuity of operations.
Gulf War-Related Issues:
    Mr. Chairman, you also requested that we address the importance of 
good record keeping for force protection and for post deployment health 
care and on the status of development of the National Center for 
Military Deployment Health Research.
    In preparing to care for veterans of future wars, we must of 
necessity look back to the Gulf War and the lessons learned there. I 
think that everyone now realizes the impact that poor record keeping 
during the Gulf War has had on our subsequent efforts to respond to 
Gulf War veterans' health issues. Both VA and DOD have been hampered by 
poor records of immunizations given to U.S. service members, inadequate 
troop location data, limited data on exposures to potential health 
hazards, and the absence of baseline health data on new military 
recruits. It is my understanding that the Department of Defense (DOD) 
has vigorously applied many lessons learned from our experience with 
the Gulf War. I believe that they are developing a strategy to protect 
the health of military members from medical and environmental hazards 
associated with military service to the maximum extent possible. For 
example, I understand that DOD is actively working on a computer-based 
record that will enable more accurate assessments of the effectiveness 
of military health care, will help direct preventive services for 
military members, and will be useful for other agencies with 
responsibility for veterans' health such as the VA. Both VA and DOD 
recognize the need for a continuous assessment of the current and 
future health of military members through medical surveillance, 
longitudinal health studies, adequate medical record documentation, and 
clinical follow-up. In response, DOD has initiated its Millennium 
Cohort study--a long-term longitudinal study of the health of a 
representative group of active duty service members. These activities 
will also serve us well as we face health issues from future veterans 
from U.S. military missions.
    Congress responded to some of the lessons learned in the Gulf War 
by passing PL 105-368. In response to Sec. 103 of that law, VA 
requested the Institute of Medicine (IOM) to establish a committee of 
experts to provide recommendations on establishing a national center or 
centers for military deployment health research. Their November 1999 
report, National Center for Military Deployment Health Research, 
contained two major recommendations: 1) that VA establish Centers for 
the Study of War-Related Illnesses, and 2) that there be established a 
National Center for Military Deployment Health Research (NCMDHR) under 
the auspices of the Military and Veterans Health Coordinating Board 
(MVHCB) that would focus on the health of active, reserve, and guard 
forces, and veterans and their families. On September 7, 2000, a joint 
inter-agency operational plan concurring with both recommendations, was 
signed by the Secretaries of the Departments of Veterans Affairs, 
Defense, and Health and Human Services, and was transmitted to 
Congress.
    Regarding the first recommendation, on May 8, 2001, I announced the 
establishment of two new Centers for the Study of War-Related Illnesses 
(CSWRI) at East Orange, NJ, and Washington, DC VA Medical Centers. 
These new centers are in part a response to debilitating but often 
difficult to diagnose health problems of some veterans returning from 
virtually all military and peacekeeping missions. For the second 
recommendation, we reported that the NCMDHR concept required broad 
cooperation from the Departments of Defense, Health and Human Services, 
and Veterans Affairs, and that this can be best assured through the 
MVHCB. We also reported our belief that an evolutionary approach 
towards establishing a new National Center will afford the best 
opportunity to ensure that we arrive at a structure and function that 
best meets the needs of our service personnel, veterans, and their 
families. We therefore proposed that the National Center be composed of 
the existing Research Working Group (RWG) of the MVHCB, which will 
serve as the operational arm of this Center. Following the September 
2000 joint report, the interagency RWG has adopted IOM's NCMDHR concept 
by generating regular research reports about existing deployment health 
research, identifying gaps and duplicative efforts, and making 
recommendations for correcting deficiencies using both federal and non-
federal research capabilities.
                   va's history of disaster response
    We are proud of our history of responsiveness to local and national 
disasters. The list is too long to include all our efforts, but just 
within the past 12 years, we have compiled a notable record of service 
in times of crisis. For example:
    In 1989, as aftershocks of the October 17 earthquake continued to 
rock Northern California, VA opened the doors of its San Francisco and 
Martinez Medical Centers to supplement local emergency medical 
activities. Employees of the San Francisco VAMC staffed a mobile 
health-screen clinic that was deployed to area homeless shelters, and 
VA personnel were on hand at 17 federal disaster centers in the area.
    When Hurricane Hugo struck Puerto Rico and the Eastern U.S. in 
1989, VA facilities took direct hits, but their preparations enabled 
them to recover quickly and get to the business of helping their 
neighbors with services and shelter.
    VA was ready in Florida in 1992 after Hurricane Andrew, and we 
quickly deployed to serve veterans and their communities stunned by 
that overwhelming disaster.
    Even before the waters of the devastating 1993 Midwest floods 
receded, VA was helping veterans cope with the damage by instituting 
fast-response, one-day approval and processing of home-loan insurance 
issues, and delaying payment dates to allow veterans to recover from 
the disaster. We did this even though our own offices were flooded and 
many of our employees were working from home.
VA's Emergency Response Mission
    The preceding are vivid examples of the manner in which VA responds 
to emergencies. The primary responsibilities and authorities governing 
VA's emergency management efforts include:
     VA and Department of Defense Contingency Hospital System, 
Public Law 97-174, May 1982, requires VA to serve as the primary 
contingency back-up to the Department of Defense medical services.
     National Disaster Medical System (NDMS) was established in 
1984 by agreement between Department of Defense, Department of Health 
and Human Services, VA, and Federal Emergency Management Agency. It 
operates to provide capability for treating large numbers of patients 
who are injured in a major peacetime disaster within the continental 
United States, or to treat casualties resulting from a conventional 
military conflict overseas.
     Federal Response Plan, (updated 1999) implemented Public 
Law 93-288, the Robert T. Stafford Disaster Relief and Assistance Act 
as amended, and established the architecture for a systematic, 
coordinated, and effective Federal response to a disaster or emergency 
situation.
     Executive Order 12656, Assignment of Emergency 
Preparedness Responsibilities, November 1988, charged VA to plan for 
emergency health care services for VA beneficiaries in VA medical 
facilities, active duty personnel, and, as resources permit, to 
civilians in communities affected by national security emergencies and 
for mortuary services for eligible veterans and to advise on methods 
for interment of the dead during national security emergencies.
     Federal Radiological Emergency Response Plan (FRERP) (May 
1, 1996) established and organized an integrated capability for 
coordinated response by Federal agencies to peacetime radiological 
emergencies. VA's Medical Emergency Radiological Response Team (MERRT) 
is a federal resource available to respond to radiological emergencies.
     Presidential Decision Directive--62, Combating Terrorism, 
May 1998, tasked U.S. Public Health Service (USPHS), working with VA, 
to ensure that adequate stockpiles of antidotes and other necessary 
pharmaceuticals are maintained nationwide and to train medical 
personnel in NDMS hospitals.
     Presidential Decision Directive--63, Critical 
Infrastructure Protection (May 22, 1998) tasks VA to develop and 
implement plans to protect its infrastructure, including facilities, 
information systems, telecommunications systems, equipment and the 
organizations necessary to accomplish our mission to provide benefits 
and services to veterans.
     Presidential Decision Directive--67, Continuity of 
Operations (October 21, 1998) tasks all Federal Departments and 
Agencies, including VA to ensure that their critical functions and 
operations continue under all circumstances and a wide range of 
possible threats.
    VA works closely with the Federal Emergency Management Agency to 
ensure compliance with the Continuity of Government and Continuity of 
Operations requirements in Presidential Decision Directive 67, titled 
Enduring Constitutional Government and Continuity of Government 
Operations.
    VA also supports the Department of Health and Human Services in its 
mission of providing health and medical response following disasters, 
including terrorist incidents. In this regard, VA has significant 
medical assets that could assist the Nation should mass casualties 
occur. VA operates the Nation's largest integrated health care system; 
treating almost four million patients per year in hospitals and clinics 
in every state and Puerto Rico; and employing over 14,000 physicians 
and 37,000 registered nurses. As a partner in the National Disaster 
Medical System, VA is involved in planning, coordination, training and 
exercises to prepare for a variety of catastrophic events.
    VA also provides support to the primary departments and agencies 
identified in Presidential Decision Directive 62, titled Protection 
against Unconventional Threats to the Homeland and Americans Overseas. 
Our Veterans Health Administration supports HHS's Office of Emergency 
Preparedness in ensuring that adequate stockpiles of antidotes and 
other necessary pharmaceuticals are maintained nationwide. Four 
pharmaceutical caches are available for immediate deployment with a HHS 
National Medical Response Team in the event of an actual weapons of 
mass destruction incident. We also maintain a fifth cache that is 
placed on-site at special high-risk national events, such as the 
Presidential Inauguration. VA also procures pharmaceuticals for the 
Centers for Disease Control and the Prevention National Pharmaceutical 
Stockpile Program.
    VA is known worldwide as the authority in treatment of stress 
reactions and post traumatic stress disorder (PTSD). A vast number of 
highly skilled mental health staff are available for continuing 
response to the victims of the September 11 terrorist attacks and to 
respond to future events that psychologically traumatize our citizens.
    VA has recently developed a nationwide registry of VA employees who 
volunteer and are trained to respond to disasters. In the future this 
registry will provide an inventory of personnel with skills and 
experience that can be matched to response requirements for both 
internal (VA) and external emergencies. VHA is developing a national 
policy and plan for training and equipping our facilities and staffs to 
manage victims of a WIVID incident. A Technical Advisory Committee JAC) 
of both VA and non-VA experts was established in early 2000 to advise 
VA on WIVID issues. The plan will include specific precautionary and 
response measures to be implemented at all VA facilities. We expect to 
establish a national policy and initiate system wide implementation 
before the end of 2001.
    Public Law 97-174 authorized VA to furnish health care services to 
members of the armed forces during a war or national emergency. VA and 
DoD have established contingency plans whereby facilities of the VA 
healthcare system would provide the principal medical support to the 
military healthcare system for active duty military personnel when DoD 
does not have adequate medical resources under its own jurisdiction to 
meet medical contingencies. These plans are reviewed and updated 
annually. This annual review is shared with DoD and a subsequent report 
is provided to Congress. VA also completes quarterly bed reporting 
exercises to ensure that procedures are familiar to staff and are ready 
for implementation on short notice should contingency support become 
necessary.
                  emergency preparedness working group
    Although VA has plans in place to meet our critical emergency 
response missions, we know that there are new threats to America that 
we must address, and address quickly and effectively.
    Given that this new threat is real and potent, I immediately formed 
a senior-level working group to undertake an assessment of the ability 
of the VA in its entirety to manage a multi-scenario crisis. This group 
assessed our ability to carry out our missions in case of a biological, 
chemical or radiological weapons attack. It also examined our capacity 
for reconstituting our ability to fulfill our missions, if need be.
    This assessment has identified some deficiencies and opportunities 
to improve our ability to carry out all of our missions in today's 
environment. The challenges we face do not outweigh our overall 
strengths, and they do not compromise our primary mission to care for 
the nation's 25 million veterans. But they do represent challenges we 
must, and will, deal with quickly and appropriately.
    In the following, I will outline some of the challenges that the 
working group has identified. However, in order to deny terrorists any 
sort of roadmap, I will avoid mentioning specifics at a public hearing. 
I will certainly be available to discuss such details with members and 
staff of this Committee after the hearing.
    We are now facing the potential of having to respond to terrorists' 
attacks in the U.S., of providing contingency support to DoD, as well 
as continuing to care for our patients. Here are examples of our 
findings:
    1. Some regions of VA's health care system would be hard-pressed if 
they were required to treat military and civilian casualties of 
chemical or biological agents in addition to carrying out their primary 
mission of providing health care to veterans.
    2. VA needs to enhance its medical preparedness to respond to 
casualties from chemical and biological agents by providing training to 
its health care workers on decontamination procedures, and on diagnosis 
and treatment of chemical, biological and radiation injuries. VA 
medical centers are likely to play a crucial role in the initial 
response to an attack in their area. Yet their inventories of equipment 
and pharmaceuticals may not be adequate to address medical needs in the 
critical first hours of an attack, especially one involving chemical 
agents. As a result, VA Medical Centers need substantial upgrades to 
their personal protection gear, equipment, and training.
    3. A call-up of Reserve or National Guard units, or a crisis 
causing staff to be unable to report to work, could result in a 
significant medical staffing shortage.
    4. A major terrorist attack, especially one involving chemical or 
biological agents, would require a greater amount of post-traumatic 
stress counseling for military personnel, veterans, their families, VA 
employees--notably VA medical professionals and support staffs--and 
civilians. Long deployments of VA mental health staff could also have 
an impact on our ability to treat veterans.
    5. VA's security forces need to be enhanced in numbers and 
training, both to manage a domestic crisis requiring medical care, and 
to protect our veteran patients, key personnel, facilities, and 
systems.
    6. As this committee is well aware, we need to do a far better job 
securing our information and data bases from cyber-terrorism and to 
ensure that our key data centers are protected and their data back-up 
systems fully tested.
    7. VBA is dependent on the Department of the Treasury to complete 
our payment process and issue payments. We need a back-up plan and 
process in the event that this link is inoperable.
    8. Our National Cemetery Administration needs a comprehensive back-
up plan to address increased interment workload in the event of an 
emergency.
    9. VA needs to strengthen its communications protocols and its 
coordination efforts with the Department of Defense.
    10. There is a need for a more robust VA headquarters Operations 
Center, for a stronger emergency operations command and control 
structure, and for a better-defined plan for mobilizing personnel to 
relocation sites.
    11. We must periodically test our ability to respond to any 
terrorist attack through more training and periodic exercises.
    12. Finally, and most importantly, we need to educate our employees 
and veterans on the realities of chemical and biological agents and how 
best to protect themselves.
                        new actions being taken
    VA has already begun to meet these challenges. As mentioned above, 
I immediately formed a working group to conduct a quick, but thorough, 
review of our readiness. Based on their findings, I have already 
authorized the following immediate actions:
    First, to ensure that we can respond fully in the event of a 
crisis, I have directed that an immediate review be made of the working 
group's many recommendations, that those requiring immediate action be 
identified, and that a fast-track decision process be adopted to 
implement them within 90 days. VA wants to ensure that it can continue 
its mission of caring for the nation's veterans, while supporting DoD 
in case of heavy casualties on battlefields abroad, and supporting 
FEMA, HHS and CDC and state and local authorities in case of casualties 
at home. We safeguard, maintain and deliver stockpiles for HHS and CDC 
and have emergency teams available on call in case of an emergency, 
particularly one involving biological, chemical or radiological 
weapons.
    Secondly, as you are aware, the VA has the foremost source of 
medical care assets in the federal government and the largest 
integrated medical system in the nation. We are enhancing our emergency 
operations center to keep that system functioning fully in the event of 
a crisis of any nature. I have ordered this center to institute daily, 
a round-the-clock coverage, with secure data and voice communications 
links, to closely monitor VA's operational status, and to track the 
location of essential personnel for mobilization in the event of a 
crisis
    We will fully support Governor Ridge in fulfilling the mission of 
providing for homeland security, even as we continue to serve our 
nation's veterans. Above and beyond close coordination with the 
Homeland Security Council, we will continue to support DoD, HHS, CDC, 
FEMA, and state and local authorities in responding to future threats 
to our homeland.
                            va's future role
    Mr. Chairman, beyond the measures I have discussed today, VA will, 
no doubt, be a vital force in America's ability to meet tomorrow's 
challenges. I envision a VA that participates even more proactively in 
helping our communities maintain a high-degree of readiness in the 
event of natural disasters or terrorism on our homeland. Our primary 
mission will always be to serve America's veterans with honor, to 
acknowledge their sacrifices on our behalf, and to be there for them as 
they were there for America. In any discussion of homeland defense, I 
want to assure the Nation's 25 million veterans that we will stand tall 
with our federal, state, and local colleagues to protect them, their 
families, and their communities.
    The challenges we have defined in our preparedness assessment will 
also help us develop emergency response training and medical education 
opportunities that we can share with our civilian health professionals 
across America. As you know VA Medical Centers are often allied with 
medical schools and I believe these partnerships--enhanced by our 
lessons learned--will help tomorrow's health care professionals meet 
the challenges we have talked about today.
