U.S. GOVERNMENT PRINTING OFFICE

63–355 CC WASHINGTON : 2000

TERRORISM PREPAREDNESS: MEDICAL FIRST

RESPONSE

HEARING

BEFORE THE

SUBCOMMITTEE ON NATIONAL SECURITY,

VETERANS AFFAIRS, AND INTERNATIONAL

RELATIONS

OF THE

COMMITTEE ON

GOVERNMENT REFORM

HOUSE OF REPRESENTATIVES

ONE HUNDRED SIXTH CONGRESS

FIRST SESSION

SEPTEMBER 22, 1999

Serial No. 106–100

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

DAVID M. MCINTOSH, Indiana

MARK E. SOUDER, Indiana

JOE SCARBOROUGH, Florida

STEVEN C. LATOURETTE, Ohio

MARSHALL ‘‘MARK’’ SANFORD, South

Carolina

BOB BARR, Georgia

DAN MILLER, Florida

ASA HUTCHINSON, Arkansas

LEE TERRY, Nebraska

JUDY BIGGERT, Illinois

GREG WALDEN, Oregon

DOUG OSE, California

PAUL RYAN, Wisconsin

HELEN CHENOWETH, Idaho

DAVID VITTER, Louisiana

HENRY A. WAXMAN, California

TOM LANTOS, California

ROBERT E. WISE, JR., West Virginia

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

CHAKA FATTAH, Pennsylvania

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

HAROLD E. FORD, JR., Tennessee

JANICE D. SCHAKOWSKY, Illinois

———

BERNARD SANDERS, Vermont

(Independent)

KEVIN BINGER, Staff Director

DANIEL R. MOLL, Deputy Staff Director

DAVID A. KASS, Deputy Counsel and Parliamentarian

CARLA J. MARTIN, Chief Clerk

PHIL SCHILIRO, Minority Staff Director

SUBCOMMITTEE ON NATIONAL SECURITY, VETERANS AFFAIRS, AND INTERNATIONAL

RELATIONS

CHRISTOPHER SHAYS, Connecticut, Chairman

MARK E. SOUDER, Indiana

ILEANA ROS-LEHTINEN, Florida

JOHN M. MCHUGH, New York

JOHN L. MICA, Florida

DAVID M. MCINTOSH, Indiana

MARSHALL ‘‘MARK’’ SANFORD, South

Carolina

LEE TERRY, Nebraska

JUDY BIGGERT, Illinois

HELEN CHENOWETH, Idaho

ROD R. BLAGOJEVICH, Illinois

TOM LANTOS, California

ROBERT E. WISE, JR., West Virginia

JOHN F. TIERNEY, Massachusetts

THOMAS H. ALLEN, Maine

EDOLPHUS TOWNS, New York

BERNARD SANDERS, Vermont

(Independent)

JANICE D. SCHAKOWSKY, Illinois

EX OFFICIO

DAN BURTON, Indiana HENRY A. WAXMAN, California

LAWRENCE J. HALLORAN, Staff Director and Counsel

MARCIA SAYER, Professional Staff Member

TOM COSTA, Professional Staff Member

JASON CHUNG, Clerk

DAVID RAPALLO, Minority Professional Staff Member

(III)

C O N T E N T S

Page

Hearing held on September 22, 1999 ..................................................................... 1

Statement of:

Gordon, Ellen, director, Iowa Division of Emergency Management and

immediate past president, National Emergency Management Association ................................................................................................................. 6

Johnson, David R., M.D., deputy director for public health and chief

medical executive, Michigan Department of Community Health, on behalf of the Infectious Disease Policy Committee, Association of State

and Territorial Health Officials [ASTHO] .................................................. 15

Knouss, Robert F., M.D., Director, Office of Emergency Preparedness,

Department of Health and Human Services .............................................. 76

Lillibridge, Scott R., M.D., National Center for Infectious Diseases, Centers for Disease Control and Prevention, Department of Health and

Human Services ............................................................................................ 103

O’Toole, Tara, M.D., senior fellow, Center for Civilian Biodefense Studies,

the Johns Hopkins University, Schools of Public Health and Medicine .. 48

Plaugher, Edward P., fire chief, Arlington County, VA, and director,

Metropolitan Medical Response System, Washington, DC ........................ 29

Waeckerle, Joseph F., M.D., editor in chief, ‘‘Annals of Emergency Medicine,’’ fellow, American College of Emergency Physicians, and chairman, Department of Emergency Medicine, Baptist Medical Center, Menorah Medical Center ................................................................................... 36

Letters, statements, et cetera, submitted for the record by:

Gordon, Ellen, director, Iowa Division of Emergency Management and

immediate past president, National Emergency Management Association, prepared statement of .......................................................................... 9

Johnson, David R., M.D., deputy director for public health and chief

medical executive, Michigan Department of Community Health, on behalf of the Infectious Disease Policy Committee, Association of State

and Territorial Health Officials [ASTHO], prepared statement of ........... 18

Knouss, Robert F., M.D., Director, Office of Emergency Preparedness,

Department of Health and Human Services, prepared statement of ....... 82

Lillibridge, Scott R., M.D., National Center for Infectious Diseases, Centers for Disease Control and Prevention, Department of Health and

Human Services, prepared statement of ..................................................... 105

O’Toole, Tara, M.D., senior fellow, Center for Civilian Biodefense Studies,

the Johns Hopkins University, Schools of Public Health and Medicine,

prepared statement of ................................................................................... 51

Plaugher, Edward P., fire chief, Arlington County, VA, and director,

Metropolitan Medical Response System, Washington, DC, prepared

statement of ................................................................................................... 31

Shays, Hon. Christopher, a Representative in Congress from the State

of Connecticut, prepared statement of ........................................................ 3

Waeckerle, Joseph F., M.D., editor in chief, ‘‘Annals of Emergency Medicine,’’ fellow, American College of Emergency Physicians, and chairman, Department of Emergency Medicine, Baptist Medical Center, Menorah Medical Center, prepared statement of ............................................ 38

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TERRORISM PREPAREDNESS: MEDICAL FIRST

RESPONSE

WEDNESDAY, SEPTEMBER 22, 1999

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 10:06 a.m., in room

2247, Rayburn House Office Building, Hon. Christopher Shays

(chairman of the subcommittee) presiding. Present: Representatives Shays, Allen, and Tierney.

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

Marcia Sayer and Tom Costa, professional staff members; and

Jason Chung, clerk.

Mr. SHAYS. I’d like to call this hearing to order and welcome our witnesses and our guests. How does a nation prepare for the unthinkable?

The specter of mass casualties caused by a terrorist’s release of

radiological, chemical, or biological weapons grows larger on our

domestic horizon. In a world made more dangerous by the proliferation of the technologies of mass destruction and by the willingness of some to use them against us, the once improbable has

become the inevitable.

Are we prepared?

By most accounts, the answer is no. Despite significant efforts to

combat terrorism and improve national readiness, medical response

capabilities are not yet well-developed or well-integrated into consequence management plans.

Providers are not trained to diagnose or treat the uncommon

symptoms and diseases of unconventional warfare. Public health

surveillance systems are not sensitive enough to detect the early

signs of a terrorist-induced outbreak. Hospitals and clinics lack the

space, equipment, and medicine to treat the victims of weapons of

mass destruction.

Combatting terrorism challenges Federal, State, and local governments to coordinate response plans, train and equip critical personnel, and integrate military support.

In previous oversight hearings, we examined Federal spending

priorities and the role of the national government in the early response to terrorism. Today, we assess what is being done to help

States and localities build a public health infrastructure capable of

deterring, detecting, and, if necessary, treating those affected by

terrorist events.

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For more than symbolic reasons, we asked first responders to testify first, preparing for low incidence, high-consequence events is

the daily business of public safety, public health, and emergency

management professionals. We have much to learn from them as

we design and implement a Federal program to augment their

work.

Witnesses from the Department of Health and Human Services’

Office of Emergency Preparedness and the Centers for Disease

Control and Prevention will then discuss the national program to

support local first response, improve public health monitoring, and

stock the medical arsenal in the fight against terrorism.

We appreciate their testimony and their willingness to listen to

their State and local partners first.

[The prepared statement of Hon. Christopher Shays follows:]

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Mr. SHAYS. Again, I’d like to welcome our witnesses and introduce them.

We have Ellen Gordon, administrator, Iowa Emergency Management Division, and past president, National Emergency Management Association.

I understand, Ms. Gordon, that you will be leaving a little early

because of another appointment.

Dr. David R. Johnson, Infectious Disease Policy Committee, Association of State and Territorial Health Officials and deputy director for public health and chief medical executive, Michigan; Ed

Plaugher, chief, Arlington County Fire Department, Virginia, director of Metropolitan Medical Response System, Washington, DC;

and Dr. Joseph F. Waeckerle, fellow, American College of Emergency Physicians, chairman, Department of Emergency Medicine,

Baptist Medical Center of Kansas City, MO; and, finally, Dr. Tara

O’Toole, fellow, Center for Civilian Biodefense Studies, Johns Hopkins University.

At this time, we are going to recognize a very fine member of our

committee, Mr. Allen from Maine.

Mr. ALLEN. Thank you, Mr. Chairman, and thank you for holding

this hearing, which I expect to be very interesting.

Let me welcome our witnesses from all of the interested groups

here today, as well as our distinguished witnesses from the Department of Health and Human Services. We’re really glad that you

could all be with us today.

When I first heard about this hearing and conjured up an image

of what the medical response would be to a terrorist incident involving a chemical or biological weapon, I imagined what most people would probably do—paramedics rushing to a building, putting

on the yellow decontamination suits, quarantining an area, and

hosing down victims, furniture, and everything else in sight.

But from what I’ve learned in preparing for this hearing, this

may not be the most likely scenario. In fact—and I’m sure our witnesses will elaborate on this—a more likely and potentially deadly

case would involve a terrorist incident that goes unnoticed, affecting thousands and thousands of people who do not even know it.

In this scenario, it will be doctors, nurses, and the health care

infrastructure that really is the first responders. They will treat increasing numbers of patients with symptoms that may mirror influenza, for example. It will be up to them to determine the existence of the terrorist incident, to work with victims’s families and

friends to track the source of the agent, and to rapidly implement

a plan to protect the health of our society.

But how are we going to prepare the health community for such

an incident? This is the question for today’s hearing.

I look forward to hearing from all of our witnesses about challenges to the current system, as well as recommendations for improving detection, surveillance, and treatment.

How can we maximize communication and coordination among

all levels of government and leverage the assistance of private entities? And how are the exciting new initiatives underway at the Department of Health and Human Services moving us toward these

goals?

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I know this is a lot to ask of you in a single hearing, so I thank

you for your participation. It is a pleasure to meet you and I look

forward to working with all of you beyond today’s hearing.

Mr. Chairman, thank you again.

Mr. SHAYS. Thank you, Mr. Allen.

Just some housekeeping. I ask unanimous consent that all members of this subcommittee be permitted to place an opening statement in the record, and that the record will 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 witness statements in the record.

Without objection, so ordered.

At this time, I will invite our witnesses to stand so we can swear

them in.

[Witnesses sworn.]

Mr. SHAYS. Thank you. Note for the record that all five of our

witnesses have responded in the affirmative, and to say that,

though we don’t have the traditional red and green light, we have

this ridiculous little clock that will only tell me how well you are

doing, but we are going to ask that you keep it around the 5-

minute range. We do let our witnesses in certain cases go an additional 5 minutes. I know that you’ve come from different places

around the country, so we welcome your participation, but we’d like

to have you keep as close to the 5 minutes as you can, but you have

10 if you need it.

We’re going to start with you, Ms. Gordon.

STATEMENT OF ELLEN GORDON, DIRECTOR, IOWA DIVISION

OF EMERGENCY MANAGEMENT AND IMMEDIATE PAST

PRESIDENT, NATIONAL EMERGENCY MANAGEMENT ASSOCIATION

Ms. GORDON. Thank you, Mr. Chairman and Mr. Allen, for the

opportunity to appear before you today.

As introduced, I am Ellen Gordon, director of the Iowa Division

of Emergency Management, and also representing the National

Emergency Management Association this morning and the core

membership of the State directors across the country.

Also, I serve on the congressionally established advisory panel

led by the Virginia Governor, Jim Gilmore, charged with assessing

domestic response capabilities for terrorism involving weapons of

mass destruction, so I think the information from this hearing

should be very helpful to this panel. However, today it is the State

emergency management perspective in which I speak.

We are very concerned, as everyone else is, about the issue of domestic preparedness, and have been working in close partnership

with the National Governors Association to provide policy and program recommendations to the Federal Government to enhance our

coordination efforts between agencies with domestic preparedness

roles and responsibilities.

NEMA and NGA cosponsored a national policy summit this last

February that brought together for the very first time policy executives from Governors’ offices, State emergency management, and

law enforcement.

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We are also working with the Department of Justice and FEMA

and others to clearly define the role of the States and the Governors in this critically important issue, and to provide information, resources, and tools to States and local governments to enhance our preparedness and response capabilities.

Today I think it is with great pleasure to be in the same room

with some of the agencies. I think it is for the very first time that

we are here together, and I hope this talks about the future that

we, too, can start spending more time in coordinating our efforts

together.

