Testimony

Before the Committee on Veterans' Affairs, House of

Representatives

United States General Accounting Office

GAO

For Release on Delivery

Expected at 2:00 p.m.

Monday, October 15, 2001 HOMELAND SECURITY

Need to Consider VA's

Role in Strengthening

Federal Preparedness

Statement of Cynthia A. Bascetta

Director, Health Care—Veterans'

 Health and Benefits Issues

GAO-02-145T
Page 1 GAO-02-145T

Mr. Chairman and Members of the Committee:

I am pleased to be here as you discuss the impact of the September 11

events on the mission of the Department of Veterans Affairs (VA). As the

Comptroller General recently stated,1

 we at GAO, along with all

Americans, were shocked and saddened by the terrorist attacks last month

on the World Trade Center and the Pentagon. Even before these

catastrophic events, terrorism was the focus of concerted emergency

response preparations by multiple federal agencies. Now, more than ever,

we must keep our attention and vigilance focused on blunting the threat

and consequences of terrorism.

While state and local governments have primary responsibility for

managing the medical and other consequences of a domestic terrorist

incident, the federal government, including VA, plays a key role to

augment the efforts of state and local authorities. Indeed, consequence

management—the measures taken to alleviate the mass damages and

suffering caused by a terrorist incident—has increasing prominence for

federal preparedness as the nation strengthens its strategy for homeland

security. In this regard, one of VA’s health care missions is to provide

backup medical resources to the military health system and communities

following domestic terrorist incidents and other major disasters.

In the wake of the devastating attacks, you asked us to discuss (1) the

activities VA has undertaken in its emergency preparedness role and (2)

VA’s capabilities as the federal government plans for strengthened

homeland security. To do this, we drew on our work on VA’s participation

in federal terrorism preparedness efforts,2

 other GAO reports on

combating terrorism, and our broader work related to VA’s primary health

care mission.

In summary, VA currently plays a supporting role in assisting other

agencies that have lead responsibility for responding to disasters,

including terrorism. In its areas of responsibility—conducting disaster

simulation exercises and maintaining medical stockpiles—VA has taken

steps to enhance national emergency preparedness. Specifically, it has

evaluated disaster simulation exercises to help improve medical response

 1

Homeland Security: A Framework for Addressing the Nation’s Efforts (GAO-01-1158T,

Sept 21, 2001).

2

See related GAO products listed at the end of this statement.
Page 2 GAO-02-145T

procedures and strengthened the security of federal pharmaceutical

stockpiles to ensure rapid response support to local authorities who may

be overwhelmed by terrorist attack.

VA also has resources that could play a role in future federal homeland

security efforts. Its assets include the bricks, mortar, and human capital

components of its health care system, graduate medical education

programs, and expertise involving emergency backup and support

activities. In managing large-scale medical emergencies arising from

terrorist attacks, VA’s emergency response capabilities have strengths and

shortcomings. For example, most VA hospitals and clinics coordinate their

emergency plans with their local communities. On the other hand, like

their community hospital counterparts, VA facilities are less prepared to

treat victims of biological than chemical terrorist attacks. In our view,

determining how VA can best contribute to homeland security is especially

timely, given the extraordinary level of federal activity underway to better

prepare for managing large-scale disasters.

Of VA’s $48.8 billion budget in fiscal year 2001, $20.9 billion was for

carrying out its four health care missions. Its first, most visible health care

mission is to provide medical care for veterans. VA operates a national

health system of hospitals, clinics, nursing homes and other facilities that

provide a broad spectrum of medical, surgical, and rehabilitative care.

More than 3.8 million people received care in VA health care facilities last

year. Under its second mission—to provide education and training for

health care personnel—VA manages the largest medical education and

health professions training program in the United States, training about

85,000 health professionals annually in its medical facilities that are

affiliated with almost 1,400 medical and other schools. Under its third

mission—to conduct medical research—VA funding was about $1.2 billion

in 2000 for over 15,000 medical research projects and related medical

science endeavors.3

VA’s fourth mission—to serve as backup to the Department of Defense

(DOD) health system in war or other emergencies and as support to

communities following domestic terrorist incidents and other major

disasters—has attracted greater congressional interest since the

 3

These funds come from appropriations, pharmaceutical manufacturers, National Institutes

of Health, and foundations.

