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82–356 PDF 2002

RISK COMMUNICATION: NATIONAL SECURITY AND

PUBLIC HEALTH

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 29, 2001

Serial No. 107–122

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 29, 2001 ...................................................................... 1

Statement of:

Koop, Dr. C. Everett, former U.S. Surgeon General; Dr. Kenneth I. Shine,

president, Institute of Medicine, representing the National Academy

of Sciences; Dr. Mohammad Akhter, executive director, American Public Health Association; Dr. Joseph Waeckerle, editor and chief, Annals

of Emergency Medicine, representing the American College of Emergency Physicians ........................................................................................... 34

Satcher, David, U.S. Surgeon General ........................................................... 3

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

Akhter, Dr. Mohammad, executive director, American Public Health Association, prepared statement of .................................................................. 57

Koop, Dr. C. Everett, former U.S. Surgeon General, prepared statement

of ..................................................................................................................... 38

Satcher, David, U.S. Surgeon General, prepared statement of .................... 8

Shine, Dr. Kenneth I., president, Institute of Medicine, representing the

National Academy of Sciences, prepared statement of .............................. 44

Waeckerle, Dr. Joseph, editor and chief, Annals of Emergency Medicine,

representing the American College of Emergency Physicians, prepared

statement of ................................................................................................... 64

(1)

RISK COMMUNICATION: NATIONAL SECURITY

AND PUBLIC HEALTH

THURSDAY, NOVEMBER 29, 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 10:17 a.m., in room

2154, Rayburn House Office Building, Hon. Christopher Shays

(chairman of the subcommittee) presiding.

Present: Representatives Shays, Putnam, Gilman, Schakowsky,

Tierney and Lynch.

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

Kristine McElroy and Thomas Costa, professional staff members;

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

Earley Green, minority assistant clerk.

Mr. SHAYS. We call this Subcommittee on National Security, Veterans Affairs and International Relations of the Government Reform Committee hearing to order.

The title of the hearing is ‘‘Risk Communication: National Security and Public Health.’’

I welcome our witnesses. I welcome our guests to this hearing.

Anthrax is not contagious. Fear is.

In the battle against bioterrorism, fear is one of the most infectious diseases we face. For the terrorist, it is a potent force multiplier, capable of amplifying a minor, manageable outbreak into a

major public health crisis. Driven by fear alone, hordes of the ‘‘worried well’’ could overwhelm emergency rooms and clinics, impeding

diagnosis and treatment of the genuinely ill. Many would needlessly expose themselves to the risks of antibiotic treatments, incurring individual side effects and increasing the general threat of

antibiotic-resistant criteria. Fear-based worst-case scenarios can

draw scarce medical supplies and vaccines to the wrong places at

the wrong times, diluting response capabilities to meet the real

threat.

The only antidote to terrorism’s toxin of fear is the truth.

When something as unthinkable as a biological attack occurs, the

public and the media need to hear one authoritative voice conveying the unvarnished truth about the extent of risk and the public

health response. During a disease outbreak, the right information

at the right time can save lives. Rumor, speculation, implausible

optimism and mixed messages fuel panic and endanger public

health and safety.

2

In the Dark Winter exercise earlier this year, a lack of information about the extent and pace of three simultaneous smallpox outbreaks paralyzed national leadership decisionmaking. Opportunities to contain the epidemic were missed, irreplaceable vaccine

stocks were wasted, public order decayed, State borders were

closed, and communications were disrupted. National security was

compromised, and for want of the facts our very sovereignty as a

Nation dissolved.

The recent anthrax attacks also taught some hard lessons about

effective communication of critical public health information. In the

hours and days after the first case was discovered, Federal, State

and local officials struggled to rebut inaccurate, sometimes sensational, reports about the risks of a rare, little-understood disease,

inhalational anthrax.

We heard inconsistent assessments of the virulence of the pathogen and the sophistication of its manufacture. An epidemiological

tool, nasal swab culture, was widely mischaracterized as a diagnostic test. It took some time for the voices of public health and

medical experts to be heard as law enforcement and political officials gathered and disseminated information on rapidly unfolding

events.

To be prepared for the next biological attack, frank and frequent

communication of medical information, risk parameters, treatment

options and response plans should begin now, while the information can be heard and deliberated calmly.

The draft response protocol for smallpox recently released by the

Centers for Disease control and Prevention [CDC], recognizes the

significance of public health education and pre-emptive communication as integral parts of an effective outbreak control effort. But in

the event of a widespread biological attack, one that threatens agriculture, food supplies, water and human health, who will collect,

synthesize and reliably convey complex but critical information to

a nervous public?

One voice well suited to address public concerns about bioterrorism is that of the Surgeon General, Dr. David Satcher. As a former

head of CDC, Dr. Satcher brings unique experience and unquestioned credibility to our discussion of public health information,

public health infrastructure and medical data technologies. In past

oversight efforts on blood safety and hepatitis-C, he was an indispensable partner to the Human Resource Subcommittee. We appreciate his expertise and his candor then, and we look forward to his

testimony today.

All our witnesses this morning bring important information and

expertise to our discussion of better ways to fight terrorism with

the simple truth. We welcome them.

At this time we would recognize Dr. David Satcher, U.S. Surgeon

General, and invite him to stand. I’ll administer the oath, and then

we’ll take his testimony.

[Witness sworn.]

Mr. SHAYS. Thank you. Dr. Satcher, it is very nice to have you

here.

3

STATEMENT OF DAVID SATCHER, U.S. SURGEON GENERAL

Dr. SATCHER. Thank you very much, Congressman Shays and

members of the Subcommittee on National Security, Veterans Affairs and Intergovernmental Relations, the Committee on Government Reform. I’m delighted to be able to join you and certainly the

outstanding members of panel two in discussing this very important issue.

As you know, I’m David Satcher, the U.S. Surgeon General, and

I’m speaking to you about the public health response to bioterrorism and the threats of bioterrorism, and specifically the role which

the Department of Health and Human Services plays in information dissemination and risk communication.

The terrorist events on and since September 11th have been defining moments for all of us. Both as a Nation and as public health

officials we have been taken to a place where we have not been before. It sometimes was uncertain what we were dealing with and

to what extent. We had very little science of past experience to

draw upon, and we literally learned more every day. The Nation’s

focus on issues related to public health has been greatly sharpened.

There has been fear, shock, confusion and, in some cases, even

panic; and panic when it occurs, as you said, supports the aim of

the terrorists.

We have certainly encountered some bumps in the road, but it

is somewhat remarkable how well-coordinated our efforts have

been overall. The challenge was great. We were faced with the task

of coordinating communications among local governments, State

governments and the Federal Government. Each level came with

its own set of elected officials and public health officials, all with

their own concerns. The Department of Health and Human Services tried to deal with it by being forthcoming. We tried to inform

the public quickly. We let them know what we knew and when we

knew it. When the information changed because we learned something new, we tried to let them know that. Through it all, vital

public health information has been disseminated promptly and we

have delivered medicine and expertise where needed.

I believe it is fair to say that, as a result, while we have lost five

people too many to this bioterrorist attack, we have saved countless

lives. Casualties were kept far below expectations, in that the fatality rate for inhalation anthrax has been thought to be around 80

to 100 percent.

Mr. SHAYS. Now, if you had been courteous, you would have

stumbled over inhalation to make me try to feel——

Dr. SATCHER. Let me try it again. No, you did great.

The fatality rate to date in our experience has been only 40 percent. All of this demonstrates why effective communication based

on a strong and flexible public health infrastructure is so critical.

I think under the leadership of Secretary Thompson, HHS has

been working to strengthen the overall public health infrastructure

so that we’re prepared to respond to a range of disasters and emergencies, including bioterrorism. Since September 11th, we have intensified our efforts, resulting in a heightened level of preparedness. We are committed to increasing our preparedness based on

lessons learned in recent months.

4

Now, because I believe that the public health infrastructure is a

critical issue here and communication before, during and after such

an attack is so critical, I want to discuss the public health infrastructure as it exists and its role.

Our public health infrastructure consists of several interrelated

components at many different levels. Communication within and

among each level is critical, as is the need for mutual support.

At the government level, the Public Health Service, the Department of Health and Human Services, works closely with State and

local health departments. Our philosophy is to help support local

officials, rather than to try to replace them.

Throughout the recent crises, the CDC’s Health Alert Network

and Laboratory Alert Network immediately notified State and local

health departments of the latest developments on anthrax and the

possibilities of other bioterrorism attacks. In fact, the Health Alert

Network was used September 11th to immediately put State health

departments on alert for anything suspicious following the attack

on the World Trade Center.

Now, the role of the Surgeon General in all of this, of course is,

No. 1, to command the Commissioned Corps, and the Commissioned Corps consists of about 5,600 health professionals—physicians, nurses, dentists, veterinarians, environmental health specialists. That Commissioned Corps was activated on September 11th

and has been activated since. These are people who are on call 24

hours a day, 7 days a week. We have deployed hundreds of them

to New York City and to other places as needed.

The second role of the Surgeon General is to communicate directly with the American people based on the best available public

health science. Usually this results in a report from the Surgeon

General after months and years of study of a particular topic, such

as smoking and health, mental health, suicide prevention. But in

the case of a bioterrorist attack, the role of the Surgeon General

in this communication has never been clearly defined, and that is

one of the things that we have been struggling with.

The anthrax cases in Florida provided a good example of how

CDC works with State and local health officials. After the first case

there resulted in death, the CDC moved quickly to confirm the case

of the second victim early on the evening of October 7th. The Centers for Disease Control and Prevention and other components of

HHS, the Federal Bureau of Investigation, the Department of Justice, the Florida Governor’s Office, the Florida Public Health Department and local public health departments quickly formulated

a plan that got word out overnight to the AMI employees that they

needed to come to the clinic for medicine and testing the very next

morning. The CDC shipped medicine to Florida overnight and immediately deployed epidemiologists to Florida; and CDC and Florida officials issued a joint release at 11 p.m. on October 7th notifying the media and the public of the second case. So it was a good

example of local, State and Federal officials working together to get

the message out to send medicine and to mobilize people to come

to get treatment—literally overnight on a Sunday evening.

In a Federalist system, there are going to be communication

challenges between Federal, State and local government. In all of

the anthrax situations, for example, once the CDC receives initial

5

test results, it promptly begins doing more accurate confirmatory

tests. But a mayor or Governor may decide to go out and talk to

the media before the confirmatory tests are concluded. Those officials make the decision whether to do that based on their perception of the needs of the community, and we respect those decisions.

At the same time, when you try to communicate that tests are

merely preliminary, you hope that the public and the media will

hear that and appreciate what that means.

That is the first layer of the public health infrastructure.

The second layer of the public health infrastructure is the health

care delivery system, and it consists of not just the private sector

but also there are public components like community health centers, community mental health centers and others. It is a very critical front-line part of the public health infrastructure.

The Department of Health and Human Services and especially

the CDC worked extensively to reach out to various groups within

the delivery system to inform them of what we knew. The Secretary met early on with the medical associations, the biotech industry, the pharmaceutical industry, the food industry to address

bioterrorism concerns. Together with the CDC, a conference call

with the State and territorial health departments took place immediately.

We also realize that there are tremendous opportunities to

strengthen our lines of communication at this level through the use

of conference calls and through satellite and video technologies,

and we should not wait until there is a bioterrorist attack. CDC

and HHS have done two major satellite conferences with physicians and hospitals on anthrax, smallpox and bioterrorism. We

must continue to look for new ways to reach out aggressively.

The third layer of the public health infrastructure is really the

general public. The third level is by no means any less important

than the other two, especially since it actually serves as the real

front line: the public. Bioterrorism attacks first impact the public,

either individually or in groups. We rely on the public to seek

treatment or advice regarding unusual occurrences and to assist

health care providers in the efforts to detect disease early.

The public must also be informed and educated about good public

health habits, such as handwashing after handling foreign objects,

safe handling and washing of foods, thoroughly cooking meats, for

example, and the careful handling of suspicious mail and other

packages. Good public health habits are individual and community

in nature.

After October 4, we immediately made available to the media an

array of medical/scientific spokespersons, in addition to myself and

Secretary Thompson, and that included CDC Director Jeffrey

Koplan, Tony Fauci at NIH, the Secretary’s recently named special

adviser D.A. Henderson, and other officials at CDC, NIH and the

FDA. The CDC also made officials available to the local media during the news conferences conducted by local officials, whether that

was in Florida, New York or in Washington.

One challenge that we faced in these situations was the volume

of demand—and I want to really make that point. There were so

many news shows and networks who wanted to interview, there

was no way that one person could have met the media demands.