This fall and winter we hope to sponsor some regional terrorism

workshops, once again in conjunction with the National Governors

Association, and out of those workshops we expect to provide additional policy and funding recommendations to Congress and the

Federal Government following the completion of those.

The public health systems’ preparedness and readiness to respond to weapons of mass destruction incidents is well behind the

other efforts undertaken by most fire and emergency service organizations, at least at the awareness level.

One of the reasons that we believe this to be true appears to be

a lack of national program direction that provides for coordination

with the National Domestic Preparedness Office, the Department

of Justice, and FEMA; inadequate funding for local and State preparedness activities; and a concentration of resources funded toward metropolitan areas.

As a whole, the State directors of emergency management believe

that most public health systems are unprepared to respond to

WMD incidents for the following reasons.

Capabilities at the local level are disparate in terms of competency and capabilities.

Most, if not all, funding for equipment, personnel, and training

has been focused into the major urban and metropolitan areas. Terrorism knows no geographic boundaries.

There is little capacity to detect a biological and chemical event

early, and by the time the detection and implication are confirmed

by CDC or another lab in another State, the threat will have escalated many times over. This is especially true in small rural areas.

There is a lack of strong coordination of information between the

medical, emergency management, and law enforcement community.

Not all public health services nor private hospitals are properly

equipped to handle WMD issues related to decontamination, mass

casualties, and mental health care for victims, first responders, and

the community, at large.

In Iowa, as in most States, we are reaching out to our partners

in law enforcement, fire, emergency medical services, the State Department of Public Health, and our universities to integrate them

all into a State-wide terrorism consequence management strategy.

Public health is a critical component of the comprehensive plan, yet

collectively we are far from where we need to be to have a strong

integrated response capability not only in Iowa, but other States,

as well.

States need immediate help of Congress and the Federal Government to bring the public health systems up to appropriate level of

readiness and capability, and our ideas are as follows.

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One, conduct a national assessment of the public health community’s true capability to respond to WMD incident.

Two, integrate public health into response plans, including urban

and rural areas, alike.

Three, provide the same level of funding and emphasis that is

presently being directed at the first responders by Department of

Defense and Department of Justice.

Four, aiding and strengthening capacities to respond, especially

at the local level. We recommend that a public health infrastructure be built that would provide labs for sampling and the conducting of disease surveillance, and provide computer linkages between

local health agencies, hospitals, and labs, and the State health

agencies to monitor and communicate and identify trends. We believe this system would facilitate early protection and early treatment of victims.

Five, provide training and education awareness programs outside

of metropolitan areas to public health officials and emergency room

personnel and physicians, to name a few.

Last, develop guidance and standardized training to ensure the

safety of medical first responders.

It is up to all of us to work harder and more effectively at coordinating all the various players in response and recovery to this very

complex issue. Plans must be developed in every State to provide

for close coordination and communication between public health,

law enforcement, emergency medical services, emergency management, and the education community.

Funding and resources must be enhanced and used more effectively to prepare the Nation’s public systems for WMD incidents.

Readying the Nation to respond to domestic terrorism is not a

simple task, as we all know, but it must be done for the safety and

well-being of citizens throughout this country living in communities

large and small depending upon their government to be there when

they need it most.

Again, thank you for the opportunity to be here and the opportunity to leave early so I can get to my next appointment.

We stand ready to provide any further assistance to this committee as you deem necessary, and I would be happy to answer any

questions.

Mr. SHAYS. Thank you, Ms. Gordon.

[The prepared statement of Ms. Gordon follows:]

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Mr. SHAYS. Dr. Johnson.

STATEMENT OF DAVID R. JOHNSON, M.D., DEPUTY DIRECTOR

FOR PUBLIC HEALTH AND CHIEF MEDICAL EXECUTIVE,

MICHIGAN DEPARTMENT OF COMMUNITY HEALTH, ON BEHALF OF THE INFECTIOUS DISEASE POLICY COMMITTEE,

ASSOCIATION OF STATE AND TERRITORIAL HEALTH OFFICIALS [ASTHO]

Dr. JOHNSON. Good morning, and thank you for the opportunity

to be here today.

As mentioned, I am Dr. David R. Johnson, deputy director for

public health and chief medical executive for the Michigan Department of Community Health.

I am here today representing the Association of State and Territorial Health Officials [ASTHO] which is an alliance of chief health

officers in each of the States and territories. My testimony also reflects perspectives of two of our affiliates, the Council of State and

Territorial Epidemiologists and the Association of Public Health

Laboratories, as each of us plays a role in ensuring the readiness

of local and State public health systems to respond to a weapons

of mass destruction event.

My testimony will briefly address the readiness and capacity of

health care systems to respond to events involving weapons of

mass destruction, the critical role of public health, and we’ll close

with some policy recommendations.

Successful preparation for a weapons of mass destruction emergency will depend on the development of a well-orchestrated plan

to be used in responding to an event. Regardless of the nature of

the attack, the role of public health in the planning process will include identification of existing assets and assessment of needs, resource allocation for preparedness, stockpiling of supplies, medical

training for treatment, and media training for communication with

the public.

Other critical roles in planning include the development and implementation of training and education programs and communication plans.

Health officials are often the first medical personnel to be contacted by the press when an epidemic or other type of public health

threat occurs; therefore, rapid, reliable information and communication systems between local health authorities, police, fire fighters, emergency management services, emergency personnel, and

Federal agencies are essential.

Currently, CDC is providing a handful of State health departments with funding for emergency preparedness planning to serve

as models for the other States. These grants hopefully will also

make it easier to work with other relevant agencies.

In Michigan, to use our State for an example briefly, our communicable disease epidemiology division facilitates a relationship between State and local public health communicable disease epidemiology programs somewhat analogous to the relationship between

CDC and the States.

Local health departments provide routine onsite monitoring and

case investigation. State epidemiologists operate specialized surVerDate 11-MAY-2000 10:55 Jul 25, 2000 Jkt 000000 PO 00000 Frm 00019 Fmt 6633 Sfmt 6633 C:\DOCS\63355.TXT HGOVREF1 PsN: HGOVREF1
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veillance systems and provide consultive and onsite assistance for

the more unusual and life-threatening, urgent situations.

State health departments will coordinate assistance to local

health departments to help their facilities as affected localities become overwhelmed.

Because of the likely number of victims involved, State health

departments will coordinate the distribution of victims around the

State in medical treatment facilities and across State lines to nearby localities.

In a covert event from a suspect biologic or chemical agent, public health’s first efforts would be laboratory and epidemiological

analysis through the public health surveillance system.

Under most circumstances, the initial detection and response

would take place at the local level.

This type of active surveillance is dependent upon the ability of

the laboratory to rapidly and accurately analyze samples for evidence, requiring staff with technical expertise, equipment, and supplies, including biosafety level three containment facilities.

Public health laboratories, ideally suited for this critical role, will

need constant upgrading of staff skills, equipment, and reagents to

perform this function. This will clearly require additional resources, since half of the State public health laboratories, as a recent GAO report noted, do not have enough staff to conduct laboratory analysis of currently known emerging infectious diseases, such

as hepatitis C virus and penicillin-resistant Streptococcus

pneumoniae.

Training by State and public health laboratory staff of hospital

and private clinical laboratory personnel to recognize an unusual

pathogen or bacterium is another critical public health role in

emergency preparedness. The capacity to rapidly determine if a

substance contains a deadly microbe or harmless powder is essential if we want to prevent unnecessary decontamination and expensive courses of antibiotics.

In closing, preparing to meet the needs of civilian victims of a

weapons of mass destruction incident requires a coordination of the

entire health care community, as well as experts in agencies at all

levels of government.

Planning for these types of events requires special emphasis on

certain functions not normally included in disease plans. Those

functions include special surveillance operations, delivery of vaccines and anti-microbial agents, and other mitigation efforts.

In summary, State and local public health agencies need preparedness planning and readiness assessment, adequate epidemiological resources for disease surveillance, appropriate laboratory capacity and state-of-the-art diagnostic capabilities for biologic and

chemical agents, and establishment and maintenance of adequate

communications and information networks.

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State health departments have demonstrated skill and experience to rapidly mount mass immunization campaigns, administer

medications on a large scale, respond to disasters, and generate

emergency public communications.

Thank you for this opportunity to testify. I’ll be happy to respond

to your questions.

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

[The prepared statement of Dr. Johnson follows:]

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Mr. SHAYS. Chief Plaugher, we welcome your testimony.

STATEMENT OF EDWARD P. PLAUGHER, FIRE CHIEF, ARLINGTON COUNTY, VA, AND DIRECTOR, METROPOLITAN MEDICAL

RESPONSE SYSTEM, WASHINGTON, DC

Mr. PLAUGHER. Good morning, Mr. Chairman and members of

the committee.

Before I give my remarks, I would be remiss if I did not wish

the members of the Fairfax County Urban Search and Rescue

Team every success and personal safety in their efforts in Taiwan.

They began this morning.

I think it is important, as I begin my remarks, to realize that today’s fire service is vastly different than yesterday’s fire service,

and today’s needs are vastly different.

In March 1995, after the attack on the Tokyo subway system and

prior to the Oklahoma City Federal Building bombing, the Washington, DC Council of Governments Fire Chiefs Committee requested assistance to better prepare the Nation’s Capital and the

first responder community for a weapons of mass destruction event.

Efforts have been underway since that time and progress has

been made in several important areas. Your community now has

additional response services and a team that has received specialized training. Equipment has been designed and field exercises

have been concentrated at several key facilities or targets, such as

the Pentagon.

Some first responder departments have received additional Federal resources, and in those communities even more has been done

to assist and prepare the first responders.

In relation to the Metropolitan Medical Strike Team, the partnership with the Office of Emergency Preparedness, U.S. Department

of Health and Human Services has been outstanding. With very

limited resources, their program has made a difference in our ability to deal with critical life support issues, such as immediate access to essential pharmaceuticals.

The Metropolitan Medical Response System, as it is now know,

has, and will continue, with the support of the Office of Emergency

Preparedness, to improve our response capability, and is a model

program that utilizes a partnership approach to provide essential

response capability in incidents of terrorism.

Our partnership, which utilizes the resources and talents of local,

Federal, and State assets developed well beyond our original expectations. Further development of the system is underway at this

time and will, with continued support of the partners, continue to

see improvements.

Several key areas, however, are problematic, to which I will focus

the remainder of my remarks.

Early in the development of the Metropolitan Medical Strike

Team, now the Metropolitan Medical Response System, the hospital medical community was deemed critical. In the Tokyo incident, self-referral to a medical facility of the incident victim was a

major issue, and in most incident pre-planning has been deemed to

be a major factor.

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Today’s hospitals, with few exceptions, have limited or no ability

to manage the effects of manmade or natural disasters with large

numbers of casualties.

Immediate first response means hospital and medical care, not

just law enforcement, fire, and EMS responders. We have not developed the necessary infrastructure to support this critical need.

First responders will do their best to save lives, only to see the

lack of facilities, equipment, and trained staff fail to maintain or

support the saved life.

Managed care has streamlined the medical system for efficiency

and is a system from which we have all benefited. Managed care,

in fine-tuning the medical resources are, however, the wrong approach to develop hospital-based resources. This resource is so critical that we must not allow the corporate bottom line to dictate the

outcome.

I propose that this need be viewed as similar to other infrastructure needs of critical importance to our Nation, such as interstate

highways and air traffic control, both of which, as I understand,

are operated by Federal trust funds. These trust funds, which can

only be spent to support those program-specific needs for which we,

as first responders and communities asked to prepare this community, need critically.

I propose that $2 per day be assessed per occupied hospital bed,

which would be used to fund the development of a hospital-based

resource system. Every hospital could and would then have the financial resources to support the efforts of the first responders in

the event of a disaster, both weapons of mass destruction and terrorism incidents and natural disasters.

Just in the last 30 days, one of Arlington County’s three hospitals and its associated emergency room closed its doors. Almost

45 percent of our hospital-based disaster response capability just

vanished in less than 48 hours. This erosion of our emergency medical system must be stopped and reversed or the success of the

world’s best medical care will slide to an unacceptable level.

In addition, research and development must proceed on the development of a detector to aid first responders. My department has

had discussions with Oak Ridge National Laboratory regarding this

issue and have produced positive preliminary results. However,

funding has prevented the concept from moving forward.

The detector would vastly expand the early warning capability of

today’s smoke detector and could, if applied to a first responder’s

protective clothing, greatly enhance the protection of our response

community and to every occupancy to which it is applied.

Acts of terrorism have vastly changed the community in which

we live. We cannot utilize the approach of the past to deal with

this very real threat.

As individuals with whom the citizens have placed public trust,

we cannot ignore these vital shortcomings to our ability to save

lives. Public trust is earned every day.

Thank you for this opportunity to address the committee, and I

will be glad to answer any questions.

Mr. SHAYS. Thank you, Chief Plaugher.

[The prepared statement of Mr. Plaugher follows:]

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Mr. SHAYS. Dr. Waeckerle, we’ll now hear from you.

