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CHEMICAL AND BIOLOGICAL DEFENSE: DOD

MEDICAL READINESS

HEARING

BEFORE THE

SUBCOMMITTEE ON NATIONAL SECURITY,

VETERANS AFFAIRS AND INTERNATIONAL

RELATIONS

OF THE

COMMITTEE ON

GOVERNMENT REFORM

HOUSE OF REPRESENTATIVES

ONE HUNDRED SEVENTH CONGRESS

FIRST SESSION

NOVEMBER 7, 2001

Serial No. 107–114

Printed for the use of the Committee on Government Reform

(

Available via the World Wide Web: http://www.gpo.gov/congress/house

http://www.house.gov/reform

(II)

COMMITTEE ON GOVERNMENT REFORM

DAN BURTON, Indiana, Chairman

BENJAMIN A. GILMAN, New York

CONSTANCE A. MORELLA, Maryland

CHRISTOPHER SHAYS, Connecticut

ILEANA ROS-LEHTINEN, Florida

JOHN M. MCHUGH, New York

STEPHEN HORN, California

JOHN L. MICA, Florida

THOMAS M. DAVIS, Virginia

MARK E. SOUDER, Indiana

STEVEN C. LATOURETTE, Ohio

BOB BARR, Georgia

DAN MILLER, Florida

DOUG OSE, California

RON LEWIS, Kentucky

JO ANN DAVIS, Virginia

TODD RUSSELL PLATTS, Pennsylvania

DAVE WELDON, Florida

CHRIS CANNON, Utah

ADAM H. PUTNAM, Florida

C.L. ‘‘BUTCH’’ OTTER, Idaho

EDWARD L. SCHROCK, Virginia

JOHN J. DUNCAN, JR., Tennessee

——— ———

HENRY A. WAXMAN, California

TOM LANTOS, California

MAJOR R. OWENS, New York

EDOLPHUS TOWNS, New York

PAUL E. KANJORSKI, Pennsylvania

PATSY T. MINK, Hawaii

CAROLYN B. MALONEY, New York

ELEANOR HOLMES NORTON, Washington,

DC

ELIJAH E. CUMMINGS, Maryland

DENNIS J. KUCINICH, Ohio

ROD R. BLAGOJEVICH, Illinois

DANNY K. DAVIS, Illinois

JOHN F. TIERNEY, Massachusetts

JIM TURNER, Texas

THOMAS H. ALLEN, Maine

JANICE D. SCHAKOWSKY, Illinois

WM. LACY CLAY, Missouri

DIANE E. WATSON, California

STEPHEN F. LYNCH, Massachusetts

———

BERNARD SANDERS, Vermont

(Independent)

KEVIN BINGER, Staff Director

DANIEL R. MOLL, Deputy Staff Director

JAMES C. WILSON, Chief Counsel

ROBERT A. BRIGGS, Chief Clerk

PHIL SCHILIRO, Minority Staff Director

SUBCOMMITTEE ON NATIONAL SECURITY, VETERANS AFFAIRS AND INTERNATIONAL

RELATIONS

CHRISTOPHER SHAYS, Connecticut, Chairman

ADAM H. PUTNAM, Florida

BENJAMIN A. GILMAN, New York

ILEANA ROS-LEHTINEN, Florida

JOHN M. MCHUGH, New York

STEVEN C. LATOURETTE, Ohio

RON LEWIS, Kentucky

TODD RUSSELL PLATTS, Pennsylvania

DAVE WELDON, Florida

C.L. ‘‘BUTCH’’ OTTER, Idaho

EDWARD L. SCHROCK, Virginia

DENNIS J. KUCINICH, Ohio

BERNARD SANDERS, Vermont

THOMAS H. ALLEN, Maine

TOM LANTOS, California

JOHN F. TIERNEY, Massachusetts

JANICE D. SCHAKOWSKY, Illinois

WM. LACY CLAY, Missouri

DIANE E. WATSON, California

STEPHEN F. LYNCH, Massachusetts

EX OFFICIO

DAN BURTON, Indiana HENRY A. WAXMAN, California

LAWRENCE J. HALLORAN, Staff Director and Counsel

KRISTINE MCELROY, Professional Staff Member

JASON CHUNG, Clerk

DAVID RAPALLO, Minority Counsel

(III)

C O N T E N T S

Page

Hearing held on November 7, 2001 ........................................................................ 1

Statement of:

Kingsbury, Nancy, Managing Director for Applied Research and Methods,

General Accounting Office, accompanied by Betty Ward-Zukerman, Assistant Director, Applied Research and Methods, General Accounting

Office; and William W. Cawood, Assistant Director, Defense Capabilities and Management, General Accounting Office ..................................... 9

Winkenwerder, William, Assistant Secretary of Defense for Health Affairs, Department of Defense, accompanied by Lt. General Paul K.

Carlton, Jr., the Surgeon General, U.S. Air Force, Department of Defense; Lt. General James B. Peake, the Surgeon General, U.S. Army,

Department of Defense; and Read Admiral Donald C. Arthur, Jr., Deputy Surgeon General, U.S. Navy, Department of Defense ........................ 31

Letters, statements, etc., submitted for the record by:

Kingsbury, Nancy, Managing Director for Applied Research and Methods,

General Accounting Office, prepared statement of .................................... 12

Kucinich, Hon. Dennis J., a Representative in Congress from the State

of Ohio, prepared statement of .................................................................... 5

Winkenwerder, William, Assistant Secretary of Defense for Health Affairs, Department of Defense, prepared statement of ................................ 34

(1)

CHEMICAL AND BIOLOGICAL DEFENSE: DOD

MEDICAL READINESS

WEDNESDAY, NOVEMBER 7, 2001

HOUSE OF REPRESENTATIVES, SUBCOMMITTEE ON NATIONAL SECURITY, VETERANS

AFFAIRS AND INTERNATIONAL RELATIONS, COMMITTEE ON GOVERNMENT REFORM, Washington, DC.

The subcommittee met, pursuant to notice, at 10:04 a.m., in room

2154, Rayburn House Office Building, Hon. Christopher Shays

(chairman of the subcommittee) presiding.

Present: Representatives Shays, Putnam, Gilman, Lewis,

Schrock, Kucinich, Allen, Lantos and Tierney.

Staff present: Lawrence J. Halloran, staff director and counsel;

Kristine K. McElroy, professional staff member; Jason Chung,

clerk; Michael Bloomrose, intern; David Rapallo, minority counsel;

and Earley Green, minority assistant clerk.

Mr. SHAYS. Good morning. I would like to call this hearing to

order and welcome our witnesses and our guests.

The modern battleground can be a toxic and biological minefield.

In far-flung deployments, indigenous diseases, parasites and environmental exposures pose unique health threats. Fighting and surviving in battle space contaminated by chemical and biological

weapons demand medical countermeasures and treatment capabilities beyond those needed to deal with bullets and bombs.

To be ready to prevail on distant and increasingly dirty battlefields, the Department of Defense [DOD], is charged to recruit,

train—retrain, train, equip and motivate a force capable of meeting

diverse missions. One critical element of that readiness mandate is

the capacity of medical personnel to protect the health of the men

and women in uniform and, when necessary, treat the wounds of

modern warfare.

The Gulf war brought home some hard lessons about the adequacy of medical readiness in the face of microbial as well as military assault. Baseline medical data on deployed troops was found

lacking. Records on the use of vaccines and drugs against chemical

and biological [CB], threats were not kept. The military services

appeared to have different approaches to health surveillance, training of medical personnel, and treatment protocols.

Soon after the war, the General Accounting Office [GAO], and

the DOD inspector general [IG], identified a number of shortcomings in DOD’s capacity to provide medical support for the numbers of contaminated casualties anticipated. In 1996, the GAO and

IG found many of those same problems persisted; so the subVerDate 11-MAY-2000 09:42 Oct 29, 2002 Jkt 000000 PO 00000 Frm 00005 Fmt 6633 Sfmt 6633 C:\DOCS\82172.TXT HGOVREF1 PsN: HGOVREF1
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committee requested GAO determine what the Department is doing

to adapt military medical force structure and training to meet

emerging CB threats. We asked GAO to assess whether DOD is

augmenting medical rosters with the specialists needed to diagnose

and treat CB casualties, and we wanted to know the extent all

medical personnel are receiving mandatory standardized training

in the treatment of chemical and biological warfare exposures.

The GAO findings released today indicate DOD has some efforts

under way, but has yet to succeed in reshaping conventional medical planning to address the unique challenges of chemical and biological warfare. Training in medical management of CB casualties

is limited, and treatment scenarios are almost never included in

combat exercises.

One intractable aspect of the longstanding disconnect between

the Department’s assessment of the CB threat and medical readiness to meet it appears to be an inability or unwillingness to approach the problem jointly. The service branches cling to different

assumptions about casualty estimates and evacuation rates. Based

on those assumptions, each service reaches different conclusions on

which and how many medical personnel will be needed to treat CB

injuries.

The war against terrorism is being fought against an unconventional enemy with no compunction about using unconventional

weapons. Those being sent to fight the war deserve to know medical support will be available whether they face tanks or toxins,

mines or microbes. To help ensure they have that support, GAO

today made several specific recommendations to clarify planning

assumptions and improve medical readiness. The Department of

Defense will address those proposals and describe current and

planned capabilities to protect the health of deployed forces.

Our witnesses this morning bring important information and insights to our oversight of defense medical readiness. We anticipate

their being here—we appreciate their being here and look forward

to their testimony.

At this time I would like to recognize the ranking member, Mr.

Kucinich.

Mr. KUCINICH. Thank you, Mr. Chairman.

Good morning, and let me welcome all those who will be witnesses from the General Accounting Office and the Department of

Defense. I am glad you could be with us today.

Mr. Chairman, thank you for holding this hearing. The topic is

extremely important. Our military has recognized a grave threat,

the threat that chemical or biological agents might be used against

them in the theater of war. They’ve made some movement toward

dealing with this contingency, but as we will hear in a few moments, it appears they have not been fully able to realign and prepare the medical force for this threat.

The General Accounting Office report lays out some disturbing

findings, and the Department of Defense appears to agree with the

majority of them, that the Pentagon leadership is not providing

adequate guidance. They should not have developed tools—they

have not developed tools to determine how the medical force should

be structured, and the services disagree among themselves on a

host of issues. Medics are not trained sufficiently, and even those

3

that have received training do not feel they are proficient; that is,

if the military leadership can locate them without a functioning

tracking system in place.

I am glad that the Assistant Secretary is with us today to respond to these comments and provide us with his view of the steps

DOD must take to overcome these challenges. In his position he no

doubt will play a key role in advocating for these changes within

the Pentagon.

I would highlight, however, one important observation in the

GAO report. While the Assistant Secretary’s commitment is essential, most exercises are controlled by those responsible for

warfighting. As GAO points out, ‘‘concurrence of the military operation staff will be essential if medical participation is to be included in combat exercises and not the first they cut when it gets

in the way of other goals or becomes too hard.’’ So in addition to

having a task of his own to focus on as he returns to the Pentagon,

I hope the Assistant Secretary carries this additional message back

with him.

Finally, Mr. Chairman, I would like to raise an issue that I believe is an urgent priority for members of this subcommittee. As

you know, the administration announced last spring that it was

considering reversing the previous administration by opposing the

ongoing international negotiations for mandatory facility inspections under the Biological Weapons Convention. I was concerned

when I heard this because I believe that inspections are the core

component of these negotiations. They force proliferators to either

hide their activities at legitimate locations or go underground into

rudimentary and dangerous facilities. Either way their lives are

made more difficult. In fact, Ambassador Mahley himself, the State

Department official in charge of the negotiations, previously testified before this subcommittee in favor of inspections, and he said,

‘‘actually talking to scientists and production workers on the

ground as well as observing the atmospherics at a facility are ways

for experienced observers to detect anomalies. One can never discount either the whistleblower prospect of an employee or the ineptitude of a coverup of an elicit activity. While there is no way to

judge the likelihood of such an outcome, the deterrence component

is useful since it complicates the life of a potential proliferator.’’

When the new administration came in, however, Ambassador

Mahley ordered an interagency review of the negotiations. According to recent press accounts, this review is what spurred the administration’s reversal. Although I was concerned by the administration’s reversal, I was somewhat heartened that this subcommittee will have the opportunity to conduct its oversight role and examine the rationale behind the decision.

At a hearing in July, Congressman Tierney asked Ambassador

Mahley to deliver to the subcommittee a copy of the interagency review he ordered. Congressman Tierney’s request would have allowed us to better understand why the administration saw no

value in continuing to negotiate. Ambassador Mahley agreed to

provide the report, and Mr. Tierney’s request was adopted on the

record without objection. Unfortunately this was 4 months ago, and

we’ve received nothing from the administration in the meantime.

And particularly in light of recent events, I would have expected

4

the administration to seriously have rethought its position, but

from the press I’ve seen, it appears they’re going full throttle in an

effort to kill the negotiations for mandatory inspections.

Congresswoman Schakowsky also asked about this at our last

hearing. While acknowledging the State Department officials were

busy with counterterrorism efforts, Ms. Schakowsky rightly questioned why it had taken the Department so long to deliver the

analysis. This subcommittee recognized Ms. Schakowsky’s concerns

and promised they would be addressed. That was over 3 weeks ago,

and still the administration has not provided that information.

This issue has become even more urgent, Mr. Chairman, because

the United States is about to send Ambassador Mahley to Geneva

in 2 weeks to convince the world of our newly reversed position. We

will be telling them that inspections are not necessary anymore,

even though the United States originally called for them, and even

though Ambassador Mahley himself once listed a litany of reasons

we urgently needed them. We will be telling them that inspections

are not necessary anymore even after September 11th attacks and

even after multiple anthrax attacks.