6

By making several people available with expertise, we could more

readily service this demand and at the same time draw upon the

diversity of expertise that we had available, and there were times

when the media requested specific people based on what they saw

as a specific area of interest or expertise.

Now, the second week in October, the Secretary and senior members of the HHS team began holding daily teleconferences with the

media. The CDC began doing daily press calls with the media

about a week later.

Now, the interesting thing about bioterrorism, of course, and the

way it differs from the public health response to other problems

and infectious diseases, is that it requires a partnership with the

criminal justice system. In instances of naturally occurring disease

outbreak, those three levels would be sufficient. But because the

disease outbreak is bioterrorism, it is intentionally triggered, a

public health emergency response must include the criminal justice

system as part of this infrastructure, while striving to maintain the

appropriate independence of the public health system. That has

been an ongoing challenge, but I think, for the most part, communication with the Department of Justice has been good.

I would make four types of recommendations for strengthening

risk communication before, during and after a bioterrorist attack.

First, it is critical that we continue to strengthen the public

health infrastructure, and we must ensure that all components of

that infrastructure are strengthened. And this is not just about

treating diseases or emergency. This is about promoting health and

preventing diseases. That is right now, in my opinion, the Achilles

heel of the American health system. We have not adequately invested in the public health infrastructure, especially as it relates

to health promotion and disease prevention, and that is why we

have trouble with antibiotics and antibiotic resistance and people

understanding why it is not appropriate to take antibiotics when

not prescribed—or not as prescribed.

We must continue to improve educational opportunities and information sharing between the Public Health Service and front-line

health providers. This is critical. Many doctors at the local level

still fail to report disease diagnosis to Federal officials, and this

has been a long struggle to get any reportable diseases, unusual

cases reported to the Public Health Service. By the same token,

Federal officials sometime fail to provide local providers with a national picture on a timely basis that they can use in terms of their

index of suspicion. This can be strengthened, and it must. The

mechanism must be put in place to ensure that we have an ongoing

dialog that will make it easier for providers to access information.

In the minds of some people, and it is an old saying, that all public health is ultimately local, and there is a lot of truth to that saying, so there must be local efforts as well as Federal and State efforts to educate the community as well as health care providers.

We have a tremendous opportunity to improve our system of risk

communication and to be much better prepared for the next major

bioterrorist attack, which hopefully will not come, but, in order to

do that, we must work together, and we must begin by making a

commitment to strengthen the public health infrastructure.

7

Thank you, Mr. Chairman. I will be happy to respond to any

questions. As you know, I have submitted a more extensive written

statement for the record, but the Department would also be happy

to respond to any questions that you would like to submit.

Mr. SHAYS. Thank you very much.

[The prepared statement of Dr. Satcher follows:]

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Mr. SHAYS. I want to just first get some housekeeping out of the

way. I appreciate your statement. It was thorough and very helpful.

I ask unanimous consent that all members of the subcommittee

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 statement in the record. Without objection,

so ordered.

And I would note the presence of Ms. Schakowsky from Chicago

and Mr. Tierney from Massachusetts.

I’d be happy to start with questions, but I’d be happy—if you’re

all set, we could start with you. I recognize Ms. Schakowsky.

Ms. SCHAKOWSKY. Thank you, Mr. Chairman; and thank you

very much, Dr. Satcher, for being here.

I have to tell you that I was somewhat surprised by your description of the administration’s handling of the anthrax crisis, that it

was so glowing, frankly, especially considering some of the major

missteps that we have all seen. You call these mere bumps in the

road, and you said that actually you thought coordination was remarkable in your statement. But I was surprised because the administration has, in fact, been highly criticized by many highly

qualified experts, especially in the arena of risk communication,

which we’re mainly focusing on today, and especially in light of

several deaths, which at least some people say might have been

averted.

I’d like to direct your attention to some of the statements that

were made—and some of the individuals are going to be on our second panel with—well, there are four—remarks were made on the

record, so you’ll excuse me if you’re being quoted here.

But Dr. C. Everett Koop, former U.S. Surgeon General, said that,

‘‘I’m communicating information to the public on bioterrorism. I

would not give the administration a high mark.’’

Dr. Mohammad Akhter, executive director of the American Public Health Association, said, ‘‘health departments have obtained information from CNN more rapidly than they have from each other

or from the CDC.’’ It went on to say that law enforcement, intelligence agency and public health officials, ‘‘stumbled over each

other in responding to the anthrax outbreak.’’

Dr. Kenneth Shine, President of the Institute of Medicine, believes, ‘‘the effectiveness of communications to the public and to

health professionals about the anthrax terrorism were found wanting.’’

And, finally, Dr. Joseph Waeckerle, editor of the Annals of Emergency Medicine, found that, ‘‘crisis communication was often inaccurate and misleading or too scanty. No centralized leadership, no

voice of authority and inconsistent information resulted in the

American public remaining in an informational vacuum.’’

My concern, therefore, in terms of your remarks is that I think

it’s important that we take a very cool eye as we look back and

take a studied look at what exactly happened in order to put in

place what needs to be done, and so I’m wondering really, in light

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of those comments, how your interpretation of the events could be

so different from those that I just quoted to you.

Dr. SATCHER. Well, let me first say, as you know, I have tremendous respect for the four people you’ve quoted. I’ve worked very

closely with them over the years, and even since this outbreak. And

clearly, as I said in my statement, there were problems in our response to this outbreak, and it is true that, since I knew that they

were going to emphasize the negatives, I thought it was important

to also point out that there were many positives. And we don’t

point that out. We do a great injustice to the people at the local,

State and Federal level who have been working so well together.

There have been problems, but they have saved a lot of lives.

I could go into that in more detail, about what could have happened and what the terrorists intended to do and what anybody

would have projected would have happened if we had discussed

this 6 months ago, what would have happened when you had the

first anthrax attack. Most people would have projected that we

would have lost many more lives, especially dealing with aerosolized anthrax.

So the rapid response of getting medication to anyplace in the

country within a few hours, the rapid response of getting epidemiologists on the scene within a few hours and acting in such a

way as to determine who was exposed and therefore who needs to

be—receive prophylactic antibiotics—over 30,000 people, perhaps

35,000 to 40,000, have been started on antibiotics, and at least

5,000 continued it for 60 days. Many of those people could have

gotten inhalation anthrax.

We deeply regret the five deaths that have occurred, and obviously we keep retracing what could have been done differently to

save those lives. But I think the point of the matter is we have to

also build on our strengths. We have to know what they are.

And we have to also know what our weaknesses are. I’ve tried

to point out what I think those weaknesses are.

It is going to be very difficult to satisfy the media with one person being the spokesperson, for, No. 1, there are—I have done 40

interviews on television and radio within the last few weeks, and

that doesn’t begin to tell you how many requests there have been.

What about all the other people—Tony Fauci, Dr. Fauci from NIH,

who has done many interviews, Dr. Henderson, the Secretary?

There have been many people.

The problem—and I think you’re right, and I would agree—we

have to figure out a way to better coordinate the message that we

send out. But the difficulty is, this is a dynamic situation. I mean,

it’s changing every minute, and we don’t actually know what the

terrorist is going to do next, and we don’t necessarily know how he

or she is going to do it. And in that environment to try to communicate a message——

The public wants to hear from you on a very timely basis, but

they also want your statements to be definitive. They don’t want

you to say, our preliminary information is the following. The CDC

is continuing to do tests. And then tomorrow you come back and

say, well, on further testing, that sample was not negative. It was

positive. Well, that, in fact, is accurate, that is true, but the fact

22

of the matter is it’s a dynamic situation, so if you’re going to keep

the public informed——

And there is a lot to be said for that in terms of dealing with

the kind of panic that Congressman Shays described. You try to

give up-to-date information.

But the question is, do people really appreciate that a test may

be preliminary, that using nasal swabs to screen people at the outset was not necessarily a bad idea in terms of determining who

might have been exposed in a given situation?

The problem was that the public misunderstood that nasal swabs

were not definitive tests. And so when people came back and said,

even though your test was positive, when we did further tests at

CDC it was negative, so you don’t have to continue Cipro—or, in

other cases, even though you had a negative nasal swab, because

we have determined that you could have been exposed, we’re going

to put you on Ciprofloxacin or Doxycycline for the next 60 days.

Those are not easy messages to communicate to the general public, and I think anyone could be justified at selecting the negative

things that have happened and weaknesses and focusing on those.

And I think there is something to be said for that, and I think it

makes a contribution to the whole distribution, but I also think

somebody needs to stop and say, some things went right here, and

we’ve got to build on those things that went right and to make sure

that in the future more things go right.

That is the perspective that I’m taking. Because it is very clear

to me that you have the experts here to criticize what happened.

Mr. SHAYS. What I’ll do is I’ll ask questions. Then we’ll go to Mr.

Tierney, and then we’ll go to Mr. Putnam.

I think it’s very clear that it’s been a pretty dramatic few

months, and I think it’s pretty clear that we had some people who

were not only having to deal with this issue but they were new to

the job as well. But you have been around for a while, and I consider you a pretty steady hand. I’d like to have you give me an assessment of whether you felt you were playing the role you should

have played as the Surgeon General. I view you as, you know, the

chief health care spokesperson for the government.

Dr. SATCHER. Well, let me say a couple of things.

I think I could have played a more impactful role. The Surgeon

General functions best—and there is a lot of history, Dr. Cooper

and others—when the Surgeon General has the ability to base his

or her statements on the best available science. Throughout history, Surgeon General’s reports have been based on extensive examination of the research that has been done in an area. The

American people have come to trust those reports because they are

so solidly based in public health science, not politics, not personal

opinion.

We have not been here before where you have to respond to an

ongoing bioterrorist attack. You really don’t have time to assemble

all of the science, and the science is also changing, and therefore

there are a lot of questions that people want to ask. Some of them

relate directly to the science. Some of them relate to organization

and management. And so there have been interviews done in all

of those areas.

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I think Secretary Thompson saw himself as responsible for a department that included the Centers for Disease Control and Prevention, the National Institutes of Health that is responsible for

the research to produce better drugs and vaccines and supplies——

Mr. SHAYS. You can move the mic a little away because——

Dr. SATCHER. I’m sorry.

Mr. SHAYS. No, you don’t need to apologize that you have such

a nice voice. It carries well.

Dr. SATCHER. Thank you—the Food and Drug Administration. So

he is responsible for all of these agencies, and I think he felt there

was a responsibility to communicate about the overall picture within a department.

Now, has the Secretary—has the Surgeon General in the past

been in a position to speak for the entire Public Health Service?

Yeah, many years ago before the structure was changed. But the

structure is completely different today than it was when the Surgeon General was the head of the Public Health Service, and so the

situation in terms of day-to-day communication about what is happening in a department is not a role that the Surgeon General has

played in recent years.

The Surgeon General has reported on specific issues based on the

best available science. Surgeon General Koop reported on HIV/

AIDS in 1986. The AIDS epidemic started in 1981. We learned a

lot about AIDS in those years before the report went out. I could

say the same thing about my report on mental health.

So I think one of the problems we have here is we have not done

the job that we need to do at redefining the role of the Surgeon

General, communication about a dynamic bioterrorist attack, that

are ongoing, where the science is evolving on a day-to-day basis.

We think we need to do that because I think there is a critical role.

Mr. SHAYS. I’m going to have you turn the mic a little closer but

not too much closer. That’s perfect.

You basically said that we’ve learned a lot. Just about say, anthrax, just walk me through some of the things. One of the things

we learned was that inhalation anthrax was something we thought

could kill somebody. I mean, when we had hearings on the anthrax

vaccine in the military, it was, you know, if you inhaled it, you

were dead, and we learned that is not so, where also it’s conceivable that—we’re learning that—some of the people that died were

people who were dealing with some—who were either older or were

dealing with some physical challenges, that they become more susceptible to the inhalation anthrax, killing them, as opposed to

being healed through antibiotics.

Just walk me through some of the things we’ve learned.

Dr. SATCHER. Well, let me just say I think one of the most painful lessons that we have learned involved the deaths of the two

postal workers at the Brentwood facility, because I think, up until

that occurrence, the assumption and the public health line was

that people exposed to an envelope in an office that had been

opened were susceptible to anthrax and needed to be treated prophylactically. But many statements of the CDC up until that time

had said we have no reason to believe that a closed envelope passing through a post office could expose people. We know better than

24

that now, and it would have been greater if we had known that before.