STATEMENT OF JOSEPH F. WAECKERLE, M.D., EDITOR IN

CHIEF, ‘‘ANNALS OF EMERGENCY MEDICINE,’’ FELLOW,

AMERICAN COLLEGE OF EMERGENCY PHYSICIANS, AND

CHAIRMAN, DEPARTMENT OF EMERGENCY MEDICINE, BAPTIST MEDICAL CENTER, MENORAH MEDICAL CENTER

Dr. WAECKERLE. Good morning, Chairman Shays and Congressman Allen and Congressman Tierney. It is a pleasure to be here.

As said earlier, I’m Joe Waeckerle. I’m a practicing board-certified emergency physician in Kansas City. I currently serve as editor in chief of ‘‘Annals of Emergency Medicine,’’ which is a leading

journal in emergency medicine. More importantly, I currently serve

as the chair of the task force for the American College of Emergency Physicians which is developing strategies for training physicians, nurses, and other personnel. It is a multidisciplinary task

force of health care personnel who are focusing on issues which

heretofore have not been addressed.

I am here today to testify on behalf of ACEP, the American College of Emergency Physicians, which represents over 20,000 practicing emergency physicians and over 100 million patient visits per

year.

Recent U.S. Government initiatives have recognized the threat of

weapons of mass destruction and have appropriated funds for initial planning and response programs. To date, these response programs are well founded and provide an important foundation for

defense, but, unfortunately, they are incomplete.

ACEP believes that, prior to further program development and

implementation at the Federal level, there needs to be a reconsideration and modification to our current approach to domestic planning and preparation.

The contemporary model that serves as a planning framework for

our community is the hazardous material or HAZMAT model. The

HAZMAT model approach emphasizes a sentinel event occurring,

the expectation of rapid detection and identification of the offending substance and reliance on decontamination, especially on scene

by first responders to alleviate the situation.

Today, however, we believe that this approach is no longer adequate for some chemical agents and nearly all biological agents.

Decontamination may not be indicated in many chemical incidents,

as we once thought it to be. Decontamination is time and labor and

personnel intensive and requires tremendous resources. It is impractical to decontaminate every individual involved. But perhaps

the most important flaw in our current model is the fact that the

HAZMAT approach does not address the use of biologic weapons,

possibly the greatest threat facing our Nation.

There are four critical links to effective response missing from

this approach.

First, we must consider all potential weapons, notably biologics,

their specific characteristics, and a different approach to detection,

identification, and defensive protective measures.

Second, sophisticated surveillance systems must be established

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nology supporting epidemiological warning networks at the local,

regional, and national level can provide real-time valid information

critical to early detection and identification. In an additional benefit, it would be useful for many of the public health issues of importance to our society today.

Third, specific training for emergency health care personnel is

absolutely vital. For biologic weapons, the first responders will not

be fire and police but will be health care professionals, especially

emergency physicians and nurses. And the scene will not be the

streets, but local emergency departments and clinics.

To have an effective emergency medical response to a terrorist

attack in the United States, a focused educational effort on health

care professionals, especially emergency physicians, nurses, and

EMS personnel, is paramount. Only through to be and practice will

health care professionals develop the clinical knowledge and degree

of suspicion necessary to initiate an effective response.

Fourth and finally, a central Federal coordination office is essential to the development of an effective national response to terrorist

attack.

No matter what type of incident, the local community, whether

large or small, must respond quickly and appropriately and must

have the ability to be self-sufficient for 24 hours as outside assistance may not be available.

Only through adequate planning will the community response be

successful. Centralized coordination of the many important Federal

initiatives will allow local and State professionals the opportunity

to obtain valuable planning, training, and resource information efficiently.

In conclusion, although a terrorist attack is a low probability

event for any one city or town, America’s emergency medical community believes it is not a matter of if or where but when. The

price of freedom in our country is our vulnerability.

We have recognized the threat of terrorism, and we have again

to implement deterrent and response strategies appropriately

based on existing fire and emergency services.

ACEP believes that we must now modify our approach to include

current and future threats of biologic terrorism and other chemical

weapons. This more-comprehensive approach will require knowledgeable emergency health care professionals supported by a sophisticated medical surveillance infrastructure at the local level.

ACEP urges Congress to implement education, planning, and response programs facilitated by a central Federal office designed to

meet these challenges so that we can all better protect our patients

and our country.

Thank you for the opportunity to present to you all.

Mr. SHAYS. Thank you, Dr. Waeckerle.

[The prepared statement of Dr. Waeckerle follows:]

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Mr. SHAYS. Dr. O’Toole.

STATEMENT OF TARA O’TOOLE, M.D., SENIOR FELLOW, CENTER FOR CIVILIAN BIODEFENSE STUDIES, THE JOHNS HOPKINS UNIVERSITY, SCHOOLS OF PUBLIC HEALTH AND MEDICINE

Dr. O’TOOLE. Thank you, Mr. Chairman.

I am Tara O’Toole. I am a physician and public health professional. I am here today as a member of the Johns Hopkins School

of Health Faculty, where I am a senior fellow in the Hopkins Center for Civilian Biodefense Studies.

I am going to confine my remarks to preparedness for acts of terrorism involving biological weapons, only.

The Hopkins Center for Civilian Biodefense was founded about

a year ago under the leadership of D.A. Henderson, in large part

out of concern that the distinctive features in responsiveness to

acts of terrorism using biological weapons, were not being clearly

recognized within the Federal preparedness programs.

Supported by both the Schools of Public Health and Medicine at

Johns Hopkins, the center is focused on three strategic areas.

First, increasing awareness of the threats posed by bioterrorism

amongst professionals in the medical and public health communities.

Second, building the knowledge base that is needed to respond

appropriately to biological weapons of greatest concern. As Dr.

Waeckerle mentioned, there is much yet to learn about how best

to respond to such events.

Third, we are trying to catalyze the development of operational

systems, and particularly public health systems, that would enable

us to respond effectively to intentional epidemics.

The center is responsible for convening a national working group

that published consensus recommendations on how to medically respond to anthrax and smallpox in the ‘‘Journal of the American

Medical Association.’’ Additional recommendations on other pathogens of high concern will be forthcoming.

We are also beginning a project to design a template to try and

identify the essential elements needed to create the institutional

capacity to allow hospitals to respond effectively to bioterrorism.

A terrorist attack on U.S. civilians using biological weapons will

cause an epidemic. As Congressman Allen noted in his remarks,

the response to such an event would be fundamentally different

and involve different kinds of professionals and organizations than

a response to terrorist attacks using chemical weapons or conventional or nuclear explosives.

If we are going to construct effective response programs, we must

recognize these essential distinctions between bioterrorism and

other types of terrorist attacks.

Were a covert bioterrorist attack to occur, it would most likely

come to light gradually, as astute clinicians became aware of an accumulation of inexplicable deaths among previously healthy individuals.

Regardless of the specific scenario or the scope of the attack, the

medical community and hospitals will be key components of any effective response. In addition, State and local public health agencies

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will also have vital roles to play in managing an intentional epidemic.

Indeed, how effectively and how rapidly these public health and

medical professionals respond will have critical impacts on the

scope and the outcome of the epidemic.

There are now a number of very laudable Federal programs underway which address the challenges associated with bioterrorism.

All of these programs—all of them—are designed to support local

response efforts. In fact, most analyses and exercises to date, as Dr.

Waeckerle alluded to, indicate that Federal resources cannot be

mustered for 24 to 48 hours after a terrorist attack; thus, for the

first day or two cities and States will be on their own.

To date, there has been very limited involvement on the part of

clinicians and hospital leaders in the drills and exercises sponsored

by the Federal preparedness programs. This is not because the people running these programs have failed to try to get these participants to the table, but it is the case that to date most doctors have

never seen a case of anthrax or smallpox or plague, and most hospital laboratories are not equipped to definitively diagnose those

pathogens.

State and local public health agencies have been under-funded

for decades, as the Institute of Medicine pointed out in 1988. They

have got to be upgraded. This will not be simple. It will require a

concerted, long-term effort. There are no silver bullets.

The ability of public health agencies to conduct rapid epidemiological analyses, to identify and track and, if necessary, vaccinate

or isolate infected persons, or get them appropriate antibiotics will

have a critical impact on our ability to manage the epidemic and

limit suffering and death.

I would suggest four areas of attention for your consideration.

First, we need to continue to enhance existing Health and

Human Service programs’ upgrade for local public health capacity.

The recent initiatives of the Centers for Disease Control are critically important in this regard and should be continued and, in fact,

enhanced.

A coherent 5-year plan that identifies the most important essential elements of public health response and that helps to ensure the

capacity to coordinate regionally among different institutions that

will be involved in bioterrorism response would be very helpful.

Again, there will be no quick fix.

Second, we have got to get the medical community and hospitals

engaged in response planning and preparedness efforts. Given the

financial pressures and competing priorities that beset clinicians

and hospitals today, this will not be easy.

It is important, first of all, that the medical community become

aware of the threat posed by biological weapons and able to diagnose the most likely pathogens that might be used as weapons.

We would suggest that the effort to make this happen proceed

via professional societies such as the American College of Emergency Physicians, and that selected groups within the medical profession, such as emergency doctors, infectious disease specialists,

internists, and so forth, be taught, through their professional societies, how to recognize and treat the pathogens of highest concern.

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Again, the professional societies have a distribution system and

a history of teaching physicians that is likely to be more efficient

than curricula developed by for-profit contractors.

Hospitals, as we all know, are beset by many competing pressures, as Mr. Plaugher pointed out. In order to get hospitals to participate in planning efforts, we are going to have to construct a

careful menu of incentives and programs that allow them to do so.

They are not looking for another mission to pursue. And we have

got to make the case that the consequences of a biological attack

would be so calamitous that even the low probability of such an

event warrants their attention.

We must get hospital leadership engaged, which has been difficult to do to date.

We believe that, in order for that to happen, Federal leadership

will be necessary from both the Congress and the executive branch.

Third, as all of my colleagues on the panel have mentioned, coordination and collaboration is essential.

A biological attack is going to provoke the efforts of a huge panoply of agencies and institutions at all levels of government. Coordinating such an affair is not easy, as we all know. There have been

mighty efforts made to date to accomplish that on the Federal effort, which I know will continue.

Let us remember that coordination requires resources, time, and

money. I would suggest that a deliberate effort to create structures

that would allow coordination and collaboration on the local level

and would connect those efforts to Federal structures might be very

helpful and deserving of consideration.

Finally, human disease is always a social phenomenon with important ethical, legal, and cultural implications. An intentional epidemic will raise difficult questions such as the authority of governments to impose quarantines or isolates individuals with contagious illness, the legal liability associated with vaccinations, the

use of military personnel on American soil, and so forth.

Many of the relevant public health laws that would be invoked

in such situations date back to the Civil War. Moreover, such authorities differ from State to State quite considerably.

Examination and consideration of these matters should be undertaken now, not in the midst of a national disaster, and I think it

would be helpful to get scholars from academia, as well as legal experts in the Department of Justice, and from HHS involved in such

a matter.

That concludes my remarks. I’d be happy to answer questions.

Mr. SHAYS. Thank you, Dr. O’Toole.

[The prepared statement of Dr. O’Toole follows:]

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Mr. SHAYS. We’re going to start with Congressman Allen, and

we’ll have a number of questions to ask all of you. Thank you.

I appreciate the fact that you all tried to summarize your statements, but I think you still got the main points out. Thank you.

Mr. ALLEN. I want to thank you, also. I have been to a lot of congressional hearings, but I have to say that you all did a very good

job of making suggestions for areas in which we need to work, an

excellent job of pointing to the areas where we need to pay some

attention.

You’ve left me with a whole range of areas I’d like to talk about.

I think what I’ll do is just flag for you the areas of institutional

capacity that a couple of you have raised, and the question of how

to engage the medical community. I think that is the absolutely

central issue.

Let me flag that and leave it aside for a moment and go to questions about laboratories. It seems that part of the problem in incidents of bioterrorism is how do we figure out what is going on. And

so that raises issues about the capacity of State labs, hospital labs,

to detect some of these agents.

Can you sort of—and I think this is open to any one of you—even

if every State had a laboratory capable of analyzing these agents,

aren’t we still talking about delays and travel time and—should

every State have one hospital or one State public health department that is capable of doing this? What do you envision as a way

to deal with this detection issue as quickly as possible?

That’s for anyone who would like to answer.

Dr. JOHNSON. A couple of thoughts on that from a State public

health perspective.

Mr. SHAYS. If I could interrupt, it would probably make sense for

all of you to answer, because you all have different perspectives on

the issue, even if it is a short response.

Dr. JOHNSON. There are several levels to a response to that important issue.

First of all, obtaining the appropriate samples, both environmental samples and human specimens, is something for which

training will be needed. That has to happen at the local level. It

has to happen both from public health authorities, but, more importantly, from medical first responders and emergency medical

personnel. Knowing what specimens to get and where to send

them, who to call, is an important part of this whole process.

I think clearly our perspective would be that, at a minimum, at

a State level, and certainly even at below the State level at certain

metropolitan areas, and so forth, there has to be the laboratory capacity to rapidly assess both biological and chemical agents.