The administration is sending the Ambassador to Geneva with a

reverse foreign policy predicated on the executive analysis that

Congress has had no opportunity whatsoever to review. Mr. Chairman, you are planning a December delegation to Geneva for subcommittee members to discuss these very negotiations, but without

cooperation from the State Department, participation in such a delegation will be fruitless. I’m really concerned about how this committee can conduct adequate oversight of administration policies if

the most basic requests are not met with cooperation. This is a vitally important issue of inspections under the Biological Weapons

Convention. It definitely needs to be addressed. I hope that all

members of the committee will join in demanding full cooperation

from the administration, and we are certainly at a link between

that and the issue of medical readiness, because if we don’t do

something to control the proliferation of biological weapons, all

these hearings are going to be in vain because you will never be

ready. We have to try to stop these weapons at their inception.

Thank you, Mr. Chairman, for your time.

Mr. SHAYS. I thank the gentleman.

[The prepared statement of Hon. Dennis J. Kucinich follows:]

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Mr. SHAYS. Mr. Schrock is next in line, but I understand he

doesn’t have a statement; so I would call on Mr. Gilman.

Mr. GILMAN. Thank you, Mr. Chairman.

Chairman Shays, I want to thank you for holding today’s hearing

in conjunction with the other hearings you’ve held on medical readiness in the event of a bio or chemical attack. We have to truly examine the overall state of the Department of Defense’s ability to

treat casualties resulting from any chemical or biological attack on

U.S. military personnel, and we’re all very much concerned about

making certain our military personnel are properly taken care of

as they address some of the problems confronting our Nation today.

For many years the armed services have placed, regrettably, a

minimal amount of resources into training medical personnel in the

treatment of chemical or biological injuries. While the possibility

existed that these weapons could be used against our personnel in

the field, the fact remained that such forces had not encountered

the use of such agents during World War I or World War II, and

ever since, regrettably and sadly, the terrible events of September

11th as well as the anthrax episode last month have sharply focused our national attention on terrorism and underscored our vulnerability to future chemical and biological attacks. Indeed the bioterrorism debate has been transformed from a question of if to the

inevitability of when.

We’re dealing with an evil enemy that’s fanatical in its beliefs

and apparently has no qualms whatsoever about using any and all

weapons at its disposal, not only nuclear, but including chemical

and biological agents. Given this, it makes sense for the armed

services to adjust their training for medical personnel to incorporate a greater emphasis on the diagnosis and treatment of chemical and biological casualties.

Initial examinations of the services’ medical structures, however,

are not encouraging. None of the armed services, the Army, the

Navy, the Air Force, even the Coast Guard, have updated their

medical requirements—have not updated their medical requirements to include chemical/bio scenarios, and while specialized

training is offered, only 37,000 of the more than 203 medical personnel have received any specialized chemical/bio warfare training

in the past 4 years.

Mr. Chairman, while we cannot expect the military to overhaul

its entire medical training program overnight, we would expect to

see some major changes being planned in the wake of the events

that have occurred since September 11th. We look forward to hearing from our witnesses today on the progress that the Department

of Defense has made in this now sadly necessary new requirement

as we fight a fanatical enemy.

Thank you, Mr. Chairman.

Mr. SHAYS. Thank the gentleman.

Mr. Lantos. Not here.

Mr. Tierney.

Mr. TIERNEY. Mr. Chairman, thank you, but I’m going to put remarks on the record if I decide to do that, and we will move this

along for you. Thank you.

Mr. SHAYS. Mr. Allen.

Mr. ALLEN. Mr. Chairman, I want to thank you. I’ll do the same.

9

Mr. SHAYS. And we have Mr. Lewis.

OK. Thank you. I appreciate the Members being here. I know

many of you have many other committee meetings today. Wednesday is not the day we should have hearings, frankly.

Let me recognize our witness, and we’ll swear her in. Her name

is Dr. Nancy Kingsbury, Managing Director for Applied Research

and Methods, U.S. General Accounting Office. Is there anyone, Doctor, who would possibly be responding to a question that should

stand when we swear you in? If so, that would make sense to have

them do that.

Ms. KINGSBURY. Betty Ward-Zukerman and Bill Cawood, who

have done a lot of work on chem/bio issues.

Mr. SHAYS. OK. Why don’t we have them stand up as well, and

we’ll swear you all in. Raise your right hands, please.

[Witnesses sworn.]

Mr. SHAYS. Note for the record all three have responded in the

affirmative. And just before I recognize you to begin your testimony, I’ll take care of some housekeeping here.

I ask unanimous consent that all members of the subcommittee

will be permitted to place an opening statement in the record, and

that the record remain open for 3 days for that purpose. Without

objection, so ordered.

I ask further unanimous consent that all witnesses be permitted

to include their written statements in the record, and without objection, so ordered.

What we do, Doctor, as I think you know, is we keep the clock

on for 5 minutes, and then we roll it over for another 5 minutes

and hope you would finish before you get to 10.

Ms. KINGSBURY. I will plan on it, thank you.

STATEMENT OF NANCY KINGSBURY, MANAGING DIRECTOR

FOR APPLIED RESEARCH AND METHODS, GENERAL ACCOUNTING OFFICE, ACCOMPANIED BY BETTY WARDZUKERMAN, ASSISTANT DIRECTOR, APPLIED RESEARCH

AND METHODS, GENERAL ACCOUNTING OFFICE; AND WILLIAM W. CAWOOD, ASSISTANT DIRECTOR, DEFENSE CAPABILITIES AND MANAGEMENT, GENERAL ACCOUNTING OFFICE

Ms. KINGSBURY. I very much appreciate being here, Mr. Chairman and members of the committee, to share with you our work

today, and I’m going to give you the very short version of the main

points of our work here this morning since we have the report

that’s just out. Everybody can see the details.

You asked us to determine how DOD had adapted its medical

personnel to emerging chemical and biological threats. Specifically

we looked at two things, how DOD and the services had addressed

chemical and biological threats in planning for medical personnel

in their distribution across medical specialties, and the training

provided to medical personnel in the treatment of chemical and biological casualties.

We found that neither DOD nor the services had systematically

examined the current distribution of medical personnel across specialties with respect to their adequacy for chemical and biological

defense. Although the services had begun a review of the staffing

10

of deployable medical units for chemical warfare scenarios, they

had not done so for biological warfare scenarios. General assessments of requirements have at best roughly extrapolated from the

results of modeling for other medical requirements to factor in

chemical and biological warfare requirements.

As recommended by DOD studies, joint protocols for treating

chemical and biological casualties have recently been completed,

but agreement has not been reached among the services on which

medical personnel are appropriate to provide treatment. This is important to provide integration of medical treatment in the event of

an attack.

DOD officials attributed the lack of systemic efforts to several

factors, including the failure to establish chemical and biological

readiness as a medical priority in defense planning guidance, data

and methodological constraints that complicate the task, disagreements among the services about the capacity to implement evacuation policy, and pessimism that medical personnel could effectively

treat substantial numbers of chemical and biological casualties.

In general, service medical planning officials maintain that specialized training rather than systematic assessment of needed specialties is the appropriate way to address any need for additional

medical skills in the military setting. However, we found that the

extent of training as well as testing and exercises for medical management of chemical and biological casualties is limited. While

progress has been made since the Gulf war in increasing the availability of such specialized training, the courses are voluntarily and,

except for basic training and daunting chemical protective gear, not

widely attended. From 1997 to 2000, as Mr. Gilman suggested,

fewer than a fifth of the uniformed medical personnel completed

any specialized training, and only about 21⁄2 percent have taken

the 7-day onsite medical management of chemical and biological

casualties course, which is the most comprehensive training available.

We note that most training does not currently include individual

proficiency testing, and in one study that we are aware of where

proficiency testing was conducted, proficiency was not demonstrated in a number of key tasks, such as clearing airways or

controlling bleeding. Notwithstanding these negative results, however, we think the effort to do proficiency testing is encouraging.

Even medical personnel who have been trained cannot readily be

identified in the event of an emergency because tracking systems

either do not exist or are not currently functioning. Thus the availability of trained personnel in a given situation is uncertain.

Another way the DOD provides combat readiness training is the

conduct of field exercises. However, exercise scenarios that include

chemical and biological defense elements have been almost nonexistent. For example, the last joint chemical and biological medical

exercise that was completed was in 1994, and the next one is not

planned until 2005. Officials told us that exercises involving medical support for chemical and biological casualties were rare because

of conflicting priorities encountered by both warfighters and medical personnel and because of the difficulty and expense of conducting them. Officials also said that such exercises are not planned because of the potential that the chemical or biological elements

11

would overwhelm the exercise and prevent the other objectives

from being achieved.

In our report we make a number of recommendations to DOD to

resolve these issues, including clarification of the requirements for

chemical and biological contingencies in defense planning guidance,

reaching agreement among the services and joint staff about which

medical personnel are qualified to provide specific treatments to

ensure consistent approaches in joint activities, developing medical

training requirements for chemical and biological contingencies, assessing the effectiveness of training with rigorous proficiency

standards and tests, and tracking individual training and proficiency, and increased chemical and biological exercises involving

medical personnel to an extent commensurate with current chemical and biological threat assessments.

Given the threat of mass casualties in a chemical and biological

event, exercises should explore the extent of medical capabilities

and the full consequences of scenarios that overwhelm them.

I think I will stop my statement here, Mr. Chairman. I will be

happy to take your questions.

Mr. SHAYS. Short, concise, and right to the point.

[NOTE.—The report entitled, ‘‘chemical and Biological Defense,

DOD Needs to Clarify Expectations for Medical Readiness,’’ may be

found in subcommittee files.]

[The prepared statement of Ms. Kingsbury follows:]

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Mr. SHAYS. Mr. Gilman.

Ms. KINGSBURY. I take that as a compliment, sir.

Mr. SHAYS. You should.

Mr. GILMAN. Thank you, Mr. Chairman.

We want to thank GAO for their review at a very critical time

and for your very alarming review of what has been done to date.

Why is chemical and biological training not mandatory?

Ms. KINGSBURY. It has not been. I am not actually sure we know.

Do we know that there have been reasons?

Mr. GILMAN. Is there any reason given to you?

Ms. KINGSBURY. I suppose there is only so much training that

can be done, and you have to prioritize it.

Mr. SHAYS. I think you have chairs on either side. This way you

can whisper in their ears if you want.

Mr. GILMAN. Why don’t you bring your assistants—— Mr. SHAYS. Hold on 1 second. We will keep the clock running.

The two I swore in, would you please—whom did I swear in?

Ms. KINGSBURY. Bill.

Mr. SHAYS. Come on.

Mr. GILMAN. Don’t be shy. We won’t bite.

Ms. KINGSBURY. Thank you.

In the overall scheme of things, I think training is something

that you spend part of your time on, and you spend part of your

time on your job. It’s just the way the priorities have been. We

have noticed, though, that at the same time the training has been

voluntary and not been done, the people who talk about the threat

have been quite alarmist, if you will, quite concerned about the

threat, and perhaps justifiably so as recent events have shown. So

I look forward to your asking the DOD witnesses about that.

Mr. GILMAN. I note in your report that key readiness—I’m

quoting from your report on page 3—key readiness evaluations

used to advise the President on readiness to implement the national security strategy had never set a scenario for the unified

commanders requiring medical support for weapons of mass destructions, and officials told you that CB medical support is rarely

exercised because of conflicting priorities encountered by

warfighters and medical staff and because it’s difficult and expensive. Did you explore that any further?

Ms. KINGSBURY. I have personally had a couple of discussions

about that because I think it’s important to understand why that

happens. My own sense of it, and I have actually been told by a

couple of officials, that the serious chemical and biological scenarios

are showstoppers. They stop the exercises, and so they just don’t

do them.

Mr. GILMAN. And you also indicate that in sum, the DOD and

the services had not fully addressed weaknesses and gaps in modeling, planning, training, and tracking or proficiency testing for the

treatment of CB casualties, and resulting medical structures not

being rigorously tested for its capacity to deliver the required medical support.

Did you explore that with them to see what was going to be done

to correct that?

Ms. KINGSBURY. Well, they have agreed with our recommendations in that regard and note in our report in their comments that

19

they are planning to do some additional things to try to address

these issues, and I’ll be happy to let them talk about that. We’ve

been making these recommendations since 1993, and we—that’s

often a role that GAO plays. We make recommendations, and agencies do or don’t followup on them, and this is one where I think

the story is still a little disappointing.

Mr. GILMAN. Since 1993, you’ve been making these recommendations, and there has been no progress?

Ms. KINGSBURY. There’s been some progress. I think that’s fair

to say. They have developed additional training. They are training

more people as we go along, but we still can see gaps between what

they seem to say they need and what is actually being delivered.

Mr. GILMAN. Well, my time has run, but just one last question.

Why has the medical training been limited here in this area in

your—— Ms. KINGSBURY. Some officials have told us it’s a matter of expense. Some officials have told us it’s a matter of priorities. It’s

been limited.

Mr. GILMAN. We gather that. All right. I hope we can explore

that further.

Thank you, Mr. Chairman.

Mr. SHAYS. I thank the gentleman.

Mr. Kucinich.

Mr. KUCINICH. Dr. Kingsbury, thank you for your work on this

report, and I would like to address a practical consequence of this

report with this question: If we had ground troops in Afghanistan,

does the Department of Defense have a medical training structure

in place to adequately protect or respond to soldiers who would be

injured by a biological or chemical weapon attack?

Ms. KINGSBURY. Our work predates the Afghan adventure, and

I don’t think I want us to talk about whether they have adequate

forces in place. There are representatives in the military here to

deal with that. That’s a very—— Mr. KUCINICH. But you——

Ms. KINGSBURY [continuing]. Sensitive issue, and I would rather

let the Department of Defense answer that question, sir.

Mr. KUCINICH. But wait a minute. You gave us a report, Dr.

Kingsbury—— Ms. KINGSBURY. I did.

Mr. KUCINICH [continuing]. That says as a consequence, medical

readiness for CB scenarios cannot be insured. Did you say that?

Ms. KINGSBURY. In general we support that statement, sir. I just

can’t speak to the situation in Afghanistan.