We know more about, for example, how mail can be handled and

how envelopes can be ripped apart, but there was no evidence in

this case that had happened. So let me just say we still don’t have

the full answer to what happened in the Brentwood post office, but

we do know that somehow at least two postal workers were exposed.

You would have to assume, Congressman Shays, that many more

workers were exposed; and the question is, why haven’t they come

down? Because, obviously, we got to them early enough. If we had

known beforehand of the potential of the spores to escape in a post

office setting and infect people in that environment, we could have

perhaps saved those two people.

By the same token, getting back to the second level, if people on

the front lines who take care of patients had been more acutely

aware and had the appropriate level of suspicion, it might well be

that we could have saved those two postal workers. But all of that

is in retrospect. I think that is the most painful lesson we’ve

learned, is how critical it is to really have the kind of working relationship with the front line that leads people on the front line to

have the appropriate level of suspicion at a time like this and to

make sure that everybody is asked about their work environment.

If they show up with an upper respiratory infection—but, remember, there were hundreds of thousands of people who showed up

with upper respiratory infections during those 2 days.

I think we’ve also learned that the American public needs much

more information about the use of antibiotics and vaccines, the appropriate use. I know CDC has had a strategy going to try to reduce drug resistance in recent years, and part of that has been to

make sure that people understood that if you take antibiotics inappropriately you do great damage not only to yourself potentially

but other people. I can tell you that the American people are going

to a doctor’s office today asking for antibiotics for the common cold,

as we speak. There are people going saying, I want a penicillin shot

or I want this antibiotic, because I believe that will help me get

over this cold that I have. So we have a lot of education to do so

that the American people really understand and appreciate the

dangers, and we take that responsibility——

Mr. SHAYS. Just a second—and I appreciate Mr. Tierney’s patience here, but it is absolutely imperative in that circumstance

that the physician tell the patient it would be a terrible mistake

to have an antibiotic. Correct? I mean, it’s——

Dr. SATCHER. That brings you to the second level. You know, I’ve

trained primary care physicians in my career; and I remember in

an area like Watts training them and counseling them about when

you go out there to take care of patients make sure that you do this

and that. And they come back and say, well, if we don’t do it, the

patient goes to find another physician who will.

So we’re caught up in a situation here where many physicians

on the front line—and we’ve talked about this with—the American

Academy of Pediatrics and the American Academy of Family Physicians feel an unusual pressure to prescribe antibiotics for patients,

25

and they’ve done it within recent weeks, patients who have requested antibiotics and even other things that they wanted.

So it is a team, it is a partnership, and I think everybody in that

partnership has to be empowered and better informed.

Mr. SHAYS. I look forward to asking some more questions of you,

but let me recognize Mr. Tierney for a good 7 minutes.

Mr. TIERNEY. I don’t need all that time. Thank you.

I have a question to followup on—— Mr. SHAYS. Could I just interrupt? I apologize. I didn’t acknowledge the presence of Mr. Putnam or Mr. Lynch and appreciate both

of them being here. I’m sorry. Thank you. Thank you.

Mr. TIERNEY. Thank you.

I want to followup on what you have just spoken about in a

minute, but first let me ask you, there was a Dark Winter—it was

the name of a program or the exercise I guess that was gone

through by a number of people. During the course of that, former

Senator Nunn made a comment that there is an inherent conflict

between health and law enforcement when you have a situation

like we have with anthrax, and then there were reports in the

newspaper in Florida that the FBI had actually told public health

officials that they couldn’t speak publicly about what was going on.

Would you talk about what happened in Florida and what happened and a little about that conflict and how you would remedy

that?

Dr. SATCHER. Well, let me just say that I’m not going to give details about what happened that you might want, but let me just

say there is a difficult situation when you have a bioterrorist attack. Everybody wants to find out who is doing this. And I think

whether you’re in public health or law enforcement your first priority is how do we stop this from happening. So if the Department

of Justice or the FBI say to us, we really want to treat this information carefully so that we don’t tip off the terrorists as to what

we have, we have to cooperate with that.

I mean, when there’s a natural occurrence of influenza or something, we can control the prevention. We can’t when it’s a bioterrorist attack until we find the person or persons who is doing it. Our

hands are tied, and we don’t know what they’re going to do next.

So I would say those of us in the Public Health Service appreciate the role of the criminal justice system in dealing with a bioterrorist attack, and when they need cooperation that is critical to

carrying out their responsibilities we believe that it’s our responsibility to cooperate.

Mr. TIERNEY. Do you see that conflicting sometimes with the

need to get information to the public?

Dr. SATCHER. Most definitely.

Mr. TIERNEY. And how do you reconcile that?

Dr. SATCHER. Well, we’ve tried to do that, and you’ve seen several interviews done even with the White House and Governor

Ridge where people have asked questions and we’ve just said we

can’t respond to that right now. That’s in the hands of the FBI and

Department of Justice, if they were not there to respond themselves. So we have tried to explain that in some cases we were not

able to give information because we felt that it might endanger the

investigation. That is what we’ve tried to do. It’s not easy, and it

26

is a very difficult conflict to deal with, as Senator Nunn pointed out

in that exercise.

Mr. TIERNEY. Do you think that we’re properly using technology

that is available to us to get the public health message in a crisis

situation down to doctors at the local level and hospitals at the

local level community centers?

Dr. SATCHER. I think we are now, but I think we should have

done it before there was an attack. I think we educated and communicated with hundreds of thousands of physicians since the attack. But what it says to me is that, whereas in the past we have

relied on physicians to go to meetings and conferences to become

educated about bioterrorism, we could have used the satellite system for ongoing communication with providers, and hopefully in

the future that is what we will do. I think it’s an area where we

can make a lot of improvement, and I made that as a recommendation.

Mr. TIERNEY. You have.

Dr. SATCHER. Yes, and included it in the testimony.

Mr. TIERNEY. Last, let me just ask you this. The end of your answer responding to the Chairman Shay’s question, you talked about

doctors going out and saying that they’ve got a great deal of pressure from patients to give antibiotics to others. How much of that

do you attribute to this phenomenon of advertising by the manufacturers and placing their seed in the mind of patients?

Dr. SATCHER. Yeah. I think in recent years, with the Internet especially but with advertising in general, I think many patients

come to physicians asking for drugs that they’ve heard about

through the newspaper or through the Internet. So it is a major

part of the problem. I don’t think it’s a problem that we can’t solve,

because I think there are a lot of positive things about a betterinformed patient and patient community, but somehow we’ve got to

get to the point where we have everybody on the same wave length

as to how we protect the health of the public.

Again, my opinion is—and I had this opinion for many years and

I’ve stated it for many years—there’s no place in the world better

than this country when it comes to treating diseases and crises.

The problem is, how do we protect the health of the public? How

do we promote health and prevent disease? I think that’s the Achilles heal of our health system, and it’s reflected in that interaction.

Mr. TIERNEY. Thank you.

Dr. SATCHER. Uh-huh.

Mr. TIERNEY. Yield back.

Mr. SHAYS. I recognize—thank the gentleman and recognize Mr.

Putnam.

Mr. PUTNAM. Thank you, Mr. Chairman.

Dr. Satcher, to followup somewhat on the previous line of questioning, there have been a number of complaints from local law enforcement officials about the FBI’s refusal to share information

with them that were critical to their mission. Have you found the

FBI unwilling to share information, even if it may be of—information you don’t share publicly, but have you found them to be willing

to share with you the information you need to accomplish your mission as a public health officer?

27

Dr. SATCHER. Well, because that’s handled at a departmental

level, I can only say to you that Secretary Thompson’s position has

been that he’s had good communication with the Department of

Justice and the FBI, and that communication would take place at

his level. And that is—you know, his official position is that he’s

had good communication with the Department of Justice and the

FBI.

Mr. PUTNAM. I’ve just been handed something that indicated that

the Secretary has admitted to being frustrated at times in attempting to acquire and pass on information to the public on anthrax

due to the classifications or other FBI restrictions.

Dr. SATCHER. Well, I think that is a different issue. I think clearly, as I said in answer to Mr. Tierney’s question, it’s frustrating

when the public wants you to pass on information that you can’t

pass on because it’s a part of the investigation. But I thought your

question was, are we getting information that we need from the

FBI, as opposed to can we pass on information that we’d like to

pass on to the public? In the latter case, it has been very frustrating, as Senator Nunn defined it. But I thought you were asking me,

is the communication between the Secretary and Attorney General

and the FBI satisfactory? I have not heard him complain about

that. I’ve heard him complain about being limited in his ability to

then pass on this information to a public that expects him to pass

it on.

Mr. PUTNAM. You’re correct. The first question you did answer

adequately.

With regard to sharing of the information with your local health

officials, State and local health departments, how many of them

have access to your Health Alert Network and Lab Alert Network?

Dr. SATCHER. The Health Alert Network is actually now available to all State health departments. As you know, the State and

local health departments vary tremendously in their capability.

That is one of the weaknesses of the public health infrastructure,

the tremendous vulnerabilities among State and local health departments. There has been a program in place now for over 5 years

and Congress has provided funds through the CDC to strengthen

State public health laboratories. We still have a long ways to go,

as you know.

There are States in this country that don’t have a trained epidemiologist. There are local health department—there are local

communities that don’t have a local board of health. And so the

problem in the country today as I see it is a great heterogeneity

among the various States and local communities.

I think the Health Alert Network needs a lot of support. It needs

more funding. We also need the Laboratory Alert Network to be

continually developed and strengthened.

So the official statement I think from the CDC is that 50 States

are receiving funding under the Health Alert Network grant program, in addition to Guam, the District of Columbia, New York

City, Los Angeles and Chicago. You know, we fund some localities

as if they were States because they are so big.

Thirteen States are connected to all of the local health—all of

their local health jurisdiction, only 13. Thirty-seven States have

begun connecting to local providers.

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So it is true that 50 States are receiving funds, but there’s a lot

of difference—there is a lot of heterogeneity in terms of what happened within those States and their ability to use the information.

Mr. PUTNAM. It’s essentially—in terms of disseminating information quickly, it’s little more than an e-mail or a fax, isn’t it? I

mean, please—— Dr. SATCHER. Well, the Health Alert Network is based on the

best technology.

Mr. PUTNAM. So, I mean, surely the technology and the price

pressures for cheap technology would be such that there shouldn’t

be any States or any health department or any hospital or any doctor’s office out there that not have access to—— Dr. SATCHER. Well, I would like to refer you to Senator Frist’s

statement when he and Senator Kennedy introduced legislation to

provide $3.5 billion for strengthening health—the public health infrastructure. He pointed out how many health departments did not

have a computer in this country. So, as strange and shocking as

it may seem, there is tremendous heterogeneity among—especially

among health departments but also State health departments. But

I would refer you to his testimony about the major problem that

we have in terms of the technology that is available in many different situations.

Mr. PUTNAM. And very quickly, as my time has expired, because

of the crossover of anthrax, for example, being essentially an animal disease and some of the—how much coordination is there between the HHS and USDA and between the medical professionals

and veterinarians to coordinate information as the entry points for

some of these may actually be through animal or agricultural products?

Dr. SATCHER. Yeah. I think there’s room for improvement in this

area, but I do want to say that the Commissioned Corps, which I

oversee, which has 5,600 health professionals, has over 100 veterinarians; and we have sent people from our department to areas

where there were outbreaks that involved animals, including outbreaks recently in England and in places in Europe in terms of

mad cow disease. So we do have veterinarians in the Public Health

Service, and we do have a working relationship with the USDA. I

think everyone would agree that we can do much to strengthen

that working relationship.

Mr. PUTNAM. Thank you, Dr. Satcher.

Mr. SHAYS. I thank the gentleman.

At this time, I would recognize our newest member. It’s wonderful to have you here, Mr. Lynch. Do you have questions?

OK. Thank you.

Mr. Gilman, do you have any questions you would like to ask?

Or I have some that I could quickly ask and give you some time.

Mr. GILMAN. Well, thank you, Mr. Chairman. I want to thank

you for holding today’s hearing to examine the overall level of communications between the Federal Government and the public

health system regarding bioterrorism risks, and I want to thank

our panelists who are here today.

For many years discussions about the possibility of a biological

terrorist attack occurring in our Nation was relegated to the academic and policy discussions. Regrettably, the terrible events of

29

September 11th and the subsequent anthrax incidents in New York

and Washington sharply focused on our national attention on terrorism and underscored our vulnerability.

You and I attended a hearing earlier today with our arms Secretary in the State Department, and he noted how many nations

there were who have been developing biological weapons. It’s certainly an important element for us to take a good, hard look at,

both in terms of where the threat originates and what specific

agents pose the greatest danger. So far, the media has focused its

attention only on anthrax and smallpox, yet those represent only

two out of the many agents which could conceivably be utilized.