We’re pleased that we are just now beginning to receive some

Federal support to develop that capacity in the State of Michigan,

and other States are, as well.

But I’d say at this point my quick assessment would be that

there is a great deal of variability across the country as to the level

of that capacity presently.

Mr. PLAUGHER. Mr. Allen, I have been very fortunate for the last

2 years in working with Oak Ridge National Lab on the reinvention of the household smoke detector. We have 77 million smoke

detectors in this country that are more than 10 years old and need

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to be replaced, and now is the time to look at new technology to

see if we can avoid false alarms and those type of things associated

with it.

I also have an obligation to try to return home every night to 64

people who protect Arlington County, and that’s the fire fighters

and paramedics, so that if there is some way that I can design a

detector that will provide them personal protection, as well as better protection for our residents—and so I went to Oak Ridge and

asked them could they, in fact, do that, knowing full well that that

was a huge, huge obstacle.

It was amazing, because their response was, ‘‘Absolutely, and we

can use existing technology to do that.’’

And so we’ve continued to explore with Oak Ridge a couple of

very exciting technologies, but we have run into a funding issue,

and we no longer can pursue the project because we simply don’t

have the funds to do that. And it will do both of those items with—

they are different technologies, but remember, now, we threw out

to them this quest of ours to do the two-pronged approach in our

dialog with them.

I’ve had a chance to actually visit in Florida the Oak Ridge Lab

that is designed to do detector enhancements, primarily for the Department of Energy facilities, but it is pretty remarkable the concepts they’re talking about. They’re talking about a detector that

is similar to what we know as today’s smoke detector that would

be able to detect over 40,000 different substances, and we are also

talking about a detector that would be capable of detecting bios and

other type of things that—again, there are two entirely different

technologies.

So we think this is critical. We think the detector’s capability is

absolutely essential.

Mr. ALLEN. Are you saying you wouldn’t need different detectors

for different biological agents?

Mr. PLAUGHER. They have started research on what are called

‘‘forescens,’’ and forescens are individual microorganisms that are

designed to specifically react to certain presence of certain things,

such as anthrax and those types of things, and then they simply

glow. The task is to measure the glow to make sure that you’re not

getting false positives and that sort of thing.

It is some pretty exciting stuff, but, again, they’ve run into a

funding problem.

Mr. ALLEN. Thank you.

Dr. WAECKERLE. I’ve had the unfortunate experience of actually

responding to some events, both chemical and biologic, in my career. The crux of a response is, as we’ve all stated to you, detection

and identification of the offending substance.

To date, the Institute of Medicine emphasizes in a recent report

that was requested by the Office of Emergency Preparedness that

we have no current technology that allows us to detect and identify

rapidly, with high sensitivity and specificity, meaning accurately

and validly, any chemical or biologic agents in the field.

We therefore must rely on technology of the future to help us.

Preston, in his book, ‘‘The Cobra Event,’’ talks about a black box

that identifies DNA sequencing of biological agents. Well, it’s great

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for a book and it sold a lot of copies, but it is not real yet. I would

like it to be real, as I think we all would.

That, therefore, to answer your question, Congressman Allen, requires us to go to conventional methods such as gathering cultures

and submitting them to State and Federal labs.

In our responses, we’ve been hamstrung because of the fact that

we had no State labs or local labs which can rapidly and validly

identify organisms while we are at the scene, which therefore

causes us not to know what we are dealing with and whether or

not we should be administering antibiotics prophylactically or appropriately to the victims.

We now have the capability of calling the CDC and the FBI, because they have lab capabilities, but it still takes 8 to 24 hours to

receive information.

So you are correct in your question, which is pointing out what

are the deficits and where do we need to go. We need to go to two

areas. One is to develop better technology, and the other is to have

a better infrastructure in public health labs and agencies to support us at the local level.

The problem with responding to—having the Federal family respond is that they may not be able to get there, depending on the

incident—again I reiterate—for 24 to 48 hours, and the past history of every natural and terrorist event in the United States has

demonstrated that to be a very real concern.

Dr. O’TOOLE. Well, there’s no question that the labs need upgrading. I think, though, it is very difficult to answer simply whether

there should be one lab in each State. One could certainly argue

that a State like California needs more than one and perhaps you

can regionalize the effort in other areas of lesser populations.

My understanding——

Mr. ALLEN. I always am thinking about the State of Maine.

Dr. O’TOOLE. Lucky you, Congressman.

I understand that the State laboratory directors have been working with the Centers for Disease Control to come up with such a

strategy, and your question might be well directed toward Dr.

Lillibridge when he testifies.

I will point out, however, that, again, in terms of bioterrorism,

no one is going to be sending a lab sample anywhere unless a clinician has a suspicion that there is a diagnosis that might be related

to a biological weapon.

I have great respect for the national laboratories. I served as Assistant Secretary for Energy for 4 years. Nonetheless, I think there

is very limited usefulness for these rapid detection systems in the

context of bioterrorism, as opposed to rapid laboratory diagnostic

systems.

Again, a strategy has to take into consideration specific aspects

of the different organisms.

It is quite feasible, for example, to train every hospital laboratory

to be able to diagnose anthrax definitively. That is not a good idea

in the case of smallpox. Among other reasons, you don’t want just

anybody handling smallpox and contaminating a laboratory of a

hospital.

So, again, one needs to have a very measured strategy. Figuring

out that strategy has to be a matter of thoughtful consideration.

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Mr. ALLEN. Thank you very much.

Mr. SHAYS. Thank you, Congressman Allen.

This committee is the National Security Subcommittee that oversees national security and veterans affairs for programs, and we

have special responsibility to look at terrorism, both at home and

abroad. And we’re probably one of the committees that actually has

that responsibility both on an international and national level, and

local, as well.

It is really the primary focus of the committee. I am almost overwhelmed, the more we get into this, the different groups that we

need to set up. I mean, we have metropolitan medical response systems, we have disaster medical assistance teams, we have the National Guard teams, we have special forces and their ability within

an hour to go to almost any area of the country. I mean, all of this

is reassuring, in one way, because it tells me we are thinking about

it.

In all of our view—and I think all of us share that we have a

long way to go.

What interests me is that this is a hearing on nuclear, chemical,

and biological, and all of you kind of have focused a bit on the biological, which isn’t a criticism but is kind of, in a sense, an affirmation that the biological represents the most mysterious, I think.

You have a fire, you can basically assess it. You have a flood, you

can basically assess it. If a building collapses, you basically can assess it. A chemical explosion, horrific, long-term, incredible implications, but you know what happened.

The chemical and biological, though, could happen—both chemical and bio could happen without our knowing, correct? It’s not just

biological. What represents the threat with biological is that it

would continue to grow and fester, where the chemical would basically be an event that would happen. We would know about it pretty soon.

Let me ask you this first part. Would we know chemical before

we would know biological?

Dr. WAECKERLE. There are characteristics, sir, that you would

look for in a chemical event that are unique and would guide you

to an appropriate response in a more timely fashion than a biological event.

The characteristics of a chemical event, for the most part, is it

will be a sentinel event, as you correctly pointed out. Despite the

fact that it could be clandestinely spread, it will manifest itself

pretty quickly through what we call ‘‘toxidromes,’’ in other words,

a toxic substance demonstrated in patients by presentation that is

fairly characteristic, and therefore we can address it.

Unfortunately, for most chemical incidents, all its reliance heretofore on antidote and contamination may not be correct or warranted to the degree that we thought.

Mr. SHAYS. Let me not get into that. I just want to—in terms of

detection, because we didn’t have the reassurance for the Gulf war

veterans that we were on top of whether our Gulf war veterans

were exposed to chemicals.

My sense is that if you don’t respond within a few days to the

chemical, the damage is done, and then you may not even be able

to know it happened.

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Dr. WAECKERLE. Actually, if you don’t respond within a much

shorter timeframe than that for most chemical warfare—

weaponized chemical agents, then the patient will, unfortunately,

suffer death or disease and you can no longer intervene. There is

a very short time window of opportunity.

Mr. SHAYS. I think we all have a sense of how horrific a nuclear

explosion would be and the implications of that both in the short

term and long term.

I’d like to just have you define to me the difference, and then I’m

going to ask the respondents how they would deal with it. Maybe

that will be my next round. Just in terms of chemical and biological, short answers, the differences. I want the differences.

Dr. WAECKERLE. Well, I’ll start, and Dr.——

Mr. SHAYS. Let me just tell you what I think is the obvious, and

then——

Dr. WAECKERLE. Please.

Mr. SHAYS. The chemical and biological both may not be detectable right away.

Dr. WAECKERLE. I think, for the most part, chemical events using

the agents that we are aware of will be manifest within minutes

to hours; biologic agents, contrast, you’re right, are insidious and

may not manifest for days to weeks.

Mr. SHAYS. Both can be introduced into the community in small

dosage and have horrific effects.

Dr. WAECKERLE. Certainly more so biologics than chemicals.

Chemicals have to have a certain dose effect, and to do so they

have to be spread or dispersion methods have to be used for these

chemicals to affect large populations.

Chemical events are dramatically different because they will

manifest themselves quickly. They are best utilized by a terrorist

in a confined space to capture a confined population, and they will

manifest themselves—at least the ones that we have been exposed

to and ones—for example, the sarin gases and et cetera, and the

weaponized agents—they will manifest themselves almost, relatively speaking, almost immediately, and the astute clinicians

that are well-trained and health care professionals should be able

to identify, from the symptoms and signs of the patients, what

chemicals have been used.

Mr. SHAYS. Would a chemical linger like biological?

Dr. WAECKERLE. A chemical enter?

Mr. SHAYS. Would a chemical exposure—would the exposure of

the chemical linger indefinitely?

Dr. WAECKERLE. Only certain chemicals, because most of the

chemicals that are weaponized will either kill you or not kill you,

depending on your exposure and the chemical, itself. There are only

a couple of chemicals that have long-term, lasting effects, and those

are a couple of the pulmonary agents and the skin—what we call

‘‘blister agents.’’

Mr. SHAYS. You make an assumption, though, that a terrorist

would choose to have it be a pretty high dosage. There’s also a concern that you could have low dosage that would have a long-term

negative impact.

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essarily be a benefit of them in the weapon because it won’t manifest high death and disability in a sensationalized fashion.

The other thing, of course, is that to chronically expose people to

chemicals would require a dispersion method that is not readily

available.

Mr. SHAYS. Usually terrorists want a quick impact. I understand

that. But, going now to biological, biological can start small and

just continue to grow and fester almost indefinitely. And then is

the concern that it goes up proportionately or geometrically?

Dr. O’TOOLE. Again, it depends upon the agent. A contagious disease, which can spread from person to person——

Mr. SHAYS. I thought any biological would be contagious. I made

a wrong assumption?

Dr. O’TOOLE. No. All biological agents are infectious in the sense

that, you know, they affect the human body once they are inhaled

or injected or imbibed, but not all are transmissible from person to

person. That would be a contagious disease. Smallpox is a highly

contagious disease. Were someone to use smallpox——

Mr. SHAYS. Anthrax is not?

Dr. O’TOOLE. Anthrax is not.

Mr. SHAYS. And both are biological?

Dr. O’TOOLE. Correct. So, in the case of an anthrax attack, you

would see a sudden number of very sick and dying individuals

some time between 24 hours to 48 hours after the attack, and then

people would continue to get sick, depending upon when they fall

ill, which is highly variable in anthrax infection for the next 60

days. But you would get this sudden boom and people who are

deathly ill coming into your emergency departments, unlike smallpox, which would start with the trickle of people looking like they

had chickenpox or some other viral illness with fever and malaise.

But if you didn’t catch the smallpox, isolate the people and the

contacts who had been infected early on, then the infection would

grow and grow.

During the smallpox eradication campaign the WHO held in the

1970’s, each case of smallpox infected between 10 and 20 contacts.

So the number of people infected goes up by a log with each generation.

Mr. SHAYS. That is pretty much geometric.

Dr. O’TOOLE. Yes.

Mr. SHAYS. I’m going to recognize Mr. Tierney after I allow Dr.

Johnson and Chief Plaugher to just respond to the question I’ve

asked from your perspectives, but then, when I come to my second

round of questions, I would love to visualize the impact of a biological or chemical effect on the public health network, because, you

know, what I wondered is if you—how many medical centers we

are going to need, medical response areas, in light of your point

about extra bed spaces. That would be a gigantic loss. And would

we want to imagine a system where we could literally transport

people who are in hospitals who are getting other services out of

those hospitals to other hospitals around the country so that then

those hospitals could just focus on the biological response, or something like that. I’d love to have you walk me through that.

Maybe, Dr. Johnson and Chief Plaugher, you could respond to

the question that I asked.

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Dr. JOHNSON. Certainly. Just very briefly, in terms of the differences between chemical and biological, I agree with what my colleagues have said about those important differences.

I’d emphasize once again that detection in the case of biological

agents being used is extremely important, and we heard a description of a couple of potential scenarios where, if we don’t have a

high index of suspicion and we don’t have clinicians or others in

the health care field thinking that this may be a possibility and

putting together sometimes some subtle clues about a small series

of patients they may encounter, if that doesn’t happen, then we

don’t trigger our other systems. We don’t trigger our public health

system.