Background
Page 3 GAO-02-145T

September 11 terrorist attacks in the United States. This role, however, is

not new. Since the early 1980s, when a national system was put in place to

provide for local medical responses when a disaster occurs, VA has been

providing medical support. In fiscal year 2001, less than one-half of 1

percent of VA’s total health care budget, $7.9 million, was allocated to this

mission.4

VA was first formally assigned a federal disaster management role in 1982,

when legislation tasked VA with ensuring the availability of health care for

eligible veterans, military personnel, and the public during military

conflicts and domestic emergencies.5

 In the immediate aftermath of the

September 11 attacks, VA medical facilities in New York, Washington,

D.C., Baltimore, and Altoona, Pennsylvania, were readied to handle

casualties. In prior emergencies, such as hurricanes Andrew and Floyd

and the 1995 bombing of the federal building in Oklahoma City, VA

deployed more than 1,000 medical personnel and provided substantial

amounts of medical supplies and equipment as well as the use of VA

facilities. VA’s role as part of the federal government’s response for

disasters has grown with the reduction of medical capacity in the Public

Health Service and military medical facilities.

VA established an Emergency Management Strategic Healthcare Group

with responsibility for the following six emergency response functions:6

• Ensuring the continuity of VA medical facility operations. Prior to

emergency conditions, VA emergency management staff are responsible

for minimizing disruption in the treatment of veterans by developing,

managing, and reviewing plans for disasters and evacuations and

coordinating mutual aid agreements for patient transfers among VA

facilities. During emergency conditions these staff are responsible for

ensuring that these plans are carried out as intended.

 4

In addition to this amount, in fiscal year 2001, VA received $62 million from the

Department of Health and Human Services (HHS) to support various aspects of HHS

terrorism-related preparedness.

5

The 1982 VA/DOD Health Resources Sharing and Emergency Operations Act (P.L. 97-174)

authorized VA to ensure hospital backup to DOD. At the same time, growing concern about

the lack of a medical response plan for civilians led to a 1984 administrative establishment

of a national medical system that would back up DOD and handle domestic disasters as

well.

6

Formerly, VA’s Emergency Management Preparedness Office had this responsibility.
Page 4 GAO-02-145T

• Backing up DOD’s medical resources following an outbreak of war or

other emergencies involving military personnel. In 2001, VA has plans for

the allocation of up to 5,500 of its staffed operating beds for DOD

casualties within 72 hours of notification.7

 In total, 66 VA medical centers

are designated as primary receiving centers for treating DOD patients. In

turn, these centers must execute plans for early release or movement of

VA patients to 65 other VA medical centers designated as secondary

support centers.

• Jointly administering the National Disaster Medical System (NDMS). In

1984, VA, DOD, the Federal Emergency Management Agency (FEMA), and

the Department of Health and Human Services8

 (HHS) created a federal

partnership to administer and oversee NDMS, which is a joint effort

between the federal and private sectors to provide backup to civilian

health care in the event of disasters producing mass casualties. The system

divides the country into 72 areas selected for their concentration of

hospitals and proximity to airports. Nationwide, more than 2,000 civilian

and federal hospitals participate in the system. One of VA’s roles in NDMS

is to help coordinate VA hospital capacity with the nonfederal hospitals

participating in the system.

• Carrying out Federal Response Plan efforts to assist state and local

governments in coping with disasters. Under FEMA’s leadership, VA and

other agencies are responsible for carrying out the Federal Response

Plan,9

 which is a general disaster contingency plan. As a support agency,

VA is one of several federal agencies sharing responsibility for providing

public works and engineering services, mass care and sheltering, resource

support, and health and medical services. VA is also involved with other

agencies in positioning medical resources at high-visibility public events

requiring enhanced security, such as national political conventions. VA

also maintains a database of deployable VA medical personnel that is

intended to help the agency to quickly locate medical personnel (such as

nurses, physicians, and pharmacists) for deployment to a disaster site.