    Mr. Chairman, that concludes my statement. Thank you.
    My colleagues and I would be pleased to respond to your questions.
                                 ______
                                 
Response to Written Questions Submitted by Hon. John D. Rockefeller IV 
                         to Anthony J. Principi
    Question 1. VA has a great many resources--including staff I 
consider to be among the best trained in treating PTSD, partnerships 
with local hospitals throughout the United States, and a nationwide 
communications system. How can VA and Congress ensure that these 
resources are used as effectively as possible, at every level, during 
disasters?
    Answer. There is a practical distinction between using VA resources 
at the national level and using VA resources at the local level. You 
have correctly pointed out the local partnerships that VA medical 
centers form in their communities that provide mutual support during 
local disasters. Associated activities are within the purview of local 
medical center directors under the guidance of the Veterans Integrated 
Service Networks (VISNs). At the national level, VA uses its external 
resources for disaster assistance as prescribed by statutes and 
interagency agreements. Currently, VA contributes its resources to a 
national response pursuant to requests from the Department of Health 
and Human Services (HHS), the lead federal agency for health and 
medical support.
    The VHA medical system, as a whole, therefore, does not have an 
assigned mission in national disaster preparedness. VHA may provide 
individuals and medical resources to assist HHS, sign memoranda of 
understanding with civilian hospitals for the provision of disaster 
beds, and help train NDMS hospital personnel in the treatment of 
weapons of mass destruction (WMD) victims. However, VA medical centers 
are not currently viewed in these contexts as an overall national 
disaster resource.
    VA medical facilities are situated in and around likely future 
disaster areas and should be prepared to accept ``walk-in patients'' 
under the Humanitarian Act. To this end, VA is training its staff to 
recognize and appropriately respond to victims of chemical, biological, 
or radiological agents. We must upgrade our decontamination 
capabilities and establish VA pharmaceutical stockpiles for VA facility 
response. VA medical facilities are a national asset and should be 
recognized as such in the emergency planning process.
    VA has long years of expertise in the diagnosis and treatment of 
war-zone-related Post-Traumatic Stress Disorder (PTSD). Since the time 
of the Gulf War, VA has, with the help of colleagues from the 
Department of Defense (DOD), developed expertise in the diagnosis and 
management of acute stress responses in combat settings including 
training in the assessment of biological, chemical and radiological 
injuries and mental/emotional responses to such attacks. We have 
enhanced our learning with experience in various disaster responses 
including earthquakes, hurricanes, the Oklahoma City Bombing and, most 
recently, the attacks on the Twin Towers and the Pentagon.
    We have developed ongoing relationships with DOD elements and HHS, 
which includes the Center for Mental Health Services (CMHS) as well as 
the American Red Cross (ARC) in relation to disaster response. VA's 
National Center for PTSD (NCPTSD) has, in collaboration with our 
Readjustment Counseling Service (RCS), created a Disaster Management 
Manual and trained dozens of VA clinicians in post-event counseling 
techniques. The NCPTSD, following its mandate for promoting education 
on PTSD, developed a web site with disaster relief information 
(www.ncptsd.org/disaster.html), which has been visited thousands of 
times since the September 11 attacks.
    We have identified 400 clinicians from mental health, social work, 
chaplain service, and RCS who have been specially trained in post-event 
mental health response techniques. Psychiatrists, psychologists, social 
workers, nurses, counselors, and chaplains are among the diverse 
disciplines whose members have received such training. A number of 
these VA clinicians have received Red Cross training and have deployed 
with the ARC in the post-September 11 response.
    VA's communication abilities include not only web sites as noted 
above, but also regular teleconferences among staff (e.g., monthly 
Mental Health Strategic Healthcare Group (MHSHG) PTSD Hotline calls) 
during which disaster related information is shared. Since September 
11, MHSHG and the NCPTSD participated in the Primary Care/Prevention 
Management (PC/PM) Hotline call and shared information on assessment of 
PTSD in primary care populations. We also shared information from the 
PC/PM group on assessment of anthrax via Outlook to MHSHG's Mental 
Health VISN Liaison and Field Advisory Board e-mail groups so that our 
mental health clinicians will be able to offer their patients 
information consistent with that provided by their PC colleagues.
    In summary, VA mental health and RCS clinicians are trained in 
disaster response, and more can be trained in these approaches. We 
anticipate Network-based planning to facilitate coordination among VA 
and non-VA facilities in response to the current or future terrorist 
attacks as well as natural disasters.
    Question 2. VA has reported that there are more than 16,000 
employees in VHA alone who are members of the Reserves or National 
Guard members. How many reservists are in other key components of VA? 
What impact will the call up of some or all of these reservists have on 
VA's ability to perform its role in an emergency? What contingency 
planning has VA undertaken to ameliorate the impact, if any?
    Answer. The figure provided at the October 16th hearing regarding 
VHA was incorrect. A further review of information provided to VA by 
the Department of Defense and verified through VA workforce information 
systems indicates that as of June 30, 2001, the total number of VA 
employees subject to military mobilization is 15,149. Of these 
individuals, 8,316 are members of the retired reserve who are 
significantly less likely to be mobilized than those in the ready 
reserve category. Based on these updated figures, VA employs 6,833 
ready reservists, of whom 296 were on active duty on November 26, 2001. 
A total of 6,215 are in VHA, 423 are in VBA, 50 are in NCA, and 145 are 
assigned to VA's staff offices.
    The Preparedness Review Working Group, chaired by Charles 
Battaglia, the former staff director of the Senate Select Committee on 
Intelligence and the Senate Committee on Veterans' Affairs, determined 
that a major call-up would adversely impact VHA. Since many of VHA's 
reservists are medical professionals, a call-up would compromise VA's 
ability to provide routine health care for veterans, acute health care 
for wounded U.S. soldiers, and emergency health care for military 
personnel and civilians wounded during incidents of domestic terrorism. 
The impact on VA's other key components is projected to be minimal. 
Ready reservists are fairly evenly spread throughout the Department's 
employee population. The workload of those called to duty would be 
distributed among fellow employees within each organization.
    To ameliorate the potential impact, VA has requested and received 
from the Office of Personnel Management delegated authority to waive 
dual compensation (salary offset) for re-employed annuitants and waive 
repayment of voluntary separation incentive payments (buyouts). 
Effective October 31, 2001, VA may use these authorities on a case-by-
case basis to temporarily replace employees called to active duty in 
security, patient care, benefit delivery, and related support positions 
when no reasonable staffing option exists to perform mission-critical 
duties.
    Question 3. This year, VA received funding to train personnel for 
the National Disaster Medical System (NDMS) for the first time--less 
than $1 million. The report of VA's Preparedness Review Working Group 
suggests that a one-time startup funding package of $18 million would 
be required to equip VA's medical centers for emergencies. 
Realistically, will these resources be sufficient if VA is asked to 
take on a more prominent role in the public health response to domestic 
emergencies?
    Answer. VA received $832,000 from HHS at the end of FY 2001 for the 
purpose of developing a training plan for NDMS hospital personnel in 
the treatment of WMD victims. VA has agreed with HHS that these funds 
will be used to conduct a WMD training needs assessment and pilot 
project. These funds are adequate for the needs assessment and pilot.
    Under the agreement transferring the funds, there is no requirement 
for equipment. This requirement is separate and distinct from the 
package of the Preparedness Review Working Group. The Preparedness 
Review Working Group estimated a cost of $118 million to equip VA 
medical facilities to support emergencies. Much of the $118 million 
would be spent on Personal Protective Equipment (PPE) for health care 
workers, establishment of decontamination facilities, and to create VA 
pharmaceutical caches to support VA medical facilities in the event of 
an attack. Although this estimate represents a one-time start up cost, 
there would be associated recurring costs with maintaining readiness 
and continued training. VA has already recognized, based on increasing 
drug costs that these costs will escalate. VA is working to re-estimate 
this cost.
    Question 4. As you confirmed at the October 16 hearing, interagency 
coordination frequently results in less than ideal partnerships. 
Although VA now has a role at the newly created Federal Office of 
Homeland Security operations center, many previous interagency public 
health preparedness planning efforts have excluded VA. What steps are 
needed to ensure that VA has a place at the planning table with FEMA, 
HHS, DOD, DOJ, and other critical agencies?
    Answer. The President's Executive Order establishing the Office of 
Homeland Security specifically names VA as a contributing agency to the 
Homeland Security Council. In addition to our presence at the Homeland 
Security Operations Center, VA is actively participating in the 
Citizens Preparedness Task Force as well as the Homeland Security 
Council's Deputies Committee and Policy Coordinating Committee. VA is 
not positioned to be a lead agency for public health preparedness, but 
it does provide considerable support to other Federal agencies in the 
event of disaster and emergency. Our primary mission remains to serve 
America's veterans and their families with dignity and compassion and 
to be their principal advocate in ensuring that they receive the care, 
support and recognition earned in service to this Nation. Nevertheless, 
VA takes its crisis response and support role very seriously, and has 
been very active in interagency emergency planning efforts including 
FEMA's Interagency Advisory Group (IAG), Continuity of Operations 
Working Group (CWG), and Federal Response Plan Emergency Support 
Function working groups. We are making progress in expanding our role 
in public health preparedness, especially in light of our participation 
in the Homeland Security Policy Coordinating Committee. We are actively 
working to join other public health related interagency working groups 
and policy coordinating committees. We expect that our role in public 
health preparedness will continue to expand; especially as other 
Federal agencies recognize VA's potential as a source of emergency 
resources, such as medical supplies and pharmaceuticals, as well as 
response capabilities.
    Question 5. The misunderstanding between on-site responders and VA 
staff during this summer's flooding in West Virginia illustrates the 
breakdown between agreements made at the agency level--such as VA's 
Memorandum of Understanding with the American Red Cross--and their 
implementation at the State and local level. Neither local VA employees 
nor the state public health professionals knew that this interagency 
agreement existed, nor what sharing of resources it might allow. What 
can be done to ensure that interagency agreements made between VA and 
its partners at the national level are communicated to state and local 
stakeholders? How does VA headquarters propagate innovative sharing 
programs developed by individual VA facilities or networks and their 
community partners?
    Answer. At the national level, the process to provide disaster 
relief and services to states and local governments by federal 
departments and agencies is through the Federal Response Plan (FRP), 
which implements the Robert T. Stafford Disaster Relief and Emergency 
Assistance Act, as amended. The memorandum between the Department of 
Veterans Affairs (VA) and the American Red Cross (ARC) was developed to 
provide a written description of mutual support and promote 
understanding and cooperation between VA and the ARC. While promoting 
volunteerism among VA employees, it also underscores that the FRP is 
the vehicle through which VA will provide requested resources made by 
or through the ARC for disaster relief. Currently, VA has no national 
policy regarding either the promotion or restriction of local VA health 
care facilities in developing independent support agreements, as long 
as they meet guidelines and legal requirements established by the 
Veterans Integrated Service Network (VISN).
    As a result of a meeting held in October of this year between West 
Virginia VA health care facilities, state representatives, and a 
representative from your staff, a memorandum of understanding (MOU) is 
under development between VISN 6 and the State of West Virginia to 
provide VA assistance for counseling and medical services for future 
disasters during the interim period prior to a Presidential Disaster 
Declaration. A new Emergency Management Guidebook, under development 
for the Veterans Health Administration, will include guidance on local 
MOU development and describe mechanisms (existing plans and agreements) 
needed to meet local requests for assistance in lieu of the existence 
of a local agreement. In fact, an entire chapter is being dedicated to 
community support activities in disasters and emergencies. It will 
include mechanisms for informing local stakeholders of national 
agreements.
    Question 6. How can VA most effectively use its partnerships with 
other federal agencies to supplement its own emergency preparedness 
efforts? For example, what technologies could VA adapt from Department 
of Defense programs to develop biological/chemical sensors, rapid 
diagnostic assays for biological exposures, or cybersecurity 
protections?
    Answer. VA's WMD preparedness is consistently enhanced by its 
collaborative efforts and partnerships with other departments and 
agencies. Through an Inter-Service Support Agreement with the DOD, the 
Domestic Preparedness hospital provider training was presented at 40 VA 
medical centers in the past year. Through a similar agreement between 
VA and DOD, a 12-hour nationwide satellite broadcast (featuring DOD and 
VA faculty) on ``Medical Response to Chemical and Biological Agents'' 
aired in November and December. Other broadcasts on chemical, 
biological, and radiation injuries have been aired in the past two 
months and have included faculty from VA and DOD.
    Question 7. We know that if VHA is to perform its fourth mission, 
and its primary mission, its doctors need good information on what has 
happened to troops in the field. How is VA working together with the 
Department of Defense to create information tools that can be used 
easily by both VA and the military?
    Answer. The key to finding out what has happened to troops in the 
field is maintaining access to a comprehensive medical record on DOD 
personnel to include: (1) health status prior to deployment; (2) 
immunizations and prophylactic medications received during deployment; 
(3) medical encounters while deployed; (4) exposure assessments of 
hazards encountered while deployed; and (5) health status upon 
redeployment. DOD has made significant progress in developing both 
policies and the information tools needed to assist in executing those 
policies. Deployment health information is maintained in the Defense 
Medical Surveillance Activity, and VHA has access to that database. In 
addition, the Government Computerized Patient Record (GCPR), which is a 
joint VA/DOD/HHS information management/information technology project, 
will facilitate electronic transfer of health information from a DOD 
database to a VHA database. At present, some health information is 
available to be transferred electronically, but additional efforts are 
underway to expand this capability.
    Another information tool, a health survey, is being employed in a 
comprehensive collaborative VA/DOD research project, the Millennium 
Cohort Study. This is a multi-year scientific protocol that will assess 
the consequences of deployments on the health of a cohort of 100,000 
military personnel. As results are made available from this study, VHA 
will be better able to address veterans' health needs.
    In addition, the DOD has developed a new system for military 
casualty management and movement to final destination hospitals in the 
United States, including those of VA. The United States Transportation 
Command Regulating and Command and Control Evacuation System 
(TRAC2ES) includes a web-based information system that 
provides details on the patient's medical condition from time of entry 
into the system until delivery at the final destination hospital. The 
system also provides the ability to update patient information while 
the patient is enroute. VA has been involved with DOD in coordinating 
and implementing this system to ensure that VA health care facilities 
that will be receiving active duty casualties will receive the latest 
information on arriving patients.
    We believe that the Military Veterans Health Coordinating Board, 
which includes representation from VA, DOD, and HHS, can play an 
important role in obtaining information on experiences and exposures of 
U.S. service personnel in the field, as well as assisting in the 
identification of resulting health care needs. Independent, non-govern 
mental organizations such as the National Academy of Sciences also 
provide important scientific information that assist VA in carrying out 
its missions. VA is working with DOD on tools to disseminate 
information in user-friendly forms, including clinical guidelines, 
pocket cards, self-study programs, and satellite teleconferences. Of 
course, the cooperating Departments will implement all appropriate 
measures to ensure the privacy and security of sensitive personal 
information.
    Question 8. Given the military's history of poor medical 
surveillance of deploying troops, what proactive steps can VA take to 
prepare to address the needs of returning service members?
    Answer. Following the Gulf War, VA has worked closely with DOD to 
address issues related to deployment health and surveillance. For 
example, the VA has collaborated with DOD to develop clinical practice 
guidelines to assess health concerns among military personnel following 
hazardous deployments, and to evaluate military personnel and veterans 
for chronic fatigue syndrome and fibromyalgia.
    In May 2001, VA announced the establishment of two dedicated 
research centers, the Centers for the Study of War-Related Illnesses, 
to respond to the health problems of military veterans and to improve 
the health care of active duty personnel and veterans with war-related 
illnesses. Because these illnesses have to be studied with the same 
scientific rigor American medicine has applied to other health 
problems, the Centers have four major components focusing on veterans' 
health issues: research, clinical care, risk communication, and 
education. The two Centers are located at the East Orange, NJ, and 
Washington, DC, VA Medical Centers.