And so that training and that ability to recognize that something

unusual is going on and then the willingness and the understanding to report to local, State and other health authorities, those are

very critical links with the biological attack.

Mr. SHAYS. I think I was most interested—the thing that caught

my eye the most was the fact that we, in some metropolitan areas,

have public health specialists who just monitor the types of events

in terms of pharmaceutical needs or the type of entries into hospitals, is there an over-event of a certain kind of illness that then

would trigger a concern.

I imagine that is happening in some metropolitan areas but not

in others?

Dr. JOHNSON. I would agree with that assessment. I think there

is a great deal of variability about how closely this kind of monitoring is taking place.

Mr. SHAYS. But since Federal dollars pay for that, I would think

it would be a good way to start getting to the detection area.

Chief, do you want to respond?

Mr. PLAUGHER. Yes. Your question was about the difference,

chemical and biological——

Mr. SHAYS. How it impacts.

Mr. PLAUGHER. And how it impacts. I think you also have to add

in whether there is a warning or whether, you know, it is without

warning or is yet to be detected with just the event, itself.

I also think you have to throw into the matrix the issue of the

hoaxes, which can also be equally devastating to a community, just

the panic. If somebody says, ‘‘I have done this,’’ and, in fact, we

have no way to know whether they have or have not, and we might

have to mass inoculate a large number of people for just a simple

hoax issue.

So I think it is a very complicated matrix that we are trying to

deal with, with little if any—the resources necessary to be successful. You know, we’re continuing to basically shoot in the dark at

several of our concepts.

But I think that, obviously, from what we have known in recent

events, such as the Tokyo, and you have a chemical event that’s

very noticeable, people were immediately down, the responders also

went down. People suffered in medical communities. They also

went down because of a lack of preparedness to deal with those

type of things.

You know, the pandemics that we’ve had in this Nation from the

biologics, as well as the recent development of very sophisticated

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biologics, also gives us concern for our ability to detect, but also to

then adequately respond with the medical care necessary.

National stockpiles of pharmaceuticals, to the extent and the size

and capacity of those, how do we administer those, they are all

very, very complicated issues that we, as part of the responder

community—because then we have to step out of our first responder role, but we are still part of the response community, and

how do you deal with mass treatments of folks and that sort of

stuff. And we have folks who are licensed to administer medicines

and that sort of thing, paramedics, those types of things. So it is

a very, very complicated thing.

So your question is simple and straightforward, but the answer

is very complex and very difficult because of the nuances of the situation.

Mr. SHAYS. Thank you.

Mr. TIERNEY. Mr. Chairman, this is an interesting issue and we

could be here all day.

I want to thank all of you for your testimony and the seriousness

with which you present this issue.

I have, obviously, a range of interests. Let me try to get to them.

We have, obviously, an issue of protection aspect of that. Chief,

you indicated that on the technology part of it you’ve already got

Oak Ridge working on that. I assume that we’re talking Federal

dollars there for the most part?

Mr. PLAUGHER. That’s correct, and there are a couple of issues,

not only in Oak Ridge but Sandia and in some of the other national

labs that are working on several protective capabilities, as well as

decontamination substances and those types of things.

Mr. TIERNEY. So what we need to do here is to make sure that

it has been adequately funded and that those efforts go forward?

Mr. PLAUGHER. Absolutely.

Mr. TIERNEY. With respect to personnel who would be obligated

to identify or at least recognize that, I would assume that those go

back a little bit to the training exercise here. What are we doing

about the curriculum at various medical colleges, public health people that teach public health or paramedics, or whatever? Are we

doing anything about having that become part of the curriculum.

Dr. WAECKERLE. Actually, that’s the task force that I’m chairing

is the Multidisciplinary Consortium of Health Care Professionals.

It currently includes doctors, nurses, paramedics, EMTs, fire, police, toxicologists, and, unfortunately, a few groups who are invited

to come to the table. But, as each of my colleagues has stated to

you, we are not—the clinicians, which will be essential in the detection of especially biologic attacks, are not properly prepared.

I might add to that the hospitals and hospital personnel and the

administrators and some of the major organizations in the country

have not seen the wisdom of being involved and signing up, as well.

Mr. TIERNEY. Let me try to break this in two parts, if I can. The

first part is those people coming into the system as people that will

treat people or diagnose people. Is there anything now to deal with

the curriculum at those institutions?

Dr. WAECKERLE. We have just completed the first phase of our

grant process when this multidisciplinary has defined the core conVerDate 11-MAY-2000 10:55 Jul 25, 2000 Jkt 000000 PO 00000 Frm 00072 Fmt 6633 Sfmt 6633 C:\DOCS\63355.TXT HGOVREF1 PsN: HGOVREF1
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tent essential to health care professionals who would be faced with

these challenges.

The second part was soliciting funds for—we hope to obtain them

through HHS and CDC to establish the core curriculum.

The third phase would be then to offer to the professional societies, which we believe, as Dr. O’Toole has suggested, is the best

strategy and not through private companies, education of all the

health care professionals based on——

Mr. TIERNEY. Let me break in. I want to get back to that level

of people entering the system, so we’re talking about the institutions that will be teaching these new people as they come through.

You are developing a curriculum. It hasn’t been implemented yet.

Dr. WAECKERLE. That’s correct.

Mr. TIERNEY. I would guess that we would want to have some

assurance it was implemented right across the board. Since many

of these institutions are private, you know, it is going to be difficult

to require them to add this to their curriculum.

Dr. WAECKERLE. That’s a major challenge of the strategy that—

we looked at these and we called these ‘‘barriers and challenges.’’

I would be happy to supply the committee with the report if you

so wish. But the major barrier is how to ask—notice I used the

word carefully—the health care professionals to obtain this information so that they are competent.

The strategies——

Mr. TIERNEY. These are people that want to be professionals.

These are people that aren’t professionals yet. These are the people

that are in school training to become that. So the question is how

do you get those institutions to require that they take that kind of

background training?

Dr. WAECKERLE. Well, Congressman, that’s very observant. The

issue with that is we have to train the people in bits in the emergency departments——

Mr. TIERNEY. How do we get at that?

Dr. WAECKERLE. The medical students? Is that what you’re getting to?

Mr. TIERNEY. I mean, getting to the fact that there are two different tracks to go on—people that are coming up through the pipeline and the trained people that are already in the pits.

So my question on this part of it right now is, What are we going

to do about having a curriculum that those people have to take so

that they don’t become people that have to be trained later. Do you

get all that?

Dr. WAECKERLE. I have it, and I appreciate it. Thank you.

Mr. TIERNEY. So that’s the idea. And I guess where I’m leading

with this is it is something that we ought to think about conditioning Federal education aid to these institutions to have them

adding this to their curriculum once it gets developed as appropriate.

Dr. O’Toole.

Dr. O’TOOLE. Yes. I think awareness is growing amongst educational institutions that this has to be done. The board that licenses or grants certification to internists, for example, this year

inserted questions involving biological weapons into its licensing

and certification exam, and we have had conversations with other

70

similar entities who are looking around for guidance on what they

should do here.

There isn’t, as Dr. Waeckerle suggested, any simple way of plugging new curricula into already overcrowded medical school curricula, but that is where, you are quite right, things have to start

flowing from.

Mr. TIERNEY. So that would be one point, and you’re already

looking at that.

The other point would be adding on the your favorite subject,

which is people that are already in the pits. That is something that

I think was recommended to be done through the professional organizations.

What kind of a role would you envision State or Federal Government having on that effort, or would they have none and just leave

it to the professional organizations, in your view?

Dr. O’TOOLE. Well, professional organizations will need money to

develop the curricula that are tailored to emergency physicians or

to internists and so forth, such as the curricula that Dr. Waeckerle

developed to help people in the pits.

There are a number of different-flavored pits out there in medicine these days, and the curricula should be tailored to different

specialists’ concerns.

Mr. TIERNEY. Let me ask this. I have a number of States that

I’m aware of around the country that are sitting on incredibly large

surpluses in their budgets. Is there an effort afoot to educate these

State governments, the legislatures and the Governors’ offices, and

get them focused on this issue so that their resources are directed

in this way?

I think people tend to think it is going to be a crisis in biological

agents and chemical and look to the Federal Government, when, in

fact, as you are pointing out, a lot of the response is very, very

local.

I don’t know of a lot of States that are focusing on this or putting

parts of their budget toward this issue.

Dr. Johnson.

Dr. JOHNSON. I think that is beginning to happen, and I think

that the national leadership on this, we’re starting to recognize or

appropriate that, and that’s stimulating some of that education and

awareness at the State level.

Mr. PLAUGHER. I agree. I have written two letters to my own

State, the State of Virginia, and asked them for assistance in this

regard. The first letter they lost. The second letter they’ve chosen

to not respond to.

But then, because I am very stubborn, I said, ‘‘Well, I won’t accept that,’’ so I started talking to a couple of my Senators that I

know in my community, State Senators I know in my community,

and asked them to work through legislation in the last legislative

session in Richmond to even study the issue, and so they proposed

a resolution before the State Senate asking the State Health Department to study this issue.

The response that came back was that we don’t have the $50,000

to study our capacity to deal with this in the State of Virginia,

chemical or biological, and it just died for lack of funding.

71

So, you know, again, I hear what you’re saying and I agree with

you absolutely that the States have an absolutely critical role in

this whole issue.

I find it difficult to get the proper emphasis on it, and so I appreciate that.

Mr. TIERNEY. The last question, I’m very concerned with what is

going on with our community hospitals, even before we get into

this issue. In State after State they are being gobbled up, in many

cases by for-profits. They are being consolidated, and people have

to travel a great distance to get to an emergency room, great distance to get to a hospital bed.

That seems to be directly in contravention to the needs that we

have here if some sort of crisis sets in.

Are you aware of any effort afoot to have individual States develop a plan of available emergency areas and hospital beds so that

they are reasonably spread throughout the respective States and

would address a situation like this? And, if not, what do you think

we could do to help facilitate that?

Dr. O’Toole.

Dr. O’TOOLE. The State of Maryland has done fairly extensive

analysis of how they would respond to a weapons of mass destruction and has surveyed the resources and availability of hospital

beds, and the picture is fairly alarming, even in as relatively rich

a State as Maryland.

I would suggest that, given the many demands on the State

health departments, it is going to be very difficult for them to muster the resources to actually address the kind of response needs

that come up in these weapons of mass destruction scenarios. Politically, I think it is going to be very difficult for that to ever take

place.

We have begun conversations with various hospital groups and

people from hospitals. We’ve gotten a lot of interest from some hospital leadership in being engaged in conversations that would move

toward an understanding of what needs to be done.

It is very complicated. On a given day, it might not be prudent

to move everybody out of the intensive care unit at Johns Hopkins

and make that the center of a response to a smallpox attack, for

example. There probably has to be some flexibility in any plan.

Whether you want to designate one or a group of hospitals in a

region to be the centers of response to a weapons of mass destruction attack or put all hospitals to some minimum threshold level

of capacity is still an open question.

What you do with the staff in an attack is going to be very, very

problematic. You have, first of all, to protect them from being afflicted with the same malady that is besetting your patients. Many

people are probably going to leave their posts out of fear for their

own health or to go and make sure their families are OK. Many

of the people who staff hospitals today are working women, and if

you are going to put them on 12-hour shifts to handle an emergency you have to figure out what you are going to do with their

kids meanwhile.

So there is a whole host of questions that are just beginning to

be investigated. Again, no simple answers yet. What we need to do

is, first of all, muster the resources to address those questions

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thoughtfully and get everybody to the table who needs to be there

to discuss them.

Mr. SHAYS. Thank you very much.

Mr. PLAUGHER. To answer your question, every day in northern

Virginia, which is probably one of the most prosperous places in

the Nation, runs out of hospital beds for us to take emergency patients to. It is an acute crisis, particularly not only the day-to-day

aspect of trying to find a bed for a patient that is suffering a heart

attack or any other type of unfortunate incident, but I know last

winter, when we had a mini flu situation going on in the Washington metropolitan area we couldn’t find any beds. We were really

trying to figure out what to do with people. It was horrible, and

I am, as a fire chief, also responsible for emergency medical services in my community, and I’ve got patients and no place to take

them to.

This is without the terrorist incident. I mean, this is without the

catastrophic event. I mean, this is just day in and day out.

Mr. TIERNEY. I think the problem I see in many States is that

there has not been the kind of planning that the State convention

is doing. I don’t see the greater majority of States getting out there

and taking an analysis of how these hospitals are consolidating,

how they are shutting down, what the picture looks like.

In my own State, we’ve gone from over 130 hospitals to less than

60. And there is no plan for those 60 that remain, whether they’re

all in one place, one part of the State or another, what their services provide.

I think it is incumbent on us to somehow encourage some real

sensible planning that takes into account, among just the ordinary

needs day-to-day, and this kind of catastrophic event that might

occur and we reasonably should be planning for.

Mr. PLAUGHER. Again, as in my previous remarks, I said 45 percent of our emergency room capacity just up and closed 1 day. They

came to us and said, ‘‘We’re going to give you a 60-to 90-day notice.’’ Forty-eight hours they closed the doors because of advice of

legal counsel and said there’s too much liability because our staff

was walking away and getting better jobs and that sort of thing,

so they just closed.