Still, those two agents are the ones that have garnered the most

attention.

In the case of anthrax, the events following the contaminated

mail incidents in October have shown that there is much room for

improvement on the part of our own government and the communication process, and while officials at CDC and HHS have demonstrated improvement in their communication strategy over time,

their early missteps, particularly in downplaying the initial risk of

exposure, has led to additional complications as the situation—it’s

vital, therefore, that these Federal health officials have learned

from those past mistakes and are able to ensure the public that

they will not be repeated in the future.

So I want to just ask one question. Have the various Federal and

public health services considered adopting a daily briefing program

similar to those conducted by the White House, the Department of

Defense with regard to the bioterrorism situation?

Dr. SATCHER. Yes. Congressman, I mention in my testimony that

both the Secretary of Health and Human Services and the CDC

have initiated daily briefings for the press since the second week

in October. So there have been ongoing interactions. I think that

is the part of the strength of the communication, but it is also a

part of the things that people are going to be able to criticize. Because by having daily briefings, you’re also going to give information that is evolving, which means that some of it is preliminary,

and therefore how do you deal with preliminary information where

the results are going to change.

But I think the daily briefings are important and think they

have been very helpful to members of the media and, therefore, to

the general public.

Mr. GILMAN. Dr. Satcher, who has the overall responsibility of

conducting our Nation’s defense against bioterrorism? Is there any

one person or any one agency?

Dr. SATCHER. Well, it’s really the Justice Department that has

the overall responsibility for defense against bioterrorism——

Mr. GILMAN. And is——

Dr. SATCHER. And all of the bioterrorists, including the exercise

that was discussed earlier with Senator Nunn. It is understood

that the first responsibility in terms of protecting the American

people and guarding against criminal behavior, which we’re talking

about here—we’re talking about criminal behavior, where there is

a criminal somewhere attacking——

30

Mr. GILMAN. But, Dr. Satcher, what I’m trying to pinpoint is

where is the overall responsibility for coordination and to make certain all of the agencies are working together on this.

Dr. SATCHER. Oh, right now, of course, it’s the new Office of

Homeland Security in the White House, but that’s a new office.

Mr. GILMAN. And does that Homeland Security Director have the

responsibility then of coordinating——

Dr. SATCHER. Coordinating, yes.

Mr. GILMAN [continuing]. All of our efforts on bioterrorism?

Dr. SATCHER. Governor Ridge, the head of homeland security

today, has the overall responsibility for coordinating all of the efforts.

Mr. GILMAN. And do you report to him with regard—or do you

work with him with regard to——

Dr. SATCHER. I report to Secretary Thompson in the Department

of Health and Human Services, and he deals directly with Governor Ridge.

Now, Governor Ridge has often asked me as Surgeon General to

join him at the White House for conferences with the media. But,

in our department, that relationship is with the Secretary, as it is

with—you know, with other departments, Department of Justice,

Attorney General.

Mr. GILMAN. Dr. Satcher, do you sit in with other agencies to explore what has to be done on bioterrorism?

Dr. SATCHER. Agencies within the Department of Health and

Human Services?

Mr. GILMAN. All of the agencies.

Dr. SATCHER. No. Again, that interaction would be at the level

of Secretary Thompson.

Mr. GILMAN. And do you sit in with Secretary Thompson on that

kind of direction?

Dr. SATCHER. There are times, but that is really not the major

role of the Surgeon General. If the Surgeon General did that——

Mr. GILMAN. I realize that.

Dr. SATCHER. If the Surgeon General did that, it would be very

difficult then to be responsible for the Commissioned Corps and deploying people under an emergency basis and continuing to speak

with the American people all over the country. So it is not a dayto-day responsibility of the Surgeon General.

Mr. GILMAN. So the Surgeon General then doesn’t have any responsibility on planning with regard to bioterrorism or——

Dr. SATCHER. Well, the Surgeon General has input to planning,

yes, definitely, but not to be involved in meetings with departments. Because when you say—you’re talking about meetings with

the Department of Justice and——

Mr. GILMAN. Well, I want to ask you, if you had some thoughts,

constructive thoughts on what should be done on bioterrorism, who

would you pass that on to?

Dr. SATCHER. Secretary Thompson of the Department of Health

and Human Services.

Mr. GILMAN. Thank you.

Thank you, Mr. Chairman.

Mr. SHAYS. I thank the gentleman.

31

Dr. Satcher, we could ask you a lot more questions. We have another panel we want to get to. I want to ask you just a few, though.

I want to ask you how you would define the role of the Surgeon

General in terms of you and anyone who follows you as it relates

to bioterrorism.

Dr. SATCHER. The Surgeon General has two major areas of responsibility as I see them today. The first area is the responsibility

for the Commissioned Corps, the 5,600 health professionals who

are on call 24 hours a day, 7 days a week to respond to any threat

to the health of the American people, whether it’s a bioterrorist attack or whether it’s a natural outbreak. And we often deploy people

when there are floods, tornados, an epidemic in this country or

even in another country if it’s a threat to the health of the American people.

So September 11th, while on the way to the airport, I stopped

and activated the Commissioned Corps readiness force, and we

have sent many of those people to New York City and other places

to respond. That’s a very important day-to-day responsibility of the

Surgeon General; and, as you know, we deployed the Deputy Surgeon General to Capitol Hill, Dr. Ken Moritsugu, who has been intimately involved with briefings on Capitol Hill since the letter to

Senator Daschle.

The second and perhaps in some ways most important responsibility of the Surgeon General when you really think about it is

the direct communication with the American people based on the

best available public health science. The context of that communication historically for the most part has been to look at an area

of concern to the American people, does smoking cause lung cancer? So Dr. Luther Terry’s report was the first ever Surgeon General’s report on smoking and health.

There have been many reports on that topic since, and during my

tenure, of course, I have released reports in areas of mental health,

suicide prevention, youth violence prevention, oral health. I released three reports on smoking and health, including women and

smoking. Those reports were all based on thorough public health

science examination of those areas.

So when we speak to the American people, we speak with the

kind of authority based on a lot of the investigation.

But I believe that we have to define a clearer role for the Surgeon General in terms of bioterrorist attack. I think that’s one of

the things that we’ve learned that the American people do, in fact,

want to be able to rely on the voice of authority and credibility in

public health science. And so I think that as we look at how to improve the system of communication, I think the role of the Surgeon

General is critical in this. But it’s got to be very clear that there

are political issues involved in responding to an outbreak, there are

organizational issues. And the question is, which of those issues

are we going to look to the Surgeon General to speak on? And I

think the Surgeon General has to speak on the public health

science.

Mr. SHAYS. It strikes me that the Surgeon General has consistently over the years, you and those who preceded you, as basically

being the voice where the science takes you and not an office that

can be manipulated by political considerations. Obviously, political

32

considerations can come in terms of typing of a report and so on,

but in the end, what you issue is viewed to be the truth untainted

by political considerations, and I mean, you and those who preceded you.

In other words, I consider you, kind of your position, an honest

broker, an honest voice, and is that a view that I should consider

or should I consider you basically under a secretary, and if the secretary says change your report, you have to change your report?

Dr. SATCHER. Well, I think the first description is the one that

is accurate for a Surgeon General. But I also want to add something to that.

Mr. SHAYS. Sure.

Dr. SATCHER. As you know, there are times when there are disagreements. I’ve issued a report on promoting sexual health and responsibility for sexual behavior, which was not supported by the

Secretary or the White House, but they did allow the report for the

public health science, but it was not necessarily politically a report

that was supported.

I do want to make it very clear, Congressman Shays, that the

Surgeon General’s office is, in fact, impacted by politics. The budget

of the Surgeon General’s office has been virtually depleted since

1994. So there is virtually no budget. The Surgeon General relies

upon NIH, CDC, other agencies when we do a report even. Because

there is no—the funding is not there. A lot of the changes that

have taken place have resulted from disagreements with things

that came out of the office of Surgeon General.

I have been very fortunate, I think it has something to do with

the fact that I was director of CDC before, and I’ve had an ongoing

working relationship with people in these various agencies now for

several years, so I have not had difficulty getting support to do a

report on mental health, for example. I didn’t have the money in

the Surgeon General’s office to do that. I didn’t have the money to

do the youth violence prevention report. I had some.

So in every one of these areas, I’ve had to rely upon other agencies within our department. So while on the one hand I say to you

that it is the responsibility of the Surgeon General to issue reports

that are based on the best available public health science and not

politics and not personal opinion, I would not be honest if I said

those things don’t impact upon the strength of the Office of the

Surgeon General. As you imply, clearly, organizationally, the Surgeon General reports through the Secretary.

That’s the way the organization is. That affects budget, that affects everything. And that’s the reality. I would like to see it—to

be honest with you, I would like to see it different. I would like to

see the Surgeon General able to have a strong office and able to

report on based on the best available public health science, even

when there is disagreement about that. I’m talking about the future, not talking about myself.

Mr. SHAYS. I appreciate your candor. I know you’re talking about

the future. I apologize that I haven’t been as aware that since

1994, this office has gotten less and less resources.

Dr. SATCHER. You might want to look at the budget of the Office

of Surgeon General.

33

Mr. SHAYS. There’s a lot we should look at. I would ask this one

last question. You have to respond to the FBI. But do they ever

have to respond to you? Can you ever trump the FBI? They trump

you, they trump the health care side. Can the health care side

trump the FBI? You go from detection and prevention of a terrorist

attack, you have crisis management, investigating the crime, you

got the consequence of the act. But isn’t there times when the consequence of the act should trump the crisis management?

Dr. SATCHER. Yeah. I don’t know if I would use that term because it implies expedition when I think it ought to be looked at

as a partnership. The FBI is very dependent upon the public health

service for information. Whether it’s the CDC and, of course, there

is the U.S. Army Medical Research Institute for Infectious Diseases

[USAMRIID], that does a lot of the analysis. But the FBI is often

dependent upon the public health service for information that they

will use in their work. And that’s certainly been true with the anthrax outbreak. They have looked to the CDC for information about

the nature of the strain, for example.

It is very important that in all of the four letters that have been

sent with anthrax, they have all been of the same strain. It’s upon,

it seems as if to date, the letter sent to Chile may well be a different strain. All of this is information that comes out in a laboratory. It is all information that the FBI uses in its investigation.

Mr. SHAYS. But would it be wrong for me to make the assumption that if someone’s life is in danger, that trumps their trying to

protect evidence? In other words, if an envelope is there that could

be dangerous, and if we could have that envelope and we could

begin to see what’s in it, should I believe that because they may

want to protect the evidence that—— Dr. SATCHER. Oh, I see your point, yeah. I don’t think that the

decision would ever be made. You know, at least I don’t think so.

I can’t think of an instance where someone’s lives have been put

at danger because the information was protected for the investigation. I think the overall goal here is to save lives. And we believe

that in the case of a bioterrorist outbreak, finding the person who

is behind it is very critical to saving lives. But I can’t think of an

instance where we have endangered lives of people because, you

know, we don’t get information where it was suppose to. We didn’t

take action. We may not have explained to the public why we took

a particular action.

Mr. SHAYS. As always, I appreciate you coming before our committee. Appreciate your candor. I appreciate your good work. I

would just invite you to make any closing comment if there is anything you wanted to say or question you wish we had asked, I invite you to make a comment before we go to our next panel.

Dr. SATCHER. One of the things that we’ve talked about is the dynamic nature of this situation. And when the exercise that Congressman Tierney mentioned with Senator Nunn took place, we

were actually in a different place in this country than we are now.

The FBI had the lead for crisis management with bioterrorism.

FEMA had the lead for consequence management and the department reported through them. There was no homeland security office. So even since the bioterrorist operation took place, we have

seen changes even in how we’re organized and how people report.

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This is a dynamic situation and hopefully moving in the right direction. I think this hearing is so important in that regard.

Mr. SHAYS. Thank you very much. Appreciate you being here.

We’ll call our final panel and obviously thank them for their patience. All of them are busy people and I know have other places

to be. I invite Dr. C. Everett Koop, former U.S. Surgeon General;

Dr. Kenneth I. Shine, president, Institute of Medicine representing

the National Academy of Sciences; Dr. Mohammad Akhter, executive director, American Public Health Association; Dr. Joseph

Waeckerle, editor and chief, Annals of Emergency Medicine, representing the American College of Emergency Physicians. I will invite you gentlemen to stand. I will catch you before you all sit

down and administer the oath.

[Witnesses sworn.]