    A major factor in influencing VA's decision to establish these 
centers included the need to develop better ways of meeting the health 
needs of war veterans, particularly veterans with difficult to diagnose 
symptoms. Historical studies demonstrate that since at least the U.S. 
Civil War, veterans have returned home with unexplained symptoms. From 
this experience we have learned that combat casualties do not always 
result in obvious wounds, and that some veterans inevitably return with 
difficult to diagnose yet nevertheless debilitating symptoms. We do not 
yet fully understand the causes of many of the illnesses suffered by 
veterans returning from wars and hazardous peacekeeping missions.
    In addition to the new research centers, VA is committed to sharing 
with America's military veterans and their families the information 
that we have relating to their health problems and concerns. VA's 
Office of Public Health and Environmental Hazards has published a 
national newsletter regarding Agent Orange issues for 19 years and a 
national Gulf War newsletter for about 9 years. This office also has 
produced fact sheets, brochures, videotapes, posters, and web pages on 
these subjects.
    VA is currently planning similar publications for veterans serving 
in Afghanistan and surrounding areas. The first product will be a new 
fact sheet and brief on health issues related to service in 
Afghanistan. It will cover infectious diseases and environmental 
hazards that U.S. service members may encounter in that region of the 
world.
    Question 9. Have VA's existing emergency preparedness programs and 
recommendations been implemented equally throughout the service 
networks?
    Answer. VA has established national emergency preparedness programs 
and provided implementation guidance commensurate with existing 
directives. For example, each VISN has a separate Service Support 
Agreement (SSA) with the Emergency Management Strategic Healthcare 
Group (EMSHG) defining mutual support. In essence, EMSHG provides the 
emergency preparedness expertise and guidance in return for 
administrative support. The implementation of emergency preparedness 
programs has relied heavily on VISN and medical facility directors' 
prioritization related to the use of limited resources for associated 
equipment, training, and exercises. Consequently, the status of these 
programs varies somewhat by location.
    In order to develop more consistent implementation, VHA is 
developing policies and guidance in the form of a Directive to define 
the requirements that all VISNs must meet. VHA is also developing a 
Guidebook to provide sample policies, procedures and methods to meet 
new JCAHO standards and also ensure more consistent outcomes across all 
facilities.
    Question 10. There is a delicate balancing act to be pursued in 
readying VA medical centers for surges in patient demand. How will you 
ensure that you have sufficient staff and medical supplies on hand to 
deal with a disaster without depleting VA's already limited resources 
to care for veterans?
    Answer. A surge in medical requirements within VA could come from 
two primary sources, local casualties who come to VA medical centers, 
or the VA/DOD Contingency Hospital System, which accepts military 
casualties returning from overseas.
    Under the VA/DOD Contingency Hospital System, some stabilized 
patients would be transferred from designated Primary Receiving Centers 
to Secondary Receiving Centers and other steps, such as postponing 
elective surgeries, would be implemented to free medical center assets. 
VA's Prime Vendor system could be used to obtain necessary supplies 
very quickly. Overseas casualties would be expected to arrive in groups 
through available air transportation, allowing some time for VA medical 
centers to adjust staffing and supply levels. There is no doubt, 
however, that the greater the requirements, the greater the strain will 
be on the VA healthcare system.
    Question 11. How can Congress modify existing law so as to gain a 
better estimation of how many active duty or civilian casualties VA 
might be able to treat during a conflict or domestic crisis, rather 
than simply counting beds as under current law?
    Answer. In order for hospital beds to be an asset in an emergency 
crisis or contingency, they must be ``staffed,'' and equipped beds, and 
the capability must exist to transport patients to those beds 
expeditiously. In other words, the medical capability must exist and be 
accessible to the patient. However, the ratio of related services to 
beds is a difficult measurement given that medical and relative 
capability is often subjective, such as in the case of multi-purpose 
hospital beds. In addition, accessibility will likely be dependent on 
air transport availability that may be unpredictable. Estimates may be 
improved with the use of standardized reporting requirements and 
periodic evaluation of resultant data.
    Question 12. Given VA's existing communications infrastructure 
(including its telehealth capabilities), its broad geographic presence, 
and its pivotal role within the Federal communications centers system 
during presidentially declared disasters, do you see a larger mission 
for VA in fortifying communications between Federal, state, and local 
responders? Is there a need to highlight VA's current communications 
functions to other Federal agencies and state and local front-line 
responders?
    Answer. VA facilities are integral parts of each community, the 
hospital systems, cooperative medical education efforts, and mutual 
support agreements at the local government level. In emergency medical 
planning, VA's Area Emergency Managers (AEMs) routinely work with 
local, county, and state officials and cooperate in many joint training 
and exercise initiatives.
    With its communications infrastructure, clinical resources and 
telehealth capabilities, VA is in a position to play an increased role 
within the federal communications centers system during presidentially-
declared federal disasters. We have asked EMSHG to consider these 
issues and to make appropriate recommendations in this area.

    Chairman Rockefeller. Can you just describe to me the 
interagency planning process? I hope that you can do this 
without damaging yourself, your agency, and your future working 
relationships, but I have been stunned in the last 4-plus weeks 
at the number of agencies that seem to have fully designated 
power to do virtually anything. I am wondering what happens 
when agency leaders sit down and decide, all right, who is 
going to do what? How are resources going to be allocated?
    In other words, what I am really asking you is, from the 
VA's perspective, when you went to HHS, who decided what 
responsibilities and powers VA would have? I have a feeling 
that the VA has been left out of some of that decisionmaking. 
You do not have to answer that, but that is my view in what 
they bring to the table in these situations. How does your view 
of the interagency system of response work? Has it been as ad 
hoc as I think? Maybe it has been ad hoc because there has been 
no other choice, there not having been a similar experience. 
What are your views?
    Mr. Principi. I do not know, but certainly a similar 
experience in recent history, the Galveston floods that killed 
hundreds of thousands of people. I believe that the response, 
the interagency cooperation, the response of this crisis was 
quite good from my perspective.
    I think it is very important that VA be at the table, and 
not for recognition or credit purposes, but to realize VA is 
the largest health care system completely under Federal 
control, 1,200 sites around this Nation and in most communities 
in America, with 200,000 people under Federal control that may 
be used to respond to these crises. So I think it is very, very 
important that VA be at the table and I am optimistic under 
Director Tom Ridge's leadership that VA will be at the table, 
perhaps not as a member of the permanent council, but certainly 
to discuss the role we can play in responding to crises.
    Perhaps Dr. Murphy, from her experience in recent years at 
VA, can talk about how we work with the Federal Response Plan 
and the National Disaster Medical System in a coordinated way.
    Chairman Rockefeller. And when you do that, could you 
answer a further question, Dr. Murphy? I apologize for not 
introducing you. There has been an awful lot of talk about PTSD 
and that fear is not linear, it comes in waves and it affects 
different people in different ways at different times and you 
could be far away from it and be affected, be close to it and 
not be affected. But PTSD is going to be a very major part of 
the psycho-social work which is done on all of this. There is 
nobody that even touches the VA in terms of PTSD.
    I went through an hour's meeting this morning in which all 
these things were discussed and VA was never mentioned. They 
were not there and they were never mentioned. I am wondering 
what your thoughts are about that, even as you respond to what 
the Secretary asked you to.
    Dr. Murphy. First, related to the Federal Response Plan, I 
think the plan was very good in that it organized a coordinated 
response to a national emergency and designating particular 
agencies to take the lead. As far as it went, I think when 
employed, the Federal Response Plan can work well.
    The VA has three, or actually four areas of responsibility 
under that plan in the emergency support functions, including 
public works and engineering, mass care, resource support, and 
health care and medical services. We are not the principal 
agent in any of those areas. We are a support agency.
    For the mass care, the American Red Cross is the principal, 
and for health and medical services, the principal agency is 
HHS. Sometimes there is confusion between those two functions. 
Let me give you an example related to trauma counseling.
    We recently got a request from the American Red Cross that 
they needed some trauma counselors, and, in fact, that is not 
in their principal area or in their emergency support function. 
The request should have come through HHS under the Federal 
Response Plan. We cannot instruct VA employees to volunteer to 
provide trauma counseling under the auspicies of the American 
Red Cross. Many VA employees, thousands of them, stepped up and 
wanted to volunteer their services after September 11. However, 
VA has no authority to officially direct our employees to 
volunteer, either to the Red Cross or other non-government 
organizations. We do not have that authority.
    In order for us to respond to that request under the 
Federal response plan, the request must be for Health and 
Medical Services Emergency Support Function through HHS. We can 
find ways to work around some of those authorities, but 
sometimes it does create significant logistical difficulties. 
In general, we can make it work. With effort, make it work 
well.
    Related to PTSD and trauma counseling, we have not yet seen 
the full impact of the injury that resulted from the attacks on 
September 11. Clearly, we have learned from our experience with 
veterans and also from the Oklahoma City bombing, we do not 
expect the full impact of this to begin until 3 to 6 months 
after the attack. That is when the full impact of the trauma 
will start to be seen and when the real peak in people 
requiring mental health services will occur.
    We know that after the Oklahoma City bombing, the number of 
requests for mental health services more than tripled in our 
veteran population. If you consider the number of people who 
are impacted by this event, either directly in New York or 
across the country by watching it on TV, the mental health 
impact and the injury related to that is going to be enormous. 
We need to start working together to plan for that impact.
    Chairman Rockefeller. Thank you.
    Senator Specter?
    Senator Specter. Thank you very much, Mr. Chairman, and 
thank you for convening this hearing. Earlier today, FEMA 
Director Joe Allbaugh appeared before the Environment and 
Public Works Committee discussing this subject, and the 
Appropriations Subcommittee on Labor, Health, Human Services, 
and Education has scheduled a hearing for Friday to look into 
what sort of appropriations are necessary. I think it is very 
important--as do you, as shown by your having convened this 
meeting--to focus on what areas of responsibility VA will have, 
and I think it is also helpful to VA to have these kinds of 
questions so that it may rethink where it is going.
    When the Gulf War was upon us, I traveled around the 
country. I was ranking member then--I am still ranking member, 
there was a hiatus in between, however----
    [Laughter.]
    Senator Specter [continuing]. And I recall visiting 
hospitals at that time. It was a decade ago. My fondest 
recollection was going to the Veterans Administration hospital 
in Wichita, KS, if I may digress from relevancy, if that is 
ever a concern here in the Senate, where my father was treated 
in 1937 when a spindle bolt broke on his truck and it rolled 
over on him, crushing his arm, and I used to ride a bicycle 
miles out to the VA hospital, which was way beyond the 
outskirts of town. Now it is part of the city of Wichita, and I 
found the records when he was admitted. I think it was August 
7, 1937.
    But coming back to relevance, at that time, the VA was 
concerned about the possibility of having many servicemen and 
women coming back. That appears unlikely now, hopefully, that 
we will not be fighting that kind of war. But should the 
situation change, would you be in a position to have hospital 
space available to treat wounded service personnel if this war 
on terrorism takes that turn?
    Mr. Principi. We certainly can care for a certain 
percentage of those servicemen.
    Senator Specter. Well, Mr. Secretary, that depends upon how 
many there are, as to what the percentage is. But in absolute 
numbers in beds, how many beds could you make available if the 
necessity arose?
    Mr. Principi. We have reported to DoD that we can make 
7,500 beds available within 72 hours of request. Now, I have 
the authority as Secretary to give a priority to servicemen and 
women wounded in battle over non-service-connected veterans. 
They cannot take precedent over service-connected disabled 
veterans, but it is conceivable that based upon the number of 
casualties, we could increase that number over a period of 
time. We have roughly 20,000 acute care hospital beds. We have 
additional bed capacity if those beds were staffed. So 
certainly with 72 hours or about 72 hours, 7,500 beds would be 
made available.
    Senator Specter. With respect to the Office of Homeland 
Security that has been mentioned here, last Friday, the 
Government Affairs Committee held a hearing on legislation 
which has been introduced to give some structure to what is 
going on there. Senator Lieberman and I introduced legislation 
last Thursday on the concern that even though Governor Ridge 
has the confidence of the President and people may say no to 
him and not to the President, it is hard to go to the President 
every time there is an interagency dispute.
    Would you confirm that? When you have interagency battles, 
are you able to go to the President with regularity to have 
them resolved either for or against you?
    Mr. Principi. I pick and choose my battles that I take to 
the President very carefully, of course.
    Senator Specter. Are you picking and choosing your 
questions and answers, too? [Laughter.]
    Mr. Principi. If need be, I will go to the President and 
fight for my Department, but----
    Senator Specter. Have you been asked by Governor Ridge to 
join his effort? Has he sought your resources, if not your 
counsel?
    Mr. Principi. No.
    Senator Specter. How about the issue of pharmaceuticals? 
That was a big topic. Senator Rockefeller and I spent a good 
part of the morning trying to figure out what is happening with 
the anthrax attack on Senator Daschle, and it is a little hard 
functioning today since I do not have an office. We are 
displaced. My staff is coming under the displaced worker 
legislation the way it looks now. [Laughter.]
    But do you have antibiotics----
    Mr. Principi. Yes, we do.
    Senator Specter [continuing]. In large quantity? How many 
people could you take care of if the worst came on an anthrax 
problem?
    Mr. Principi. Yes, we do. I will ask Dr. Murphy if she has 
the precise number. We stockpile four caches of 
pharmaceuticals, medical/surgical supplies for the National 
Disaster Medical System. We do a lot of the procurement of the 
pharmaceuticals for HHS. We have antibiotics, of course, in all 
of our medical centers. As for the number of patients we can 
treat I will defer to Dr. Murphy.
    Dr. Murphy. VA manages the Office of Emergency Preparedness 
and CDC pharmaceutical caches, but would deploy them at the 
instruction of those two organizations. We do have limited 
supplies of pharmaceuticals and other medical supplies at our 
medical centers.
    One portion of the plan that we have developed at Secretary 
Principi's request recommends that we have caches of 
pharmaceuticals at each of our medical facilities for use in 
carrying out our primary mission, veterans health.
    Senator Specter. And how many people can you care for if 
the need arose?
    Dr. Murphy. I would be happy to provide a separate briefing 
on the full scope of what we are proposing and the number of 
people that we would propose to treat.
    Senator Specter. Thank you. My red light is not on. I see 
that Senator Rockefeller's chairmanship has a kindler and 
gentler lighting system. The red light does not go on.
    Chairman Rockefeller. Well, I was talking too much and not 
giving Fran and Tony enough time to answer, so I intervened 
that way. Senator Nelson?
    Senator Nelson. Thank you, Mr. Chairman.
    Obviously, there is a lot of concern about pharmaceuticals 
and being in a position to back up not only the Department of 
Defense, but also for public concerns, as well. Who is 
responsible for determining the medical supplies that are being 
kept at the National Pharmaceutical Stockpile and is there a 
process that does not involve national security for determining 
what medical supplies should be included and to what extent, 
quantities and procedures in place?
    Dr. Murphy. Those caches are actually under the control of 
HHS. We do the procurement for the CDC caches and we actually 
manage the OEP caches. CDC has a group of experts who determine 
the specific contents of each of those pharmaceutical 
stockpiles will be. I think it is well developed and well 
focused.
    Senator Nelson. In terms of the quantities and what might 
be available in the case of some critical outbreak, who 
determines what the supplies might be and what the potential 
outbreak requirements might be?
    Dr. Murphy. Again, the determination for the national 
response is made by HHS, and I believe that Secretary Allen is 
prepared to tell you about some recent changes that they have 
proposed, going from 2 million doses currently available in the 
CDC caches to 12 million, but I will let him give you further 
details on that.
    We would, within our Department, determine the content of 
our local supplies and also the quantities required for our 
immediate response for our staff, our veterans and any walk-in 
patients.
    Senator Nelson. So there is coordination between what would 
be internal or for veterans and what would be external beyond 
veterans' needs?
    Dr. Murphy. Yes. As VA developed our internal guidance on 
caches, we reached out to the Department of Defense and HHS 
experts and coordinated the response with them.