 7

Annually, VA’s medical centers estimate the number of beds that could be made available

to receive returning military casualties. As of 2001, VA’s plan would provide up to 7,574

beds within 30 days of notification.

8

Within HHS, the Office of Emergency Preparedness is in charge of NDMS activities.

9

The Federal Response Plan is authorized by the Robert T. Stafford Disaster Relief and

Emergency Assistance Act (P.L. 93-288, as amended).
Page 5 GAO-02-145T

• Carrying out Federal Radiological Emergency Response Plan efforts to

respond to nuclear hazards. Depending on the type of emergency involved,

VA is responsible for supporting the designated lead federal agency10 in

responding to accidents at nuclear power stations or terrorist acts to

spread radioactivity in the environment. VA also has its own medical

emergency radiological response team of physicians and other health

specialists. When requested by the lead agency, VA’s response team is

expected to be ready to deploy to an incident site within 12 to 24 hours to

provide technical advice, radiological monitoring, decontamination

expertise, and medical care as a supplement to local authorities’ efforts.

• Supporting efforts to ensure the continuity of government during national

emergencies. VA maintains the agency’s relocation site and necessary

communication facilities to continue functioning during a major national

emergency.

In addition to these functions, VA plays a key support role in the nation’s

stockpiling of pharmaceuticals and medical supplies in the event of largescale disasters caused by weapons of mass destruction (WMD).11 These

stockpiles are critical to the federal assistance provided to state and local

governments should they be overwhelmed by terrorist attack. Under a

memorandum of agreement between VA and HHS’ Office of Emergency

Preparedness (OEP), VA maintains at designated locations medical

stockpiles containing antidotes, antibiotics, and medical supplies and

smaller stockpiles containing antidotes, which can be loaned to local

governments or predeployed for special events, such as the Olympic

Games. In fiscal year 2001, OEP reimbursed VA $1.2 million for the

purchase, storage, and maintenance of the pharmaceutical stockpiles.

VA also maintains stockpiles of pharmaceuticals for another HHS agency,

the Centers for Disease Control and Prevention (CDC). Under contract

with CDC, VA purchases drugs and other medical items and manages a

spectrum of contracts for the storage, rotation, security, and

transportation of stockpiled items. VA maintains the inventory of

pharmaceutical and medical supplies called “12-hour push packages,”

 10For example, the Nuclear Regulatory Commission is the lead agency for an emergency

that occurs at a nuclear power plant. In other circumstances, the Department of Energy or

the Environmental Protection Agency could be the lead federal agency.

11The term weapons of mass destruction refers to chemical, biological, radiological, nuclear

agents or weapons, and large conventional explosives.
Page 6 GAO-02-145T

which can be delivered to any location in the nation within 12 hours of a

federal decision to deploy them. It also maintains a larger stock of

antibiotics, antidotes, other drugs, medical equipment, and supplies

known as vendor-managed inventory12 that can be deployed within 24 to 36

hours of notification. In fiscal year 2001, CDC contracts included an

estimated $60 million to reimburse VA for its purchasing and management

activities associated with the stockpiles, including the cost of medical

items.13

Consistent with the agency’s fourth health care mission, VA operates as a

support rather than command agency under the umbrella of several

federal policies and contingency plans for combating terrorism.14 Its direct

emergency response activities include conducting and evaluating terrorist

attack simulations to develop more effective response procedures and

maintaining the inventories for stockpiled pharmaceuticals and medical

supplies.

Our prior work on federal coordination of efforts to combat terrorism

found that VA led many disaster response simulation exercises and

conducted follow-up evaluations.15 These exercises are an important part

of VA’s efforts to prepare for catastrophic terrorist attacks. The exercises

test and evaluate policies and procedures, test the effectiveness of

response capabilities, and increase the confidence and skill level of

personnel. Those exercises held jointly with other federal, state, and local

agencies facilitate the planning and execution of multiagency missions and

help identify strengths and weaknesses of interagency coordination.