Mr. KUCINICH. If you say in your report that the Department of

Defense and services—I am quoting directly—had not fully addressed weaknesses and gaps in modeling, planning, training,

tracking, or proficiency testing for the treatment of CB casualties,

wouldn’t it follow that if we were to have our men and women on

the ground in Afghanistan, and they were subjected to a biological

or chemical weapon assault, that we might not be able to care for

them given this report?

Ms. KINGSBURY. I think the phrase ‘‘we might not be able to’’ is

a fair statement.

Mr. KUCINICH. I thank you. No other questions.

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Mr. SHAYS. Thank you.

Mr. Lewis.

Mr. LEWIS. Thank you, Mr. Chairman.

Thank you, Dr. Kingsbury, for your testimony. Why do you think

the medical personnel training has been limited—and the reason I

ask that is because, of course, we’re talking about chemical and biological here, but after all the years that we faced the threat of a

nuclear attack, was there any training for medical personnel to

deal with a major catastrophe in regards to the nuclear equation

that could be brought around to the possibility of a chemical or biological attack?

Ms. KINGSBURY. Well, the military structure—the military medical structure serves two purposes. It serves a peacetime purpose,

and it serves a wartime purpose, and I think those two things create a very difficult challenge to make sure you’re prepared for the

perhaps unlikely but nonetheless devastating possibilities of a

chemical or biological attack. And this is made more complicated

by the fact that the issues that you need to address medically for

nuclear, chemical or biological are actually quite different and require different skills.

So it’s a very complicated issue, and I wish we saw a really clear

solution to it. We make some recommendations in our report and

hope that the Department of Defense can move quickly in the right

direction.

Mr. LEWIS. What are some of those steps that could bring them

in a more positive direction in medical training?

Ms. KINGSBURY. Well, we address many of those in our report.

We talk about the need to track who’s had the training; the need

to do proficiency testing and make sure that the people who are

there in fact can demonstrate the skills, not just say they know it;

better planning in defense planning guidance, clearer priority for

this. That’s what drives what the warfighters do. That’s what

drives what DOD ultimately thinks is going to happen on the battlefield, and I think that’s where it has to start.

Mr. LEWIS. OK. Thank you.

Mr. SHAYS. Thank the gentleman.

At this time recognize Mr. Tierney.

Mr. TIERNEY. Thank you, Mr. Chairman.

Dr. Kingsbury, thank you for your testimony. In your report you

conclude that the persistence of this troublesome situation has

been caused by one of three factors, a disagreement about the significance of the threat, the failure of leadership, or an acceptance

of a high level of risk. Can you walk us through each of those

three?

Ms. KINGSBURY. Wait a minute. I’ve just gone blank.

Mr. TIERNEY. OK. Well, the first one was——

Ms. KINGSBURY. What page are you on?

Mr. TIERNEY [continuing]. A disagreement about the significance

of the threat. The second was a failure of leadership. The third was

an acceptance of a high level of risk. You know, each of those would

contribute in some degree to the persistence of the situation.

Ms. KINGSBURY. Well, let’s start with the threat first. I mean, I

think that although there has been a great deal of commentary

about the threat and obvious concern about it, if you really look in

21

a lot of the places we’ve looked across a whole spectrum of issues

related to chemical and biological warfare, the resources, the training, the commitment to meet the threat doesn’t seem to match the

level of threat assessment that’s out there, and we’ve been sort of

puzzling about that as we’ve put this work together, some of the

work that Bill Cawood has done and others. We really think it

starts with that problem.

With respect to leadership, I point particularly to the difficulties

of achieving a joint outcome here. I think it’s very important because we’re fighting jointly increasingly so that the services get together and reach agreement on how medical casualties in this

arena need to be managed.

And with respect to risk, I think the events of the last couple of

months clearly have heightened our sense that risk is real, and

that the medical difficulties are a real challenge. Just identifying

what’s happening is perhaps one of the more real challenges.

I am encouraged actually by a byproduct of the last 2 months.

I am a great believer that if you’re looking for something, you’re

more likely to find it, and I think that the last couple of months

has heightened perhaps our ability to detect these things going forward.

Mr. TIERNEY. Just as a comment, I have to say that when earlier

you were talking about there being a reason for the services not addressing this gap between the appraisal of the threats and the Department of Defense medical preparedness to meet them, as some

people say, it’s an expense, and some people say it’s the priorities, well, at $330 billion plus in that Department of Defense budget

every year, I would have to say that it’s a lack of responding to

your priorities more so than not a lack of having the money. Or

God help us if it’s the other way around.

Of the three items that we just discussed on which you base your

analysis, which one of those do you think is the more prominent,

the primary cause of this situation?

Ms. KINGSBURY. Right now I think I need to go back to the starting point. I think it needs to be sorted out in how DOD is choosing

to plan for warfare going forward. If these priorities get into the

defense planning guidance, they will get fielded. They will get

done. All of the services are very capable of doing things when they

decide to do them. I think it’s important to start there.

Mr. TIERNEY. On page 10 of your report, you said that the Army

Medical Department officials said they were not authorized to

structure medical care for biological contingencies. I am wondering

what do these medics mean when they say they’re not authorized

to prepare for attacks using biological weapons?

Ms. KINGSBURY. I’m sorry, sir, where are you?

Mr. TIERNEY. Page 10. Do you—yeah. Why don’t you——

Ms. WARD-ZUKERMAN. I think they were indirectly referring to

the fact that preparation for biological contingencies was not something that the DPG had directed them to do.

Mr. TIERNEY. The DPG being?

Ms. WARD-ZUKERMAN. The defense planning guidance.

Mr. TIERNEY. Did you determine any reason why they hadn’t

been directed to do that? I mean, it’s pretty amazing at this point

in time to think that they hadn’t been.

22

Ms. WARD-ZUKERMAN. We just, you know, looked at the sort of

the immediate reason that they had not done it.

Mr. TIERNEY. On the question of evacuations, at least as I understand it, the faster the injured are removed or lifted from the area,

the fewer medical personnel may be needed in the field. Is that a

fair assessment?

Ms. KINGSBURY. Yes, sir.

Mr. TIERNEY. And in that regard what is the joint and strategic

capabilities plan?

Ms. KINGSBURY. The joint and strategic——

Ms. WARD-ZUKERMAN. The joint and strategic capabilities plan is

developed to provide missions to the commanders-in-chief in the

various areas that DOD operates, and it follows the guidance in the

defense that’s put together by OSD in the form of defense planning

guidance.

Mr. TIERNEY. And is there, in fact—one of the things they talk

about is following that pattern of getting the people that are affected out of the area quickly so that there is less need for medics

on the front line.

Ms. WARD-ZUKERMAN. We didn’t specifically look at the joint

strategic capabilities plan, but Army officials did cite concerns

about the actual speed with which people could be evacuated.

Mr. TIERNEY. Thank you.

I see my time is up, Mr. Chairman. Thank you.

Mr. SHAYS. It’s my intention to come back, but if the gentleman

would like to ask questions now, he could do that if he’s not coming

back.

Mr. ALLEN. I could do it very quickly.

Mr. SHAYS. OK. Mr. Allen.

Mr. ALLEN. Thank you, Mr. Chairman. My questions will be—I’ll

try to keep this well under 5 minutes.

Based on your analysis of the availability of medical personnel

in the military services, let’s just imagine that the outbreak of anthrax was an outbreak of smallpox instead. How many military

health care personnel are there available to treat someone infected

with smallpox who’s been vaccinated? I mean, is there anyone in

the services among their health care personnel who can walk in

and care for a smallpox victim without fear of contracting the disease themselves?

Ms. KINGSBURY. Mr. Allen, we did not specifically look at that

issue, and with three very distinguished Surgeons General in the

room, I would rather defer that question to them.

Mr. ALLEN. Mr. Chairman, is there a way to get an answer to

that question either later, or can we bring that out?

Mr. SHAYS. Let me just ask you. Your response to the question

is based on what?

Ms. KINGSBURY. Well, we did—as you well know, Mr. Chairman,

we tend not to want to make observations about things that were

not included in the scope of our work, and we did not specifically

ask questions about the preparation to treat smallpox victims in

the present moment, and I just—I don’t have any basis at all for

answering your question. It’s not that I don’t think it’s a fine question.

23

Mr. SHAYS. But I do think that we can ask the next panel and

pursue that.

Ms. KINGSBURY. I would prefer that. Thank you, sir.

Mr. ALLEN. Mr. Chairman, my point was we’ve been talking

about training of personnel, and that’s sort of one area, but having

personnel who can treat patients without being themselves subject

to getting the disease, it seems to me at least equally important.

Ms. KINGSBURY. I would agree with you, and it applies not only

to smallpox, but any other number of biological toxins out there. I

think that’s an important part of the bigger picture.

Mr. SHAYS. We’re going to stand at recess. We just have one vote,

and we’ll be back——

Ms. KINGSBURY. Yes, sir.

Mr. SHAYS [continuing]. And then we’ll finish up.

[Recess.]

Mr. SHAYS. Call this hearing to order and apologize. We had two

votes, not one.

What I would like to do is first state—I would like to acknowledge that there appears to be very good will between GAO and

DOD and cooperation between both. And also to express appreciation that there wasn’t an attempt to try to smother this report or,

if there was, that it wasn’t something that was pursued.

Because we’re in new territory here. This is, I think, a very, very

significant report but one that needs to be addressed. I think,

frankly, by making sure that this is public, we have an added incentive to have people understand why resources need to be spent

for DOD. I mean, we are clearly in a race with the terrorists to

shut them down before they have a better system for chemical and

biological weapons, nuclear waste or nuclear weapons. We’re at

war, and I think a lot of people in our country don’t fully appreciate it.

We all have to kind of think distinctly. We have to reorient our

military differently. We need to reorient how we think about foreign aid. We need to do a lot of things. I mean, I’ve had some in

the military tell me if we had put more resources into the State

Department we might have prevented some of our military from

having to be in some places risking their lives.

When President Lincoln addressed Congress when—it’s unbelievable to me, but we lost 10,000 men a month for 4 years in the Civil

War. He addressed Congress, and he said, the dogmas of the quiet

past are inadequate to the stormy present. The occasion is piled

high with difficulty, and we must rise with the occasion. As our

case is new, so we must think anew and act anew. We must

disenthrall ourselves, and then we shall save our country.

My view is that we’re all being asked to think anew. And obviously the military is part of that. So I just want to put that on the

table and say that I don’t have a lot of judgment as to why we’re

here, but I am interested in what we can do to see us think anew

and act anew.

What I wanted to do was I wanted to go down, Dr. Kingsbury,

the recommendations that you made and understand what each

one was and understand what you think DOD’s response was. I’m

referring to page 47 in your report. Specific comments on recVerDate 11-MAY-2000 09:42 Oct 29, 2002 Jkt 000000 PO 00000 Frm 00027 Fmt 6633 Sfmt 6633 C:\DOCS\82172.TXT HGOVREF1 PsN: HGOVREF1
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ommendations made by DOD. It appears that they basically concurred with every one.

Ms. KINGSBURY. Yes, sir.

Mr. SHAYS. Is your mic on?

Ms. KINGSBURY. It is now, yes, sir.

Mr. SHAYS. Let me say that so, in your judgment, they concurred

with every one. Is there any one recommendation or more than one

in which you feel they qualified their response to it?

Ms. KINGSBURY. I don’t think I would feel that they qualified

their response. At the time they made their response they said they

are taking certain actions, and the actions they described I would

say were the first step necessary to actually make something happen differently. So, being GAO, we always maintain a certain

healthy skepticism that this is actually going to move forward in

the way it needs to, but it was certainly a positive first step.

Mr. SHAYS. What I’m going to do is do 5 minutes, then roll over

for the next 5.

I missed that last sentence, I’m sorry, that last part.

Ms. KINGSBURY. The point I’m making, sir, is that they did concur explicitly with each of our recommendations. Then they described the steps that they were going to take. The first step that

they were going to take, referring it to the Joint Planning Council

or whatever. As I say, we will be happy to watch and make sure

that something comes from that first step.

Mr. SHAYS. What I get a sense of is there’s an obvious concern—

I had one. I had a concern that they agreed with the criticisms, but

there wasn’t a sense of time line or when certain things would actually take place.

Ms. KINGSBURY. That’s correct, sir.

Mr. SHAYS. You had—basically, the GAO recommended the

SECDEF, which is—what is that?

Ms. WARD-ZUKERMAN. Secretary of Defense.

Mr. SHAYS. For EF? Oh, Secretary of Defense—‘‘address the gap

between the stated CB threat and the current level of medical

readiness by clarifying the Department’s expectations regarding

medical preparation for CB contingencies and, as appropriate, by

directing the Joint Staff to integrate biological medical readiness in

DPG.’’

And again DPG is——

Ms. KINGSBURY. Defense Planning Guidance.

Mr. SHAYS. That’s the key document.

Ms. KINGSBURY. Yes.

Mr. SHAYS. DOD responds, concur. It says, ‘‘As the coordinating

body with the services and the CINCs on issues of this nature, the

Joint Staff will be requested to conduct a reexamining of CB medical training issues and provide suggested adjustments to enhance

the DOD’s medical readiness posture.’’

What does that say to you?

Ms. KINGSBURY. That says they’re going to look at the issue

again. It does not say what solutions they expect to come out of it.

Mr. SHAYS. OK. The second recommendation—if you just look at

DOD’s response and tell me what you think that’s saying and if

you’re satisfied with that.

25

Ms. KINGSBURY. Well, again they’re going to—they’ve asked the

Joint Staff to address the issue of what the steps are that are going

to be taken to actually get a Common User Data base established.

It is not evident from this response.

Mr. SHAYS. So on the second DOD response you would want to

know what steps they’re going to take.

Ms. KINGSBURY. Yes, sir.

Mr. SHAYS. OK. The third one.

Ms. KINGSBURY. Oh, let’s see—— Mr. SHAYS. They basically are agreeing, and we just need to

know now what ‘‘agree’’ means.