    Senator Nelson. Now, would that apply to any American 
civilians living abroad, such as diplomats in American 
embassies in foreign lands?
    Dr. Murphy. The State Department would have jurisdiction 
over that particular issue and I do not know enough about the 
details of their system to speak knowledgeably about it. Maybe 
Secretary Allen can answer that question.
    Senator Nelson. Thank you, Mr. Chairman.
    Chairman Rockefeller. Thank you, Senator Nelson.
    I want to again pursue what I brought up before and then 
give one other question. I am worried that VA is not at the 
table enough. Tell me if you disagree, and there is an HHS 
secretary coming right up afterwards and he will have a chance 
to shoot me down and put me in my place. But I think it is true 
to say that HHS has been wanting to get into the emergency 
preparedness business for a long time and they are there. My 
question is, are they bringing the public health community 
sectors with them that they need?
    My judgment is that VA is not at the table. As you said, 
Mr. Secretary, VA is the largest health care system in the 
entire country, with everything at its disposal, and you are 
not--in my judgment--at the table enough when decisions are 
being made. I place part of that blame upon HHS and their 
unwillingness to reach out. I do not understand that. I think 
Tommy Thompson is one of the President's great, great 
appointments, like you. I think he is terrific. I was thrilled 
when he was nominated. But I do not understand that and I want 
to get your view on that.
    Second, Julie Fischer just gave me this perfect segue, 
Fran, for you. You indicated that PTSD does not take place for 
6 months, in that range, but mental health stress, all kinds of 
other things surely do. You have elevated PTSD to a much more 
sort of formal description than I was thinking of. I was 
thinking of shorter-term needs.
    We had in West Virginia an experience during our floods 
that I want to relay to you. During those floods, the VA mental 
health counselors wanted to volunteer but they could not. They 
could not because, No. 1, the American Red Cross--to which I 
made my contribution and everybody else did and they did a 
wonderful job--would not answer their telephone calls. Second, 
unless VA staff were certified by the Red Cross, they could 
counsel nonveterans. Well, I do not assume that any of those VA 
folks who wanted to go out and be helpful in a devastated one-
third of West Virginia were certified.
    This kind of thing makes me very, very angry because it 
shows how rigid we can be when all circumstances call for us to 
become less rigid and adjust and, in fact, for people like the 
Secretary and yourself to be able to make ad hoc decisions for 
which you may later be dragged across the carpet, but you could 
care less because you know you did the right thing. You know 
you did the right thing.
    I remember once--not just once--when I was Governor that we 
had terrible floods in 1977. I condemned coal property up on a 
mountain. I condemned it. Nobody had ever done that before. It 
was considered heretical. Four years later, out of the how many 
millions dollars being spent by lawyers on all sides, the 
Supreme Court upheld us. The land was condemned. We built 
houses. People moved up there, lived there, got out of the 
flood plains.
    Now, I am not trying to make a hero of myself, but I am 
simply saying sometimes you have to do things which are not in 
anybody's book. They are odd. They cause tensions. They cause 
people to get upset. It does not make any difference if you are 
doing the right thing because we have never been through 
September 11 before.
    And I want to get your response, and I hope the light will 
go off so as not to embarrass me again, about why it is that we 
do that. People are looking to the Federal Government for 
leadership and they are finding great leadership and you have 
done great things, but we could be doing much better things and 
we ought to be. The whole question of making government less 
rigid, letting us cross barriers, paying the consequences 
later, all of that strikes me as a normal consequence and 
responsibility for a post-September 11 behavior.
    Mr. Principi. I agree with your assessment about Secretary 
Thompson. I think he is indeed one of the finest cabinet 
secretaries I have the privilege of serving with. I believe as 
Governor of the State of Wisconsin, he had a deep appreciation 
for the role of VA and I am confident we are going to see VA 
play an important role alongside the Department of Health and 
Human Services in responding to these tragedies.
    I agree with you, Senator. VA is a national resource. It is 
very large. Again, it is under Federal control and it would be 
a tragedy if we did not utilize this Department to its maximum 
ability to respond to crises. So you are right.
    Are we at the table as much as we should be? Probably not. 
Is there good cooperation? I think so, and I expect to ensure 
that our voice is heard and that we can play a role. Again, we 
do not need to take the lead role. That is the role for HHS. 
But we need to be there as their partner in responding to 
tragedy because it is going to take all of the elements of 
government to come together if we are going to succeed. As I 
indicated at the outset, if there were more casualties, I think 
it would have overwhelmed the whole system, so we are all going 
to have to be in this together to respond to this type of 
tragedy.
    As far as crossing the line and doing what is right, I 
agree with you there. I think Mayor Giuliani demonstrated----
    Chairman Rockefeller. He sure did.
    Mr. Principi. The whole command center was in the World 
Trade Center and it was destroyed, and within 24 hours, he 
mobilized that city and created a new command center and just 
said, ``Make it happen.'' He did not care how it happened, but 
within 24 hours, three football fields were at the Federal 
agencies, State and local agencies, military, VA, Red Cross 
were all on the same pier providing services to the citizens of 
New York. That would not have happened without strong 
leadership who said, ``Make it happen.''
    Our people in New York did that. They pulled citizens off 
the street. They did not ask, ``Are you a veteran or are you a 
nonveteran?'' They just said, ``Do you need help? We are here 
to help you.'' That is the kind of leadership I look for in VA 
and that is what we are going to do over the next 4 years.
    Chairman Rockefeller. He is well-knighted, Mayor Giuliani. 
He is.
    Did you have any further questions?
    Senator Specter. No, thank you, Mr. Chairman. I do not.
    Dr. Murphy. I would say just a few more words about PTSD. 
We have approximately 400-plus trauma counselors in VA and 
thousands of mental health professionals. The American Red 
Cross requires that their certification program be completed by 
people who wish to volunteer for their activities.
    Chairman Rockefeller. Why?
    Dr. Murphy. Well----
    Chairman Rockefeller. I mean, what is so sacred?
    Dr. Murphy. They have a training course that they believe 
in.
    Chairman Rockefeller. That is standard.
    Dr. Murphy. It is standard for the Red Cross. When a VA 
employee volunteers for the American Red Cross, that employee 
is no longer under our jurisdiction as VA staff they become a 
private citizen volunteer. In fact, as a volunteer they no 
longer have the liability protection of a Federal employee 
because they are functioning outside of their Federal 
responsibilities and as a volunteer to the American Red Cross. 
The Red Cross uses their certification as an entre into their 
system and as a means to ensure that their volunteers have the 
minimum skills required.
    Chairman Rockefeller. I am sorry. I find that repugnant. 
They cease to be VA employees in order that the Red Cross can 
count them as volunteers, and, of course, therefore they would 
not do that because they work for the VA.
    Dr. Murphy. Many of our employees do volunteer their time 
under the auspices of the American Red Cross. Secretary 
Principi has also given us the authority to provide 
humanitarian assistance in New York and in Washington under our 
own services and authority.
    I did not mean to suggest that PTSD occurs only in the 
chronic condition but that there is a peak later in time. 
Clearly, there is an acute form of PTSD and stress response. In 
fact, I have recently heard an astounding statistic that there 
were 1.9 million new prescriptions for anti-depressants in the 
country since mid-September and over two million anti-anxiety 
drug prescriptions and sleep medications prescribed. Clearly, 
the 9/11 events are already having an impact and we need to 
address the acute problems, but I would like everyone to 
recognize that the full magnitude of injury has not yet been 
realized.
    Chairman Rockefeller. That is extremely helpful. I thank 
you both very, very much. These hearings are unfair to you 
because you do not get to say what you really want to say----
    [Laughter.]
    Chairman Rockefeller. No, no, I am not doing my usual OMB 
number. I am just saying that there are more things that you 
would like to say--for example, what you just said, which is 
very, very helpful. The hearing process is not friendly to 
allowing you to say that and I regret that.
    The next panel is the Honorable Claude Allen, who is Deputy 
Secretary of Health and Human Services; the Honorable David 
Chu, Ph.D., Under Secretary of Defense for Personnel and 
Readiness; and Bruce Baughman, who is Director of the Planning 
and Readiness Division, Readiness, Response, and Recovery 
Directorate of FEMA.
    Gentlemen, you are all welcome. Your statements are in the 
record and we welcome, with discretion of time, what you have 
to say.

 STATEMENT OF CLAUDE A. ALLEN, DEPUTY SECRETARY OF HEALTH AND 
                         HUMAN SERVICES

    Mr. Allen. Mr. Chairman, Senator Specter, members of the 
committee, thank you for this opportunity to appear before you. 
I will try to be very brief and to address your question 
specifically as it relates to the mission of HHS and our 
relationship with the Veterans Administration, DoD, and other 
partners.
    The events of September 11 clearly bring us to a point that 
we are looking at our preparedness, our state of readiness, and 
I think that what was demonstrated there is that the system 
does work, that there are areas where the system needs to be 
improved, but it certainly does work.
    With regard to what happened in New York, is New York City 
took the lead in responding. They were the first to respond and 
they were the first to make decisions. The State brought their 
resources to bear, at that time. At the Federal level, we 
positioned our resources there, as well. In fact, 2 days after 
that event, Secretary Thompson and I traveled to New York. We 
met with Mayor Giuliani and his Health Director. We met with 
the State Health Director, Commissioner of Health, and other 
professionals and were able to be responsive on the spot to 
their needs with regard to providing them with epidemiologists. 
Some of our epidemiological officers are positioned in New York 
to do surveillance of conditions coming into the emergency 
rooms. We were also able to begin working with them in response 
to some of the immediate mental health challenges that were 
incurred, in addition to beginning to address the longer-term 
questions of post-traumatic stress syndrome.
    What I want to say is that while the Federal response there 
was very quick and very swift, it was very much in the 
background. Much of what was going on on the front lines was 
led and headed appropriately by the local government and the 
State government. But with the assistance of VA and other 
Federal partners, we were present and continue to be present 
there in providing services and assistance.
    Under Secretary Thompson's leadership, as you already 
identified, our Department has changed considerably in how we 
are working and moving toward addressing the needs of America 
in this era of terrorism and bioterrorism. And as you know, 
Congress will appropriate $20 billion toward recovery efforts 
and preparedness measures. To ensure the safety and well-being 
of Americans here at home and abroad, the administration will 
request more than $1.5 billion in new funds for bioterrorism 
preparedness at the Department of Health and Human Services. 
When combined with the administration's original request of 
$345 million, HHS will be provided a total of $1.8 billion in 
fiscal year 2002.
    Let me highlight just a few areas in which this money will 
be spent. Part of the money will go directly toward augmenting 
the National Pharmaceutical Stockpile, which will include about 
$643 million to expand the existing stockpile. This is going to 
include adding to the already existing eight push packs of 
medicine and supplies that are stationed throughout the Nation. 
Indeed, one of those push packs was moved to New York within 7 
hours of the disaster. This money will also be used to provide 
enough anthrax antibiotics for treatment of 12 million people 
for a 60-day period, which is an increase from our current 
supply of 2 million coverage with a 60-day supply. In addition, 
we will also initiate additional procurement of smallpox 
vaccine and other essential pharmaceuticals.
    Our relationship with VA and DoD and other Federal partners 
is one that is very important to the Department. Our 
preparedness in domestic circumstances is very different than 
what the VA's mission is with regard to supporting our 
veterans. While HHS is really the lead under the Federal 
Response Plan for a domestic health response, that is done in 
coordination with VA and DoD.
    Again, a good example of that is the floods in Houston just 
last year. The VA was a very crucial partner in responding to 
that emergency. And indeed, what they were able to provide 
there included nothing short of providing basic hospital 
services when that area was not able to handle the treatment of 
people needing care.
    And so there are many areas that we will find that VA and 
its services--its abilities--will be brought to the fore in a 
time of emergency, but it all depends on what the immediate 
need is from the local and State government. We are positioned 
to move anywhere in the country, but we will work closely with 
State governments and local governments to do that and not 
undermine what might be a very good system already in place. We 
will simply be there to support and to augment that.
    Let me stop there and see if there are any additional 
questions that you may have that I can answer, but I would be 
glad to address any specific issues you may have.
    [The prepared statement of Mr. Allen follows:]
Prepared Statement of Claude A. Allen, Deputy Secretary, Department of 
                       Health and Human Services
    Mr. Chairman and Members of the Committee, I am Claude A. Allen, 
Deputy Secretary of the Department of Health and Human Services (HHS). 
I am pleased to be here today to discuss the role of HHS's Office of 
Emergency Preparedness (OEP) in the Federal Response Plan.
    The nation watched in disbelief, on the morning of September 11th, 
as American Airlines flight #11 crashed into the North Tower of the 
World Trade Center. As we all know, shortly thereafter, United Airlines 
flight #175 crashed into its twin building. Within minutes, we had 
activated our Department's Emergency Operations Center (EOC), knowing 
that our Department and our National Disaster Medical System (NDMS) 
partners in the Department of Veterans Affairs (VA), the Department of 
Defense (DoD), and the Federal Emergency Management Agency (FEMA) might 
be called upon to assist New York City in its response.
    By the end of that tragic morning, with the almost simultaneous 
crashes of American Airlines flight #77 into the Pentagon, the crash of 
United Airlines flight #93 in Pennsylvania and the collapse of the 
World Trade Center buildings, Secretary Thompson had ordered activation 
of the entire NDMS, including notification of all of its 7,000 
volunteer health workers and 2,000 hospitals. Verbal mission 
assignments were being obtained from FEMA, and teams were beginning to 
prepare to move during that day to staging areas around New York City 
and within Washington, D.C. It is a day that witnessed heroic actions, 
rapid responses, and profound grief.
                     hhs preparedness and response
    HHS agencies that play a key role in our Department's overall 
bioterrorism preparedness include the Office of Emergency Preparedness 
(OEP), the Centers for Disease Control and Prevention (CDC), the Food 
and Drug Administration (FDA), and the National Institutes for Health 
(NIH). HHS is the primary agency responsible for health and medical 
response under FEMA's Federal Response Plan. This plan provides HHS, 
along with FEMA, 26 other Federal Departments and agencies, and the 
American Red Cross, with a framework to respond to an emergency.
    The broad goals of a national response to an emergency, including 
acts of terrorism, or any epidemic involving a large population, are to 
detect the problem, control the epidemic's spread and treat the 
victims. At HHS, our efforts are focused on improving the nation's 
public health surveillance network to quickly detect and identify the 
biological agent that has been released; strengthening the capacities 
for medical response, especially at the local level; expanding the 
stockpile of pharmaceuticals for use if needed; expanding research on 
disease agents that might be released; developing new and more rapid 
methods for identifying biological agents and improved treatments and 
vaccines; improving information and communications systems; and 
preventing bioterrorism by regulation of the shipment of hazardous 
biological agents or toxins. HHS has also worked to forge new 
partnerships with organizations related to national security.
    We are striving at HHS to strengthen our readiness and response, 
and our ability to respond has been greatly improved over the last 
several years. The system is not perfect, however, and we must continue 
to accelerate our preparedness efforts.
    As you know, much of the initial burden and responsibility for 
providing an effective response by medical and public health 
professionals to a terrorist attack rests with local governments, which 
would receive supplemental support from state and federal agencies. 
However, if a disaster or disease outbreak reaches any significant 
magnitude, such as what occurred on September 11th, local resources 
could be overwhelmed and the federal government may be required to 
provide protective and responsive measures for the affected 
populations.
       office of emergency preparedness role in federal response
    Within my Department, the Office of Emergency Preparedness is the 
primary agency responding to requests for assistance and resources. 
OEP's main function is to manage the National Disaster Medical System 
(NDMS) as well as the Public Health Service Commissioned Corps 
Readiness Force, which could be called into action depending upon the 
severity of the event. One of OEP's missions is to manage and 
coordinate, on behalf of HHS, the federal health, medical, and health 
related social service response and recovery to major emergencies, 
federally declared disasters and terrorist acts. OEP directs and 
manages Emergency Support Function #8 (health and medical services) of 
the Federal Response Plan. This includes coordinating the activities of 
12 other federal departments nationwide, including the Departments of 
Veterans Affairs, Defense, Transportation, Energy, and Agriculture, the 
Environmental Protection Agency, and others.