Again, that means we have to readjust how we deal with the

day-in and day-out needs, much less—if we were right now, to this

day, to have another incident where a group of visiting dignitaries

visiting the Pentagon are injured in an incident, which we had

about 15 of them, the local hospital that we used that day would

not be there. So, I mean, this is a pretty serious, serious situation.

Mr. TIERNEY. I agree.

Mr. SHAYS. We want to get to our next panel, but I would like

to just visualize, if someone wants to run through a scenario. I

want to pick—let’s pick a city that—Dr. Johnson, you are based

where?

Dr. JOHNSON. I’m based in Lansing, MI, the capital city.

Mr. SHAYS. OK. How many hospitals are there?

Dr. JOHNSON. We have four hospitals in the city.

Mr. SHAYS. And the population?

Dr. JOHNSON. Population, several hundred thousand. It sort of

depends on which communities you include in that.

73

Mr. SHAYS. OK. So it is around 200,000, give or take?

Dr. JOHNSON. In the cities.

Mr. SHAYS. Give me a biological event. This is East Lansing?

Dr. JOHNSON. This is Lansing.

Mr. SHAYS. Lansing. In Lansing, give me a biological event that

could happen.

Dr. O’TOOLE. OK. Terrorist releases anthrax at a football game.

How many people——

Mr. SHAYS. And Michigan State is right next door, right?

Dr. JOHNSON. Michigan State is in East Lansing. Right. There

would be 75,000 people at the football game.

Mr. SHAYS. And how far away is that?

Dr. JOHNSON. They’re contiguous.

Mr. SHAYS. OK. Can we do it at the football game?

Dr. O’TOOLE. We’re at the football game. People, presumably

from all over the State, and, indeed, maybe from all over the country, are at this game.

Mr. SHAYS. Yes.

Dr. O’TOOLE. Some time between 24 and 48 hours later, people

start getting sick. Within a period of time, depending upon the astuteness of the clinicians in the emergency department, doctors

start noticing that they have previously healthy people coming in

with cough, fever, in large numbers. They send them home thinking it is some kind of common viral illness.

Twenty-four hours later they come back and they are dying. They

are very desperately ill. No one knows why.

Dr. JOHNSON. I’ll just interrupt to say that this won’t be in East

Lansing, necessarily, or in Lansing.

Dr. O’TOOLE. Right. This will be all over the area.

Dr. JOHNSON. Right.

Mr. SHAYS. And some who might have flown back to St. Louis

or something.

Dr. O’TOOLE. Absolutely.

Mr. SHAYS. It wouldn’t be a high incidence there, so they

wouldn’t maybe pick that up.

Dr. O’TOOLE. No.

Mr. SHAYS. But in this case, I don’t want to say ‘‘at least,’’ it is

not contagious, correct?

Dr. O’TOOLE. Correct.

Mr. SHAYS. In this circumstance.

Dr. O’TOOLE. Correct. Depending upon the astuteness of the clinicians and what the informal mechanisms doctors in different hospitals have for talking to each other, and how connected the medical community is to the public health community, eventually—

probably pretty quickly, within a matter of hours, I would think,

doctors are going to realize that something very unusual was going

on. At that point, at the very latest, the public health agencies will

be contacted.

Mr. SHAYS. How does that happen?

Dr. O’TOOLE. Well, that’s a good question. It mostly doesn’t happen. There has been a tremendous disconnect between the medical

community and the public health community over the past decade,

for all kinds of reasons, including the diminution in resources

available to the public health agencies.

74

Hopefully, somebody will think to call the public health people at

the State or local level, but it is unlikely that they are going to call

and say, ‘‘Listen, I think I have anthrax,’’ which in most States is

a reportable disease. They are going to say, ‘‘There’s something

strange going on here. Can you help me? Have there been any

other cases around town that look like this?’’

Mr. SHAYS. Describe for me how many people in your hospital

beds—you have 40, probably have 800 hospital beds in your community or——

Dr. JOHNSON. Probably a touch more than that, but that’s the

right number.

Mr. SHAYS. And two-thirds of them would be full?

Dr. JOHNSON. At any given time in the middle of flu season

and——

Mr. SHAYS. Football season?

Dr. JOHNSON. Football season.

Mr. SHAYS. OK. So now how many would probably be knocking

on the door of that hospital?

Dr. JOHNSON. Well, I suppose it would depend. To carry out this

scenario, it would depend on the efficiency with which the organism was dispersed at the football game. You could potentially

have hundreds to thousands of people.

Mr. SHAYS. Let’s just stay there are six entrances and the terrorists cover two entranceways or two exits, so let’s just say one-third

of the people really were exposed.

Dr. O’TOOLE. First of all, it is important to——

Mr. SHAYS. Let’s just say 20,000.

Dr. O’TOOLE. Let’s say only 10 percent of them are in East Lansing getting sick on this given day. It is important to realize that

there hasn’t been a mass disaster involving a lot of sick people, as

opposed to a sudden accumulation of dead bodies, in American history in recent times. How a hospital would respond even to 200

sudden very sick people is an open question, I think, in most communities.

Also, at that point you’re not——

Mr. SHAYS. A hospital to respond to 2,000 would be——

Dr. O’TOOLE. It would be overwhelming.

Mr. SHAYS. Chief?

Mr. PLAUGHER. They’d shut their doors.

Mr. SHAYS. They would shut their doors?

Dr. O’TOOLE. Absolutely. Security would become a major problem.

At that point, the public health community will come into the

picture. In the recent outbreak of St. Louis encephalitis in New

York, for example, it was an astute clinician who realized she was

seeing two cases of something unusual, called Marcy Layton in the

New York City Health Department. Dr. Layton and her colleagues

came down, talked to the patients and their families to find out if

there was any commonality between these patients. Somewhere in

the course of taking the history of the patients and the public

health investigation, it would probably be determined that everybody who is sick was at the football game, so now we know something happened at the football game.

75

Mr. SHAYS. And, to continue that story, the dead crow in Greenwich, someone noticed it and wondered why and gave it to the examiner, and they found encephalitis there, but that’s—someone

might not have taken that route.

Dr. O’TOOLE. That’s right. So some of this is circumstantial, it is

happenstance, and it is going to vary from situation to situation.

But that points out why awareness among many different kinds of

professionals is so critical.

At that point, the ability of the public health department to come

in and do rapid and accurate epidemiological analyses ask what

was the common feature that unites all of this? OK. Now you’ve got

to get that it was the football game where you think something

happened. Maybe you’ve even diagnosed anthrax by now.

What you have to do now is muster a massive logistic campaign,

get everybody who was at that stadium antibiotics. Once you are

actually ill from anthrax and manifesting symptoms, it is too late

for medicine to save you, so you’ve got to go out and find all 70,000

people, now spread probably all over the world, and get them antibiotics without causing a mass panic.

Mr. SHAYS. Let me just kind of rob this question but ask you

this. Would anthrax with some be like that and with others it could

be a week or two?

Dr. O’TOOLE. Yes.

Mr. SHAYS. OK.

Dr. O’TOOLE. What happens is you inhale the spores of anthrax

into your lungs. They then travel to the lymph nodes in the middle

of your chest, where they germinate, and that’s when they start

causing symptoms.

Mr. SHAYS. That’s how they germinate differently in others?

Dr. O’TOOLE. For different time periods, for reasons we do not

understand.

In the Russian outbreak of anthrax in 1979, which was caused

by an accidental release of anthrax from one of their military facilities, people became symptomatic anywhere from 24 hours to about

40 days afterward.

Mr. SHAYS. You may have already had 300 deaths.

Dr. O’TOOLE. Absolutely.

Mr. SHAYS. I’m prepared to go to the next panel. I mean, we

could keep you here a long time.

Let me just give each of you the last word.

Dr. Johnson.

Dr. JOHNSON. I appreciate the opportunity to go through a brief

scenario like this. I think that highlights the challenges that we

face, and the support we are all going to need from medical care

providers all the way through local and State health departments

to not only detect but to handle situations like this. We look forward to working with you on that.

Mr. SHAYS. Thank you.

Mr. PLAUGHER. Operation of a medical emergency disaster system, which we call ‘‘MEDS’’ is absolutely critical for our Nation. We

have serious needs across the board for health care, and I think

that we need to just simply try to figure out an approach that

makes sense that will make it a consistent funding source and a

consistent approach so that it is uniform, so that as you visit and

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relax and enjoy your vacation some place, you can rest assured that

the community is there to support you and your family’s needs, not

based upon how good a State does or does not approach this concern.

Dr. WAECKERLE. Thank you for the opportunity to be here. There

are a number of challenges which we have identified today, and it

is a multifaceted approach by multidisciplinary personnel.

The only thing I might add to submit to you for your consideration is a current issue of the ‘‘Journal’’ which I serve has devoted

the whole content to this area.

While I know I can’t submit for the record a whole issue of the

‘‘Journal,’’ there are manuscripts written by——

Mr. SHAYS. We’ll submit it for the record.

Dr. WAECKERLE. Thank you.

Then the whole issue of the ‘‘Journal’’ is available to you for your

information and perusal.

Dr. O’TOOLE. Well, I would just reemphasize the need to get the

medical community and hospital leadership in the game, involved

in response preparedness, and also accentuate the critical importance of cooperation and collaboration and the need for resources

to make that happen and, finally, just thank you for your attention.

Mr. SHAYS. Well, thank you all. We appreciate your being here.

Our final panel is comprised of Dr. Robert Knouss, Director, Office of Emergency Preparedness, U.S. Department of Health and

Human Services; and Dr. Scott L. Lillibridge, Director, Bioterrorist

Preparedness Response Program, National Center for Infectious

Disease, Center for Disease Control, Department of Health and

Human Services.

Again, I want to say that I appreciate much that our Federal officials, who traditionally go first, were willing to go second. I think

both doctors realize that it will help us better understand your testimony. So it is appreciated and it is also very beneficial to the

committee.

I will ask you to stand so I can swear you in, as we do all our

witnesses.

[Witnesses sworn.]

Mr. SHAYS. Dr. Knouss, we’ll have you start, and, again, thank

you for your patience.

STATEMENT OF ROBERT F. KNOUSS, M.D., DIRECTOR, OFFICE

OF EMERGENCY PREPAREDNESS, DEPARTMENT OF HEALTH

AND HUMAN SERVICES

Dr. KNOUSS. Thank you very much, Mr. Chairman. I really want

to commend you for holding these hearings. These are some very

important subjects, and obviously, in terms of preparedness of our

country, we are just now beginning, and there is a substantial road

ahead of us as we try to address the issues that you are already

highlighting this morning.

I am Robert Knouss. I direct the Office of Emergency Preparedness. I’m going to try to summarize some of the things that I have

provided in my testimony, and I want to provide a little bit of background.

Presidential Decision Directives 39 and 62 have given the Federal Bureau of Investigation the lead in crisis management and the

77

Federal Emergency Management Agency the lead for consequence

management in the event of the release of a weapon of mass destruction.

The Department of Health and Human Services is the lead for

health and medical preparedness as one aspect of consequence

management, and an annex to FEMA’s Federal response plan describes the role of HHS and other departments and agencies of the

Federal Government in responding to the threat or the actual release of one of these horrific weapons.

I would like to go to some of our approaches at the present time

to preparing our country for being able to address the challenges

of the release of one of these weapons, and I want to mention that

a fundamental truth in emergency preparedness and response is

that all disasters are local. This was emphasized on several occasions by the previous panel.

As a result, our approaches for preparedness and response have

to be part of the developing local and State response resources,

while assuring that the Federal response capabilities are able to

support their efforts.

The detonation of a large bomb or the release of a chemical agent

will have very serious obvious but localized effects. They can

produce mass casualties with severe medical consequences with

high mortality rates.

Health care, to be effective, must be rapid and appropriate. In

other words, there would be an immediate medical, public health,

and environmental emergency. Immediate response would be directed at saving lives and reducing the longer-term health consequences.

Biological weapons, on the other hand, require a different type

of response than that required by chemical weapons, particularly

if the agent is covertly released.

Victims may only recognize the need to seek care days after their

exposure to the biological agent, as was being discussed in the example that you used of the release of anthrax at a football game

in East Lansing.

There would be no readily identifiable incidents and the medical

and public health communities could be challenged with overwhelming demands for curative and preventive treatment to the affected population.

Determining what the agent is, who may have been exposed, and

when, and whether or not the agent is transmissible from person

to person becomes a local challenge with national impact particularly if the agent is contagious.

And, with your permission, Mr. Chairman, I would like to just

use an illustration. I included this chart in the testimony that I

presented to you. I don’t know what the chart number is. I believe

it is chart No. 6 in my testimony.

Basically, it is helpful to try to illustrate the differences between

a chemical and biological weapon, because frequently in our responses and in our response planning we tend to lump these all together as a single kind of response to a terrorist act.