 12These vendor-managed inventories are carried on the manufacturers’ inventory records as

either “government owned” or “government reserved” and may be rotated with the vendor’s

normal operating stock in order to ensure freshness. The 12-hour push packages comprise

approximately 20 percent of the stockpile; the vendor-managed inventory comprises the

remaining 80 percent.

13CDC has been working with VA since 1999 to build its stockpiles. In addition to the fiscal

year 2001 funds, CDC received $51 million in fiscal year 1999 and $52 million in fiscal year

2000 for purchasing items for the stockpiles.

14For a compendium of relevant policy and planning documents, see Combating Terrorism:

Selected Challenges and Related Recommendations (GAO-01-822, Sept. 20, 2001).

15See Combating Terrorism: Federal Response Teams Provide Varied Capabilities:

Opportunities Remain to Improve Coordination (GAO-01-14, Nov. 30, 2000).

VA Has Taken Steps

to Enhance Federal

Emergency

Management

Preparedness

VA Has Conducted and

Evaluated Disaster

Simulation Exercises
Page 7 GAO-02-145T

VA has sponsored or participated in a variety of exercises to prepare for

combating terrorism, including those involving several federal agencies

and WMD scenarios. In addition, VA participates in numerous other

disaster-related exercises aimed at improving its consequence

management capabilities. The following are examples of terrorism-related

exercises in which VA has participated.

• In March 1997, in conjunction with the state of Minnesota, VA participated

in the “Radex North” exercise in Minneapolis, which simulated a terrorist

attack on a federal building. The attack involved simulated explosives

laced with radioactive material, requiring the subsequent decontamination

and treatment of hundreds of casualties. One of the objectives was to test

the capabilities of VA’s radiological response team. The exercise had 500

participants and was designed to integrate the federal medical response

into the state and local response, including local hospitals.

• In July 1997, VA participated in “Terex ‘97” in Nebraska. The exercise’s

main objectives were to provide federal and state public health agencies

with integrated training in disaster response and to assess coordination

among federal, state, and local agencies for responding to a catastrophic,

mass-casualty incident. The VA hospital in Lincoln provided bed space for

mock casualties wounded by simulated conventional explosives. In

addition, VA management staff worked with other federal, state, and local

health care officials to coordinate emergency response efforts.

• In May 1998, VA, DOD, and HHS cosponsored “Consequence Management

1998” in Georgia. The 2-day exercise trained and evaluated federal medical

response team personnel in emergency procedures for responding to a

WMD attack. In organizing the event, VA’s radiological response team

worked with the Marine Corps’ special response force to decontaminate

mock casualties. The VA medical center in Augusta supplied logistics

support, including stockpiled pharmaceuticals.

• In May 1999, VA sponsored “Catex ‘99” in Minnesota. Over 80 groups

representing federal, state, and local governments, the military, volunteer

organizations, and the private sector worked with VA to train for a masscasualty WMD incident. In a scenario depicting simultaneous chemical

weapons attacks throughout the Twin Cities region, VA activated and

oversaw an emergency operations center, which coordinated response

efforts, including simulated casualty evacuations to hospitals in Detroit,

Cleveland, Milwaukee, and Des Moines.
Page 8 GAO-02-145T

• In May 2000, VA participated in “Consequence Management 2000” in

Georgia. Developed jointly by VA, DOD, HHS, and various state and local

agencies, the exercise trained federal emergency personnel in procedures

and techniques for responding to a WMD attack. The event also served to

familiarize federal, state, and local agencies with the U.S. Army Reserves’

role in the event of a catastrophic terrorist incident. Simulating a masscasualty terrorist attack in Georgia, VA emergency response teams

performed triage and decontaminated patients exposed to chemical and

radiological agents. Several VA medical centers in Georgia, Alabama, and

South Carolina provided care to simulated serious casualties.