Ms. KINGSBURY. Well, in this response they do cite certain NATO

standardization agreements which are certainly steps in the right

direction of this effort. But there’s a great deal that needs—I would

say there’s a great deal that needs to be done here in terms of the

planning models and so forth that don’t at the moment explicitly

account for chemical and biological needs except very roughly.

Mr. SHAYS. Let me just read on the next page. It says, ‘‘However,

if the GAO recommendation pertains to the evacuation, EVAC, policy, DOD non-concurs.’’ So here we have a non-concurs. So what does it relate to?

Ms. WARD-ZUKERMAN. I think that the response that DOD gave

made reference to evacuation policy, but it was our sense that the

real disagreement was about evacuation capability. The Army officials specifically indicated to us that they had developed a medical

force structure adjusting for the fact that they were skeptical about

the actual evacuation capabilities that would be available when

needed. Their response basically talks about evacuation policy

which there is a policy that’s written on paper that, you know, that

is agreed. But the issue is more—— Ms. KINGSBURY. Implementation.

Mr. SHAYS. On recommendation 4, ‘‘the GAO recommended that

the services develop CB medical training requirements and assess

the effectiveness of training with rigorous proficiency metrics and

standards.’’ What do you feel their response is there? And what’s—— Ms. KINGSBURY. Well, again, it’s been referred for further development, and the proof is in the pudding. The implementation of

these—the actual existence of proficiency tests is what we would

ultimately look for to see whether that recommendation was carried out. We would not conclude that it was until we began to see

some of that—— Mr. SHAYS. OK.

Ms. KINGSBURY [continuing]. In practice.

Mr. SHAYS. When you get a concurrence, do you then in your documents respond to the concurrence? In other words, I’m kind of

puzzled why we wouldn’t go the next step and say the things that

specifically they need to do some kind of time line to do it.

Ms. KINGSBURY. Well, we certainly continue to follow what they

do. I think as a general matter, unless we have done specific work

that points to a particular solution to a problem of this sort, we

would not substitute our judgment for the agency’s or the service’s

about how best to do it. We believe that’s their responsibility. We

would look to see what they did and whether it met either the spirVerDate 11-MAY-2000 09:42 Oct 29, 2002 Jkt 000000 PO 00000 Frm 00029 Fmt 6633 Sfmt 6633 C:\DOCS\82172.TXT HGOVREF1 PsN: HGOVREF1
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it or the literal meaning of our recommendation, and we do track

these over time.

Mr. SHAYS. The GAO recommendation 5, ‘‘The GAO recommended that the services develop and maintain information

management systems to monitor completion of required CB training and track the proficiency of medical personnel, at least for the

first responders and key personnel in high risk areas of operations.’’ Then they say they concur. How did you respond to their concurrence?

Ms. KINGSBURY. Well, they concur with the suggestion which in

principle I would not disagree with which is that it might be better

to actually track proficiency itself, rather than tracking training.

Training is, at best, a surrogate for proficiency. If they could develop a system to actually track the proficiency of medical personnel, that would be, in fact, a better solution. That is, in our experience, probably harder to do.

Mr. SHAYS. Let me just say, for DOD’s benefit here, I would love

when they—and would expect that they will expound on the DOD

response and give us some kind of sense of what’s required and

time lines of some kind, not obviously by month but give us a sense

of what it’s going to take to do these things.

The last one, ‘‘The GAO recommended that the Joint Staff,

CINCs and services increase the realistic exercise of medical support to a level commensurate with current CB threat assessments.

To the extent there is a threat of mass casualties, exercises should

explore the limits of medical capabilities and the full consequences

of the scenarios that overwhelm them.’’ What about this one?

Ms. KINGSBURY. Well, as I said earlier, we are concerned that,

as we look at the conduct of exercises, that the exercise of the medical piece, particularly in the chemical and biological scenario, is

rarely, if ever, addressed. And when we ask why we are often told

it’s because it’s such a big piece of it and would get in the way of

achieving the other objectives of the training.

I certainly can be sympathetic to that, but that implies that if

it actually happens you couldn’t deal with it, and I think if we are

going to be truly prepared we would have to have some knowledge

of at what point is this manageable with great effort and at what

point is it not and is there anything we can do about that. Recognizing that this may be a low probability event in the overall

scheme of things, it is a very high consequence of that. It seems

to us that some real exercises need to be done.

Mr. SHAYS. I want your definition of low probability. Not that

there would be chemical and biological attacks but they’ll be massive, that they’re low probability. It’s not low probability that there

will be an attack.

Ms. KINGSBURY. Relative to being shot at I expect it’s a lower

possibility, but it’s perceived as higher now than before.

Mr. SHAYS. Is there—you’ve done an assessment—— Ms. KINGSBURY. I don’t know what the actual probability is. The

current threat assessments tend to describe it as a low probability,

low consequence attack. That’s the only place we would draw that

conclusion. We’re not making an independent assessment of that.

27

Mr. SHAYS. You didn’t really look at the probability.

Ms. KINGSBURY. No, sir. We just looked at what the threat assessment said.

Mr. SHAYS. Because I just want to make sure that you’re not

kind of giving credibility to something I think is not true.

Ms. KINGSBURY. I would not want to do that, sir. Thank you.

Mr. SHAYS. The bottom line is you made an assumption, if there

was an attack, how could we respond to it. You did not look at the

threat assessment.

Ms. KINGSBURY. Well, we looked at it. We did not make an assessment of it. But I am reflecting what we were told by the people

who were responsible for conducting exercises about why they did

not include these scenarios in the exercises. Those descriptions

were a part of those discussions.

Mr. SHAYS. Mr. Kucinich.

Mr. KUCINICH. I want to go back to something you said a moment ago that implies if it happened we wouldn’t be able to deal

with it. What do you mean? If what happened?

Ms. KINGSBURY. If we actually had an attack that resulted in

mass casualties in the battlefield.

Mr. KUCINICH. What do you mean we wouldn’t?

Ms. KINGSBURY. At this point we don’t know whether we would

be able to deal with it, because it has not been exercised. The people who do the exercise believe it can’t be dealt with. I’m talking

mass casualties here.

Mr. KUCINICH. I understand that. And today in the front page of

the L.A. Times President Bush is quoted as saying the threat is

that terrorists also want chemical and germ weapons, President

warns, as he tries to rally support from abroad. And in the article

it says that the President had not previously raised such a concern

in public, that the terrorist network is seeking weapons of mass destruction.

Now, in this context which we’re in, maybe not when you first

started your report, we’ve got to look at this current context.

Ms. KINGSBURY. I completely agree with that, sir.

Mr. KUCINICH. We are in a conflict now.

Ms. KINGSBURY. Yes, sir, we are. And those weapons are probably out there.

Mr. KUCINICH. For the first time we have a President saying

publicly that terrorists are trying to obtain nuclear, biological,

chemical weapons; and we have the GAO saying that the Department of Defense does not have a structure in place to protect the

health of the troops essentially, if I read your report correctly.

And I see from other reports, Mr. Chairman, that there’s questions about whether enough vaccines are available from the private

sector. There is even discussion in the government going on right

now about the government itself being involved in the production

of vaccines.

Now, this isn’t the question you have to answer, but it’s a question I want our friends from the military to get ready for, and that

is, under these circumstances, how could the military possibly recommend a ground assault in Afghanistan where our men and

women could be exposed to a biological or chemical weapons attack

28

and not have structures in place to make sure that they have some

protection?

This is a very serious issue here. The context has changed from

when this report first began to be worked on. And, you know, I

think that we have to remember back in World War I when soldiers were met with mustard gas, they had no idea of how to deal

with it. You know, the gas mask came up but still there were people dying in the trenches.

We need to be very—I think this issue that is brought to this

committee of a low-probability, high-consequence effect needs to be

looked at more carefully. Because if the probability increases, that

means that the consequences have to increase commensurately.

So I appreciate the Chair calling this hearing. But we need to

look at the very severe implications of this for not only the health

care infrastructure of the Department of Defense but the linkage

to military strategic analysis, planning and initiation. Thank you.

Mr. SHAYS. If the gentleman would let me followup before Mr.

Putnam, you may want to followup because I may be qualifying

your concern. But I want to make sure you looked force wide, correct?

Ms. KINGSBURY. Yes, sir.

Mr. SHAYS. So, you know, my recollection when I have had the

opportunity, as this committee has a great opportunity to do, to be

out in the field with some of our special forces, they do have capabilities that would not be force wide; and I think that we’ll be able

to address that later.

But your statement, if this were an all-out attack with lots of

people, we’d have some real challenges. But I think, frankly, that

if the numbers are small, we have that limited capability to do it.

Mr. KUCINICH. If I may, Mr. Chairman, I’m just making my

statement and analysis from what’s presented on the record, not

from any secret information I have.

Mr. SHAYS. It’s not that this report—and that’s what I want to

clarify. This report was a report done based on looking at the entire services. You didn’t look at any specific, specific unit or did

you?

Ms. KINGSBURY. No, in this work we did not. We’ve had other

work in the past where we have.

I think it’s also important to recognize in this report we only

looked at how they do planning for medical resources and how they

train for responding to these kinds of events. We did not look at

equipment and things of that sort as a part of this work.

Mr. KUCINICH. If the Chair would just permit me to make this

observation, and that is it has been broadly stated and reported in

the media that the use of ground troops in Afghanistan has not

been ruled out. So that’s why I raise the issue. I thank the Chair.

Mr. SHAYS. I think it’s very important to make that point.

Is it your intention to stay while we have the testimony of our

second panel?

Ms. KINGSBURY. I’m at your disposal, sir.

Mr. SHAYS. I would welcome that. It may be that we would want

you to just respond or add some clarification.

In your statement which, as I said, was short and to the point,

you attribute the lack of systematic evidence to several factors, inVerDate 11-MAY-2000 09:42 Oct 29, 2002 Jkt 000000 PO 00000 Frm 00032 Fmt 6633 Sfmt 6633 C:\DOCS\82172.TXT HGOVREF1 PsN: HGOVREF1
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cluding failure to establish chemical and biological readiness as a

medical priority to defense planning guidance. There’s no dispute

about that. That hasn’t been done. Data methodology constraints

that complicate the task. Just elaborate what you mean by that.

Ms. KINGSBURY. Well, the whole question—I mean, there are

models that are used and we haven’t looked at them in depth to

make a determination about what kinds of medical resources are

needed in the various services and in the various scenarios. And

the data to support those with respect to—certainly to biological

and chemical areas has never been developed because they haven’t

actually had any experience on which to develop them. So it’s a

very rough kind of order of magnitude kind of analysis that goes

into adding and factoring in chemical and biological.

Mr. SHAYS. Disagreements among the services about capacity to

implement evacuation policy. If you could just elaborate, give it

some color, so we know how to ask the—our three branches what

that means. I mean, can you give me some example?

Ms. KINGSBURY. One service, if they’re on the ground like the

Army, needs to make certain assumptions about how many people

who are casualties can be evacuated by forces provided by another

service, for example, the Air Force. And those assumptions, when

written in planning guidance, the officials that we met with told us

that they did not believe that capacity would actually be delivered

when it was implemented. So the guidance says that it will be

there, but there is differences of opinion among the warfighters and

the medical folks about whether that would actually happen.

Mr. SHAYS. Pessimism that medical personnel could effectively

treat substantial numbers of chemical and biological casualties. In

other words, even if they had a plan or because they don’t? In other

words—— Ms. KINGSBURY. Certainly because they don’t. And, again, the

way you work these things out is in planning for exercises and the

like. And if you look at the possibility of an exercise and mass casualties, I think the people involved in it reach conclusions that they

can’t do it and it would stop the exercise. My own reaction to that

is, yes, and it would stop the battle, so you really ought to think

about it. But I think that’s why we raised the issue in that way.

It’s such a big problem and everybody understands it to be a very

big problem, almost so big that there haven’t been the resources to

try to understand it well enough.

Mr. SHAYS. And probably the thought that it wouldn’t have to because people wouldn’t cross that red line.

Ms. KINGSBURY. Right.

Mr. SHAYS. Which we know after September 11th there is no red

line.

Ms. KINGSBURY. Doesn’t appear to be.

Mr. SHAYS. No, there is no red line.

On page 3, you said, even medical personnel who had been

trained could not be readily identified in the event of an emergency

because tracking systems either do not exist or are not currently

functioning. Thus the availability of trained personnel in a given

situation is uncertain.

What we learned with the Gulf war is there were very few people

in the Department of Veterans Affairs and DOD that dealt with

30

hazards—dealt with what toxic material that you would deal with

in the workplace, and so there weren’t a lot of people who had specialties. In fact, there were only—out of over 2,000 there were only

like 3. And it was so stunning that it was almost incomprehensible.

You couldn’t comprehend it. But what you’re saying is, if you have

medical personnel who are trained, we don’t really know where

they are right now.

Ms. KINGSBURY. That’s correct.

Mr. SHAYS. OK. Within the system.

Ms. KINGSBURY. That’s correct.

Mr. SHAYS. Let me do this—do you have another question?

Mr. KUCINICH. No.

Mr. SHAYS. I think that your recommendations are on the record.

We know what their response was. Your comment would be that

they agree with the recommendations. It’s really a question of what

agree means. In other words, how they go about implementing the

recommendations, what kind of time line they’re on and so on.

Ms. KINGSBURY. And what kind of priority it has, yes, sir.

Mr. SHAYS. Well, we’re going to try to give it a high priority. But

I honestly don’t think we need to. I think it was a real wake-up

call from hell on September 11th. So thank you very much, and

we’ll look forward to maybe calling you back and, if we do, you

have still been sworn in so we’ll just remember that. Thank you.

We’ll go to panel No. 2. We have one testimony from Dr. William

Winkenwerder, Assistant Secretary of Defense for Health Affairs,

Department of Defense; accompanied by General Paul K. Carlton,

Jr., Surgeon General, U.S. Air Force; General James B. Peake, Surgeon General, U.S. Army; and Admiral Donald C. Arthur, Jr., Deputy Surgeon General, U.S. Navy.