The release of a chemical agent will precipitate a very rapid requirement on our first responder community, as Chief Plaugher

was indicating. Therefore, for chemical weapons in the initial

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stages of the response, mainly the public safety and fire response

communities will be involved for the detection and extraction of victims, for administration of an antidote, for decontamination of victims at the site, for triage of their medical problems, for provision

of primary care at the scene, and for safe transportation to definitive care facilities.

On the other hand, the initial response, when we’re dealing with

a biological agent, is going to fall—the burden is going to fall—on

the public health community. So now we have public safety and

public health communities at the local level that are involved.

On the right-hand side of the chart, I have indicated are really

some of the initial challenges to the public health community, because of the need to be able to detect that an incident has occurred,

if there is a silent release. Much of that can be done through surveillance systems that would be set up and, with the help of enhanced laboratory capability, the causative agent identified.

Then, as part of our response, must be able to offer preventive

health services or prophylaxis in the form of vaccinations or antibiotics for protecting the population that may have been exposed

but has not yet become ill.

Both of these kinds of weapons would create an enormous demand on the health care system.

Mr. SHAYS. Let us just ask a question here.

Dr. KNOUSS. Sure.

Mr. SHAYS. I love to see parallels. It really on the first, the chemical/biological, it is really detection identification would be true for

both?

Dr. KNOUSS. Yes.

Mr. SHAYS. OK. So when I see detection on the right, I could say

detection/identification. So those are two that are similar.

The next thing is extraction of victims in chemical. That would

be the next thing that would happen in chemical.

Dr. KNOUSS. These aren’t necessarily given in the sequence that

they would be happening.

Mr. SHAYS. The administration of antidote, that makes sense.

Decontamination of victims, triage, provision of primary care. I

guess——

Dr. KNOUSS. And all of that would be happening at the scene.

Mr. SHAYS. Eventually with biological you’d see some of the

same. Ultimately, you’d have some provision of primary care.

Dr. KNOUSS. You may or may not, because the incident scene is

going to be very different. Mainly——

Mr. SHAYS. I say eventually.

Dr. KNOUSS. Eventually, yes.

Mr. SHAYS. In other words, it’s almost like I draw a line on the

chemical and biological, and then I can start putting down some of

what I see over chemical. I’m asking, I’m not telling.

Dr. KNOUSS. They really aren’t parallel situations, because in a

chemical release these are going to be happening very rapidly.

Mr. SHAYS. That’s not the question. I’m just asking this. I’m asking if ultimately everything that happens—most everything that

happens with chemical would happen with the biological, it just

wouldn’t happen as soon. Wouldn’t you ultimately transport to a

care facility in the biological?

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Dr. KNOUSS. Yes. Now, yes, that’s essentially what I’m trying to

illustrate at the bottom of this, that both of these events create an

enormous demand on the health care delivery system, the hospital

system.

Mr. SHAYS. OK.

Dr. KNOUSS. And so we really have three communities that are

involved and the level of preparedness has to be enhanced—the

public safety and emergency medical services community, the public health community, and the health services delivery community.

Mr. SHAYS. OK.

Dr. KNOUSS. Frequently, what we forget even in a chemical incident is that there is going to be an enormous demand placed on

the health care delivery system, and if events such as a mustard

exposure occurred, the long-term consequences and the long-term

impact on the health care delivery system is going to be felt for a

year or years to come.

Mr. SHAYS. Thank you.

Dr. KNOUSS. Moving away from this particular illustration of the

fact that we really have the need to be able to emphasize public

safety, public health, and health services response capabilities, I

want to just turn for a moment to our metropolitan medical response systems that were mentioned on several occasions by the

first panel, and that is that in one of these events, the traditional

roles and relationships of emergency organizations are going to be

stressed, obviously.

Mr. SHAYS. This is chart five?

Dr. KNOUSS. This is chart No. 5. Correct.

For an effective response, law enforcement and emergency management and fire, emergency medical services, hospitals, public

health, mental health, environmental organizations, the military,

National Guard, and others must be effectively linked to all levels

of government.

We have been trying to focus attention on increasing the capacity

of local jurisdictions to initiate the response to the release of a

weapons of mass destruction through the creation of metropolitan

medical response systems. To date, we have entered into contracts

with 47 metropolitan jurisdictions in the United States to help

them plan their response to a chemical or a biological weapons release, to increase their pharmaceutical supplies, to equip their first

response personnel, and to train their health care providers. We

hope to be able to do this eventually in 120 large metropolitan

areas around the United States. In fact, the President has included

support for an additional 25 cities in his fiscal year 2000 budget

request.

That gives you a kind of overview of just a few of the issues that

we are trying to deal with.

What I’d like to do in the remaining minute or two that I have

is respond to your request that we try to identify areas requiring

improvement or challenges.

First, I truly believe that we need a greater commitment of participation of the health sector, particularly the hospital community.

That need was illustrated in a variety of the comments that were

made by the first panel.

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The health care systems in most cities are not centrally organized, they are not easily accessible for systems planning, they are

generally unprepared for weapons of mass destruction events, and

they lack incentives to prepare.

Many local communities lack a single public official who has direct authority over hospital preparedness and response, as well as

public health systems. This has made developing comprehensive

systems in cities difficult.

While first responder systems are receiving significant funding,

there is little identified for WMD-related medical response, let

alone hospital facility modifications, equipment, staff, training, and

exercises.

Mr. SHAYS. Why don’t you take each of the ones you want to talk

about, because I think you have, like, five of them, and then just

ad lib on each of those.

Dr. KNOUSS. OK. The second is that linking emergency response,

public safety, mental health, public health, and health care systems will continue to be difficult and will require special attention

if communities are to be effectively organized and prepared to respond to a WMD event.

I say that for a variety of different reasons. Most of our communities have their first responder, their law enforcement and their

fire/EMS organized in fairly similar ways under a public safety

structure, even though there are variations between communities

in that structure, as well. But frequently the health systems fall

outside. Public health systems have very, different organizational

structures throughout the United States.

In some cases, States are responsible for local public health systems; in other States the local public health systems, as in the case

of North Carolina, are largely as we’ve seen during these floods, is

completely independent from State control.

So with the public health structure we have highly variable organizational structures. In the first responder community it is a little

bit different. And to bring them together at the city, metropolitan,

or county level is, indeed, sometimes very challenging.

Third, health care professionals require increased weapons of

mass destruction-related knowledge, skills, and competence, including new credentialling and certificate measures.

Dr. Waeckerle spoke to that issue. I would like to add a few more

comments if the opportunity presents itself during our response.

But suffice it to say that one of the keys that we think exists to

being able to encourage health professionals to seek an education

in the area of treatment of these kinds of exposures during a weapons of mass destruction release is to try to influence the content

of their board certification and licensure examinations.

By doing that, we are going to call more attention to the fact that

self-education and continuing education, as well as curriculum development for their basic professional training and continuing education is a professional responsibility.

We would take the same approach with our hospitals through accreditation standards that might be applied by the Joint Commission for Accreditation of Health Care Organizations.

Building local weapons of mass destruction response systems

through the continued support of metropolitan medical response

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systems is essential and, as I mentioned, we have made a budget

request for continued development of these systems around the

United States.

Finally, I would just mention that we must pursue civilian research solutions to technical scientific gaps and problems related to

weapons of mass destruction detection, prevention, and medical

treatment. Just recently, through support that we have given to

the National Academy of Science’s Institute of Medicine, we have

published a research agenda for the Nation for dealing with what

technological developments are required through the coming years

in order to be able to best ensure the ability of our civilian population to respond.

Mr. SHAYS. That has a better cover than the magazine. [Laughter.]

It looks sinister, at least.

Dr. KNOUSS. That provides a terrific lead-in, but I think I won’t

spend my time on that. But I would like to leave these copies for

the committee.

As I sit here today, Mr. Chairman, in summary, I cannot tell you

that the Nation is prepared to deal with the large-scale medical effects of terrorism, but we are working very diligently to prepare

local medical systems and public health infrastructures to enhance

the national health and medical responses, to provide for a national

pharmaceuticals stockpile, but I want to mention that there is no

silver bullet.

The issues are complex and cross-cutting between various cultures—I talk about that in terms of government cultures—disciplines in the public and private sectors.

The Department of Health and Human Services—I want to reiterate this—our Secretary is committed to assuring that communities across the country are prepared to respond to the health consequences of a weapons of mass destruction.

Again, Mr. Chairman, I want to thank you for this opportunity

to be here.

Mr. SHAYS. Thank you very much.

[The prepared statement of Dr. Knouss follows:]

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Mr. SHAYS. You got me a little concerned when I asked you to

ad lib, because actually the first one you took longer than if you

had read it, so you did a nice job. Thank you.

Dr. Lillibridge, thank you.

STATEMENT OF SCOTT R. LILLIBRIDGE, M.D., NATIONAL CENTER FOR INFECTIOUS DISEASES, CENTERS FOR DISEASE

CONTROL AND PREVENTION, DEPARTMENT OF HEALTH

AND HUMAN SERVICES

Dr. LILLIBRIDGE. Thank you, sir.

I’m Dr. Scott Lillibridge from the Center for Disease Control and

Prevention. I am the Director of the Bioterrorism Preparedness and

Response Program.

I’d like to thank you for the opportunity to be here to discuss enhancing national public health capacities to respond to bioterrorism

and the opportunity to listen to the first panel’s comments.

I will describe the actions that CDC is taking as part of the

DHHS effort to increase public health preparedness, enhance laboratory services, and expand disease surveillance to improve our

Nation’s response to this important issue.

In the past, an attack with a biologic agent was considered very

unlikely; however, now it seems entirely possible.

It is CDC’s responsibility to provide national leadership in the

public health and medical communities in a concerted effort to detect, diagnose, respond to, and prevent illness, including those that

occur as a result of bioterrorism or any other deliberate attempt on

one of our citizens.

In 1998, CDC issued, ‘‘Preventing Emerging Infectious Diseases—’’ with a special cover—‘‘A Strategy for the 21st Century,’’

which describes CDC’s plan for combatting today’s emerging diseases and preventing those of tomorrow.

The plan also emphasizes the need to be prepared for the unexpected, whether it be a naturally occurring event such as a worldwide influenza epidemic, or the deliberate release of anthrax by a

terrorist.

Increased vigilance and preparedness for unexplained and unexpected illnesses are an essential part of the public health effort to

protect the American people against bioterrorism.

To this end, as part of CDC’s overall bioterrorism plan, we are

providing approximately $40 million, through cooperative agreements with States and large metropolitan health departments, to

enhance preparedness and response to such an attack.

Because the initial detection of bioterrorism will most likely

occur at the local level after a period when patients have incubated

the disease, it is essential to educate and train members of the

medical community who may be the first to examine and treat

these victims.

CDC will promote the development of new disease surveillance

networks, which will better link critical care facilities, components

of the emergency medical system, to public health agencies and authorities.

In response to bioterrorism related outbreak, the most likely scenario will be that CDC, the Department of Defense, Department of

Justice, and security agencies will be alerted to the event only after

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State or local health officers, medical practitioners, or other workers in the health sector of identified a cluster of cases or diseases

that are highly unusual and potentially unexplained.

For this reason, CDC will work to provide State and large metropolitan health departments with training, tools, financial resources

for outbreak control and investigations.

To ensure the ready availability of drugs, vaccines, prophylactic

medicines, and chemical antidotes and equipment that might be

needed in a medical response to a biological or chemical terrorist

incident, CDC is working to establish a national pharmaceutical

stockpile to be utilized when necessary and appropriate to contain

the spread of disease in such an outbreak.

In the event of a biological or chemical terrorist attack, rapid diagnosis will be critical so that prevention and treatment measures

can be implemented rapidly.

CDC is providing assistance to State and major metropolitan

health departments to improve capacity to diagnose these agents.

CDC is also working with public health partners, such as the Association of Public Health Laboratories, to implement a network of

laboratories to provide for most immediate and local diagnosis in

the event of a suspected bioterrorism attack.

In order to assure the most effective response to a bioterrorism

event, CDC coordinates and communicates closely with the Department of Justice, FBI, NDPO, and many others in the Federal infrastructure, such as HHS, OAP, FDA, NIH, and FEMA, and many

other partners in this response effort.

Strengthening communication among clinicians, emergency

rooms, infection control practitioners, hospitals, pharmaceutical

companies, and public health personnel is of paramount importance. The health alert network component of the CDC, State and

local preparedness initiative will provide national electronic communications from public health officials working to detect and respond to bioterrorism and other unexplained health threats.

CDC is working to ensure that all levels of the public health

community are prepared to work in coordination with medical and

emergency response communities to address these important

threats.

In conclusion, the best public health method to protect our citizens against the adverse health effects of terrorism is the development, organization, and enhancement of life-saving public health

tools. Expanded laboratory, surveillance, outbreak response, health

communications, and training, and public health preparedness resources at the State and local level are necessary to ensure that we

can respond when the alarm is sounded.

Thank you very much for your attention. I will be happy to answer any questions you may have and am delighted to have this

opportunity to speak. Thank you.

Mr. SHAYS. Thank you very much.

[The prepared statement of Dr. Lillibridge follows:]

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Mr. SHAYS. Mr. Tierney.

Mr. TIERNEY. Thank you, and thank both of you for your testimony.