• In May 2000, VA participated in “TOPOFF 2000,” a national, “no-notice”

exercise designed to assess the ability of federal, state, and local agencies

to respond to coordinated terrorist attacks involving WMD. The event was

the largest peace-time terrorism exercise ever sponsored by the

Department of Justice and FEMA, and incorporated three main crisis

simulations: a radiological scenario in Washington, D.C.; a chemical

scenario in New Hampshire; and a biological scenario in Colorado. VA

provided consequence management support to other federal agencies,

identified hospital bed space for potential casualties, and dispatched

medical personnel to various locations. VA also placed its radiological

response team on alert.

VA also conducts follow-up evaluations of these simulation exercises.

Evaluations typically include, among other things, operational limitations,

identified strengths and weaknesses, and recommended actions. Our work

shows that VA has a good record of evaluating its participation in these

exercises. The evaluations generally discuss interagency issues and are

disseminated within VA. Among the favorable findings from VA’s reviews

were that emergency personnel were activated quickly and were deployed

to incident sites fully equipped and prepared; personnel demonstrated

high levels of motivation and technical expertise; and interaction among

federal, state, and local personnel and between civilian and military

counterparts was positive. The reviews also identified the following

concerns:

• On-site medical personnel experienced communications problems due to

incompatible equipment.

• Communication between headquarters and field offices was at times

hindered by an over-reliance on a single means of communication.

• Unclear standards and inadequate means for reporting available bed space

also posed problems.
Page 9 GAO-02-145T

• Caregivers sometimes had difficulty tracking patients as they progressed

through on-site treatment stages.

• Incident-site security was a recurrent concern, especially with respect to

decontamination controls.

We have made a number of recommendations to federal lead and support

agencies to improve such interagency exercises and follow-up evaluations,

including the dissemination of evaluation results across agencies.16

VA has improved the internal controls and inventory management of

several medical supply stockpiles it maintains for OEP and CDC to

address previously identified deficiencies. VA is responsible for the

purchase, storage, and quality control of thousands of stockpile supply

items. It maintains stockpiles at several sites around the country for

immediate use by federal agency teams staffed with specially trained

doctors, nurses, other health care providers, and emergency personnel

whose mission is to decontaminate and treat victims of chemical and

biological terrorist attacks. In 1999, we found that VA lacked the internal

controls to ensure that the stockpiled medical supplies and

pharmaceuticals were current, accounted for, and available for use. 17

However, our recent work shows that VA has taken significant corrective

actions in response to our recommendations that have resulted in

reducing inventory discrepancy rates and improved accountability.18

At the same time, we have recommended additional steps that, VA, in

concert with OEP and CDC, should take to further tighten the security of

the nation’s stockpiles. These include finalizing and implementing

approved operating plans and ensuring compliance with these plans

through periodic quality reviews. VA supports these recommendations and

is taking action with OEP and CDC to implement them.

 16See GAO-01-822.

17Combating Terrorism: Chemical and Biological Supplies Are Poorly Managed

(GAO/HEHS/AIMD-00-36, Oct. 29, 1999).

18Combating Terrorism: Accountability Over Medical Supplies Needs Further Improvement

(GAO-01-463, Mar. 30, 2001).

VA Has Improved

Inventory Management of

Medical Stockpiles
Page 10 GAO-02-145T

VA has significant capabilities related to its four health care missions that

have potential applicability for the purpose of homeland security. At the

same time, it is clear that some of these capabilities would need to be

strengthened. How best to employ and enhance this potential will be

determined as part of a larger effort currently underway to develop a

national homeland security strategy. As the Comptroller General recently

noted, this broad strategy will require partnership with the Congress, the

executive branch, state and local governments, and the private sector to

minimize confusion, duplication of effort, and ineffective alignment of

resources with strategic goals. It will also require a systematic approach

that includes, among other elements, ensuring the nation’s ability to

respond to and mitigate the consequences of an attack.