Mr. SHAYS. Note for the record that our witnesses have responded in the affirmative. I would invite you to give your testimony as I called you. We’ll start with you, Dr. Koop, and go to Dr.

Shine, Dr. Akhter and Dr. Waeckerle. What I’ll do is I’ll—we’ll

have a 5-minute clock. We’ll roll it over, but hope that you could

stay within the 5 minutes, but if you roll over, you have another

5 minutes if it’s necessary.

Dr. Koop, it’s always wonderful to have you here. Thank you.

We’ll start with you. Let’s make sure that mic is on.

STATEMENTS OF DR. C. EVERETT KOOP, FORMER U.S. SURGEON GENERAL; DR. KENNETH I. SHINE, PRESIDENT, INSTITUTE OF MEDICINE, REPRESENTING THE NATIONAL ACADEMY OF SCIENCES; DR. MOHAMMAD AKHTER, EXECUTIVE

DIRECTOR, AMERICAN PUBLIC HEALTH ASSOCIATION; DR.

JOSEPH WAECKERLE, EDITOR AND CHIEF, ANNALS OF

EMERGENCY MEDICINE, REPRESENTING THE AMERICAN

COLLEGE OF EMERGENCY PHYSICIANS

Dr. KOOP. Good morning, Mr. Chairman and members of the

committee.

Mr. SHAYS. It’s not on yet, Dr. Koop.

Dr. KOOP. Now?

Mr. SHAYS. Yeah.

Dr. KOOP. Sorry. I am C. Everett Koop, a pediatric surgeon by

training and the Surgeon General of the United States for two 4-

year terms, from 1981 to 1989. I appreciate much your invitation

to testify before you.

Our public health care system has been weakened in the past 8

years and the recent bioattacks have stressed its ability to protect

the American public. We were not prepared for the anthrax bioattack, regardless of its source, and the fear generated by it far

outweighed the health threat.

Morally, I think we really never thought anyone would do it, but

they did and the public is still uncertain, that they would deliver

a catastrophic attack by some other bioterror. Think of the distraction and chaos involved with fewer than 50 anthrax victims, real

or uncertain, in the anthrax scare, how would our resources handle

not 50 but 5,000? How about 50,000? How about 5 million?

The public health service has a long and distinguished history of

protecting America in the past from many threats that have

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reached our border or have originated domestically. However today’s threats are unique in a world without borders, and therefore

require new strategies and policies coupled with operational plans

to combat the threats to our Nation’s health care and to our people.

Our domestic defense system has not been able to protect the

American people or their economy from the present small bioterrorism attacks. What will we do with weapons of mass destruction or

weapons designed to maximize panic and mistrust in our health

care system?

Mr. Chairman, your staff asked me to answer a few questions on

communicating information to the public on terrorism. And I would

not give the government high marks in this recent episode. The

spokesperson in such situations is usually the Surgeon General,

and usually in the setting of a press conference and not a talk

show. And yet I have heard almost nothing from him and those

who were his surrogates, except Drs. Fauci and Koplan, who have

not been accurate.

I don’t mean Fauci and Koplan, I mean the others. That is particularly egregious because as you know, the current Surgeon General was, for some time, director of the Centers for Disease Control

and is eminently qualified in this area.

Communicating threats to the public are based, I think, on common sense. And I have a few rules that I don’t really think about

when I talk, but I made them up in response to the question. First

of all don’t make statements especially predictions that are not

based on fact. Deliver warnings with enough information to prepare and protect without causing panic. Choose words understandable to a 10th or 12th grader, and go over the draft again and

again so there is no ambiguity. Make certain that the public understands the difference between an immediate threat versus a longterm outcome, and between fatal and a nonfatal threat. Inform the

public frequently and in increasing depth. Squelch rumors that are

untrue, such as AIDS can be transmitted by contact with door

knobs and toilet seats. Translate science for the non scientific public and never speculate or indulge in opinions. And finally, and perhaps most important, keep the press on your side through honesty

and forthrightness.

There will likely be a series of biothreats, chemical threats, agro

threats and cyberthreats, nuclear threats and threats to our food

supply and our water supply over the next months and years until

we win our international war against terrorism. While recent actions were designed to cause maximum panic and economic harm,

future threats may indeed be aimed at causing catastrophic numbers of casualties.

This likelihood needs a new strategy where all of America is

linked together using our strengths of command communication

and control technologies to defeat future attacks. We need to be

able to rapidly mobilize all of our health care resources to be concentrated on wherever the threat appears, even if it appears in

multiple sites simultaneously. The defense against bioterrorism is

not to be found in the military, their responsibility is primarily

strategic offense. Anticipated threats against civilians cannot be

prevented unless we destroy the source or have extraordinary and

credible intelligence for a specific site at a specific time. But we can

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mount multiple plans tailored to the threat aimed at managing the

assault, containing its spread, treating victims and controlling the

ensuing panic.

A new biodefense system needs to address the possibility of

weapons of mass destruction such as contagious weapon that will

overwhelm the limited surge capacity of our health care system,

our pharmaceutical industry, and the public health service. These

weapons can be unleashed from abroad and move silently within

individuals traveling throughout our country, undetected, until the

first sentinel case is found.

At a similar time in history, Winston Churchill, deeply troubled

by England’s lack of preparation for World War II said this, ‘‘the

responsibility of ministers (that is, government officials) for the

public safety is absolute and requires no mandate. It is, in fact, the

prime object for which governments come into existence.’’

A new biodefense system must be created based on a net centric

command information and control technology, based on advances in

biotechnology, telemedicine and robotics that can reduce the effect

of bioattacks on us with weapons of mass destruction. A terrorist

attack designed to cause catastrophic levels of casualties by spreading a contagious disease or a chemical or radiation illness across

America needs to be met with a health care system that increases

dramatically that surge capacity to respond within hours and not

days. This will protect the health of America and provide security

to our people, our economy, and ultimately to our freedom-based

way of life.

Fortunately, most of the bioterrorist agents are treatable with

antibiotics, with the exception of smallpox, a deadly disease without treatment with a latency of incubation period of 12 days.

Again, fortunately, the victim of smallpox is usually rendered sedentary by the severity of the illness by the 14th to 16th day after

exposure. Smallpox, as you know, has been eliminated from the

globe since 1977. And few people have been vaccinated since that

time.

The doses of vaccine on hand are minuscule compared to the

number needed to immunize the public. We have no experience at

all that says our vaccine is efficient against modern smallpox,

which may have mutated or have been bioengineered. There is, indeed, frightening evidence published this year suggesting it is possible to make people more susceptible to a pox virus, while at the

same time, turning off the victim’s own natural immune protection.

After a dirty nuclear bomb or radioactive material in conventional explosives goes off in some major city, or we have a smallpox

epidemic, the country will settle down in disarray to establish a

widespread protection plan. And if we will do it then, why not now.

I don’t know if CDC’s plans announced in the Washington Post 2

days ago are inclusive of this knowledge.

The creation of this new system should be done as a large-scale

project. It will be expensive, but not nearly as expensive as doing

nothing. It would take advantage of the strengths of America and

can be accomplished rapidly if we start now to build it. If we commit to this plan, this administration can assure the American public that we can protect them from any biothreat. We cannot not

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stop all threats, but we can help to reduce the harm to both our

people and our economy.

Without such a plan in place, I don’t think we can reduce the

present panic which many of our people feel. We need to uphold the

trust in our health care system and the ability of our government

to provide security to the American people. To win the war, we

need both a successful offensive strategy that will work in time,

and a defensive strategy that will protect America while we wait

for this win in the war against terrorism.

Mr. Chairman, I would be pleased to, as you and your members

of the committee choose, to elaborate further.

Mr. SHAYS. Thank you very much, Dr. Koop.

[The prepared statement of Dr. Koop follows:]

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Mr. SHAYS. Dr. Shine.

Dr. SHINE. It’s a privilege to meet with you. I’m Ken Shine. I’m

president of the Institute of Medicine. For the last 3 years, I’ve also

served on the Commission of—congressionally mandated Commission on Weapons of Mass Destruction, chaired by Governor Gilmore

of Virginia.

I should preface my comments based on the discussion with Dr.

Satcher that 2 years ago, we recommended the creation in the Executive Office of the President of an entity which provided overview

of threats of weapons of mass destruction including bioterrorism.

That office as a consequence of September 11th has been created

with Governor Ridge in charge.

One of the recommendations we made was that there ought to

be an associate director of that office for health. And that’s not

happened. We believe that it’s extremely important that there be

such an individual because that’s the site at which the interface between HHS, the criminal justice system, the Department of Agriculture, a lot of other places would come together and that’s the

place where relationships between the medical professions, the

public health community also could come together in an overall approach to bioterrorism.

As the chairman pointed out, terrorism is about creating fear, rumors, anxiety, misinformation and chaos. I would argue, sir, that

credible information is critically important as medicine for that terrorism. We did not do well in the anthrax outbreak. There were

multiple talking heads on television, including a number of pseudo

experts, one identified himself as an expert on the anthrax virus,

anthrax is not a virus, it’s a bacteria. We had situations in which

the Web was covered with all kinds of information about anthrax

which was incorrect. We had all kinds of promoters promoting all

kinds of variety of materials that you should purchase or promoting

antibiotics and so forth.

We were so concerned about this that the Presidents of the National Academy of Science Engineering and myself issued a statement early in October identifying what we thought were reliable

Web sites, those at the National Library of Medicine, the CDC and,

at that time, Johns Hopkins. But we believe that we did not do a

good job with regard to communication with the American people.

There are four issues that I would like to just briefly touch upon.

First, within the government, within the Department of Health and

Human Services there needs to be a single credible medical public

health expert who is the spokesperson for the Department. That

doesn’t mean that other people can’t speak on the subject, but it

means that that individual should be responsible for communicating with the public about these issues, that individual is credible

because he or she has professional knowledge, has current information, and in coordination with law enforcement, is articulate,

knows, like Dr. Koop has shown over and over again, how to translate information to the public, and doesn’t talk down to the public.

That individual ought to be able to stand next to political leaders

and administrators and be available so that when a question is

asked by the media, that the political leader to turn to that individual and get an immediate answer. That individual has to be so

credible that when he or she doesn’t know, she can say he or she

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doesn’t know. And in a report we did in 1996 on understanding

risk, our evidence is that if the person is credible, if the person provides information, saying I don’t know in fact increases the credibility. Does not diminish it.

Tony Fauci performed that function extremely well when he was

put into use in this area. But that didn’t happen until well into the

outbreak. And the fact that there was no individual doing that was

a clear deficit. The Associate Director of the Office of Homeland Security, if that individual were a health person, could serve a similar function. But if that’s the case, they ought to coordinate their

activities so the same information is provided that does not confuse

the public.

Second, we need much more attention to the Internet, the Web

sites within government, in this case, the CDC. The CDC does have

a Web site. We identified it as one of the more reliable ones. But,

in fact, there were times when you couldn’t get into it. It was not

always easy if you were a health professional to get the information

you needed. And I should emphasize that we heard at our commission hearings from people in local public health departments about

the number of calls they got from health professionals about what

to do. And they were not informed during the early stages of the

outbreak.

The role of the Internet in this regard needs to be enhanced. And

Mr. Chairman, that would require resources because it is necessary

that all public health departments have computers, that you can

have the use of the Internet as a way of getting them information.

I would emphasize that the people working in this area work 24

hours a day, 7 days a week during this outbreak. In fact, that was

the testimony to how poorly staffed they were and how poorly prepared we were. But we need to invest in the Internet the Web site

communications.

Mr. Chairman, I would emphasize we need to learn from the lesson in anthrax so that if there’s a problem with agriculture, the

Department of Agriculture is prepared with a spokesperson and a

Web site. If there’s a problem with the radiologic episode, that the

Department of Energy is. We don’t know who the spokesperson

would be if there was a chem outbreak. It seems to me that we

need to think about that.

Third, we need to do a better job in both understanding and

doing risk communication with the public. What is the risk, what

is the benefit, how do you measure those. Dr. Satcher has made

reference to some of the problems with antibiotic use. I would use

the smallpox debate as an excellent example. Here we have an

agent where once we have stores of vaccines, we got to decide how

to use them. The public needs to understand, if we vaccinate the

entire population, we will kill several hundred people by the act of

vaccinating. In fact, we’re going to probably kill and make sick a

lot more than that because of the large number of immuno-compromised people that were not around at the time that smallpox

was being protected against.