    When there is a disaster, FEMA, as the Nation's consequence 
management and response coordinator, tasks HHS to provide critical 
services, such as health and medical care; preventive health services; 
mental health care; veterinary services; mortuary activities; and any 
other public health or medical service that may be needed in the 
affected area. OEP, as the Secretary's action agent, will direct NDMS, 
the Public Health Service's Commissioned Corps Readiness Force, and 
other federal resources, to assist in providing the needed services to 
ensure the continued health and well being of disaster victims.
    The National Disaster Medical System is the vehicle for providing 
resources for meeting the medical and mental health service 
requirements of ESF #8, including forensic services. Begun in 1984, 
NDMS is a partnership between HHS, VA, DoD, FEMA, state and local 
governments, and the private sector. The System has three components: 
direct medical care; patient evacuation; and the non-federal hospital 
bed system. NDMS was created as a nationwide medical response system to 
supplement state and local medical resources during disasters and 
emergencies, to provide back-up medical support to the military and VA 
health care systems during an overseas conventional conflict, and to 
promote development of community-based disaster medical systems. The 
availability of beds in over 2,000 civilian hospitals is coordinated by 
VA and DoD Federal Coordinating Centers. The NDMS medical response 
component is comprised of over 7,000 private sector medical and support 
personnel organized into approximately 70 Disaster Medical Assistance 
Teams, Disaster Mortuary Operational Response Teams, and speciality 
teams across the Nation.
                        disaster response teams
    Our primary response capability is organized in teams such as 
Disaster Medical Assistance Teams (DMATs), specialty medical teams 
(such as those that would provide burn and pediatric care), and 
Disaster Mortuary Teams (DMORTs). Our 27 level-1 DMATs can be 
federalized and ready to deploy within hours and can be self-sufficient 
on the scene for 72 hours. This means that they carry their own water, 
portable generators, pharmaceuticals and medical supplies, cots, tents, 
communications and other mission-essential equipment. These teams have 
been sent to many areas in the aftermath of disasters in support of 
FEMA-coordinated relief activities. In addition, staff from OEP and our 
regional emergency coordinators also go to the disaster sites to manage 
the team activities and ensure that they can operate effectively.
    OEP's National Medical Response Teams (NMRTs) can provide medical 
treatment after a chemical or biological terrorist event. Each one is 
fully deployable to incident sites anywhere in the country with a cache 
of specialized pharmaceuticals to treat up to 5,000 victims of chemical 
exposures. The teams have specialized personal protective equipment, 
detection devices and patient decontamination capability.
    Our mortuary teams can assist local medical examiner offices during 
disasters, or in the aftermath of airline and other transportation 
accidents, when called in by the National Transportation Safety Board 
and the Federal Bureau of Investigation.
    In the last few years, OEP has deployed to New York, Florida, 
Texas, Louisiana, Alabama, Mississippi, the Virgin Islands and Puerto 
Rico in the aftermath of hurricanes and tropical storms. Our mortuary 
teams and management support teams have deployed to Rhode Island, 
Pennsylvania and California to assist local coroner offices after 
airline crashes. And we have supported local and federal efforts during 
special events such as World Trade Organization meetings, NATO 50th 
Anniversary events, Democratic and Republican National Conventions, 
Presidential inaugural events, and State of the Union Addresses in 
Washington, D.C. Most recently, OEP and NDMS have deployed to Texas to 
respond to the health and medical needs caused by Tropical Storm 
Allison, and to New York, Pennsylvania and Virginia in the aftermath of 
the horrors of September 11, 2001.
                        ndms agency partnerships
    HHS, through OEP, manages and provides medical and mental health 
services, and mortuary services during disasters, and DoD has the lead 
responsibility for patient evacuation activities. DoD and VA share 
responsibility for definitive care activities, including managing a 
network of about 2,000 non-federal hospitals to ensure that hospital 
beds can be made available through a system of Federal Coordinating 
Centers (FCC). In addition, the VA provides other needed medical 
support during disasters. During the response to Tropical Storm 
Allison, the VA provided additional staffing to our Emergency 
Operations Center, dozens of additional medical and nursing personnel 
at the scene, and opened its VA hospital in Houston to receive patients 
when a majority of the hospitals in the Houston area were flooded and 
not able to receive patients. Currently, the VA is actively involved 
with us in New York City and in Washington, D.C. They have provided 
staff for our ESF #8 EOC, area managers to assist our Management 
Support Team in New York, mental health experts and crisis counselors, 
and nurses to treat burn patients both in New York and Washington.
    The VA is partnering with OEP on other activities as well. The VA 
is one of the largest purchasers of pharmaceuticals and medical 
supplies. Capitalizing on this buying power, OEP and VA have entered 
into an agreement under which the VA manages and stores the four 
National Medical Response Team specialized pharmaceutical caches. The 
VA has purchased all of the pharmaceuticals and supplies, rotates the 
stock, maintains the inventory, ensures the security of the caches and 
ensures that the caches are ready for deployment. Additionally, during 
FY 2001, OEP provided funds to the VA to begin to develop plans and 
curricula to train NDMS hospital personnel to respond to WMD events.
                          other oep activities
    OEP is working on a number of fronts to assist local areas 
hospitals, and medical practitioners to effectively deal with the 
effects of terrorist acts. HHS is taking the necessary steps to prepare 
our Nation for the health effects of terrorism, recognizing that should 
a chemical, nuclear, or bombing terrorist event occur, our cities and 
local metropolitan areas would bear the brunt of coping with its 
effects. In addition, we realized that the local medical communities 
would be faced with severe problems, including overload of hospital 
emergency rooms, medical personnel injured while responding, and 
potential contamination of emergency rooms or entire hospitals. 
Consequently, in FY 1995, HHS began developing the first prototype 
Metropolitan Medical Response System (MMRS). These systems, managed by 
local governments, are capable of providing triage and patient 
decontamination, population-based pharmaceutical prophylaxis and 
necessary medical care. In fact, the health care capacity issues that 
they are addressing are important regardless of the cause of mass 
casualties--for example, earthquakes, disease pandemics or terrorist 
events. To date, OEP has contracted with 97 of the Nation's largest 
metropolitan areas for MMRS development, and plans to initiate an 
additional 25 contracts during this fiscal year.
    In FY 1999, Congress appropriated funds for OEP to renovate and 
modernize the Noble Army Hospital at Ft. McClellan, AL, in order for 
the hospital to be used to train doctors, nurses, paramedics and 
emergency medical technicians to recognize and treat patients with 
chemical exposures. The Noble Training Center is working with 
universities, medical centers, and other federal agencies to train 
medical practitioners, emergency room staff, hospital administrators, 
medical first responders, and others to ensure that our citizens 
receive the best possible medical care after a WMD event. Working with 
CDC and the VA, a training program was developed for pharmacists 
working with distribution of the National Pharmaceutical Stockpile.
                               conclusion
    The Department of Health and Human Services is committed to 
ensuring the health and medical care of our citizens. We are prepared 
to mobilize quickly the health care professionals required to respond 
to a disaster anywhere in the U.S. and its territories and to assist 
local medical response systems in dealing with extraordinary 
situations, including meeting the unique challenge of responding to the 
health and medical effects of terrorism. The Departments of Veterans 
Affairs and Defense are critical partners in these efforts.
    Mr. Chairman, that concludes my prepared remarks. I would be 
pleased to answer any questions you may have.

    Chairman Rockefeller. Let us go on to Dr. Chu.

 STATEMENT OF DAVID CHU, PH.D., UNDER SECRETARY OF DEFENSE FOR 
                    PERSONNEL AND READINESS

    Mr. Chu. Thank you, Mr. Chairman, Senator Specter, and 
members of the committee. It is a great pleasure to be here to 
represent the Department of Defense and to testify regarding 
the Department of Defense's view of VA support.
    As you know, the 1982 legislation authorized the VA to 
serve as the principal health care backup to the Department of 
Defense in the event of war or national emergency that involves 
armed conflict. The Department of Defense operates its own 
medical care system, the military health system, which consists 
of just under 80 hospitals and several hundred clinics 
worldwide and serves a population of just over eight million 
people.
    Because this is a deployable system, we do have a 
significant number of capabilities that allow us to respond in 
a mobile mode to contingencies such as occurred in New York, 
and I am proud to report that we did play a small role. As you 
are probably aware, the hospital ship Comfort deployed in New 
York within 48 hours of the disaster under the direction, I 
should emphasize, of the Health and Human Services leadership. 
And indeed, of course, the Army's Delorenzo clinic at the 
Pentagon, in addition to teams from Walter Reed, were some of 
the first responders to the attack on the Pentagon itself.
    The 1982 law led, as this committee is aware, to the 
establishment of the VA/DoD Contingency Hospital System, which 
is codified in a memorandum of understanding between the two 
cabinet departments. That system is activated by the Secretary 
of Defense after he or she determines that we need VA's help 
and so notifies the Secretary of Veterans Affairs, who in turn 
commits the VA resources.
    Within the United States for military medical operations, 
the Commander in Chief of the United States Joint Forces 
Command is in charge and develops an integrated medical 
operations plan for the continental United States, and, of 
course, the VA and DoD contingency hospital system supports 
that plan.
    The VA/DoD system is supplemented by what Secretary Allen 
described, and that, of course, is the National Disaster 
Medical System, which he has outlined here. I think the success 
of the joint venture was demonstrated in the aftermath of 
September 11. The Secretary of HHS did activate the National 
Disaster Medical System and both VA and DoD began reporting, as 
they were required to do, with their bed availability to what 
is called the Global Patient Movement Requirement Center, 
located at Scott Air Force Base. Again, as Secretary Principi 
testified, tragically, there was not a significant number of 
casualties to care for. But I do think the events of September 
11 highlighted the importance of a coordinated Federal response 
to national disaster.
    You asked, Mr. Chairman, in your letter of invitation that 
I address also the issue of medical record keeping for our 
military forces, which was, to put it as politely as possible, 
problematic during the Gulf War and suffered from some of the 
defects that you and your committee have identified. I am 
pleased to report that the Department of Defense has made 
significant progress since that date in trying to rectify those 
deficiencies.
    We have now a new set of direct instructions that outline 
the kind of records that must be kept and the medical 
surveillance that must be maintained. We have both a pre-
deployment health assessment that is to be completed and a 
post-deployment assessment to which it is to be matched. I took 
the step just within the last 2 weeks of reminding all elements 
of the Department of the requirement to report on the units to 
which each individual is attached, both the unit to which the 
individual is attached for administrative purposes as well as 
the unit to which he or she is attached in terms of actual 
operations in the field.
    Over the longer term, we are looking to the second version 
of the Composite Health Care Systems, known as CHCS II in 
bureaucratese, to give us the kind of computer-based record 
that could be accessed from around the world within the context 
of what we call a Theater Medical Information Program for the 
kind of record that I think you are aiming for as the standard 
we should----
    Chairman Rockefeller. Which will not be ready until 2003, 
am I right?
    Mr. Chu. The CHCS II operational test will take place just 
about 1 year from now, so yes, it will be a couple of years 
before we have this widespread. But I should emphasize that 
this is a long-term program. It is not something we can do 
overnight. It is important, I would emphasize, in terms of 
clinician acceptance, on which its excellence and data accuracy 
depend to get this right so the clinicians will actually use it 
and put the information in that we need.
    In conclusion, sir, I simply want to emphasize that the 
collaborative efforts between the Veterans Administration and 
the Department of Defense continue on a daily basis. The 
excellent relations among our personnel and our relationship 
also with HHS, I think, give us great confidence that VA will 
be there to help DoD when we need it and that we will both 
function well within the larger system as far as the domestic 
United States is concerned for which HHS is responsible. Thank 
you.
    Chairman Rockefeller. Dr. Chu, I know you have other 
appointments and I do not want you to keep them----
    [Laughter.]
    Chairman Rockefeller [continuing]. Because I have some 
questions for you, but if you have to, you have to and we 
understand.
    Mr. Chu. I am good for a little while longer, sir. Thank 
you.
    Chairman Rockefeller. OK.
    [The prepared statement of Mr. Chu follows:]
Prepared Statement of David Chu, Ph.D., Under Secretary of Defense for 
                        Personnel and Readiness
                              introduction
    Mr. Chairman, I am pleased to be invited here today to present to 
you and the members of the Committee the Department of Defense's views 
on the Department of Veterans Affairs' (VA's) role as principal backup 
to the Department of Defense in the event of war or national emergency. 
The Department of Defense places enormous value on all of its sharing 
partnerships with the Department of Veterans Affairs. Since the outset 
of the sharing program which was established under the 1982 
legislation, ``Department of Veterans Affairs and Department of Defense 
Health Resources Sharing and Emergency Operations Act (38 USC 811(f)), 
DoD has subscribed to the promise for improved economies of operation 
that health resources sharing has held.
            va as backup to dod in war or national emergency
    In addition to promoting greater peacetime sharing of health care 
resources between VA and DoD, this vital legislation authorized the VA 
to serve as the principal health care backup to DoD in the event of war 
or national emergency that involves armed conflict. The Military Health 
System (MHS) consists of 78 hospitals and more than 500 clinics 
worldwide serving an eligible population of 8.3 million. In addition, 
we have medical units capable of deploying with our Armed Forces to 
provide the preventive and resuscitative care that our troops may 
require while serving outside the United States. We emphasize the 
prevention of injury and illness. We identify hazardous exposures, and 
record immunizations and health encounters in a computerized fashion 
for patient safety and any needed patient care events. We deliver the 
healthcare benefit as defined by the Congress and ensure high quality 
healthcare to all eligible beneficiaries in all scenarios. The Military 
Health System relies on fully trained and militarily prepared 
healthcare personnel. Our primary responsibility is to provide medical 
support for our deployed forces, and those capabilities are 
inextricably linked to our hospital and clinic operations, A robust 
healthcare delivery system is our strategic lynchpin to ensure that our 
force is healthy and that our medics are prepared to deliver medical 
support in contingencies.
    Because of our constant vigilance and need to be prepared to 
support the Armed Forces in any location around the world, military 
medicine has a tremendous ability to provide health and medical 
capabilities rapidly in a mobile or deployed mode. Some of these 
capabilities include field hospitals, specialized medical augmentation 
teams, field laboratory diagnostic capabilities, medical evacuation, 
public health, vector control, patient tracking, veterinary support, 
medical supply support, and mass casualty care. Additionally, we have 
our stationary military medical treatment facilities located around the 
nation that have inpatient capabilities.
    The military health system continues to leverage the wartime 
capabilities of the men and women in our armed forces for domestic 
consequence management in support of the civil authorities. I am very 
proud of the efforts of our military medical team in response to the 
events of September 11th. The hospital ship USNS Comfort was dispatched 
within 48 hours to New York City with Navy medical personnel from the 
National Naval Medical Center. The Army's Delorenzo clinic staff at the 
Pentagon was among the first responders to the attack on the Pentagon. 
Additionally, Walter Reed Army Medical Center immediately dispatched 
three trauma teams, a preventive medicine team and two combat stress 
teams to respond to the Pentagon crisis.
    In response to the 1982 law authorizing a new contingency role for 
the VA, a Memorandum of Understanding (MOU) was executed between the 
Secretary of Defense and the Administrator of Veterans Affairs 
(presently the Secretary of Veterans Affairs), specifying each agency's 
responsibilities under the law. Plans have been developed and are 
jointly reviewed and updated every year by VA and DoD. The VA/DoD 
Contingency Hospital System is outlined in the Veterans Health 
Administration Handbook 0320.1 of May 1, 1997.
    The VA/DoD Contingency Hospital System is activated by the VA after 
the Secretary of Defense determines that DoD needs VA medical care 
resources because of a military conflict or another type of national 
emergency. The Secretary of Defense notifies the Secretary of Veterans 
Affairs, in writing, of any need for medical care contingency support. 