In this regard, VA has a substantial medical infrastructure of 163 hospitals

and more than 800 outpatient clinics strategically located throughout the

United States, including the largest pharmaceutical and medical supply

procurement systems in the world and a nationwide register of skilled VA

medical personnel. In addition, VA operates a network of 140 treatment

programs for post-traumatic stress disorder and is recognized as the

leading expert on diagnosing and treating this disorder.

VA holds other substantial health system assets. For example, the agency

has well-established relationships with 85 percent of the nation’s medical

schools. According to VA, more than half of the nation’s medical students

and a third of all medical residents receive some of their training at VA

facilities. In addition, more than 40 other types of health care

professionals, including specialists in medical toxicology and occupational

and environmental medicine, receive training at VA facilities every year. In

recent years, VA expanded physician training slots in disciplines

associated with WMD preparedness.

In 1998, several government agencies, including VA, contributed to a

presidential report to the Congress on federal, state, and local

preparations and capability to handle medical emergencies resulting from

WMD incidents.19 The report outlined both strengths and weaknesses in

regard to VA’s emergency response capabilities. The report noted the

potential for VA to augment the resources of state and local responders

 19The report, Preparations for a National Response to Medical Emergencies Arising from

Terrorists’ Use of Weapons of Mass Destruction, was required by the Veterans Benefits Act

of 1997 (P.L. 105-114), and submitted by the President to the Congress in July 1998.

Considering VA’s

Strengths and

Limitations Important

in Planning for

Homeland Security
Page 11 GAO-02-145T

because more than 80 percent of VA hospital emergency plans are

included in the local community emergency response plan. However, the

report also noted that

• VA hospitals do not have the capability to process and treat mass

casualties resulting from WMD incidents.

• VA hospitals and most private sector medical facilities are better prepared

for treating injuries resulting from chemical exposure than those resulting

from biological agents or radiological material.

• VA hospitals, like community hospitals, lack decontamination equipment,

routine training to treat mass casualties, and adequate on-hand medical

supplies.

Currently, VA’s budget authority does not include funds to address these

shortcomings.

Myriad federal efforts are underway to strengthen the nation’s ability to

prevent and mitigate the consequences of terrorism. Consideration of what

future role VA may assume in coordination with its federal partners in

consequence management is an important element. Currently, the agency,

in a supporting role, makes a significant contribution to the emergency

preparedness response activities carried out by lead federal agencies.

Expanding this role in response to stepped up homeland security efforts

may be deemed beneficial but would require an analysis of the potential

impact on the agency’s health care missions, the resource implications for

VA’s budget, and the merits of enhancing VA’s capabilities relative to other

federal alternatives.

Mr. Chairman, this completes my prepared statement. I would be happy to

respond to any questions you or other Members of the committee may

have.

For more information regarding this testimony, please contact me at (202)

512-7101. Stephen L. Caldwell, Hannah F. Fein, Carolyn R. Kirby, and Paul

Rades also made key contributions to this statement.

Concluding

Observations

Contact and

Acknowledgments
Page 12 GAO-02-145T

Bioterrorism: Public Health and Medical Preparedness (GAO-02-141T, Oct.

9, 2001).

Bioterrorism: Federal Research and Preparedness Activities (GAO-01-915,

Sept. 28, 2001).

Combating Terrorism: Selected Challenges and Related Recommendations

(GAO-01-822, Sept. 20, 2001).

Homeland Security: A Framework for Addressing the Nation’s Efforts

(GAO-01-1158T, Sept. 21, 2001).

Combating Terrorism: Accountability Over Medical Supplies Needs

Further Improvement (GAO-01-463, Mar. 30, 2001).

Combating Terrorism: Federal Response Teams Provide Varied

Capabilities; Opportunities Remain to Improve Coordination (GAO/01-14,

Nov. 30, 2000).

Combating Terrorism: Chemical and Biological Medical Supplies Are

Poorly Managed (GAO/HEHS/AIMD-00-36, Oct. 29, 1999).

Combating Terrorism: Analysis of Federal Counterterrorist Exercise

(GAO/NSIAD-99-157BR, June 25, 1999).

(290134)

Related GAO Products