And I would remind you that choosing not to vaccinate such individuals may not protect them from the virus of vaccinia if we did

mass vaccination. On the other hand, we know how to use the vaccine to surround cases of smallpox. That was how it was eradicated

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from the globe. So if you have adequate stores, you can follow the

cases, you have several days after exposure in which you can vaccinate. There is probably some residual immunity in our population. And so if you look at the risk benefit, you can come up with

some logical ways to develop a policy that the public can understand. I’m very worried about the potential in agricultural terrorism of hoof and mouth disease. But in contrast to the situation in

Europe in which cattle were slaughtered by the tens of thousands,

you can immunize animals against hoof and mouth. Do we have

the vaccine and did the public understand that meat would be safe

if, in fact, you stopped an epidemic using it?

Finally you already heard the concerns about public health. I

would emphasize in 1988, the Institute of Medicine issued a report

called the ‘‘Future of Public Health.’’ In that report, we said that

the public health system was in disarray. And everything has been

downhill since. The reality is that we missed hantavirus for a significant period of time because reporting systems for hantavirus

were inadequate. We know that West Nile virus got going because

we laid down on the mosquito abatement programs and allowed

mosquitos to proliferate, so when a bird got infected we now had

an outbreak.

You’ve heard about the problems with regard to resources. We

need people, facilities, research and particularly communications.

And may I emphasize that we need that for the entire system all

the time. We had an outbreak of two cases of meningococcus meningitis in a town in the middle of the country earlier this year.

Thousands of people took antibiotics and vaccines because of one

uninformed statement by a doc on a television station. It was entirely inappropriate. The point is that the communications become

absolutely critical.

Finally, there are communications about risk which are based on

science and are based on the need for the truth, as you put it. But

remember, there are many irrational kinds of fear and anxiety.

And we need to understand what those are. And it is entirely possible that we ought to have a mechanism by which the CDC either

through focus groups or through networks similar to what Nielsen

uses or others can test what the public is, in fact, frightened of and

communicate information which will be addressed to their fears as

well as addressed to the scientific truths. Thank you, Mr. Chairman.

Mr. SHAYS. Thank you very much Dr. Shine.

[The prepared statement of Dr. Shine follows:]

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Mr. SHAYS. Dr. Akhter.

Dr. AKHTER. Thank you, Mr. Chairman, members of the committee. I really appreciate the opportunity to be here this morning. My

name is Mohammad Akhter. I am the executive director of the

American Public Health Association. We represent the public

health workers in this country, both Federal, State, local level of

protecting the health of the American people every single day. So

what I’m going to say is not——

Mr. SHAYS. You don’t represent, say, the directors of the public

health?

Dr. AKHTER. Many of them are our members, yes, sir. It’s a professional organization. We are a professional organization, scientific

organization, and as such, many of the members are professional

directors. Like Dr. Satcher is, for example, one of the members of

the American Public Health Association. So we speak on the basis

of science and actual on the ground experience.

So, Mr. Chairman, despite what my senior colleagues and some

of the other folks in the government may have said before, I want

to say one thing about the previous anthrax attack and that is,

that a lot of people worked very hard, but the fact is we got lucky.

We were very fortunate that there were handful of cases and that

took place in an area where we have very good resources.

And we were able to deal with it. If the same situation would

have taken place in another part of our Nation, we wouldn’t be so

lucky. And so my comments are based upon what can we do for the

future. And there are four areas of risk communication that I very

quickly want to run by you for your consideration: The first is the

communication between the front line workers in bioterrorist attack. It’s not the fire chief who pulls the alarm. It’s not the disaster

preparedness director who pulls the alarm. It is the physician, a

paramedic, a nurse, an EMT on the front line. If those people were

not connected with the health department, there is no communication. Then we have difficulty.

Handful of health departments right now have that capability.

Where the cases are reported, as long as somebody sees a suspicion

case, the case gets reported to the health department. So that this

system could be activated, we could do the followup, do the tracking. So the capacity needs to be built at the local level, the local

health department, particularly those health departments that are

50,000 or less population. They are the ones who really do not have

that capacity.

My second area of communication, risk communication deals

with the communication between the Federal Government, State

government and local government. Despite the grants that were

given, despite the health alert network that’s been in place, the reality on the ground as we speak, Mr. Chairman, today, is that 10

percent of the local health departments do not have e-mail capability. 50 percent of the local health departments do not have high

speed Internet connection. So you can give them the information.

Even if they receive it, they cannot forward that information to

their physicians in their area, to the hospitals in their area, to the

ambulance providers in the area. So there is a bottleneck there.

And we really don’t have the full communication in place that

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could be very effective in saving lives and protecting against disease.

The third area, Mr. Chairman, is the area of communication between the public health community, the Department of Defense,

and the Intelligence Community. I had the great honor of serving

for 30 years of public health positions, including being the director

of health for the State of Missouri.

Not until I became Health Commissioner in Washington, DC, did

I ever have the opportunity to work with the Defense Department

or the Intelligence Community. These communities have not

worked very well together. We don’t have the history, we don’t

have the tradition of working together. So when they come together, as is the case is imperative now that we all work together

to deal with this new situation, we don’t have any structure. We

don’t have any authority, any way to really do this thing together.

And collaboration between different agencies at the State level,

even within the agency, is a very difficult task. And it will not take

place, Mr. Chairman, until and unless there is a directive from the

very highest level of our government, perhaps from the President,

to make sure that the Defense Department that has a wealth of information on these areas, Intelligence Community, law enforcement, and public health community, work together to share information. And if necessary, give several key health officials the FBI

clearance so they can get the information on a need-to-know basis

they can prepare and protect the health of the American people.

And finally, Mr. Chairman, I come to the major issue of communication with the public. When it comes to bioterrorist attack, we

aren’t dealing with anthrax or smallpox virus, we are dealing with

people who may have been exposed to anthrax, who may have been

affected by the anthrax and who are afraid of anthrax. And what

these people need is clear, concise, usable information from an authoritative source. And I’m sorry to say and I agree with my colleagues here that we were unable to provide that in the past. And

I see no change as we speak today, Mr. Chairman, to be able to

do that. All the things that I’ve learned in the communication is

that you need to have a single, centralized person responsible who

could provide that information to the American people.

Dealing with bioterrorism is a public private partnership. All the

doctors, the hospitals, the ambulance providers are private people.

They work with the Health Department very closely to be able to

protect the health of the American people. One of such entity out

there is the American news media. Frankly, many of our people

learned—got the information from the news media faster than they

got through our own channels of communication in public health.

And we should bring the news media in on the table so that we

could have the news media sit down with the key folks.

So here is what I recommend in my closing. That at each level

of our government, Federal Government, State government, and

the local government, a single source be identified for communication with the public and that the news media be brought in in communication, and we need to work out the protocols and the way

how we’re going to provide the information to the people so people

get the right and accurate information so we can get the support

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and the confidence of the American people to deal with this new

and emerging situation.

Mr. Chairman, I thank you very much for this opportunity. Be

glad to answer any questions you might have.

Mr. SHAYS. Thank you, Dr. Akhter.

[The prepared statement of Dr. Akhter follows:]

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Mr. SHAYS. Dr. Waeckerle.

Dr. WAECKERLE. Chairman Shays, members of the subcommittee

and fellow panelists, good morning. It’s a privilege to be here.

Mr. SHAYS. Privilege to have you.

Dr. WAECKERLE. I’m Joe Waeckerle. I’m a practicing emergency

physician, board certified and residency trained. I live in Kansas

City, MO. I currently serve as editor-in-chief of the Annals of

Emergency Medicine of the American College of Emergency Physicians and have chaired the Task Force on Health Care and Emergency Services Professionals on Preparation for Nuclear Biologic

and Chemical Attacks. I also have worked as a consultant to the

Federal Bureau of Investigation. I have served on the task force of

the Defense Science Board for the Department of Defense looking

at biologic threats to the American people and the American continent and have worked closely with the CDC and the Office of

Emergency Preparedness.

I’m here today to testify on behalf of the American College of

Emergency Physicians who currently has 23,000 members. We take

of over 100 million patients per year, and hopefully I will represent

them well.

Emergency physicians as earlier stated are in the front line of

biologic preparedness in this country. We are the new first responders along with our colleagues, the nurses and the EMT paramedics. And the new scene of terrorism in this country will be the

emergency departments of America where the patients present for

care.

To that end, we must be clinically able to recognize and initiate

a response because early detection will save lives and mitigate any

biologic terrorism in this country. We have attempted to foster that

in our membership and across the country by the task force educational programs and the development of curricula for the public

and our patients as well as for our members.

Today we’re going to focus on a discussion of the challenges of

crisis communication. This is appropriate since the September 11th

incident has centered on a tragic and senseless loss of innocent

lives. More importantly, however, we have witnessed what many of

us have feared most for a long time and have discussed with you

previously, including my visit here in September 1999 before you.

And that’s the use of biologic agents by terrorists. America has unfortunately learned that the consequences of a biologic attack are

incredibly severe, even of the small isolated incidents that we have

faced recently, much less a large scale attack. Biologic weapons are

formidable weapons of uniqueness and complexity that a specific

defense strategy is fundamental to our protection.

As many of you know in the room, good communication is absolutely essential to any national strategy. That’s what we’re here for

today. In times of crisis, the citizens of America look to you, other

elected leaders and government officials, for information and direction. At no time in contemporary history was this more evident

than after the recent tragic events that we’ve experienced. In the

early stages of this event, it was apparent that crisis communication strategy was evolving. There was no obvious centralized leadership, no voice of authority, and inconsistent information that was

soon outdated or required correction on a daily basis. This resulted

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in the American public remaining in an informational vacuum as

stated earlier. The public did not have a steady flow of updated information, so seized any information from anyone, no matter how

unproven, to reassure themselves. For example, many patients presented to our emergency departments across the country asking for

diagnostic nasal swabs to determine if they had anthrax. Because

they thought this was the right thing to do. They did not know and

were not told by anybody that nasal swabs were not diagnostic entities but were, in fact—they did determinations of exposure and

use for epidemiologic investigation. Therefore, they were erroneously informed. The appropriate treatment of anthrax caused an

unnecessary public controversy as well. Initially, the public was appropriately told that cipro was the treatment of choice. Later the

public was told that doxycycline was the preferred treatment.

Many of those who were potentially exposed and therefore prophylactically treated, including many in this area in the United

States, in the Washington, DC, area, became concerned that they

did not receive the best treatment. This issue, in fact, became contentious at some point, but it could have been prevented with proper communication. Appropriate authorities, all they had to do was

explain to the American people that ciprofloxacin was initially chosen because we didn’t know if the bacteria had been genetically enhanced to be weaponized. Once tested, determined that it had not

and was sensitive to standard therapy, standard therapy was appropriate and preferred.

During difficult times, it is also natural for the general public,

who is uneducated in these areas, to respond with unreasonable solutions. The preoccupation of the media with the question of gas

mask use was likely provoked by the public’s unanswered concerns

for personal protection. Although the use of gas masks was repeatedly dismissed by many experts, the public look for a credible Federal authority to convince them that the use of gas masks and

other protection devices was unnecessary.

Finally, there was the dilemma of how to balance the release of

sensitive information to inform and protect our American public

versus when to keep it confidential to maintain national security

or prevent public panic. This decision should have been carefully

analyzed on a case-by-case basis. And despite the fact that it may

have been, mistakes occurred. The controversy surrounding the release of potential threats to the Golden Gate Bridge in California

was an example. The FBI and the governmental authorities were

in a no-win situation, as was the Governor of California. If they released it and it did not occur, they were wrong. If they didn’t release it and it did occur, we suffered a tragic event unnecessarily.

Fortunately, many of these communication deficiencies can be

corrected. Consistency is an absolute must. The American public

expects leaders who are knowledgeable authorities, and more importantly, who can effectively communicate the knowledge to the

public. A consistent message is usually best conveyed by a recognizable voice, regularly scheduled press conferences located at

the same site and time to be considered. The media deadlines also

conveys a message of reliable and responsible leadership. The message delivered should be clear, for all to understand, concise and

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to the point without much elaboration or any speculation and above

all, credible and correct.

The public can appreciate, in my opinion, that the situation may

change if they are told it may change so that the message may

vary from moment to moment. The partnership with the media established prior to any incident will promote the goals of crisis communication. I have not seen evidence of the partnership in our national strategy. Disseminating correct and helpful information will

control rumors, limit the use of pseudo experts, foster cooperation

and thereby enhance our ability to respond. The partnership with

the media is critically important because they are the public’s primary source of information. Go to any emergency department in

America and we had on CNN so we could learn what was going on.

We only have to remember the most trusted man in America during his tenure was Walter Cronkite, not a Federal, State or local

official, and that’s because he demonstrated those areas of crisis

communication that we just discussed.