The Secretary of Veterans Affairs commits VA to provide support and 
communicates this commitment to the Secretary of Defense in writing. 
Through the VA/DoD Contingency Hospital System, DoD receives periodic 
estimates of VA contingency bed availability.
    The Commander-in-Chief (CINC), US Joint Forces Command (JTFCOM) has 
overall responsibility to ensure integrated CONUS medical operations. 
Consequently, CINC JTFCOM has in place the Integrated CONUS Medical 
Operations Plan (ICMOP) that coordinates all CONUS medical assets in 
support of DoD casualties. ICMOP is supported by the VA/DoD Contingency 
Hospital System Plan.
    One important objective of the overall planning effort is to assess 
VA's contingency bed capacity. Accordingly, VA medical centers assess 
13 specific bed categories (that include highly specialized beds) 
required by DoD. These assessments take into account the impact on 
local operations of VA employees subject to mobilization, since long-
standing VA policy is that no employee is unavailable for active 
military duty in a national emergency by reason of his/her position or 
assignment.
    The VA and DoD bed contingency plans are also supplemented by the 
National Disaster Medical System. This robust bed expansion capability 
will be activated subsequent to a war or national emergency requiring 
more than the combined resources of the DoD and VA. This joint Federal, 
State, and local mutual assistance organization provides for a 
coordinated medical response in time of war, national emergency, or 
major domestic disaster resulting in a mass casualty situation. 
Patients are evacuated to designated locations throughout the United 
States for care that cannot be provided locally. They are placed in a 
national network of hospitals that have agreed to accept patients in 
the event of a major disaster. DoD is a primary Federal agency 
responsible for administering the NDMS. Other agencies sharing 
responsibilities with DoD include the Department of Health and Human 
Services (DHHS), FEMA, and the VA. NDMS may be activated by the 
Assistant Secretary of Defense for Health Affairs in support of 
military contingencies when casualties exceed the combined capabilities 
of the VA/DoD Contingency Care System. The Assistant Secretary of 
Health (DHHS) may activate NDMS in response to a domestic conventional 
disaster. Under the latter circumstances, DoD components, when 
authorized, will participate in relief operations to the extent 
compatible with U.S. national security interests.
    The success of this joint venture was aptly demonstrated 
immediately following the September 11th attack on the World Trade 
Center Towers and the Pentagon. In anticipation of receiving 
casualties, The Secretary of Health and Human Services activated NDMS 
whereupon both VA and DoD began to report bed availability to the 
Global Patient Movement Requirements Center (GPMRC) located at Scott 
Air Force Base, Illinois. There were however no casualties evacuated as 
a result of this tragedy, as local resources were able to handle health 
care requirements.
    The events of September 11th have highlighted the importance of a 
coordinated federal response to national disasters. While each of us 
must ensure that our health care system is capable of meeting the 
demands of our respective missions, we recognize the vital role the 
Department of Veterans Affairs plays in providing backup to the 
Department of Defense in the event of war or national emergency.
                         medical record keeping
    Mr. Chairman, you asked that we address our efforts to improve 
medical record keeping in light of the lessons learned from the Gulf 
War and subsequent deployments. As you know, record keeping during the 
Gulf War was problematic: immunizations were not always recorded, 
documentation of healthcare provided to service members was not always 
locatable following the war, record keeping policies were not 
standardized, and automated systems were not fully implemented.
    I am pleased to report that we have made significant progress. We 
have published directives and instructions and issued policies on 
record keeping and medical surveillance during deployments, we continue 
to develop and improve automated record keeping systems, and we 
continue to work with the VA to facilitate transfer of medical records 
for our veterans and retirees.
    Specifically, we are leveraging advances in technology to improve 
our medical records. We have two automated systems that when combined 
will form the longitudinal view of health information that captures 
health encounters for every service member. These two systems are the 
Composite Health Care System II (CHCS II), also referred to as the 
military computer-based patient record, and the Theater Medical 
Information Program. Our collaboration with the VA on information 
systems will allow these computer-based patient records to be available 
to the VA should the contingency system be activated.
      national center for military health and deployment readiness
    Finally, Mr. Chairman, I would like to address the efforts to 
establish a National Center for Military Health and Deployment 
Readiness. As you know, our role in this effort was to respond to the 
Institute of Medicine recommendations through a joint report with the 
VA. With the VA, we concurred with the two recommendations and the 
report was submitted to Congress. The VA has taken action to achieve 
both recommendations. In May of this year, VA announced establishment 
of two new Centers for the Study of War-Related Illnesses, one at the 
East Orange, New Jersey, VA Medical Center, and the other at the 
Washington, D.C. VA Medical Center. For the second recommendation, the 
VA with support from DoD and the Department of Health and Human 
Services, proposed that the best approach for the National Center 
concept would be through the Military and Veterans Health Coordinating 
Board. Further, the Research Working Group of the Coordinating Board 
would function as the National Center's operating unit. This approach 
has been working since the September 2000 joint report.
    I would like to apprise you of a related effort underway in DoD. 
The National Defense Authorization Act of 1999 authorized the Secretary 
of Defense to establish centers for the study of post-deployment health 
concerns. in September of 1999, the Assistant Secretary of Defense for 
Health Affairs established the Centers for Deployment Health. These 
Centers comprise a research center at the Naval Health Research Center 
in San Diego, CA, a clinical center at Walter Reed Army Medical Center 
in Washington, D.C., and a Defense Medical Surveillance System at the 
Army's Center for Health Promotion and Preventive Medicine. Examples of 
the work being conducted at these centers include the Millennium Cohort 
Study. This is a cross-sectional sample of 100,000 U.S. military 
personnel who will be followed prospectively, as an integral part of 
the Department's strategy to preclude Gulf War Illnesses-type 
experiences in future deployments and to maintain troop morale, 
confidence, and effectiveness. At the clinical center, we have 
developed a Clinical Practice Guideline for Post-Deployment Health 
Evaluation and Management. This guideline will allow transition from 
diagnosis-driven treatment to a program of clinical care for post-
deployment health concerns managed in the primary care setting. The 
guideline emphasizes the patient and provider relationship and offers 
historical context for the provider, which is a dynamic information 
source necessary to establish a credible patient relationship and 
appropriately assess the patient's post-deployment health concerns. 
This guideline represents the promised improvement in treatment of our 
patients with deployment-related health concerns. The Defense Medical 
Surveillance System is a comprehensive, longitudinal, relational, 
epidemiological database where all theater medical surveillance and 
treatment data will be captured and stored.
    The goal of these Centers is to improve our ability to identify, 
treat and minimize or eliminate the short- and long-term adverse 
effects of military service on the physical and mental health of our 
service members and veterans.
    Mr. Chairman, in summary, let me say that the collaborative efforts 
between VA and DoD continue daily. Because of the resulting 
relationships among our personnel, we have tremendous confidence that 
should the day dawn when we need to call on the VA to help us care for 
our casualties, they will be ready.

    Chairman Rockefeller. Yes, Mr. Baughman?

    STATEMENT OF BRUCE P. BAUGHMAN, DIRECTOR, PLANNING AND 
     READINESS DIVISION, READINESS, RESPONSE, AND RECOVERY 
        DIRECTORATE, FEDERAL EMERGENCY MANAGEMENT AGENCY

    Mr. Baughman. Good afternoon, Mr. Chairman, members of the 
subcommittee. It is my pleasure to represent Director Allbaugh 
at this hearing on the role of the Department of Veterans' 
Affairs in emergency response. My remarks will be brief. I will 
describe how FEMA works with other agencies under the Federal 
Response Plan framework and where the Department of Veterans' 
Affairs fits into that framework.
    FEMA's mission is to reduce the loss of life and property 
and to protect the nation's critical infrastructures from all 
hazards. However, we are a relatively small agency. We do not 
own all the resources needed to respond to a disaster. Our 
success depends on our ability to organize and lead a community 
of local, State, and Federal agencies and volunteer 
organizations in responding to disasters. While we promote the 
ability of voluntary organizations, local governments, and 
States to manage the vast majority of emergencies in this 
country on their own, we do realize that from time to time, 
they are overwhelmed. When that happens, under the Stafford 
Act, we can provide a management framework and a funding source 
to marshal Federal resources in support of State and local 
government.
    The heart of our response framework is the Federal Response 
Plan. The Federal Response Plan reflects the work of an 
interagency planning group that meets in Washington and all 10 
of our FEMA regions. It develops the Federal Government's 
capability to respond as a team. This team includes 26 Federal 
departments and agencies and the American Red Cross, all of 
which are signatory to the plan.
    The plan organizes departments and agencies into 12 
emergency support functions, based upon the authorities and 
expertise of the members and the needs of their counterparts at 
the State and local government level. Each of these emergency 
support functions have a primary agency. The primary agency is 
the agency with the most authority and expertise in that 
particular area and supporting agencies are agencies that can 
provide additional relevant capabilities.
    Since 1992, the Federal Response Plan framework has proven 
to be effective time and again for managing major disasters in 
emergency regardless of cause, including the recent terrorist 
attacks in New York and at the Pentagon. FEMA's principal role 
under the Federal Response Plan is to manage the allocation of 
Federal resources to assist State and local governments where 
there is a valid need. We try and find the right resource and 
provide it at the right time and in the right place.
    The Federal Government is not always the best resource to 
meet the requirement. When it is, a department or agency may be 
able to provide that needed resource under its own authority 
with its own resources. If not, then FEMA issues a mission 
assignment that provides for reimbursement of costs associated 
with the mission. If the mission falls within the scope of the 
emergency support function, FEMA assigns it to a primary agency 
for that function. The primary agency then may sub-task that to 
another supporting agency.
    Since FEMA's concern is resource allocation, we want to 
have as large a pool as possible to address each one of these 
critical functional areas. The Department of Veterans' Affairs 
has substantial assets, including medical facilities, medical 
staff, and pharmaceuticals, and we are pleased to count them 
among the signatories to the Federal Response Plan.
    Within the Federal Response Plan framework, VA is a 
supporting agency under the Emergency Support Function No. 8, 
``Health and Medical.'' The Department of Health and Human 
Services is the primary agency for ESF No. 8 and would sub-task 
VA for medical missions as appropriate, and I defer to both 
other organizations to discuss the good work that they have 
provided under that Emergency Support Function and under the 
National Medical Response System.
    I should also mention that VA is also a supporting agency 
to the U.S. Army Corps of Engineers under our Emergency Support 
Function No. 3, ``Public Works and Engineering,'' the American 
Red Cross under ``Mass Care,'' Emergency Support Function No. 
6, and the General Services Administration under Emergency 
Support Function No. 7, ``Resource Support.''
    Mr. Chairman, that concludes my remarks. I look forward to 
any questions at this time.
    Chairman Rockefeller. Thank you.
    [The prepared statement of Mr. Baughman follows:]
    Prepared Statement of Bruce P. Baughman, Director, Planning and 
  Readiness Division, Readiness, Response, and Recovery Directorate, 
                  Federal Emergency Management Agency
                              introduction
    Good morning, Mr. Chairman and Members of the Subcommittee. I am 
Bruce Baughman, Director of the Planning and Readiness Division, 
Readiness, Response, and Recovery Directorate, of the Federal Emergency 
Management Agency (FEMA). Director Allbaugh regrets that he is unable 
to be here with you today. It is a pleasure for me to represent him at 
this hearing on the role of the Department of Veterans Affairs in 
emergency response. My remarks will be brief. I will describe how FEMA 
works with other agencies under the Federal Response Plan framework and 
where the Department of Veterans Affairs--the VA--fits within that 
framework.
              fema and the federal response plan community
    The FEMA mission is to reduce the loss of life and property and 
protect our nation's critical infrastructure from all types of hazards. 
However, we are a relatively small agency; we do not ``own'' all the 
resources needed to fulfill that mission. Our success depends on our 
ability to organize and lead a community of local, State, and Federal 
agencies and volunteer organizations. We promote the ability of 
individuals, families, businesses, voluntary organizations, local 
governments, and States to manage the vast majority of emergencies in 
this country on their own. Under the auspices of the Robert T. Stafford 
Disaster Relief and Emergency Assistance Act, we also provide a 
management framework and funding to bring the Federal Government's 
resources to bear when State and local governments need help with 
emergency or disaster situations, or when these situations involve a 
primarily Federal responsibility.
    The heart of our response framework is the Federal Response Plan. 
The Federal Response Plan reflects the labors of interagency planning 
and coordination groups that meet as required in Washington and all ten 
FEMA Regions to develop our capabilities to respond as a team. This 
team includes 26 Federal departments and agencies and the American Red 
Cross, all signatories to the plan. The plan organizes departments and 
agencies into interagency functions based on the authorities and 
expertise of the members and the needs of our counterparts at the State 
and local level.
    Currently, there are 12 of these ``Emergency Support Functions'': 
Transportation, Communications, Public Works and Engineering, 
Firefighting, Information and Planning, Mass Care, Resource Support, 
Health and Medical Services, Urban Search and Rescue, Hazardous 
Materials, Food, and Energy. Each has a primary agency--the agency with 
the most authority and expertise in that area--and supporting agencies 
that can provide additional relevant capabilities.
    Since 1992, this Federal Response Plan framework has proven 
effective time and time again, for managing major disasters and 
emergencies regardless of cause--including the recent terrorist 
attacks.
    FEMA's principal role under the Federal Response Plan is to manage 
the allocation of Federal resources to assist State and local 
governments. Where there is a valid need, we try to find the best way 
to provide the right resource to the right place at the right time. The 
Federal Government is not always the best source--there may be 
resources available commercially in the area or from a neighboring 
State government. When the Federal Government is the best source, a 
department or agency may be able to provide what is needed under its 
own authority and with its own resources. If not, FEMA issues a mission 
assignment and provides for reimbursing the costs associated with the 
mission. If a mission falls within the scope of an Emergency Support 
Function, FEMA assigns it to the primary agency for that function; the 
primary agency may then task its supporting agencies.
  the department of veterans affairs within the federal response plan 
                               framework
    Since FEMA's concern is resource allocation, we want to have as 
large a pool of available resources as we can. We recognize that as one 
of the nation's largest healthcare providers, the Department of 
Veterans Affairs has substantial assets--including medical facilities, 
medical staff, and pharmaceuticals--and we are pleased to count the VA 
among the signatories to the Federal Response Plan. Within the Federal 
Response Plan framework, VA is a supporting agency under ESF #8, Health 
and Medical Services. The Department of Health and Human Services is 
the primary agency for ESF #8, and would subtask VA for health and 
medical missions as appropriate. I defer to both organizations to 
discuss their work under ESF #8 and the National Disaster Medical 
System in more detail.
    I should note that VA's role in the Federal Response Plan does not 
end there. VA is also a supporting agency to the U.S. Army Corps of 
Engineers under ESF #3, Public Works and Engineering, committed to 
making its facilities engineering personnel available if needed. VA is 
a supporting agency to the American Red Cross under ESF #6, Mass Care, 
to provide medical supplies, food preparation, and facilities if needed 
to support shelter operations. VA can support the General Services 
Administration under ESF #7, Resource Support, with procurement and 
distribution, including technical assistance on procuring medical 
supplies and services. VA has made a commitment to supporting Federal 
Response Plan operations in whatever way they can, and we at FEMA 
appreciate it.
                               conclusion
    Mr. Chairman, that concludes my remarks. I would be pleased to 
answer any questions you or the Committee may have.

    Chairman Rockefeller. Mr. Allen, I could tell, as I think 
you could, that there was not a total sense on the part of 
Secretary Principi that he and the largest health care agency 
in the Nation were really at the table insofar as HHS is 
concerned. Now, I have expressed my high belief in Secretary 
Thompson. He just addressed our Democratic Caucus, where he got 
a standing ovation. I mean, he is absolutely first rate. That 
is immaterial to the fact that HHS seems to have difficulty in 
consulting with VA on matters that have happened since 
September 11 or which might happen in the future, and the 
ongoing emergency preparedness situation, and I would just 
appreciate your response to that.