We would welcome you to stand and swear you in. Then we’ll

take testimony.

[Witnesses sworn.]

Mr. SHAYS. Note for the record all four of our witnesses have responded in the affirmative.

I want to say again from the outset that what we’re ultimately

all interested in is how we deal with the recommendations given,

that you concur with them. And we want to understand the implications. We want to know what kind of task this represents for the

military and how we can be helpful in getting you to a position I

know you all would like to be in. And also, candidly, the implication of what Mr. Kucinich raised as well.

So what we’re going to do, Doctor, is take your testimony, and

we’ll roll over the clock, and invite all of you to respond to the

questions. So thank you for being here.

31

STATEMENTS OF WILLIAM WINKENWERDER, ASSISTANT SECRETARY OF DEFENSE FOR HEALTH AFFAIRS, DEPARTMENT

OF DEFENSE, ACCOMPANIED BY LT. GENERAL PAUL K.

CARLTON, JR., THE SURGEON GENERAL, U.S. AIR FORCE, DEPARTMENT OF DEFENSE; LT. GENERAL JAMES B. PEAKE,

THE SURGEON GENERAL, U.S. ARMY, DEPARTMENT OF DEFENSE; AND READ ADMIRAL DONALD C. ARTHUR, JR., DEPUTY SURGEON GENERAL, U.S. NAVY, DEPARTMENT OF DEFENSE

Mr. WINKENWERDER. Chairman Shays and distinguished—— Mr. SHAYS. Is the mic on?

Mr. WINKENWERDER. OK. Chairman Shays and distinguished

committee members, thank you for inviting me to appear today before your committee.

I’m Dr. William Winkenwerder, Assistant Secretary of Defense

for Health Affairs. Today I’m going accompanied by the Surgeons

General from the Air Force and the Army and the Deputy Surgeon

General of the Navy.

I have already submitted a written statement, but with your permission I would like to make a brief opening statement.

As we all know, the perception of threats posed by nonconventional weapons has changed dramatically—— Mr. SHAYS. If you tilt this, bend this up. Like this. So you don’t

talk straight in.

Mr. WINKENWERDER. Is that OK—has changed dramatically in

the last 8 weeks. As our Nation addresses this threat, DOD plays

a supporting role to civilian authorities where we have the capability to do so. The Department is working closely with Federal partners for homeland and defense matters.

DOD is the primary Federal agency responsible for administering

the national disaster medical system and sharing responsibilities

with the Department of Health and Human Services, FEMA and

the VA. We have many capabilities that can be used in support of

civilian agencies to assist in both the prevention and the management of chemical and biological attacks, and these DOD assets

have been used extensively in the current response to the domestic

anthrax attacks.

Our focus, however, has been and continues to be our men and

women in uniform, not only because their medical readiness is a

critical aspect of the success of any military operation but also because they are the most important asset. I can tell you without

equivocation that this is my No. 1 priority as Assistant Secretary

of Defense for Health Affairs.

Since coming to this office just 2 weeks ago, I have begun to review our medical readiness training programs. It is clear to me

that a solid foundation has been laid, much good work has been

done in the past few years, but clearly we can do better. And I

want to emphasize this, the threat is no longer theoretical. The

events in the past 2 months have shifted priorities. Indeed, my

mandate from Secretary Rumsfeld and Under Secretary Chu is

clear, we will focus on a deliberate but accelerated process for improving our medical readiness training programs across the board

to meet chemical and biological threats. Secretary Rumsfeld identified this requirement and this issue of asymmetric threats in his

32

Quadrennial Defense Review as he has moved the Department

from a threat-based planning model to a capabilities-based model.

I will work closely with the Surgeons General to identify areas

of concern and address those issues directly now.

I will outline some of the actions we plan to undertake in the Department, but first I want to identify those areas in which we already have made significant progress.

In recent years the military health system has placed increased

emphasis on chemical and biological readiness. Training has increased at all levels, from individual training to the unit level. The

military services have developed numerous training courses and

other resources focused on the medical response to chemical and biological events.

The courses that the Department has conducted on training materials that have been distributed have been broad and substantive. We have provided educational opportunities at every skill

level within the range of our medical personnel, from junior enlisted to speciality physicians. These training methods vary from

in-house, multi-day courses, abbreviated exportable courses, live

and rebroadcast satellite courses, Web-based courses, printed

manuals, newly printed manuals and handbooks that outline chemical or biological casualty management. With the added emphasis

on domestic response, both military and civilian health providers

have also attended these courses, I might note.

Additionally, the Uniform Services University at the Health

Sciences has robust and longstanding educational programs in the

medical aspects of chemical and biological terrorism developed for

our military medical students and graduate students. The university is now actively involved in adapting these programs to the civilian medical education community in both traditional and interactive Web-based formats. In this regard, I believe the value of our

military medical educational institution is a national asset and a

national leader in the development of education in the area of biological and chemical terrorism.

It’s very appropriate that this committee ask where we are in the

Department with respect to medical readiness training in the areas

of responding to chemical, biological or nuclear threats. In my view,

the goal of the military health system should be to ensure all medical personnel receive appropriate training commensurate with their

medical skill level and that all necessary medical planning and exercises have occurred that will ensure our personnel are ready.

Since my swearing in 9 days ago, I have begun reviewing the

basis upon which our military medical readiness plans have been

constructed, the medical infrastructure needed to accomplish our

mission, training requirements of the total medical force, active

and reserve officer and enlisted, and the means by which we monitor and evaluate the training we provide.

The General Accounting Office’s report is helpful. I believe it provides a road map of many actions that I and the Surgeons General

and others will undertake expediently to improve our ability to respond to these acts of terrorism.

From my perspective, there are three main prongs related to

medical preparedness for chemical and biological attacks: prevention, detection and response to the attack.

33

Prevention of disease remains the preferred course in any aspect

of health care delivery. It’s especially true in considering the consequences of chemical and biological warfare. With anthrax as the

current biological threat and cause of disease in our citizens, DOD

and the services have taken precautions for the men and women

in uniform. We have ensured that both adequate supplies of antibiotics and proper guidance are available to the deployment forces.

Additionally, the Department also initiated an anthrax vaccine

immunization program, as you know, to provide our service members with protection against this particular type of attack. I will be

reviewing this program to ensure that it is effective for its stated

goal.

The detection of a chemical and biological attack requires the

logistical element of equipment and emerging technology that the

Department has aggressively pursued. Detection also encompasses

the medical expertise required to identify signs and symptoms at

an early stage of an attack, particularly a biological event in which

the awareness of the attack could be delayed for days or week.

Finally, proper medical response to an attack is essential for

minimizing casualties and for sustaining our ability to fight the

war. We must ensure that we have the right people to perform

these missions, that these people are trained and that we know

specifically who is trained at what level. To address this matter,

my office and the Offices of the Surgeon General and the Joint

Chiefs of Staff have already undertaken a number of initiatives.

First, let me outline that we will be conducting a comprehensive

review of current chemical biomedical training, and I’m here to tell

you that we will be making some level of training mandatory at all

levels. If we can make mandatory training on sexual harassment,

we can make this kind of training mandatory which, obviously, is

of high importance.

Second, we will be standardizing medical response protocols

across the services.

Third, we will be enhancing medical planning tools to include development of a Common User Data base to enable the services to

conduct medical planning for contingencies involving weapons of

mass destruction.

Fourth, we will be ensuring that future training and exercises include greater medical play and providing challenging and realistic

scenarios that adequately assess the capabilities of our medical

units to function in a chem/bio environment.

Additionally, DOD will be developing a tracking system to monitor the training and the proficiency of health personnel to function

in a chem/bio environment.

Taken together, I’m confident that these actions will result in a

military health system better prepared to support our military men

and women in the coming months and years ahead.

I want to thank you for the opportunity to appear today. I appreciate the committee’s commitment to our service members and look

forward to working together to keep their safety and protection our

first priority. I look forward to answering any questions you might

have at this time.

Mr. SHAYS. Thank you.

[The prepared statement of Mr. Winkenwerder follows:]

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35

36

37

38

39

40

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Mr. SHAYS. We’ll start with Mr. Putnam.

Mr. PUTNAM. Thank you, Mr. Chairman.

Dr. Winkenwerder—did I say that correctly?

Mr. WINKENWERDER. Winkenwerder, that’s correct.

Mr. PUTNAM. This is a whale of a 2 weeks for to you have started

out in this position.

Mr. WINKENWERDER. An incredible time to arrive.

Mr. PUTNAM. We appreciate your presence here and your commitment to improving the level of quality of care in the health services.

According to the GAO report, between 1996 and 2000, you had

over 1,300 service medical personnel take your 61⁄2 day course.

Your testimony says that, since 1997, 7,800 personnel have taken

that course. Is there—how do you explain that disparity?

Mr. WINKENWERDER. Well, I would say that, due to the short notice that we had, that certainly is nobody’s fault. In preparing for

this hearing, the written remarks that were provided to the committee did omit a number of important preparedness activities and

programs that have been undertaken by all three services in the

past few years and some in just the past few months and weeks.

That’s why I was very much pleased that you’ve allowed me to

have my colleagues here, the Surgeons General, to talk about some

of those, that there have been more people trained than was——

Mr. SHAYS. Can you move your mic a little further away? Move

it back away from you a little bit.

Mr. WINKENWERDER. There have been more people trained than

has been indicated. I don’t want to suggest that in my response

that enough people or all the people that we want to be trained

have been trained. But the numbers are something better than has

been provided, and we would—thank you—and we would be glad

to provide those numbers to you.

Mr. PUTNAM. OK. I would certainly appreciate that. But you’re

standing by at least 7,800.

Mr. WINKENWERDER. Yes.

Mr. PUTNAM. OK. You also said that 19 percent of the uniformed

health service personnel have completed the specific chem/bio

training and not more than a little over 2 percent of medical officers have completed the full 61⁄2 day course and then those who

have been through it we don’t really have any way to track where

they are to get them in a hurry. How are we addressing that issue?

Why aren’t the uniformed health service personnel required to take

a specialized course and what steps do you have in mind as you

embark on this to bump that up and increase the number who will

be exposed—excuse me—who will be trained for a chem/bio event?

Mr. WINKENWERDER. Well, just in a matter of the past few days

I have requested the surgeons to develop a plan that would include

the level of training and courses that we believe would be mandatory for all personnel. Obviously, one size doesn’t fit all here. Our

goal would not be to have everybody who’s a military health care

provider attend a 3 or 6-day course. We need to target the level of

training to the particular kind of provider or professional. But,

whatever that level is, we want to make sure that everybody has

the training that they need to have.

42

Mr. PUTNAM. I guess the part about the raw numbers of this that

is a little bit disturbing is that all of us on the civilian first response side probably slept pretty well at night prior to the 11th

knowing that somebody out there on the military side had a large

team of people equipped to deal with these types of scenarios. I

think that we’re finding that there weren’t quite as many people

out there as we may have previously thought. So to the degree

what we can help you turn that around and share some of that

knowledge and training with the civilian first responders would be

very helpful.

And I see that my time is up.

Mr. WINKENWERDER. We would very much like to do that.

Mr. PUTNAM. I yield back the balance, Mr. Chairman.

Mr. SHAYS. Thank you.

Mr. Kucinich.

Mr. KUCINICH. Thank you.

Mr. Secretary, it was encouraging to hear your response to the

GAO report in saying that you will train, you will help personnel

to become more ready. At no time in your testimony have I heard

you say that the Department of Defense is ready to protect its

troops in the event of a biological or chemical weapons attack. Is

that correct? You did not say that, did you?

Mr. WINKENWERDER. I believe that we are prepared to protect

our troops.

Mr. KUCINICH. At this very moment you’re saying that we’re prepared to protect our troops. And how are we prepared to protect

our troops?

Mr. WINKENWERDER. Well, Congressman, protection of the troops

really is a multifaceted set of activities.

Mr. KUCINICH. I understand that.

Mr. WINKENWERDER. Let me just for everyone’s information talk

about that for just a moment. There’s issues of intelligence and intelligence on the ground. There’s issues of chemical and biological

detectors, early detectors in the field where we can detect agents

prior to their dispersal or at the time they might be dispersed.

There is the issue of protective clothing and equipment. Training,

obviously, we’ve talked about of troops and medical personnel, antibiotics, vaccinations. So there’s a whole host of things.

I don’t want to minimize some of the deficiencies that have been

pointed out in the area of training and planning.

Mr. KUCINICH. I understand. It’s good to hear that you’re trying

to address this, and I understand you’ve only been on the job for

9 days. This report questions the readiness of the Department of

Defense, the medical readiness. You know, not whether you have

intelligence on the ground, not whether you have chemical or biological detectors, but whether or not there is a medical readiness.

As this report says, as a consequence of their study, they’re saying

medical readiness for CB scenarios cannot be insured.

And the reason why I’m focusing on this, you know, we have to

get our time tense straight. We are ready, which means we’re

ready today, or we will be ready, which means some time in the

future, that we’re planning on this, we’re thinking about it. But the

difference is, if you have men and women in the field and they’re

43

subjected to an attack, you can’t tell them we will be ready. They

need to know they are ready.

So, based on that, Mr. Secretary, would you at this moment, understanding the work that needs to be done, be ready to recommend that or even be asked whether circumstances exist which

would be conducive to sending troops into the field in Afghanistan

without the proper medical structure in place? Would you comment

on that?

Mr. WINKENWERDER. Well, in the final analysis, we rely on our

commanders in the field and on the Joint Staff, I think that has

been pointed out, to make the determination of overall readiness.

And that includes medical readiness. I think the events of recent

weeks and the perception that possibly an enemy would be willing

to use certain agents may have changed the threat assessment.

Mr. KUCINICH. We’re on the same team here. We’re working together. Because you want to make sure that the men and women

who serve are going to be protected. I know that’s true of all the

officers who are here. That’s your life’s work. I understand that.

It’s our life’s work, too.