These communication deficiencies are not limited to just the public. My colleagues have talked about it, we have discussed in the

past, they include the Federal agencies’ ability to deal among themselves to deal with the State and local officials, and to deal with

the private sector as well as State and local officials have failed,

in my opinion, to deal effectively with the Federal Government,

with, or, and other State and local officials including, of course, the

important private public health and medical sector.

In conclusion, crisis communication using a partnership with the

media to provide clear concise credible information consistently delivered by a recognizable authority, is, in my opinion, an absolute

requirement. We must also develop principles for communication to

the public that address the dilemma between the public’s right to

know and the Nation’s national security.

Congress must provide the leadership, financial investment and

organizational and logistical support to develop not only a comprehensive national strategy with solid domestic preparedness and

response plans, but also a comprehensive communications strategy.

Good communication provides knowledge that results in an informed and cooperative America. Without information, fear prevails. And as President Roosevelt once said, the only thing we have

to fear is fear itself. Thank you for the opportunity to be here. I

look forward to answering any questions.

[The prepared statement of Dr. Waeckerle follows:]

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Mr. SHAYS. I thank you all very much. I’m going to start with

the questions, and just it seems to me, make an observation, it

seems to me that you pretty much all agree. I mean, your message

is pretty consistent, but I’d like you to tell me where you would disagree with anyone else who have spoken on the panel, and you

point that you might disagree. Or Dr. Satcher. Any comments that

were made today that you would just take exception to or not as

strongly but just disagree? Start with you, Dr. Koop.

Dr. KOOP. In general, we seem to be of one mind. We might have

little different ways of dotting I’s and crossing T’s, but I think the

thrust has been the same from all of us.

Dr. SHINE. Dr. Satcher talked about the notion that one person

can’t be everywhere and that you should have multiple—there may

need to be multiple spokespersons, that the media demand is very

high and so forth. While he is quite correct about the media demand, the fact is that if there is a single source of information

holding a daily press conference and coordinating his information

or her information with other players, you can still have multiple

exposures to the media. I don’t see that the two are in conflict with

each other. But I do believe that the notion that you can have multiple people talking is not credible.

Mr. SHAYS. I’m going to come back, because I think I disagree

with you. I would love to follow through.

Dr. AKHTER. I also generally agree with what my colleagues have

said, but I do believe in a single credible spokesperson and that

person be the Surgeon General of the United States. We were very

distressed to see the General absent in the war against terrorism

at home. What kind of army you want to see—the public health

community, we consider him to be our leader. The leader is not

visible, then the people just got confused, looking to every direction,

every which way. It was not the public who were confused but the

public health people who were confused. I think, to clarify that, it

ought to be the Surgeon General of the United States who should

stand up and speak and be the leader.

Mr. SHAYS. Which will lead me to a question, Dr. Koop, I will ask

you about, because you had the AIDS epidemic to deal with and

you were pretty much the spokesperson, it seemed to me. I’ll come

back to you on that one.

Dr. Waeckerle.

Dr. WAECKERLE. Probably don’t have a lot more intelligent remarks, but I do think that——

Mr. SHAYS. You should have——

Dr. WAECKERLE [continuing]. I could give you one example of

what I think was a very effective leader who did a very good job,

and that was Mayor Giuliani. In fact, throughout the crisis in New

York, he demonstrated all of the characteristics and all of the behaviors that we’ve all discussed before you today and reassured, informed and calmed New York City.

I would also point out to you that maybe the most effective press

conference I saw during this whole incident is when Governor

Ridge took command and had Surgeon General Satcher and had

Secretary Thompson and the Post Office Director and others involved. And while he was the main spokesperson he allowed each

of those individuals to give us an update on information so that

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there was one credible person leading the news conference at that

time or the President briefing but that we had a cadre of informed,

intelligent, responsible authorities behind him.

Mr. SHAYS. That’s a good lead-in to tell you, Dr. Shine, where I

get a little uneasy. I would begin to think if there was only one

spokesperson for the government that the government was trying

to hide something, that they weren’t allowing so and so to speak

or they won’t allow so and so to speak. I would become very suspect

and begin to question whether I was being told the full story.

Dr. SHINE. Congressman Shays, I am not suggesting that other

people don’t speak at all. What I’m saying is that when Secretary

Thompson has a press conference, for example, the individual who

is charged as the spokesperson is, just as Dr. Waeckerle described,

a certain person standing next to him, and who is able to provide

that information. Similarly, at a daily briefing that individual could

provide those briefings.

That doesn’t mean that a lot of other people will not be communicating but does mean that some—one of the things that was

striking, if you looked at the media during these episodes, was that

there are all kinds of experts who, when on television, if you

watched them carefully there were two kinds of experts. Most of

them knew the history of anthrax previously. None of them had

ever had any experience with inhalation anthrax because it hadn’t

existed to any significant extent except in Russia. And what would

happen is the media would then say, after they gave this articulate

description of anthrax, but what does it mean, though they just

had a case in a postal worker or whatever, and there were two responses.

The credible people said, well, I don’t really know the details of

that. I don’t know what the organism is. The other response was—

of the expert was to speculate based on what he or she——

Mr. SHAYS. I know that, but you can have experts on TV all the

time, including some of you will be on TV and you’ll be debating

somebody else who calls himself an expert. So that will happen on

TV. But I mean truly it will.

Dr. SHINE. That’s why there needs to be someone who has knowledge of the actual event who is in the department, who as a consequence was being briefed by what’s going on in the CDC, was

briefed by the FDA, whatever the problem is, who has access to all

that information for purposes of being the spokesperson.

Mr. SHAYS. Let me get to Dr. Koop.

I’m struck by trying to process what you’re saying, that you want

someone to help coordinate, bring people forward. But, for instance,

if I want to hear from the head of CDC, I may want to hear from

the NIH, I may want to hear particularly from the Surgeon General.

But just refresh me, Dr. Koop. There was and still is an AIDS

epidemic, but I would guess the AIDS epidemic is more prevalent

in places in Asia and Africa but still an epidemic everywhere, or

am I being sensational?

Dr. KOOP. It’s still an epidemic everywhere. And the African

countries are being very hit very hard, and some of those are actually facing genocide. Our own problems here are specifically conVerDate 11-MAY-2000 12:46 Dec 02, 2002 Jkt 000000 PO 00000 Frm 00081 Fmt 6633 Sfmt 6633 C:\DOCS\82356.TXT HGOVREF1 PsN: HGOVREF1
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centrated on Afro American women. So the country has its own

problems.

Mr. SHAYS. I just didn’t want to not call it an epidemic if it

wasn’t to be correct.

Dr. KOOP. An epidemic means—— Mr. SHAYS. I called anthrax a virus at one time before someone

corrected me, like this person.

Dr. KOOP. Anthrax affected very few people, but it was more people that you would ever expect to have it, so that’s an epidemic.

Mr. SHAYS. I recall you became the spokesperson pretty early on

when we were dealing with HIV/AIDS.

Dr. KOOP. No, I wasn’t. I was given specific orders that AIDS did

not come under my purview.

Mr. SHAYS. No kidding.

Dr. KOOP. It wasn’t until the end of Mr. Reagan’s first term

when the first-termers began to go back to their homes the Public

Health Service was filled with innumerable vacuums. Filled as

many of those as I could. That’s how I became the spokesperson.

I was really self-appointed.

Mr. SHAYS. But good thing. Because there began to be some real

knowledge about this disease. But walk me through it. So did we

have the same kind of thing we have now, a lot of different people

speaking or nobody speaking?

Dr. KOOP. In those days, nobody wanted to speak; and the people

surrounding President Reagan thought those who had AIDS deserved it. It was a very tough time.

Dr. SHINE. But having that spokesperson did not mean that Tony

Fauci couldn’t speak about HIV, that people at CDC couldn’t speak

about it. In other words, I don’t think having a spokesperson

doesn’t mean you don’t have—but what it does mean, as Dave

Satcher described, you have a telephone conference call of key players, you review where you are, you agree on what, in fact, you

know and what you’re able to say so that the message is consistent

and not contradictory.

Mr. SHAYS. Right. It begs another question, though. If the truth

is sometimes contradictory, how—— Dr. SHINE. Then you have to acknowledge that. That’s what the

truth is about.

Mr. SHAYS. Mr. Tierney, have as much time as you want.

Mr. TIERNEY. Thank you. Thank all of you for your testimony.

I guess, going back to an underlying theme that the chairman

was talking about also, is there any way that we can get the media

to be more responsible, or are we always going to be subject to the

talking heads? I noticed this in legal matters. Everybody is all of

a sudden a legal constitutional expert. It takes the whole gamut.

Now it seems to be medical issues. Are we going to be subjected

to whoever they decide to throw on the air and people are going

to get innuendo and surmise and speculation and bad information?

Or is there some way through what we do that we heighten the responsibility that there will be a responsible message and voice out

there? Anybody that wants to respond.

Dr. KOOP. I hinted at this in my remarks, and that is that the

thing that made it possible for me to do the job that I did during

AIDS I think was largely because, in the beginning, I appeared in

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the press conference atmosphere and there those days the Surgeon

General could get time on any network within 2 hours if he had

an emergency. I don’t know whether that still exists or not.

Mr. TIERNEY. Probably need to put it on a soap opera.

Dr. KOOP. But when you have all of the stations really turning

health issues into entertainment on the talk shows, then you do get

controversy because they don’t always know how to pick the right

people. And the second thing is they have very strict time constraints, and many times you can’t on the Today Show or Good

Morning America get out the whole message you have to get out

because you only have a 90-second sound bite.

Dr. SHINE. In a free society it’s going to be very difficult to manage that. On the other hand, I lived for 20-odd years in Los Angeles. Shirley Fannan was the spokesperson for the Department of

Health in Los Angeles County. When a problem emerged, she was

the first person who got interviewed. She gave information to

health providers. She gave information to the public. She was a

recognizable spokesperson. And it out balanced all of the other experts.

I would argue if you look at what happened with the American

Flight 587, the crash, the woman who was the Chair of the National Transportation Board—I don’t remember her name—but

every day for the next 5 days she was giving very good information

and she trumped—using the chairman’s term, she trumped all the

talking heads because she knew what was going on. She was prepared to say how long it was going to take to get the information,

what they knew and so forth.

And that’s I think the way you deal with the media, is make sure

that you’ve got some way of getting information across that—where

they know where to go and get it. They knew to go and get Koop.

Dr. AKHTER. Two quick things. As the health commissioner in

Washington, I had to order 2 million people to boil the water for

about a week or so when I was health commissioner. And the first

thing you do is to make the highest level possible in your government available to the news media according to their needs, their

morning news and afternoon news. So that I was available to be

available for them to talk to them and provide them the information.

Once you provide that information every single day, day in and

day out, then the need for the other side experts goes down.

The second thing, you need to really sit down with the media, as

I said earlier, in a partnership, sit down and develop a strategy.

In case of a true national emergency, how are we going to assess

the information and provide the information? And that plan has

not been worked out as we speak.

Mr. TIERNEY. I think we’re talking about something that this

current situation didn’t have done, the administration didn’t do,

was single out somebody and put them in an authoritative position.

Given what the Surgeon General said about not having any budget,

his position almost being downgraded somewhat, amongst the four

of you, who would that individual be in your estimation? Who

should that individual be that takes the stand on health issues,

public health issues in the Federal Government? Should it be the

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Surgeon General or should it be the Secretary or what’s your opinion?

Dr. SHINE. Well, I’ve made it clear in my testimony I think that

the Secretary, for example, may be communicating with the public,

but I think a credible medical public health expert has to be the

individual to play that role. Because only under those circumstances will the public believe that it’s getting effective medical

public health information.

My colleagues have made reference to the Surgeon General. The

Surgeon General would be an excellent choice, but I would argue

that for certain kinds of problems it might be the Assistant Secretary of Health, who is a physician, if that position is filled. It

could be the head of the CDC. It could be Anthony Fauci, whatever.

Mr. TIERNEY. Professional as opposed to political.

Dr. SHINE. The critical issue is, what are the attributes of that

individual? What does that individual know? Can that person communicate? Can that person be credible?

As I indicated to Congressman Shays, we’ve got lots of data from

our studies that individual can say we don’t know all the answers

and people will feel better that there is such an individual. But the

problem is, if you don’t have someone who has medical public

health credentials, then there is always a doubt on the part of the

public as to whether somebody who is an administrator or political

appointee is the right person.