    Mr. Allen. Certainly. Since September 11--in fact, prior to 
September 11--at my level, the deputies' level, we have been 
working with--I have worked with the deputy at VA to address 
these very issues. So there were issues that we were looking 
ongoingly at with regard to the relationship that the Veterans 
Administration has with HHS, not only in the area of emergency 
preparedness, but also, for instance, homelessness. We had 
scheduled a series of meetings prior to September 11 to begin 
focusing on these very issues. September 11 just brought home 
the importance of that coordination at the highest levels 
between our departments.
    In fact, even as VA was organizing its Domestic Emergency 
Response Teams, they had requested for us to participate with 
them in that and I agreed to do so on behalf of our Department. 
So while I can understand the concerns of what that 
relationship might have been prior to September 11, I want to 
assure you that Secretary Thompson had already given the 
directive that we would be working much closer together in 
areas of terrorism and bioterrorism preparedness.
    I guess that is the assurance I can give you, that we are 
working together. We have already scheduled a series of 
meetings to look at terrorism, look at domestic response to 
emergency issues, as well as other issues that we share common 
interest in, including homelessness, for example.
    Chairman Rockefeller. I was at a Federal agency yesterday 
for most of the day looking at it carefully, and there was 
great frustration expressed by that agency toward another 
Federal Government agency about an extremely important project 
which they were both doing but in which they refused to share 
information. I was stunned. I was stunned. These are very, very 
important agencies.
    I am getting at bureaucratic behavior here, and I want your 
honest answer because I want to know how often you talk--not 
the Secretaries, but you and the relevant people, HHS people, 
VA people. It came down to the fact that the director of one of 
these agencies, the head of one of these agencies was 
absolutely for the cooperation but was completely undermined by 
those who had been there longer than he had at the operating 
levels. Therefore, there was absolutely no contact on something 
which was in the national interest. It is that kind of behavior 
which is so disturbing to me and which I want you to put me at 
ease about.
    Mr. Allen. Sure. My role in the Department as the Chief 
Operating Officer is to break through those very issues that 
you describe and I can describe them within our Department 
itself, those types of issues that come up where you have 
fiefdom protection in that sense, and so I understand what you 
are saying.
    I guess my assurance to you is that in my capacity as the 
Deputy Secretary, my role is to break down those barriers, to 
make sure that the type of communication, the type of 
coordination that allowed us to respond to September 11, that 
allow us to respond to events here, must be ongoing. This is 
not something that is done once. It is something that has to be 
done continuously. We need to coordinate. We need to train 
together. We need to cooperate together.
    I have been in numerous meetings since September 11 where 
we would share many frustrations that you described. But I 
believe that the President has made it very clear to us that he 
expects us to work well together. He expects us to set aside 
petty differences and try to resolve the issues that are 
confronting us together.
    And I want to try to assure you that that is happening. If 
there is an issue that I have a concern with involving another 
agency or department, I go to the deputy of that department and 
share that concern with them and I get a response. That is the 
type of relationship that we are trying to develop within the 
executive branch, that we respond to the concerns of each other 
to try to address common problems.
    Chairman Rockefeller. There are two types of communication. 
One is when something goes wrong or when there's a need for 
something to happen, and then people call because they have to. 
The other kind--and, granted, this is not a fair test post-
September 11 when everything has been urgent--is when there is 
not an immediate response needed but people contact each other 
because they are in the business of staying in communication in 
the eventuality that that communication will flourish into 
trust and a good working relationship later.
    Since September 11, you have been in touch with what kind 
of regularity with the VA? Prior to September 11, what was the 
situation? And I do not hold you accountable to this.
    Mr. Allen. No, and I appreciate that.
    Chairman Rockefeller. We are all Federal people. We all do 
silly and smart things.
    Mr. Allen. Certainly. Prior to September 11, and that is 
what I want to emphasize to you. I think much of the 
coordination and the relationships that had been built among 
the departments started prior to September 11, and that was in 
large part because of the leadership of Secretary Thompson, 
who----
    Chairman Rockefeller. You have already said that. What I 
was asking for is a breakdown pre-September 11 and post-
September 11, the number of contacts, what drives those 
contacts.
    Mr. Allen. I would be more than happy to provide you--I 
cannot tell you what has happened down in the----
    Chairman Rockefeller. Give me a sense.
    Mr. Allen [continuing]. But I know that our Office of 
Emergency Preparedness works regularly with the VA, with FEMA, 
with DoD. Dr. Chu and I had discussions prior to September 11 
about issues related to stockpile issues. I have had personal 
conversations and involvement with Leo McKay, the deputy at VA, 
on a regular basis on issues of commonality, of common 
interest, including bioterrorism and terrorism preparedness.
    And so I cannot quantify it. I would be glad to go back and 
try to accomplish that for you, how our departments are working 
together. But I guess what I am trying to give you is an 
assurance that that has happened. It has happened before 
September 11, and clearly, it is happening post-September 11.
    Chairman Rockefeller. OK. I am going to finish. Excuse me, 
Senator Specter. Again, I go back to the 1998 law, and I am 
sorry, I just have to pick on this because I am fixed on it, 
not on it but on the general subject.
    The National Center for Military Health and Deployment 
Readiness, this is all about chemical, biological, and other 
types of battlefield exposures. We passed a law to have VA, 
DoD, HHS work together in something called the National Center 
for Military Health and Deployment Readiness. It is a fact, 
however, that the governing board which was created by that has 
never convened.
    Now, nobody knew September 11 was coming. Oh, yes, we did. 
Oh, yes, we did. We all knew it was coming. It was just a 
question of how and in what form and we were very surprised by 
its form. We were not ready for that. It is that kind of 
behavior that I am getting at, and I am not picking on you, I 
do not mean anything of that sort, I am just trying to drive 
the point home that the rules all changed, it seems to me, now, 
and for good.
    Mr. Allen. Point well taken. I do not know the specifics 
about the meetings of the board, but I can tell you what our 
Department has been doing in conjunction with the National 
Center for Military Health. CDC has been integrally involved in 
working with----
    Chairman Rockefeller. Do you know what? I do not really 
want to know what CDC has been doing. I want to know why the 
board has never met----
    Mr. Allen. I do not have an answer----
    Chairman Rockefeller. I will just give you the piece of 
paper and then you can get back to me.
    Mr. Allen. I will be glad to do that.
    Chairman Rockefeller. OK. And nothing personal, I promise 
you.
    Mr. Chu. If I could add, Senator----
    Chairman Rockefeller. Yes?
    Mr. Chu [continuing]. The implication is that the three 
departments have not done anything on this. It is my 
understanding that, indeed, responsive to the Institute of 
Medicine report on the subject, that VA has stood up two 
centers, one in Washington and one in East Orange, if I recall 
correctly, and determined that in terms of some of the issues 
that the so-called research working group that grew out of the 
Gulf War illness effort ought to be the agent for coordinating 
research among the agencies and ensuring that the right kind of 
subjects are pursued.
    I should indicate that, as you may be aware, the Armed 
Services Committees also mandated in a law the following year 
that DoD take certain actions and we have stood up within the 
Department of Defense a series of Centers for Deployment 
Health, one building on the Navy center in San Diego, one 
building on converting capabilities at Walter Reed, and 
further, a third, a medical surveillance system.
    So there has been significant action. Being a new 
appointee, I do not know whether this board has ever met or 
not, but there has been significant action by the departments 
involved on the agenda that the law mandated.
    Mr. Allen. And I think it is important to note--I am not 
sure where this comes from, but I believe the VA is responsible 
for convening the board, so I do not think that at HHS, we are 
appropriate to answer that question--why. I just simply say 
that there is work that has been ongoing----
    Chairman Rockefeller. Let us put that one aside and figure 
we are going to get the answer to it.
    Dr. Chu, you referred to it yourself, and that is the--as 
you delicately said--the problem with recordkeeping in the Gulf 
War. Those were some days, pyridostigmine bromide and the whole 
history surrounding that. And the problem there, when you look 
at it, was with massed forces. Here, we are potentially talking 
about fewer forces, more control, certainly medical people with 
smaller groups, whether they be 4 or 400.
    Keeping medical records is just not miscellaneous talk but 
tremendously important for everything that happens. That did 
not work that well in the Gulf War. There continued to be a lot 
of concerns during Joint Endeavor in Bosnia, and I would like 
to get a sense of what happened there--there had been new 
medical surveillance policies, as you indicated, they had been 
put in place, but there were still problems.
    What is going on now? You have described the high-tech 
part, but what is going on now. I'm not referring to post-
September 11, but what is the procedure now for making sure 
that if somebody takes a pill, it is recorded, and particularly 
that it has to be signed in, all that kind of thing?
    Mr. Chu. Let me deal with what I think is the most 
important issue and that is providing a baseline of people's 
health status before they deploy and being able to compare that 
with their post-deployment situation, and we now have in place, 
which we did not have, unfortunately, in the Gulf War period, a 
requirement that such an assessment be conducted and that such 
a post-deployment assessment be carried out.
    The second--and we actually have--the Department has taken 
action using the 10th Mountain Division as a test case to look 
at what they actually did to be sure that it complies with 
policy, because one of the issues in a bureaucracy is you might 
announce that this is the policy, but the question always is 
are people carrying it out faithfully.
    The second critical issue is or was and remains being able 
to track exactly where people are during a deployment and to 
what they might have been exposed during that period of time, 
and as I indicated, the Department, about a year and a half 
ago, published a very thick directive that spelled all this 
out. I reminded everybody within the last couple of weeks that 
your first data submission was due on October 11 showing all 
deployments since September 11, which does include each person 
by name, the unit to which they are administratively assigned, 
as well as the unit which they are actually deployed with.
    The further challenge, which we are energetically working 
on, is to make sure we can keep track of where all those units 
are over time so that the information can be put together. Some 
of that will have to be dealt with at the classified level as a 
practical matter, and there are certainly administrative issues 
to be overcome in carrying that out.
    So while I do not want to pretend it is perfect or that 
everyone is doing exactly as he or she has been told to do, we 
are checking on whether or not they are doing as they are 
supposed to be doing and I am hopeful that we will have a much 
better situation this time around than we did the last time.
    Chairman Rockefeller. Thank you, sir.
    Senator Specter?
    Senator Specter. Mr. Chairman, I would like the record to 
show that you have a very loyal staff. After a while, I asked 
them to put the red light on and they declined. [Laughter.]
    So I asked them to put the yellow light on and they refused 
to do that. Then I asked them to put the green light on and 
they would not put any light on. [Laughter.]
    May the record show that the chairman and I have a very 
good relationship and I joshed him just a little in saying that 
he was longer-winded when he was ranking member, but we work 
well together and these time limits are a little bit arbitrary.
    Mr. Allen, I want to pick up on one comment you made which 
is not too important in the exact language you used but it 
reflects, perhaps, an attitude and it is worth emphasizing. You 
said that you cannot have any more petty disputes between 
agencies. You should never have petty disputes. Now is the time 
to have all the disputes resolved. You have really got to get 
it done and find the answer.
    I think Senator Rockefeller pushed you exactly properly for 
the convening of the board. It is an answer, but not a very 
good answer, to say that it was the VA's job to convene the 
board, because HHS knew that VA had not convened the board. So 
there is a responsibility everywhere to get the board convened 
and that is the point that Senator Rockefeller made, that when 
Congress enacts this kind of legislation, it ought to be 
followed. There are enough disputes between the executive and 
legislative branches without simply disregarding a requirement 
like that.
    You talk, Mr. Allen, about $1.5 billion to take care of 
your needs, and Senator Byrd and Senator Stevens and Senator 
Harkin and I wrote a letter to the President asking him for 
specifics as to what he wanted done after we heard Secretary 
Thompson. I believe the incentives to put that additional 
appropriation into the $40 billion of the last $20 billion, 
which has already been authorized, but is there a sense of 
urgency in your Department that it ought to be included in the 
appropriations bill which has just been reported by the 
committee to the full Senate? Or can you wait until they divide 
up $40 billion or the last $20 billion of that which has 
already been authorized?
    Mr. Allen. Senator Specter, we have already received some 
funds out of the first $20 billion that has been authorized to 
augment the stockpile.
    Senator Specter. How much have you gotten?
    Mr. Allen. I believe it was--and I can get the actual 
figure--I believe it was $51 million that we needed to increase 
our existing stockpiles and----
    Senator Specter. So is the availability of that money 
adequate to meet your needs right now? Do you not need to have 
it included in the regular fiscal year 2002 appropriations 
bill?
    Mr. Allen. I do not have an answer for you right now on 
that because the meeting I am going to next is going to address 
that. We are working very closely with the interested----
    Senator Specter. If you do not have an answer right now, 
let us have an answer by tomorrow----
    Mr. Allen. Certainly.
    Senator Specter [continuing]. Because the bill is going to 
the floor.
    Mr. Allen. Certainly. We will be glad to do that.
    Senator Specter. Have you visited the Centers for Disease 
Control?
    Mr. Allen. Yes, I have.
    Senator Specter. I visited CDC about 18 months ago after 
hearing tales of how deplorable it was with people--noted 
Ph.D.'s, et cetera--having their desks in halls. I could not 
believe the reports I had heard, so I went to see for myself, 
and I and saw the situation was even worse. How recently did 
you see it?
    Mr. Allen. On September 13.
    Senator Specter. Well, that is some action after the 11th. 
Have there been improvements? What is it like now?
    Mr. Allen. I am not sure what the condition was when you 
visited. I would say, in many cases, the same. I think that we 
need to make critical investments in supporting the 
infrastructure there. We need to make critical investments----
    Senator Specter. Turn my red light on, please. [Laughter.]
    Mr. Allen. I believe I visited on much of the same tour.
    Senator Specter. I want to be even-handed with the 
chairman, that is all. I want to make a request for my red 
light on.
    Take a look at that.
    Mr. Allen. Certainly.
    Senator Specter. Senator Harkin and I have taken the lead 
and have added $250 million now, and that is on the way to over 
than a billion dollars for improvements. But let us know if you 
need more sooner or some of it ought to come out of the 
billions already put up because CDC is really very, very 
central.
    And since my red light is on theoretically, I am going to 
conclude, Mr. Chu, but I want to italicize what Senator 
Rockefeller has said about the records. We have had a 
tremendous problem with Persian Gulf Syndrome and trying to 
find out what happened because the records have not been 
maintained. Notwithstanding the problems of the Gulf War, they 
were not maintained on Operation Joint Endeavor in Bosnia. So 
you really ought to get your Department on notice that they 
have had fair warning and that we on this committee heard so 
many veterans complain so bitterly about what is going on, that 
really ought to be rectified.
    I have another hearing to attend--one with the Secretary of 
Treasury--so I am going to excuse myself, Mr. Chairman.
    Chairman Rockefeller. Let me conclude this by making a 
philosophical statement. Those are dangerous. I recognize the 
ease that we have as Senators to do oversight and how we get to 
ask all kinds of questions. September 11 is just a month and 4 
or 5 days ago, and you are meant to know everything and have 
all the answers. It is not fair in some ways. However, 
oversight is built into the Constitution. It is a balance of 
powers. We have to struggle mightily to have you understand 
that we are, in fact, on your side. But the only way that we 
can do that in that we are not in the executive branch--is to 
ask you the kinds of questions which at least in theory bind us 
together in a common pursuit of efficiency, expediency, 
results.
    So sometimes we appear hostile--sometimes we are hostile. 
Sometimes it is meant to be nothing more than that, and that 
goes back to the Persian Gulf situation. But I just want to 
explain myself on that. We are all in this together and I 
really do mean that, and I do not mean these hearings to be 
about one side beating up on another. They are too often like 
that and I do not like it; I sometimes engage in it and I 
apologize.
    I have one question for you, Mr. Baughman, just because I 
do not want you to feel lonely. [Laughter.]
    It is sort of a hostile one, and that is: when we were 
referring to the interagency planning and FEMA's 
responsibility, you seemed to be a little bit saying that HHS 
and VA should get their act worked out. FEMA is part of the 
deal.