I just want to revisit an area that we left off after the last panel,

and that is the access and availability of hospital space, emergency

rooms.

Dr. Knouss, I’m sorry I had to step out for 1 second. You may

have covered this. Can you talk a little bit about what is being

done at the national level to encourage the appropriate amount of

planning for emergency and hospital bed space and where do we

go from here on that?

Dr. KNOUSS. That is a very broad question and a very difficult

problem to address currently. What was being described is is that

much of our bed capacity is already taken in the country and we

don’t have the excess, immediately expandable, capacity that we

used to have in the system.

In addition, many hospitals have not seen the need to invest in

being able to be prepared for one of these events. There are a variety of different reasons for that, including the relative increase in

the level of surpluses that are available to health care institutions

and an assessment that is being made, frankly, by many hospital

administrators that this is a very low probability event in their

community; therefore, the justification for spending large amounts

of money in preparation is really not warranted.

The way we are trying to deal with some of these issues is first,

through the education of the health professionals, because, as they

become knowledgeable about what the potential impact of one of

these events might be, they obviously are going to have an influence on how that hospital administrator is going to respond to the

need to prepare.

Second, we’re looking at trying to deal with accreditation requirements, the standards that are going to be applied by the Joint

Commission on Accreditation of Health Care Organizations, to be

able to make some engineering recommendations as to how hospitals can best address the need to be able to protect themselves

and, at the same time, provide access to their facilities during one

of these events.

But, third, we are trying to fortify, strengthen the National Disaster Medical System, which was designed essentially during the

mid-1980’s as part of the contingent military hospital system to

deal with large-scale casualties overseas. If casualties had to be

brought back to the United States in large numbers for health care

here, we would have to be able to expand the capability and distribute part of that health care burden as a shared responsibility

of the entire private hospital system in the United States.

This system was later expanded to include the concept of what

do we do if we have a large California earthquake with 100,000

casualties.

Essentially, it is a system designed to provide for primary care

at the scene of an incident, transportation of mass casualties to distant hospitals, and then provide health care in 100,000 hospital

beds in a system of over 2,000 volunteer hospitals around the

United States managed both by DOD, Federal coordinating centers,

and those of the Department of Veterans’ Affairs. In this system,

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we are able to transport victims for those hospital care and essentially provide access to a far greater number of hospital beds, if

necessary.

Now, that kind of system will function if the incident is concentrated in one geographic area. Obviously, if we’re faced with

something that affects the entire country at the same time, all of

our resources are going to be pressed, and the only alternative that

we would have under those circumstances is temporary expansion

of local hospital capabilities.

Mr. SHAYS. Mr. Allen.

Mr. ALLEN. Thank you both for being here.

I want to talk a little bit about anthrax. Two sorts of questions.

One—let me ask them both, and then you can deal with them in

turn.

Is it possible to say with any degree of certainty that there are

a limited number of biological agents that would be likely to be

used in any incident of terrorism?

If you think about kind of the agent, the way it reacts, its availability, its cost, you know, as a practical matter—I know there

must be hundreds or thousands that are potential, but, as a practical matter, are there a few that we should be concentrating on?

The related question is that I understand that in the Health and

Human Service’s operating plan for anti-bioterrorism there are descriptions of additional funding set aside for research into new vaccines, particularly a new anthrax vaccine. Obviously, this committee has been interested in that whole issue, and the chairman has

held hearings on the Department of Defense anthrax vaccine.

Can you talk to us about what future research is planned and,

in particular, whether we need to develop all sorts of vaccines for

a variety of agents or even all sorts of vaccines for the different

strains of anthrax that could be developed?

Maybe one at a time start with that issue, to the extent you can.

I’d appreciate it.

Dr. LILLIBRIDGE. Sure. I’d be glad to.

I think your question raises the issue of priority, which agents

offer the most opportunities for preparedness or where do we have

the most vulnerabilities.

CDC looked at this issue about 3 months ago as we began to engage in earnest in this area, and came to the conclusion that there

were certain biologic agents for which there were tremendous

vulnerabilities in the public health community in terms of hospital

preparedness, antidotes, stockpile, preparedness, surveillance, and

a whole host of activities.

These biological agents were smallpox, anthrax, plague,

botulinumtoxin, tulauemia, and the agents of viral hemorrhagic

fever.

After looking at the public health impact of a release of these

agents, caucusing with the appropriate intelligence agencies, law

enforcement agencies, Department of Defense, disease experts, and

set about engaging to hone our preparedness effort toward getting

the antidotes, strategies, and programs in place to address we came

to the conclusion that these agents that would have catastrophic

impact were they to be released.

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Mr. ALLEN. Can I just interrupt you and ask a quick followup?

Why smallpox? I would think, No. 1, it would be hard to produce,

and I also assume that everyone over 15, or whatever it is, has

been vaccinated in this country. But maybe I’m wrong.

Female VOICE. Not true.

Mr. ALLEN. Not true? Then that’s part of the answer.

Dr. LILLIBRIDGE. Routine vaccinations for smallpox stopped about

two decades ago or more.

Mr. ALLEN. That long?

Mr. SHAYS. You forgot how long ago you were in school. [Laughter.]

Mr. ALLEN. It was more than two decades ago. [Laughter.]

Dr. LILLIBRIDGE. And, simply put, smallpox exploits unique

vulnerabilities, one, because it has been eradicated. We have no

great degree of immunity in the population. We have limited response capacities. Third, it is contagious by respiratory route, so it

can move from person to person without the help of terrorists.

Mr. ALLEN. Do you want to comment on the need for additional

research for anthrax?

Dr. LILLIBRIDGE. Let me mention a few things.

The Department has looked into that issue and CDC is looking

at recommendations on the use of the anthrax vaccine. We have

partnered with the Advisory Committee on Immunization Practice

[ACIP], the organization that sets the gold standard for immunization practice for the United States, to begin to look at this issue

in earnest.

We have research needs; and, issues related to indications in civilian populations for prophylaxis and the use of first responders.

CDC information from this activity to be forthcoming in the next

2 to 4 months as ACIP begin to look at research that has been unpublished in the past, review the literature, and convenes groups

of experts in that area.

Mr. ALLEN. One quick followup. Is there any effort to look at the

DOD vaccination program that is underway now and use whatever

information? I realize it has been questioned, the information about

side effects or reactions, I should say. Is there any effort to look

at that big pool of people that is now being vaccinated?

Dr. LILLIBRIDGE. That’s a good question, and every effort is going

to be made to look at their research and experience in that area

as part of this effort.

Dr. KNOUSS. I’d just like to add another perspective on anthrax

vaccine, because we tried to address that issue as we were looking

at the research agenda, and anthrax is one of the two vaccines that

we would like to invest some more money in further development.

The difficulty with the current vaccine when we’re talking about

the civilian population, or even parts of the civilian population is

that the current vaccine requires six doses for primary immunization and then annual boosters.

What would be very helpful at this point is to have a vaccine

that only requires one or two doses to establish primary immunity

and, like smallpox, vaccination schedules would only require revaccination on a very long-term basis in order to maintain immunity.

So really what we are talking about, if it were deemed at some

point that we do need to have a wider availability of that vaccine

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and a higher level of immunization within the population, is a vaccine that is a far more patient-friendly than the one we have now.

Mr. ALLEN. Nothing more.

Mr. SHAYS. I’m going to just ask a few questions, and I don’t

think they require a lot of response, but preface it by saying I was

an intern in Washington in 1968 when really the first plane was

hijacked to Cuba, and then you had a rash of planes hijacked for

about 10 years, and we don’t see it happening now. Admittedly, security improved, but still we still see pilots leave their doors open

sometimes when they fly and it doesn’t happen.

The concern, I would think, is not only that—once you had a terrorist attack, it might just open the door, just like these shootings

in schools. All the sudden you start seeing crazy people do crazy

things.

So what most feel, that I speak with in government and outside,

that it is not a matter of would a terrorist attack happen, it is kind

of when and where, and so it is so important that we are talking

about these issues.

In terms of hospital beds, I want to define what is—can we

have—when you go to a hospital, the reason why hospital beds are

expensive is all the support staff. It’s not the room. In fact, I have

a hospital that has a whole floor and they have rooms, but they

don’t have hospital beds.

But in this kind of circumstance, could we actually warehouse

rooms, beds, shut them off, wall them off, and then bring in support staff from around the country? Would that meet the hospital

bed requirement?

Dr. KNOUSS. That is certainly one of the possibilities for some

communities where that kind of excess physical capacity exists but

personnel are not available to operate it.

Mr. SHAYS. Is anyone suggesting that we literally have a whole

hospital floor with nurses and so on who will never be called on

until there is a disease?

Dr. KNOUSS. No. No one is suggesting that. But cities are looking, including New York City at what kind of alternate treatment

facilities could be established as extensions of the capacity of its

public hospital system that could be accessed through the existing

public hospital system in adjacent facilities, that could be readily

converted and staffed in the event that patient care requirements

increased dramatically and very rapidly.

The approach we are taking at the present time, Mr. Chairman,

is asking each community to try to look at the health care alternatives that it has available, because the solution for one community may not be the ideal solution for another community.

Mr. SHAYS. These are very important to ask. I’m just trying to

really visualize what we mean by emergency hospital bed and what

would be required to have that.

Veterans facilities, we need to—I mean, they’re where we don’t

need them in some cases and not where we need them in the populous, but I have a sense that, because these are government facilities, we’d have a little more opportunity here to basically stockpile

pharmaceutical products, maybe stockpile unused bed space.

Dr. KNOUSS. Well, the issue of stockpiling unused bed space has

not come up in any of the conversations that I have participated

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in, but it is an interesting concept, and I think it is necessary to

take a look at that as we’re looking at the total scope of the possibilities for expansion of our capability.

Mr. SHAYS. Is transportation—in this day and age, we can transport sick people and still provide them with care in transit. Is that

accurate?

Dr. KNOUSS. Well, the second idea that we’ve had about addressing that requirement—and we talked to the city of New York about

this—is actually moving out the chronically ill patients so that the

acutely ill patients from one of these incidents might be able to be

put in one of those beds near the scene. The people that have more

stable conditions could be the ones transported out of the——

Mr. SHAYS. Do we need laws to require that that happen to protect hospitals?

Dr. KNOUSS. Without asking that question specifically of our lawyers, I don’t know. I wouldn’t want to answer the question. I think

it is one of the legal issues that we have to look at across the

board, and there are a whole variety of them, including quarantine

laws.

Mr. SHAYS. When I’m sometimes bored when I’m running I think

of absurd circumstances, like literally an embassy that, over the

course of 5 years, they could build a bomb and construct a bomb

and wonder what are the legal requirements, if you were a law enforcement officer, if you would have the right, under extreme circumstances, to enter a building without having a search warrant

and so on if you had to, in event of catastrophe.

I guess my point triggered into that point is, Are we starting to

think of what kind of laws we need now to anticipate events that

could potentially be catastrophic?

Dr. KNOUSS. Yes, we are. In fact, there is a whole subgroup of

one of the National Security Council committees that is looking

specifically at that issue of legal authorities.

Mr. SHAYS. I’m all set to conclude, Dr. Lillibridge, but would you

just have any comments that you would make on the questions I

asked, or is it kind of out of your area?

Dr. LILLIBRIDGE. Thank you. Just a few comments.

On the issue of bed utilization, there are two things that come

up time and time again that we’ve heard from Dr. Johnson and Dr.

O’Toole about the need for local preparedness planning to get considerations of the health people into the disaster management

planning so that there are plans for utilization of this space and

for the rapid development rapidly of additional places that maybe

don’t require hospital level of care. It could be hotels, makeshift

areas, gymnasiums for patients who didn’t require the full range

of system care.

That won’t happen without preparedness planning on bioterrorism at the local level.

Mr. SHAYS. Thank you.

Do you have any final comments you’d like to make?

Dr. KNOUSS. My only observation, Mr. Chairman, is that this is

an enormously challenging area. It requires a level of coordination

to develop our response capabilities that is heretofore unknown,

really, at least in my experience, and I think almost in anyone

else’s that one talks to.

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We have a long way to go yet, and I appreciate very much this

opportunity to be able to share our thoughts.

Thank you.

Mr. SHAYS. Thank you very much.

Dr. LILLIBRIDGE. Thank you, Mr. Chairman.

Just a few closing remarks.

This month is the first month of the initiation of the CDC grants

program to work with States on a cooperative basis. At the end of

this month we will have 50 States enrolled in a preparedness program that will include one of the key areas or all five of the key

areas that we envision, being preparedness, labs, surveillance,

health alert network, and that this effort will need to be sustained

over a period of time as we begin in earnest to ensure preparedness

at a national level.

Thank you.

Mr. SHAYS. Thank you very much.

I notice that Massachusetts shows up a lot, and Connecticut

does. That’s something that’s——

Dr. LILLIBRIDGE. Must be a typo. [Laughter.]

Mr. SHAYS. With that, I’d like to adjourn. Thank you very much.

Dr. LILLIBRIDGE. Thank you, sir.

[Whereupon, at 12:20 p.m., the subcommittee was adjourned, to

reconvene at the call of the Chair.]

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