Dr. KOOP. It depends on who the person is and how careful he

wants to be. I can assure you that many of the things that I said

as so-called spokesperson for the government on AIDS went

through Tony Fauci’s mind and Jim Mason’s mind at CDC before

I ever said them in public. We talked about those and frequently

met with the Vice President on the same issues.

Mr. TIERNEY. I just want to mention something aside on that. I

first met you some years ago when you spoke at Salem State College up in Salem, MA, and you spoke on the subject of tobacco and

the propensity of——

Dr. SHINE. That is unusual.

Mr. TIERNEY [continuing]. And the propensity of this government

to support the export of tobacco. Even though we might be doing

a better job in trying to diminish smoking in this country, we have

started to export it and allow the export of it or whatever, and I

just want to thank you for speaking out on that issue and continuing to do the good work that you do there.

Let me just conclude by asking one last question. You, Dr. Koop,

said that we had no assurance that today’s smallpox vaccine would

be effective against the modern smallpox threat. Could you expand

on that a little bit and tell us what we might do to counteract that

problem?

Dr. KOOP. Well, the smallpox vaccine that we have was prepared

against a smallpox virus that now has been frozen in Atlanta and

supposedly Russia, but maybe many other places, for about 30

years, and there are two things that can happen. One is the virus

can mutate, but the thing that is more likely to happen is that it

can be tampered with biotechnology, so that maybe the vaccines we

have would not be effective against the virus that we’re going to

meet.

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Mr. TIERNEY. Is there anything we can do about that?

Dr. KOOP. I don’t think there’s a thing you can do about it until

you know that is the situation, but then you’ve got to make new

vaccine to cover that thing.

Mr. TIERNEY. So all of the vaccine that’s being ordered up right

now in today’s papers indicate that there’s enough vaccine to take

care of the entire country, all of that may be ineffective?

Dr. KOOP. I don’t know the details of that, but I don’t know how

they would get a terrorist version of a smallpox vaccine to work

with.

Mr. TIERNEY. So are we wasting money?

Dr. KOOP. No. I think in the protection against terrorism of any

kind, when it is all over, you’re going to say we wasted a lot of

money, but I think you have to waste the money, because it is the

only kind of precaution and prevention that you can undertake.

And when you think about the money, it is a pretty small amount

of——

Mr. TIERNEY. Well, I guess I was thinking in terms of money and

false sense of security for people, too.

Dr. KOOP. Yeah, well, the false sense of security might be secretly good for the panic that ensues, but I think you’d know pretty

soon whether or not the vaccine worked, because if—as was explained to you today, you get one case, and you surround the patient and vaccinate the people that were in touch with them, and

if they come down with it in 12 days, you know you haven’t got an

adequate vaccine.

Mr. SHAYS. Would the gentleman yield?

Mr. TIERNEY. Sure I’ll yield.

Mr. SHAYS. Because it ties into a point. That was the old method,

you kind of circle your suspects.

Dr. KOOP. It worked.

Mr. SHAYS. It worked, but it worked kind of in a rural—I don’t

know if it can work in Chicago.

Dr. SHINE. No. It was used in New York City in 1979 when there

was a case of smallpox, and several million people were vaccinated.

Mr. SHAYS. How do you do it in an airport, that they contracted

it in the Atlanta airport, and they went to 100 towns?

Dr. SHINE. Well, again, you have a—first of all, you don’t become

infectious until you’ve got the virus, that is until you’ve got pox,

until you have the actual disease. So, I mean, somebody has to

enter the country through Atlanta with a disease, and it has to be

spread in some way.

Mr. SHAYS. I don’t want to take the gentleman’s time, but you—

on record, you believe that still the best method is identify the potential candidate and encircle it——

Dr. SHINE. Because this is a key issue for the Gilmore Commission. We consulted with D.A. Henderson and Bill Fagey, both of

whom were responsible for eradicating smallpox in the world. We

consulted with people in public health and so forth. So it is not just

my own opinion. This is opinion based on people who have very active experience with smallpox that is a feasible way to approach it.

The issue is—there are always ifs and ands about it, but the

issue is balancing that against trying to immunize everyone where

you know you’re going to produce a certain amount of encephalitis,

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and you’re going to produce a certain amount of death. So you’re

trying to balance what is the risk/benefit.

Mr. SHAYS. Let me give the time back to—— Dr. SHINE. Could I just respond to you, Mr. Chairman? Two

quick points I would make. One is in terms of the investment we

make in the public health enterprise, we need a much better investment in vaccines and vaccine development that include—the

anthrax vaccine is a lousy vaccine. It takes you 18 months, 6 shots

at the present time to immunize somebody. You know, we can— there are reasons to believe that with a modest investment, we can

genetically engineer P antigen, which is the effective antigen, and

create vaccines, and then if we have the technology, if somebody

comes up with an anthrax bacteria that has a different genetic

makeup, which is what Dr. Koop was talking about, you’ve got a

rapid ability to respond because you have the technology to make

a new vaccine to a new antigen. And the same thing is true with

smallpox.

But the other point I would emphasize, and this is again part of

the Gilmore deliberations through the years, if you want—if you’re

a terrorist and you want to produce terrorist effects, you don’t have

to go to the highest technology to do it. I mean, it was box cutters

on September 11th. It was envelopes with anthrax. With regard to

smallpox, if you can get ahold of any of the existing stores of smallpox someplace, that is a terrible threat in and of itself. While engineering—bioengineering is important, and we need to prepare for

it, we need to prepare for the greater probability, which is what if

somebody gets it, it’s the currently available pox, and therefore you

want to be able to deal with it.

Mr. TIERNEY. I actually don’t have any more questions, and that

is actually intensive, because the information you all gave was

thorough and helpful, and I want to thank everybody.

Dr. SHINE. Could I emphasize again, because my colleagues have

brought up the law enforcement issue, the agriculture issue and so

forth, when the Gilmore Commission assessed our country’s preparedness, it said there had to be a place where all these came together, and you heard from Dave Satcher that he doesn’t meet with

people in Agriculture or the Justice Department. There has to be

a place to bring those together, and that is why we think the role

of health in the Office of Homeland Security is so critical to bring

those various interfaces together, including communication.

Mr. TIERNEY. Well, I wish I could be more helpful with you there.

I’ll tell you, Chairman Shays has done a great job of bringing this

to everybody’s attention. We were having hearings on the need for

a homeland security director and office long before others would

pay any attention to this committee. The problem is that now that

the President has appointed obviously a guy without a portfolio—

and the real shame of this is that if you really look at what’s going

on, he has no direction, no legislative guidance, no portfolio at all,

and a great reluctance that I still sense in this Congress to give

that kind of authority and specificity and budget authority to cut

across all those different agencies and be the one to draw them together with any authoritative basis. And I think we’ve got some

work as this Congress to do and move in that direction. We’ve got

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tion to stop saying that, oh, it can wait until next year or sometime

down the line and move forward, and I know that Chairman Shays

will keep moving on that issue.

Mr. SHAYS. Do all of you agree that office would make sense? I

mean, would you recommend—I know you do, Dr. Shine, but would

you, Dr. Akhter, Dr. Koop or Dr. Waeckerle?

Mr. WAECKERLE. If you remember in September 1999, we discussed this for a long period of time, and it was the consensus of

all the State and local authorities who Attorney General Reno convened that was the single foremost problem in America. There was

no central oversight management, and as a result——

Mr. SHAYS. As it relates to health care?

Mr. WAECKERLE. As it relates to all of the defense, to the strategy and specifically with public health and medical, as well as hospitals, because we were never able to have a coherent, collaborative

plan that integrated those three important areas.

Mr. SHAYS. Dr. Koop.

Dr. AKHTER. Mr. Chairman, it is absolutely necessary that it be

Homeland Security Office. Not for today, tomorrow, but for years

to come this threat is going to be with us. But it does need its own

budget and its own authority, and without its own budget and its

own authority, we just have window dressing.

Mr. SHAYS. I’m talking more specifically about within that office,

someone direct—we’re trying to get the—the way they broke out

the task, because I thought there was someone on—within the

office——

Dr. SHINE. But it’s second level, Congressman Shays. There’s an

associate director for prevention and so forth, and then a health

person reporting to that individual, and that is never going to get

the health issue to the level that I think it needs to be—deserves.

Mr. SHAYS. Dr. Koop, would you respond to this?

Dr. KOOP. I would agree with that entirely, and I think you have

to—I don’t like to run things by committee, but I named the most

likely threats. I think there’s got to be somebody representing agriculture, medicine, chemistry. We need probably eight people on a

panel that—making this their own job.

Mr. SHAYS. Right. OK.

Dr. KOOP. Could I raise one other quick question?

Mr. SHAYS. Sure.

Dr. KOOP. A lot of people have said that the Surgeon General

should be the person that we think about for the responsibility at

hand. I would remind you that David Satcher will not be with us

much longer, and the person who replaces him will be a very key

person in the next administration. Having been through it myself,

I can tell you that you don’t walk into that job 1 day and know how

to do it the next, and I would hope that somebody could influence

the appointment of a person who knows something about what

we’ve been talking about rather than be a political appointment.

Mr. SHAYS. OK. That’s very important. I think the same thing

applies even to the Homeland Security Office themselves. I was not

eager to see Governor Ridge be a spokesperson early on, because

there’s such a steep learning curve, which we all knew he had to

have, anyone in that position, and so I was very concerned the

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press wanted to hear from him right away, forcing him to speak

on health care issues, on defense issues and so on.

Lots we could talk about. We have a vote, and I’m not going to

keep you. Is there anything—— Mr. TIERNEY. No. Thank you.

Mr. SHAYS. You—this has been an excellent panel, and it’s— we’ve learned a lot, a tremendous amount. Is there anything that

any of you want to say in closing before we go?

Dr. SHINE. Just to reinforce the notion that when we recommended an office in the executive branch for home security—we

didn’t use that term—we said that individual should be confirmed

by the Senate and should have budgetary authority, because we

just don’t see—and I think Mohammad has emphasized this. Getting the agencies to work together, you’ve got to have some kind

of leverage, and I don’t think you can give them the budget—the

budget can’t be that big that it covers all of the areas. Therefore,

it has got to have authority to work with the OMB and say if

you’re not cooperating, if you’re not collaborating, if you’re not— there’s a stick; there’s some penalty if you don’t do that.

Mr. SHAYS. I think Mr. Tierney and I disagree a bit on this, and

so I’d be happy to have him respond, but my view right now is the

President has combined the Gilmore and the Hart-Rudman Commissions. In one sense, he has given it a Cabinet level, but he

hasn’t made it a department. You don’t have a homeland security.

But he’s given Ridge the opportunity to write his job eventually,

and he’s already said, you know, he’s going to probably suggest

there be a homeland area.

And in terms of the budget, I just have to say, if anybody crosses

Ridge, they’re crossing the President of the United States. And so

I know eventually the budget is going to matter, but right now, I

mean, if you cross Ridge, it’s going to get to the President right

away. Their offices are next door, and you’re mincemeat.

Dr. SHINE. That is absolutely true right now. The question is— Mohammad said it well—this is a long-term problem, and what is

going to happen a year from now, 2 years from now.

Mr. SHAYS. And I think he’s going to get his way, which is also

what I’d like to see happen. I think it’s going to happen.

Any other comment?

Mr. WAECKERLE. Yeah. I’d like to thank you for the opportunity

to be here, and I’d like to close with the following remarks for you

to consider. Biologic terrorism, in my opinion, has the potential to

be the doom of mankind. Now and into the future, especially as we

get into bioengineering genetically designer—designed bugs, because the State-sponsored—the State-supported, the States and the

local nuts and zealots of the world, because of the technology today

and the information available today, will be able to carry out terrorism against us. And I think that it requires an appropriate

strategy and response, as you all know and we’ve discussed today.

And there’s one major fault that I believe we need to focus on,

and that is the critical human infrastructure and the response to

biologic terrorism in this country will occur in the local community,

and it’s the triumvirate of health care professionals, public health

and hospitals, and to date, despite numerous committee hearings

and much writing and rhetoric, the local community and those key

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players have not been integrated or coordinated with any national

programs, and they have no input. And I hope that when we talk

about communication with the public and crisis communication, we

remember that many of us believe that the communication between

the Federal family and the local and State partners that we have

in this war has been neglectful, and it needs to be greatly improved.

Mr. SHAYS. I thank you for that. There’s a minicrisis, a tiny crisis that we’re going to have a vote in 4—5 minutes. So, I mean,

it’s in the process. We have 5 minutes left. Thank you all very

much. Wonderful job. This hearing is closed.

[Whereupon, at 12:29 p.m., the subcommittee was adjourned.]

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