I just want to make sure, though, that the political imperatives

which may exist somehow mesh with the realities of the medical

readiness. And I’m hopeful that the Generals and the Admiral

here, that somebody in the command level at the Department of

Defense is going to talk to you and then that somebody is going to

go over this report before we start committing troops to an invasion

of a country that, given the geography is tough enough, but the

medical readiness, that’s what I’m concerned about. I just want to

make sure that if we send our sons and daughters over to Afghanistan in order to fight terrorists that they’re not going to be injured

and not have a structure in place to be able to help them. That’s

all.

And General——

General CARLTON. I just returned from down range and looked

at the medical preparedness. I believe that we are in perfect harmony with your concerns. We’ve addressed every known factor that

we will face. We’ve made our point. We have hardened facilities

that are in the evacuation chain.

Again, raw numbers are confusing. When we say 2 percent of the

medical providers have been trained, this is a 7-day train, the

trainer course; and that’s about right for the people that will train

ours that deploy in harms way. We have a readiness skill verification program where we certify that people are prepared to go do

what they will encounter in that environment. So all of these

things have stood up.

Mr. KUCINICH. General, again we all understand what a different

environment you’re in. And again we’re working together here.

This isn’t an adversary proceeding at all. Because we need to make

sure that our men and women are going to be safe.

Now in this report here, Mr. Chairman, staff, just on page 10 of

the report, I would ask the gentlemen at the table if you would

refer to page 10 of the report, paragraph 2, the middle of the paragraph. It says, ‘‘Army Medical Department officials indicated both

that they were not authorized to structure medical care for biologiVerDate 11-MAY-2000 09:42 Oct 29, 2002 Jkt 000000 PO 00000 Frm 00047 Fmt 6633 Sfmt 6633 C:\DOCS\82172.TXT HGOVREF1 PsN: HGOVREF1
44

cal contingencies and that battlefield CB scenarios causing mass

casualties would overwhelm current medical capabilities.’’ So, you know, that’s the purpose of this meeting, to discuss this

report.

Again, as a Member of Congress, as a fellow American, I just

want to express my concern that this discussion take place in the

upper echelons of the Department of Defense before any decision

is made to commit to ground troops. And the reason I’m saying

that is that, if that decision is made, we want to make sure that

all of the areas that are covered in this report are given careful

consideration so we’re not in a situation after the fact where somebody comes back to any one of you and says, now what do we do.

And that’s why we’re all here listening to this right now.

But, you know, in a few weeks from now we could be learning

of mobilization of troops to Afghanistan, and I just want to make

sure that our men and women, that they and their families are assured that this government is going to do everything it can to make

sure that those enlisted people would be protected as best as possible under the circumstances.

So I thank the Chair for giving me this opportunity. I want to

thank the witnesses for the service that each of you gives to our

country.

Mr. WINKENWERDER. I can assure you that it is and will be a top

priority, that these matters that are in this report and the concerns

will be reviewed at the highest levels.

Mr. SHAYS. Mr. Secretary, it’s pretty amazing to come into a job

in 2 weeks and have to present a response to a report before Congress; and I appreciate you being here.

I would welcome the participation of the rest of your panel as

well in any of these questions. Because you all have been involved

in this obviously a lot longer.

On page 9 of the report it talks about, under the subheading,

that DOD and the services have not systematically reviewed the

adequacies of the medical specialist mix for the treatment of CB

casualties. And then it says, service methods for personnel planning do not specify the personnel required to manage CB casualties.

And, page 12, I want to read to you a long paragraph. I’d like

all four of you to respond, if you will.

On page 12 it says, ‘‘While maintaining that the current specialty

mix is generally appropriate to these emerging threats, service

planners did identify additional skills that would be key to successful medical management of CB warfare casualties.’’

So, in addition to this whole issue of training people for 6 days,

‘‘some Army officials expected that chemical warfare readiness

would require an increase in respiratory therapy, ward nursing,

and internal medicine. Others noted that the Army did not have

a lot of infectious disease experts in deployed hospitals for surveillance and prevention. Similarly, Air Force officials expected that

chemical warfare scenarios would require more respiratory technicians, pulmonologists, critical care nurses and intensive care beds.

They stated that the threat of biological warfare would increase the

need for infectious disease and preventive medical personnel as

well as personnel to collect baseline, predeployment data. Air Force

45

and Navy medical planners both anticipated that chemical scenarios would require more emergency personnel who could recognize and respond to symptoms quickly.’’ Although these informal assessments vary, they imply that the

current speciality mix needed revision. I’d love you to respond to

that, and then I’d like each of the branches to respond.

Mr. WINKENWERDER. Let me make two general points and then

would like very much my colleagues to respond as well. I think

with respect to chemical and biological weapons there are two

areas that come to mind that we will need to review and look at

with respect to the medical personnel mix and the numbers. One

is infectious disease, and the second is in the area of pulmonary

medicine and the support personnel because of the way the agents

work, and those would be the areas that I would expect we will be

looking at and reviewing to ensure that we’ve got adequate numbers and adequate mix deployed in proper locations, etc. And so

with that, I’ll turn it over to General Peake.

General PEAKE. Sir, we have a modular structure—all of us basically have a modular structure that can be added to or taken from.

The bases in our hospital situation is a combat support hospital.

We have the ability to bring modules, infectious disease, laboratory

and so forth to add where we see that threat, where that threat

exists and as the threat changes. We have what we call smart

teams, special medical augmentation response teams that reside in

our medical treatment facilities that include intensive care as an

example. It includes epidemiologic expertise such as that we have

loaned to HHS as they look at the Capitol Hill, as a matter of fact.

Those teams are available to be moved into theatre if that were required.

We rely on the commander in chief of that theater who looks at

the threat, who makes those assessments, and then our Title X responsibility is to provide him trained and ready folks to deal with

that. Many of those folks get their training and experience in our

military treatment facilities. There was a comment by Dr.

Kingsbury about the dichotomy, sir, if you would, of the peacetime

health care and the go-to-war health care. Well, those infectious

disease folks are—they need to be at the top of their game in their

field as an example.

So I think there is a translation there and we have quality people because of our ability to have that infrastructure that takes

care of patients every day, and then added to that is their expertise

that they get as military physicians. We are actually kind of proud

of that 2-week course. We are proud of the fact that we push those

courses out.

Mr. SHAYS. There is a big difference, though, between a 2-week

course for your medics and your nurses and so on, and your doctors

versus someone who has an actual specialty.

General PEAKE. Yes, sir. But the infectious disease folks that—

I mean, we have folks that are infectious disease specialists just

as—that work in our teaching programs, that work in our hospitals

and they’re the same folks that come out of that and deploy as part

of these specialized teams or as an internist in one of our combat

support hospitals. So we have—it’s a leavening of the force of quality people of their solid basis of clinical medicine, and then in addiVerDate 11-MAY-2000 09:42 Oct 29, 2002 Jkt 000000 PO 00000 Frm 00049 Fmt 6633 Sfmt 6633 C:\DOCS\82172.TXT HGOVREF1 PsN: HGOVREF1
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tion to that, as they go through the developmental process of an

Army physician as an example, come into the Army basic course

and they have training in MBC. Come back to the officer advanced

course, and there’s hours of training associated with that.

Mr. SHAYS. You attempted to answer my question or may have.

I’m not sure I fully understand why some of what of you’re saying

relates to this specific issue, and that’s probably my fault, not

yours. But the bottom line, there seems to be disagreement among

the different branches from this statement and it would be—first,

I will come back.

Admiral, if you would just respond to the statement and let’s see

what we get, and then I will make my point.

Admiral. ARTHUR. Yes. Good morning. Thank you.

Mr. SHAYS. Good morning.

Admiral. ARTHUR. I agree with much of what General Peake has

said. We have our operational forces, which are——

Mr. SHAYS. Move the mic a little closer, but not as close as the

doctor had it.

Admiral. ARTHUR. Have we got it calibrated now? Great. Thank

you. We’re staffed to provide forces in response to our lines projected operational requirements, and we have just about as many

people as we need to do that and not very much in excess. We have

many operational courses that we use to train people who go with

our operational forces. We have people who go with the surface

ships and they get a 6-week course. The flight surgeons get a 6-

month course. The undersea medical officers who do the diving and

submarines go to a 6-month course, and the Marines have their

own course of 4 weeks, and in each of these courses there are didactic segments which deal with chemical and biological, and there

are varying lengths. These are mainly physicians that I’m talking

about.

Mr. SHAYS. Yes. But with all due respect, what we are learning

is that you really haven’t—none of the branches have seemed to adjust to this new world environment. So you’re telling me the

courses that you have, but are we really focused on chemical and

biological? And it appears that we’re not. I don’t see how we can

say you are when you agree with every one of the points being

made in the report, and then you’re telling me we’re doing it, and

that’s why I’m confused.

Admiral. ARTHUR. Well, we’re not as prepared as we now know

we should be, and I think that was one of the points that Dr.

Winkenwerder made. We have been awakened by the September

11th incidents in that we have an area of vulnerability that we had

not recognized was of such magnitude. I would say, though, that

we have to perhaps temper the discussions with enormous difficulty in retraining the staff and equipment that would be required for an all-out response to this when they’re basically unused

for the majority of the time and in peacetime, with the tremendous

pressure we’ve had to deliver the health benefit in an austere funding environment.

So it’s very difficult to say let’s have 100 more pulmonologists

that we might need, and have the health benefit in some area go

wanting.

47

Mr. SHAYS. See, the problem is a whole host of problems exist.

Our committee has had all three commissions come before us and

said no one is known, we have not made a proper assessment of

the terrorist threat. They said we don’t have a strategy to deal with

the terrorist threat, and they say we’re not organized as a government to maximize our ability to be as successful as we could with

our resources.

So that’s what they said to your government. We saw, sadly, the

military mix, the terrorist threat and the military threat, and we’re

kind of confusing the two, it seems to me. I mean one of the things

which still have some certainty is that you’re more likely to have

a chemical and biological attack if the person can disguise that

they actually delivered it and not have to have retribution.

So now what we’ve done is we’ve said if a terrorist is moving forward and doing these acts, we’re going to hold somebody we can

identify, a country, accountable; so we are going to hold countries

accountable. But we don’t know because we haven’t done the proper threat assessment, both in the military, frankly, and the civilian

threat, the terrorist threat, but it’s probably less likely that you

would encounter chemical or biological from a military force unless

they decided to commit suicide, which obviously is a possibility as

well.

I guess where I’m coming down to, though, is that as a committee, we saw the military say everybody in the military had to have

anthrax vaccine and we used it all up, and we only have less than

20,000 left, and then we have 5 million that’s unapproved at

BioPort, some of it before they did their plan, some of it after

they’d done it; so that’s kind of this mess we find ourselves in and

what we’re trying to sort out is—what I’m trying to first sort out

is, I understand now that you are doing programs you didn’t do in

the past, your 5-day, your 6-day, your 7-day, I’m trying to understand the quote from the GAO’s report where it says either medical

personnel who have been trained cannot be readily identified in the

event of an emergency, because tracking systems either do not

exist or are not currently functioning, lest the availability of

trained personnel given the situation is uncertain. I would like just

the GAO to affirm, was that basically on identifying those in the

6-day courses, in the 7-day courses, or is it also meaning doctors

with specialties?

Ms. WARD-ZUKERMAN. That was with respect to training courses.

Mr. SHAYS. I want you to just get to the mic. If she could do that.

Ms. KINGSBURY. That was just with respect to tracking the people who had attended the training.

Mr. SHAYS. OK. Just the training. So it’s not an issue of being

able to track those with specialties. Because unfortunately at the

VA, they’re unable to track people very easily with specialties, the

Department of Veterans Affairs. We don’t have that problem in our

three branches as it relates to people with specialties?

General PEAKE. We can track people with specialties. Let me just

comment on in terms of tracking the training. We would like to be

able to do better with tracking training. Looking at that 6-day

course as an example, this morning I said pull it up, I can identify

1,747 people, 672 docs, 112 general core officers, 508 nurses that

have had that training. I can pull them out of the data base by

48

name. So I don’t think I have captured all of them. I can tell you

that. There are some data issues that—— Mr. SHAYS. The question is, though, can you get that out to the

field?

General PEAKE. Yes, sir. We can pull them off of mods. There

was——

Mr. SHAYS. OK. Let me just go to—but the specialty issue that,

wasn’t a claim from GAO. General Carlton, you wanted to make— you were doing a lot of writing. Either you wanted to make a comment or you wanted to just—— General CARLTON. Yes, sir. I’d like to make a couple comments.

We have been focused for the last 6 years on terrorists, specifically

biological and chemical, and we’ve invested heavily in them. Regarding page 12, we have something called the critical care transport team that can be a ground asset or an air asset. We have more

than 200 such teams that we’ve identified more than 150 trained

to be able to fill this specific requirement. We’ve thought it

through. We can building block those in, as General Peake indicated to you, very early. We recently certified a level 4, which the

most highly infectious disease problem for air vac use, a joint Air

Force/Army discussion.

Before we send people to the field, we have a readiness skills verification program that is a check, and we certify that they are certified to deploy depending on their skill level. We’ve been working

on that for several years now. Every one of our GME institutions

gives us military unique training. To answer that second piece that

we’d require more emergency personnel, we train the personnel to

be able to do that. One or two infectious disease people cover a

medical center currently. We have been training through those infectious disease people extensively, and actually have our premier

course, which starts next week, which is called a hospital-focused

approach to biological weapons and toxins. It’s filled up immediately and has been for 6 months.

We’ve really been focused on these for a long time, and I believe

that as you look at these, it raises a level of concern and our approach was, yes, we can do better, which is the reason that we concurred, but I don’t want you all to leave with an impression that

we have not focused on this, and we are ready at this time for the

expected illnesses in the bright percentages. If somebody threw me

2,000 casualties at one of my deployed locations and all need ventilators, I have a problem, but that’s not the current threat.

Mr. KUCINICH. Excuse me. If I may, General, you’re with the Air

Force; right?

General CARLTON. Yes, sir.