    Mr. Baughman. Yes, FEMA is part of the deal, sir. We are 
the coordinating agency. We have appointed HHS and those other 
agencies as part of the health and medical function. Rather 
than us dealing independently with 26 agencies, we have got a 
lead agency and that is HHS. HHS has got to work with VA as to 
how they are going to access VA assets.
    Now, what we have done from time to time where VA has come 
to us and said, look, we do not think that our assets are being 
fully engaged, we have sat down with HHS and VA and tried to 
work through those issues. But we have tried to work this 
system out so that the primary agency is fully engaging the 
support agencies, and in some of our functional areas, it works 
great. In this one, probably the relationship is not at its 
optimum and we will encourage them to sit down at the table 
again and work through these issues.
    Chairman Rockefeller. That is a fair enough answer.
    I would like to insert into the record prepared testimony 
from Paul Hayden, Associate Director, National Legislative 
Service, Veterans of Foreign Wars of the United States, and 
Jaqueline Garrick, Deputy Director for Health Care, National 
Veterans' Affairs and Rehabilitation Commission of the American 
Legion.
    [The information referred to follows:]
  Prepared Statement of Paul A. Hayden, Associate Director, National 
   Legislative Service, Veterans of Foreign Wars of the United States
    Mr. Chairman and members of the committee:
    On behalf of the 2.7 million members of the Veterans of Foreign 
Wars of the United States (VFW) and its Ladies Auxiliary, I would like 
to thank you for the opportunity to make a statement on such an 
important and timely topic.
    First, we would like to commend the Department of Veterans Affairs 
(VA) for its role in the response to the domestic terrorist acts that 
shocked our nation last month. According to the Office of Emergency 
Preparedness' (OEP) Situation Report #25, released on October 3, 2001, 
the VA ``is providing support to the city [New York] through its VA 
health care facilities . . .'' of which the ``VAMC Manhattan received 
and treated a total of 76 victims with an additional 17 treated at the 
VAMC Brooklyn, three at the VAMC in the Bronx and two at the Northport 
VAMC for a total of 98.'' Aside from the victims treated, the VA 
immediately deployed assistive personnel to New York City, Pennsylvania 
and Virginia.
    In communicating with VFW Service Officers and members located near 
the affected areas, we are proud to report that we have not received 
one complaint about VA's ability to complete its primary mission to 
serve veterans. Again, the VA is to be commended for carrying an 
increased workload while maintaining a continuity of services to 
veterans.
    The VFW believes that VA's authority to respond to Department of 
Defense (DOD) contingencies is well documented in PL 97-174, the 
Veterans' Administration and Department of Defense Health Resources 
Sharing and Emergency Operations Act. This Act, codified in Title 38 U. 
S. C. Sec. 8111A, and commonly referred to as VA's ``fourth mission'' 
states that VA will be the principal backup to DOD by furnishing health 
care services to active duty members of the Armed Forces in the event 
of war or national emergency ``that involves the use of Armed Forces in 
armed conflict.''
    Further, Title 38 U. S. C. Sec. 8110, dealing with the operation of 
VA medical facilities mandates the Secretary to ``maintain a 
contingency capacity to assist the Department of Defense in time of war 
or national emergency.''
    VA's role to backup the military is clear. As the recent terrorist 
attacks have proven, however, national emergencies involve civilian 
casualties as well. Without doubt, PL 97-174, passed May 4, 1982, was 
based on the Cold War expectations that we would suffer mass military 
casualties conducting a land campaign in Eastern Europe and/or on the 
Korean Peninsula. Additionally, our national security strategy at that 
time was based on nuclear weapons and the concept of Mutually Assured 
Destruction (MAD).
    As this committee considers how VA can best carry out its mission 
in the future, we feel it is important to take into account how 
national security has changed since the collapse of the Soviet Union 
and the proliferation of Weapons of Mass Destruction (WMD), 
specifically nuclear, biological and chemical. Recent reports, such as 
the U. S. Commission on National Security for the 21st Century (Hart-
Rudman Commission), have all recognized that the ``U. S. will become 
increasingly vulnerable to hostile attack on the American homeland'' as 
well as be called upon to provide frequent military intervention 
abroad. It is no longer if the terrorists strike, but when.
    So the question arises, how does VA fit into this new environment? 
One new strategy proposed for national security is homeland protection 
based on prevention, protection, and response. Common sense dictates 
that the VA, as the nation's largest health care network, will provide 
support under the response category. In fact, they already do.
    We believe it was VA's role as a federal-level partner with the 
Federal Emergency Management Agency (FEMA) and the National Disaster 
Medical System (NDMS) that allowed it to respond to the civilian 
casualties so efficiently and effectively in the hours and days 
following the attack.
    As one of 28 signatories to the Federal Response Plan (FRP) managed 
by FEMA, VA already has in place an inter-agency understanding that 
they will act as a support agency on 4 of 12 Emergency Support 
Functions (ESF) that FEMA uses to coordinate federal efforts to 
counteract the consequences of a national disaster. For example, VA's 
authority to treat the 98 victims it received in its New York Medical 
Centers was based on its support role in ESF #8, Health and Medical 
Services. Aside from Health and Medical Services, VA has a support role 
in ESF #3, Public Works and Engineering, ESF #6, Mass Care, and ESF #7, 
Resource Support.
    VA's participation with FRP is more or less a defacto fifth mission 
and the VFW feels that it provides the most logical paradigm for VA's 
future response strategies and tactics in time of national emergency.
    It is essential to point out that we are not advocating additional 
VA capacity for civilians. We, however, are mindful that DOD has been 
downsizing its medical facilities' beds for years and recent testimony 
before the Senate Appropriations Subcommittee on Labor, HHS and 
Education on the threat of biological terrorism has only highlighted 
the fragile state of the nation's public health system's ability to 
deal with multiple simultaneous disasters from WMD. The Senate 
testimony articulated that ``financial problems have also transformed 
the health care industry in recent years, sharply reducing the number 
of available hospital beds and the size of the nursing staff and 
largely eliminating `surge' capacity, or the ability to treat a sudden 
influx of patients resulting from a major disaster.''
    The same problems that threaten the public health system are the 
same ones that have been emphasized in past testimony to this committee 
regarding the VA health care system. Everyone is aware that the VA has 
been steadily transforming its health care system from inpatient to 
outpatient care for nearly a decade and the nursing shortage problem is 
nationwide. In addition, years of flatline budgeting have seriously 
eroded VA's ability to provide care to its primary constituency, the 
veteran. The lack of a ``surge'' capacity in the public health arena 
only underscores the need for one at the federal level.
    There is no other federal hospital system, other than VA, that can 
be expected to handle the overflow of patients from the public, private 
and DOD health systems resulting from a national emergency or act of 
war. Given the aforementioned testimony the potential for military and 
civilian casualties flooding the VA system and disrupting service to 
veterans is real. For example, what if there had been 6,000 wounded 
survivors instead of 6,000 fatalities as a result of the terrorist's 
actions in New York City?
    Therefore, the VFW firmly believes that VA's goals during a 
national emergency should be twofold. First, VA must work to maintain 
services to veterans, as they aptly demonstrated they could do in New 
York and Virginia, while providing backup to DOD and FEMA. Second, 
given a scenario where they are overwhelmed in their support roles of 
handling civilian and military casualties, and the situation dictates 
that traditional veteran services must be reduced or even suspended, 
they must work diligently to return civilians to the public and private 
health care providers, where possible, to ensure room for DOD personnel 
as well as for veterans whose services were interrupted.
    In order for VA to successfully respond to DOD contingencies and 
national emergencies, they must be properly prepared. Continued 
participation in local, state, and federal disaster training and the 
implementation of the FRP is the key to that preparedness. In addition, 
Congress, when using the power of the purse, must be mindful of VA's 
missions during acts of war and national emergencies. How can the VA be 
expected to carry out these support missions when it is struggling to 
carry out its primary mission of caring for the veteran?
    We are hopeful that this discussion will assist in producing sound 
policy. Again, we are thankful for the chance to participate. This 
concludes my testimony and I would be happy to answer any questions you 
or the members of this committee may have.
                                 ______
                                 
   Prepared Statement of Jacqueline Garrick, CSW, ACSW, CTS, Deputy 
  Director, Health Care, National Veterans Affairs and Rehabilitation 
                    Commission, The American Legion
    Mr. Chairman and Members of the Committee.
    Thank you for the invitation to contribute The American Legion's 
observations and recommendations to this extremely important hearing. 
On September 11, many American Legion members were sitting in the 
Committee's hearing rooms awaiting the National Commander's testimony 
before a Joint Session of the Veterans' Affairs Committees. As the 
horrendous acts began to unfold, Americans stood in disbelief. 
Fortunately, many Federal agencies are prepared to address such 
disasters with aggressive, coordinated activities.
    As a clinical social worker and Certified Trauma Specialist (CTS), 
I volunteered to provide counseling support at the Pentagon Family 
Assistance Center in the Sheraton Hotel in Crystal City, VA. The 
American Legion graciously allowed me to spend many working hours 
assisting at the Center. I worked with both the Department of Defense's 
(DoD) Behavioral Mental Health Team and a nonprofit group, the Tragedy 
Assistance Program for Survivors (TAPS). Together, these two programs 
provide much needed support services at the Center or in the Pentagon. 
The American Legion provided resource materials and made referrals for 
financial assistance and peer support. Additionally, The American 
Legion Auxiliary donated $10,000 to provide children's grief workbooks 
and other self-help materials for the survivors and their family 
members.
    The American Legion also re-instituted its Family Support Network 
to assist Reservists and members of the National Guard federalized to 
respond to this national emergency. During the Persian Gulf War, the 
Family Support Network provided much needed assistance to family 
members in local communities across the country. Services included such 
activities as childcare assistance, automobile maintenance, home 
repairs, and financial assistance provided by local members of The 
American Legion family. Over a half million dollars in grants were 
provided to the families of activated servicemembers during the Persian 
Gulf War. The American Legion renews this commitment to assist the 
citizen soldiers, sailors, airmen, Marines, and their families for the 
duration of this crisis.
    Through this first-hand involvement, I witnessed the role of the 
Department of Veterans Affairs (VA) in responding to this tragic event. 
The Veterans Benefits Administration, Veterans Health Administration 
and the National Cemetery Administration were mobilized to assist in 
answering questions, providing mental health services, filing for 
benefits, and assisting with burial arrangements. VA also worked with 
Federal Emergency Management Agency (FEMA), the Office of Crime Victims 
(OCV), American Airlines and the American Red Cross.
    VA's National Center for Post-Traumatic Stress Disorder (PTSD) sent 
six team members from the Palo Alto Education Division to the Pentagon 
Family Assistance Center within days of the attack. After consulting 
with previous DoD contacts and obtaining permission from VA, the 
Division Director decided to drive, virtually non-stop across country, 
to respond to the disaster. For more than two weeks, this team provided 
psychological support and education to the recovery workers and family 
members at two separate locations.
    At the Pentagon Family Assistance Center, VA's team provided:
     Psycho-education for counselors in support of families of 
missing or deceased.
     Debriefing of support staff, counselors, and other 
agencies (including Red Cross, FEMA, and DoD).
     Psycho-education and debriefing to Casualty Assistance 
Officers (CAO), who are charged with providing case management to the 
families of the deceased.
     Educational materials regarding disaster response for 
victims and helpers.
     Facilitator's guide for behavioral and emotional support 
debriefing for use by DoD counselors.
     Consultation with operation and mental health leadership 
in a long-term disaster response plan.
     Family support.
     Program evaluation questionnaire for CAOs to assess 
preparedness, effectiveness, and utilization of resources while 
providing services for family members of deceased victims.
    At the US Army Community and Family Support Center Command Group in 
Alexandria, Virginia, VA's team provided:
     Psycho-education regarding human response to disaster and 
utilization of psychological first aid.
     Psycho-educational materials.
     Counseling to Pentagon employees.
     A survey for staff to use as self-assessment in response 
to the disaster.
    The reputation and consultation services of the National Center are 
recognized throughout the world. The National Center provides more than 
simply long-term care for combat veterans suffering from PTSD, but also 
includes Acute Stress Disorder and Disaster Mental Health. This group 
published a guidebook that serves as the model for Pentagon relief 
efforts. The National Center for PTSD's recent performance demonstrates 
the valuable role of VA in response to such disaster. The presence of 
the National Center for PTSD was greatly appreciated by representatives 
of DoD, FEMA, Red Cross, OCV, TAPS, and the other responding 
organizations.
    Initially, DoD did not plan to include VA in the recovery efforts. 
The plan used in responding to this disaster was from the National 
Transportation Safety Board (NTSB) model, which does not include VA. 
The American Legion strongly recommends that VA be added to NTSB's 
list. Under the Aviation Disaster Family Assistance Act of 1996, the 
Chairman of the NTSB may request the assistance of--
     American Red Cross
     Department of State
     Department of Health and Human Services
     Department of Justice and the Federal Bureau of 
Investigation
     Federal Emergency Management Agency
     Department of Defense
    The National Center for PTSD has an ongoing agreement with the 
Substance Abuse and Mental Health Services Administration (SAMHSA) to 
respond to disasters. In New York, the National Center coordinated 
efforts with Federal, state, and city officials. They continue to work 
with the New York Fire Department in planning the next phase of mental 
health services to be offered.
    The National Center for PTSD provides resource materials on the 
immediate affects of trauma on survivors, families, rescue workers, and 
children through their website. As of last week, this website received 
approximately 50,000 lilts daily. The National Center expects to 
continue to play a major role in providing consultation, education, and 
research information in this post-disaster response.
    There seems to be a need for an internal VA response and 
coordination protocol in the event of a national emergency. The 
American Legion recommends that the National Center for PTSD serve as 
the lead agent in coordinating such a protocol. Since there are 206 Vet 
Centers around the country that can be activated to provide counseling 
in local communities, the Readjustment Counseling Services is another 
valuable resource in helping to provide disaster relief.
    The VA/DoD Health Resources Sharing and Emergency Operations Act of 
1982 gives VA the mission as primary backup for DoD and FEMA in the 
event of a disaster or armed conflict. The National Disaster Medical 
System Federal Coordinating Center Guide identifies plans and 
coordination protocols for local exercises and responsibilities that 
include VA. However, according to the key assumptions in the VA 
Strategic Plan 2001-2006, ``The United States will not engage in any 
major global or regional conflict during the period of this plan.'' 
Yet, the same plan lists as an objective, ``Improve nation's response 
in the event of a national emergency or natural disaster by providing 
timely and effective contingency medical support and other services.''
    The American Legion remains concerned over this assumption. 
Currently, VA lacks the resources to fully staff the additional 
inpatient beds, if needed. VA must carry out a Continuity of Operation 
plan that includes annual tests, training, and exercises; preparation 
of alternate operating facilities; and identification of designated 
emergency planners. The American Legion believes the number of VA and 
DoD sharing agreements will increase over the next few years.
    The American Legion recommends that VA should prepare a report on 
its emergency preparedness plans to treat mass casualties resulting 
from a national emergency.
    In conclusion, The American Legion is truly touched by the 
outpouring of national support for the victims and their families. As a 
nation, Americans have come together to use their sense of humanity to 
best counter terrorism. Federal and organizational bureaucracies, that 
often seemed territorial and to act in isolation, overcame those 
barriers to provide much needed comfort and services to victims and 
families.
    The National Center for PTSD will be issuing a more detailed report 
on its involvement in the response to this tragic event. The results of 
this report should help establish the framework for future national 
emergency contingency plans. VA must certainly be listed as a Federal 
agency that responds with NTSB. There should be on going communication 
and liaison activities between VA, DoD and FEMA in accordance with VA's 
mission to act as a backup to these Federal agencies. The American 
Legion requests that a new assessment and re-evaluation of VA's 
strategic plan be completed to determine if it has not underestimated 
the potential need for bed space and emergency medical care.
    Mr. Chairman, that concludes this statement.

    Chairman Rockefeller. The hearing is adjourned.
    [Whereupon, at 4:14 p.m., the committee was adjourned.]

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