Mr. KUCINICH. What does the Army say?

General PEAKE. I would say exactly the same thing. That is, we

structured our force to where would see the risk. We understand

the environment that our soldiers are in. We understand what

their force protection capabilities are and you work with them—the

maximum, you know, a credible event, and you try to structure

your forces to cover that. I believe we have good—as General

Carlton said, we would—there’s always more things to do, but in

terms of having a level of comfort of being able to care for our soldiers and being proactive about it, recently we just pumped antiVerDate 11-MAY-2000 09:42 Oct 29, 2002 Jkt 000000 PO 00000 Frm 00052 Fmt 6633 Sfmt 6633 C:\DOCS\82172.TXT HGOVREF1 PsN: HGOVREF1
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biotics as part of our DRB, or defense division ready brigade support packages, so that, you know, we plussed them out looking at

the new threat. We’ve done that since September 11th.

So as everybody sort of alluded to, this has been an, OK, now

let’s pay attention to this one a little bit more, but it’s—I sort of

feel a little that we probably sound a bit defensive, sir—— Mr. KUCINICH. You don’t have to be because you’re not under attack here. We’re together.

General PEAKE. But the fact is there have been a number of

things gone on. The issue of the planning tool that was mentioned,

it’s true, there is not one in the map, but since the early mid

1990’s, we have been working with NATO to work up planning scenarios and casualty models we now have that we are investing in

a tool to be able to go ahead and use the patient time test TRTA

files that have been developed that was alluded to in the report.

We expect we will work with the other services to move that into

the medical planning tool, but we do have a desktop model that I

was looking at this morning.

So there are a lot of positive things that are a part of this journey to getting better and we’re along that journey, as Dr.

Winkenwerder has indicated, and we will accelerate along that

highway.

Mr. WINKENWERDER. Let me also add in here if I might, just in

terms of the exercises, and I don’t want to sound as if I’m quibbling

here too much, but based on the information that these men have

given me, we have had more exercises of some sort than is indicated in the report, and I’m told roughly in the range of 20, 21 in

the last couple of years, many of them with civilian, we also have

to look at the home front issue of how to support them. So we have

an area that the military supports its civilian authorities, and so

there have been exercises, tabletop. You’ve heard of some of them.

Dark Winter and—— Mr. KUCINICH. I actually read your testimony, and I’m impressed

with what you’re trying to do on a domestic front, and all Americans are concerned with that. But with all due respect, you’ve got

a lot of work to do, I would think, and hope before you get to a

point of saying send the troops in, and you know, that’s not a decision you’re going to make, but you’re going to be called upon for

an evaluation of the medical readiness.

Now, Mr. Chairman I just want to ask one other question here

of Admiral Arthur, and that is, you raised this report, actually

touched on, and that is the question of available resources, because

that’s something that none of us can escape. There are financial

budget issues and, as you said, whether or not you can have—you

may have used a figure 100 pulmonologists and have them waiting

and seeing if anything develops. I think that’s one of the discussions considering this constantly changing picture. I think that’s

one of the discussions that you’re going to have to have, and then

if there is a need for additional funding, I’m hopeful that you’ll

come back to this Congress and inform the Members of Congress

that in order to assure medical readiness that you need to—that

this is what you need. We cannot hold you accountable if you don’t

have the resources and feel that you can’t have access to the resources. So I would just say that as surgeons general, that we need

50

to know from you just exactly what you need in order to do the job

and have a high level of medical readiness in the event that we

find ourselves on the ground with a full-scale effort in Afghanistan.

So that—— Admiral ARTHUR. Sure.

Mr. KUCINICH. And I just want you to know I heard you, Admiral.

Admiral ARTHUR. Yes, sir. I’d like to amplify one point, and General Carlton brought this up. They have two, for example, infectious disease specialists at a medical center. We can’t have 100 like

we would like. But what we do, as General Carlton said, is we

cross-train a lot of people. We have a lot of people familiar with the

basics. So I think we are capable, and we could never interest 100

pulmonologists in staying if they weren’t truly busy. But we also

train our Reserves. We train a lot of people to come in and fill in

when the requirements exist, and it’s different than the civilian

sector where people just do their one thing because they’re compensation driven. We have a system that is very much more flexible than anything in the civilian sector, and I think that’s our No.

1 strength.

The No. 2 strength is this is where the expertise is for chemical

and biological issues, and I think one of the ways that we can help

as a service, and you can help us, is to assist us in getting out the

information to our civilian sector to allow them to be more flexible

when some of these issues are raised in the domestic front.

Mr. KUCINICH. I would like to ask one final question. In the report at the conclusions and recommendations on page 36, it says

that the DOD has not developed comprehensive meaningful training requirements, adequate tracking system, or rigorous proficiency

testing. The available evidence indicates that proficiency is low

from training only a fraction of personnel to failing to conduct realistic challenging combat field exercises that include CB medical

treatment, DOD has not fully responded to the threat as stated,

and what you’re saying today, gentlemen, is that you’re moving in

that direction of addressing that; is that correct?

Mr. WINKENWERDER. Yes.

Mr. KUCINICH. I want to thank the witnesses and thank all of

you for your commitment and service to the country.

Mr. WINKENWERDER. Let me, if I might, just say one other thing

with respect to the funding. We have put in requests that are related to the additional emergency funds that have been distributed

out to the Federal Government and to DOD to lay claim to part of

that for these very issues. And as we develop our plans here over

the next days and weeks, we’ll be coming forward inside the Department to identify the requirements that we think need to be

met, and any funding or resources that are associated with that.

Mr. KUCINICH. I want to thank the Chair for allowing this opportunity to ask questions. I want to thank Mr. Putnam for his participation as well. I think this has been a productive hearing.

Mr. SHAYS. Thank the gentleman. Mr. Putnam, if you don’t

mind, if I could just finish. I think I’m figuring out that we’re probably not going to get some answers at a hearing that we need to

get because of some of it is a time line issue, and we don’t have

a sense of what it’s going to take, but where I’m getting a little conVerDate 11-MAY-2000 09:42 Oct 29, 2002 Jkt 000000 PO 00000 Frm 00054 Fmt 6633 Sfmt 6633 C:\DOCS\82172.TXT HGOVREF1 PsN: HGOVREF1
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cerned is I feel like we’re mixing different things together. For instance, Dr. Winkenwerder, when the military is telling you that

they have had training, I believe it’s training on the civilian side.

In other words, we’re coming in and there’s a challenge in the

United States. My understanding is we’re not going through exercises on the field with, you know, a massive chemical attack or not

even a massive, or a biological attack. I don’t think that’s happening yet, and so I just want to be clear as to what we’re saying is

happening.

General, you kind of wanted to finish and I’m happy to have you

finish your point, and I’d love you to address the point I just asked.

General CARLTON. Yes, sir. We added them up to find out is the

criticism true.

Mr. SHAYS. I just need to know adding what up? What are you

really adding up? What exercises?

General CARLTON. Military-specific exercise that included chembio activities in the last 2 years number 12. Civilian-specific exercises where we did things military and civilian together involving

chem-bio exercises, No. 9.

Mr. SHAYS. Right. But there is a difference, there truly is a difference between the two.

General CARLTON. Yes, sir. The presentations to senior meetings

in international presentations by just the Air Force staff number

1,000 in the last 2 years.

Mr. SHAYS. What does that mean? Slow down, I want to understand. In other words, there is dialog with people about—— General CARLTON. No, sir. Delivering a key note speech as I will

do tomorrow in Detroit, as one of my brigadiers will do at the

Southern Medical Association on Thursday.

Mr. SHAYS. And so that means that you’re thinking about the

issue.

General CARLTON. That means that we’ve addressed their civilian folks—on the military side I’m very comfortable. We’ve thought

these through. We even planned the attack on the Pentagon and

we exercised it in May. We’re prospectively thinking this ahead.

We planned the attack on New York City and D.C., invested in the

equipment to diagnose it 3 years ago, and we have all the teams

trained now. So we’re thinking ahead and we’re trying to get to our

civilian colleague to help them understand the world’s changed,

and all of a sudden they’re listening, and it’s delightful.

Mr. SHAYS. OK. Let me just tell you now why I’m confused. You

can’t concur with all of the criticisms that GAO made and then say

that the report isn’t—doesn’t reflect what is happening. That’s my

disconnect. I feel like I should take a lunch break and read the report again and see if I have read this report properly and your concurrences. It’s not——

Mr. WINKENWERDER. Let me try to clarify it because——

Mr. SHAYS. You can do that with 2 weeks on the job——

Mr. WINKENWERDER [continuing]. I do need to speak for all of us.

We concur and we agree, and agree means agree.

Mr. SHAYS. Yes.

Mr. WINKENWERDER. OK? It’s very simple. We agree. That said,

I think the difference of the discrepancy may be that we want to

leave you with the impression that some more things have been

52

done, are being done than maybe the report was able to recognize

because of the timing.

Mr. SHAYS. If the glass is one third full, you want me to know

at least it’s one third full and not empty.

Mr. WINKENWERDER. It may be a little more than one third full.

Mr. SHAYS. OK. I didn’t want to use one half. Something below

half. OK. You’re smiling, General. Is that——

General CARLTON. No, sir. I think it’s a very valid concern. I’m

very comfortable with the overseas piece. I’m scared to death for

homeland defense, and medically we have some work to do but

we’ve been engaged for 6 years——

Mr. SHAYS. But you’re talking as it relates to the military.

General CARLTON. As it relates to the military for our overseas

pieces.

Mr. SHAYS. Right. But are you saying—are you scared here for

your military or are you scared here for the civilians?

General CARLTON. I’m scared for our civilian population, that we

have a lot to share with our civilian friends on what we have done

in the last several years on the BWCW discussion.

Mr. SHAYS. OK. Well, you know what? I’m going to come back,

but I still want this paragraph identified as to where you agree and

disagree with the various points. You’re basically saying respiratory and infectious diseases is your greatest need. I’m going to

make an assumption, unless you correct me, that you feel you have

the limited numbers of people in these specialties and you’re looking to get more, I’m making an assumption if you have a limited

number, that means that if you were having to defend your forces

around the world, you wouldn’t have enough, but if we’re in Afghanistan, you can bring these resources to the field, and I make

an assumption, and I would like to have a ‘‘yes’’ on this one, that

you have the medical personnel and will have the medical personnel in the field of contention to deal with whatever bio or chemical

challenge you’re faced with. Is that accurate, General?

General CARLTON. Yes, sir, it is.

Mr. SHAYS. Is that accurate?

General PEAKE. Yes, sir, it is.

Mr. SHAYS. OK. Mr. Putnam. Don’t even give him a clock.

Mr. PUTNAM. Thank you, Mr. Chairman. I have been listening

with great interest in this, and I find myself a little bit confused

about the different training portions that have been taking place.

General Carlton, you said that what keeps you up at night is fear

for the civilian population, and I think that what you had implied

in some earlier comments was that you have been trying to prepare

some civilian health care professionals for some time, and only

since the 11th, have they been particularly interested in listening

to the progress that you’ve made? And I certainly understand that.

How prepared is the civilian population and how prepared is the

military for a situation that it’s very conceivable 6 or 8 months

from now where you have a chemical or biological attack on ground

troops engaged in combat and a massive civilian incident in an

urban area that would require substantial expertise from the

health care community? So if you could take those couple of bites

of the apple first before I go further.

53

Mr. WINKENWERDER. I’m going to try to speak for us as one voice

here on this. I think it’s not fair for us to speak for civilian preparedness across the board. I think that’s really the domain of Secretary Thompson and the leadership at the Department of Health

and Human Services to speak to that issue. I think we all know

there’s a tremendous amount of interest and training and activity

going on across the civilian sector as we speak, many cities and

towns across the country, people trying to learn and get up to

speed on these issues, and we’re here to help and support, but I

think it wouldn’t be fair to try to quantify or qualify how, you

know, where that degraded.

Mr. PUTNAM. Is it fair to say that the military is further along

in preparedness than civilian?

Mr. WINKENWERDER. I think it would be fair to say that, yeah,

and everyone should hope so. I think we are.

Mr. PUTNAM. And that in many situations, these Governors and

mayors are returning to their own military to help prepare their

own city and State for these types of incidents?

Mr. WINKENWERDER. Well, I think they’re turning to wherever

the knowledge is, and that to the point that earlier brought General Peake and General Arthur is that we can be a real source of

support that we want to be. We feel like one of our greatest capabilities is to train and educate and—on the civilian side and to— and we are in active discussions with the Department of Health

and Human Services around concepts of, you know, protecting people, protecting populations of people, how to ensure good command

and control and biological event situations and all of that.

Mr. PUTNAM. I’m not trying to box you into a position of making

any comments about the preparedness or the lack thereof of civilian health care population, professional population. What I’m trying to point out is that there is a symbiotic relationship between

civilian health care professionals and military health care professionals.

Mr. WINKENWERDER. Absolutely.

Mr. PUTNAM. It’s been 10 years since you were engaged in a

major combat situation; so you’ve put a number of your medical

professionals in emergency rooms and trauma centers in urban

areas to see what gunshot wounds are like. The civilians depend

on your expertise to prepare for chem-bio-type situations and in a

major incident that would occur while we are engaged in ground

combat, we would have a limited number of people spread around

the world and so that was really the direction I was interested in

taking us which was, you know, how are we going to deal with that

type of situation? How quickly can we standardize just the services

much less spread it out to the civilians being able to be prepared.

You have a shortage of specialists, pulmonologists and ear, nose

and throat, and there’s a number of others identified in the footnotes. To keep those folks sharp when we’re not engaged in war

they’ve got to be doing something else—— Mr. WINKENWERDER. That’s right.

Mr. PUTNAM. So there is a very connected——

Mr. WINKENWERDER. There is.

Mr. PUTNAM [continuing]. Relationship between you and civilian

population. So that was only the purpose of my question.

54

Mr. WINKENWERDER. Thank you.

Mr. PUTNAM. There is a recent Washington Times article that

highlights your board surgical teams, the Army’s board—General

Peake’s surgical teams, and indicates that they—attached to every

brigade, the closest thing yet to battle field surgery, the article

points out significant medical treatment literally is right over the

hill. Are those folks prepared for a chem-bio attack? And simultaneously, let me also ask, do the benefits of having them close for

conventional type of warfare put your first responders in jeopardy

for this new type of asymmetric threat, General Peake?

General PEAKE. Sir, they are at—when you’re putting them that

close, they’re at jeopardy for even conventional warfare, depending

on how far forward you have to go, depending on the tactical scenario, and they are—therefore have the period defensive medical

protective—chem-bio protective posture as the rest of the troops

that they’re supporting in terms of masks and so forth.

And so they basically share the hazards. You try to employ them

so you protect them reasonably, but that’s the organization’s design

to go far forward with the brigade. In terms of their ability to take

care of chem-bio casualties, those folks, like our division surgeons

as well, are folks that go get targeted to go to that course that we

were speaking about before; so they have that kind of experience.

We have within that unit ventilator support, a limited amount, but

the idea is to stabilize folks and then transfer them further back

to a more definitive facility.

Mr. PUTNAM. Mr. Secretary, you have made very clear that one

of your top priorities is to eliminate any disparities between the

services and the standardization of readiness.

Mr. WINKENWERDER. Absolutely.

Mr. PUTNAM. Do you feel that you are there?

Mr. WINKENWERDER. We’re not all the way there, but I can assure you that we’re going to be trained on to this entire issue, including that aspect of it as we speak and in the days and weeks

ahead. It’s my top priority.

Mr. PUTNAM. What sense of time line have you established as an

objective?

Mr. WINKENWERDER. I haven’t set a time line other than to set

the idea in motion that it’s now, we’re moving, we’re acting, we’re

doing, and I would be glad to get back to the committee at a later

date in terms of if that’s of interest to you with respect to what

might be realistically accomplished over what period of time. We’re

glad to try to, you know, properly set expectations, but we’re working on this. It’s our top priority.

General PEAKE. Sir, there are things that are still coming about.

I will give you an example. I’m going tomorrow to look at chembio protective shelters that are part of a Humvie that we have had

in the pipeline as developmental. Our intent is to be able to put

one of those board surgical teams within a chem-bio protective

shelter, because we do understand the environment that changed

on September 11th. That’s the kind of thing that we will put on

the fast track to field, and quickly put into place where we see that

threat.

So we’re willing to change our structure on the fly. We’re required to try to meet the threat that we see evolving.

55

Mr. WINKENWERDER. There is one other thing that I’d like to

leave the committee with, and that is the notion that much of the

discussion here is focused on managing an attack once it occurs,

and assuming there’s casualties. I know that’s not all of the discussion, but there has been a fair amount of that. It would be my plan

coming into this role that we focus a great deal of effort on how

to detect events at an early stage, and how we can prevent certain

things from happening and how we can address things during that

early phase where there’s the opportunity to treat people, whether

it’s biological with antibiotics or even a chemical situation with

antidotes and so forth, so that the whole matter of detection, the

kind of equipment we have to detect and how it works, that’s part

of all of this and that’s important and just sort of our readiness in

terms of intelligence and thinking, both in the deployed situation

as well as on the home front.

And let me add to that the whole area of vaccination. I think

that’s another issue that we’ve got to look at and relook at in the

context of the situation that we now find ourselves in.

Mr. PUTNAM. Thank you. Thank you, Mr. Chairman.

Mr. SHAYS. We’re going to get you out of here pretty soon. I’d like

the counsel to ask a few questions and then I would like to ask a

few and then we will be done.

Mr. HALLORAN. Thank you. With regard to proficiency testing,

which is a matter the GAO raised, the training numbers, as she

said, are a surrogate for how capable people actually are, what

might your near-term plans be in terms of determining the proficiency of medical units in CB casualty management?

Mr. WINKENWERDER. I’m not steeped into the details of our current proficiency testing capabilities or programs, but what I’m—

would plan to do is to work with the surgeons with respect to determining what levels of proficiency we ought to have for different

levels of personnel and that we get rapid agreement on that and

that we, sort of going along with that, have the capabilities in place

to track the proficiency.

Mr. HALLORAN. You might just solve two problems at once in

terms—are proficiency determinations made as a result of exercises?

Mr. WINKENWERDER. That’s a good question.

General?

General PEAKE. It is one measure of proficiency. You have—you

sort of have to break it down. Individual proficiency with technical

expertise, hands-on expertise, cognitive expertise, those are all elements of proficiency. And then there is unit proficiency, how that

unit works together internally, and then in the larger, it’s the systems proficiency, the evacuation system feeding the medical system

and then the further evacuations. So each of those are looked at

in a little bit different way, some from the larger exercise perspective, some from the CPX nonfield training perspective to see how

well you do with that. And then others are sort of the hands-on

skill testing that, for instance, we are initiating as we change the

military occupational specialty to 91 Whiskey in the Army, where

twice a year they want to do the specific hands-on skills to prove

that they can start that IV, to maintain that airway, can assess

56

that patient. It’s not a single question, sir, it’s an expanded question.

Mr. HALLORAN. Understood. Thank you. Sir.

Admiral ARTHUR. I’d like to add that the insulting agent may be

different than what we’re commonly seeing. For instance, it may be

a chemical agent or may be a biologic agent, but the underlying pathology, the actual disease process, is common to many of the diseases and injuries and illnesses that we see every day, and I think

the pathology and the skills that are existent in our health care

professionals today once recognized will be able to adequately treat

those same symptoms and signs that would be from chemical or

naturally occurring disease.

Mr. HALLORAN. But that’s good news and bad news. I mean,

we’re all learning everything looks like the flu in the first 48 hours.

Admiral ARTHUR. And many of them are treated symptomatically

or with specific agents. Now, we have to have an awareness that

we’ve been infected perhaps with anthrax to treat appropriately,

but we have specialists who do this, and once recognized, the treatment is fairly standardized and think we’re well equipped to do

that.

Mr. HALLORAN. Finally, let me just change the subject. And it’s

not really a curve ball because I shared this with you before, but

there is a report out today on the military blood tracking system

that the Inspector General has found it lacking in some significant

respects, and just for the record if you could comment on that,

please.

Mr. WINKENWERDER. I’m going to let General Peake do that because of his responsibility.

General PEAKE. I just briefly saw the report and I haven’t read

it in detail, but I’d be more than happy to get back to you for the

record on—— Mr. HALLORAN. Please.

General PEAKE [continuing]. On the details of it. It is an important issue to be able to track in an automated fashion the blood

and that’s why we put the DIB system in place. I know we have

some investment that we are putting in to try to improve the product, but it’s an important issue for all of us.

Mr. HALLORAN. If you would get that to the committee, I’d appreciate it.

General PEAKE. I will be happy to, sir.

Mr. HALLORAN. Thank you.

Mr. SHAYS. Dr. Winkenwerder, I appreciate the tone you set, one

of, I think, just trying to be candid, and all of you. It tells me that

we can work well with each other, and on that basis, what I would

like is on all these—on the report which is your response where

you concur, rather than just going through it in this public session,

I think we will probably get a clearer response if you have time to

think about it a little longer. But on page 47 and 48 of the report,

it talks about the recommendation and DOD’s response, and what

I’d like is for you to work with the committee and give us a sense— I think it’s fairly clear that GAO felt, and I would agree that the

responses are somewhat general.

In other words, it’s kind of like we agree and we’re going to look

into it or we’re going to—you know, as an example, it talks about

57

how, just taking this as an example, with the first recommendation, concur as the coordinating body with the services in sync on

issues of this nature. The joint staff will be requested to conduct

a reexamination of CV medical training issues and provide suggested adjustments. You know, that’s a pretty general response,

and I would like to know when that’s likely to happen and then

what’s the result of that. And so that would be—so if we—— Mr. WINKENWERDER. I will be glad to do that.

Mr. SHAYS. If we could do that, it would give us a little clearer

idea as to what some of your responses mean. The second thing I

want to do is just I honestly believe that there has been a lot of

good work obviously to deal with this issue, but I don’t want to

overstate where we’re at. For instance the 12 exercises, I don’t— can’t grasp your version of exercise versus mine or what I think of

it. Can you give me an example of what kind of exercise we’re talking about? Are we talking about an exercise where all of a sudden

we’ve got, you know, 60 people who have got a chemical—been exposed to chemicals? Are we talking about 200 people who have

smallpox? What are we talking about here?

General CARLTON. Yes, sir. I’m happy to do that. Alamo alert is

the best example that we have. It was a mil/civ cooperation, a 3-

day symposium that we put on. The first day was educational. The

second day was a smallpox attack with our city leaders in place to

include the mayor, the fire department chief, the police chief, etc.,

and they’re the shot callers. And then we played the scenario based

on what they responded. We had an outside company orchestrate

this response. The third day, then, were the critiques of what happened on the second day.

Mr. SHAYS. This committee has participated in those kinds of exercises in what we called them, the rapid deployment—the ray

teams. But how about civilians off—not the civilians. I thought the

12 was the civilians—— General CARLTON. That was a mil/civ. The example of a mil/mil

was at the joint training center where we practiced our new scenarios. The Shugart-Gordon is a training range that looks like a

city to most of us. Two years ago they started doing chemical scenarios involved there. It was a force-on-force discussion. Chemicals

are here, how do you detect, how do you protect, how do you take

care of people?

Mr. SHAYS. Was that a U.S. target?

General CARLTON. That’s the U.S. Army. It is was a joint exercise down at Fort Polk, LA.

Mr. SHAYS. Is that a field exercise?

General CARLTON. It’s field exercise, yes, sir.

Mr. SHAYS. And how many casualties?

General CARLTON. I’m sorry. I can’t tell you. I didn’t have enough

time to prepare that.

Mr. SHAYS. Would it be fair to say that there have been a minimal number given the need?

General CARLTON. I can’t give you the number.

Mr. SHAYS. No. I don’t mean the casualties. I’m sorry. I didn’t

ask my question properly. We’re talking—I guess I don’t want to

leave—I don’t want to set a false impression that we aren’t doing

enough. I don’t want to set an impression that we’ve been doing

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these exercises, and that they have really constituted a significant

military exercise, and so—— General CARLTON. Yes, sir. Pacific Warrior in February of this

year was a 2,000-person exercise that was the Korean scenario that

we played in Hawaii, and it involved a chem environment.

General Peake, I don’t think it had a biological component to it.

Mr. SHAYS. Because what we’re hearing is that there really

haven’t been many bio in particular. In other words, even this

number of 7,800 versus the 1,718, what I’m being told is that you

have onsite and you have offsite exercises, and the offsite training

exercises and that the offsite have not involved the bio exposure,

it’s just mostly chemical.

General CARLTON. In the military exercises that I have been involved with, only three have involved biological activities. None of

them were in the field. They were think tank type exercises.

Mr. SHAYS. Right.

General CARLTON. So when you start adding 17—— Mr. SHAYS. So that’s really the tabletop kind of exercise?

General CARLTON. Yes, sir.

Mr. SHAYS. I guess really when I’m thinking of an exercise, I’m

really thinking what you’re out in the field and you’re trying to expose your troops to this kind of training exercise.

General CARLTON. Yes, sir. Without exercises—some of the

things that have been very exciting are surveillance systems. We

had a real world exercise last summer, the summer of 2000 where

we had a food borne illness break out in one of our forward deployed places. The year before we had a 60 percent casualty rate

from that food borne illness. Because we had installed a new surveillance system, we had a 2.5 percent. When we could identify it

quickly, it involved using the rapid pathogen identification, and so

we’ve had some real world that we don’t call exercises, but real

world experiences with our equipment, with our toys that have

worked beautifully.

Mr. WINKENWERDER. Mr. Chairman, if it would be helpful, we’d

be glad to try to summarize these——

Mr. SHAYS. Yeah. Why don’t we do that. Because I’m really left

with the feeling that some of these are civilian responses to terrorist activities and some of them—— Mr. WINKENWERDER. Yeah.

Mr. SHAYS. But in other words, this isn’t foreign to you, I agree,

but my sense is that you do agree with this report, and the report

says there is a lot that needs to happen and I’m going to kind

of——

Mr. WINKENWERDER. And you deserve to know exactly what we

have done here, and a little more clarification on the exercises that

have taken place.

Mr. SHAYS. And Admiral Arthur, have you had many exercises

in the last—on the field, not over a desktop and not in a room on

bio?

Admiral ARTHUR. We’ve—not specifically on by bio or chemical,

but we do incorporate that aspect into our training when we train

specifically on the ground with the Marines, when we exercise the

fleet hospitals in support of the Marines or the medical battalion

in support of the Marines. We also have our shipboard casualty

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drills where we do drill for chemical and biological, when we lock

down the ship and we wash the ship and we—— Mr. SHAYS. That’s mostly for chemical; right?

Admiral ARTHUR. Chemical and biological.

Mr. SHAYS. I’m sorry. I interrupted. So you wash down the ship

and——

Admiral ARTHUR. And we have the exercises where we isolate

certain portions of the ship based on contamination. So we do these

exercises. We don’t do much with submarines. We figure they’re

pretty protected.

Mr. SHAYS. All right. Is there a question that you want to ask

yourself that you wished I had asked?

Mr. WINKENWERDER. I can’t think of one.

Mr. SHAYS. I’d like to know if GAO would just like to make any

comment before we adjourn? OK.

Well, in the spirit of the obvious need, we look forward to working with you and we’ll all take a fresh start at this. We will think

anew, we will act anew, and we’ll disengage ourselves and try to

break out of the box and in the spirit of what Mr. Kucinich said,

we need to know where there are needs, and if you tell us the

needs, then it’s our fault if we don’t respond. But if you don’t tell

us the needs, then it won’t lie on our shoulders and we’d like to

share in that responsibility. So we will adjourn this hearing and

thank all four of you for coming.

[Whereupon, at 12:49 p.m., the subcommittee was adjourned.]

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