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[House Hearing, 109 Congress]
[From the U.S. Government Publishing Office]

 
                   PROTECTING THE HOMELAND: FIGHTING 
                   PANDEMIC FLU FROM THE FRONT LINES 
=======================================================================
                             JOINT HEARING

                               before the

      SUBCOMMITTEE ON PREVENTION OF NUCLEAR AND BIOLOGICAL ATTACK

                             joint with the

                       SUBCOMMITTEE ON EMERGENCY
                 PREPAREDNESS, SCIENCE, AND TECHNOLOGY

                                 of the

                     COMMITTEE ON HOMELAND SECURITY
                        HOUSE OF REPRESENTATIVES

                       ONE HUNDRED NINTH CONGRESS

                             SECOND SESSION

                               __________

                            FEBRUARY 8, 2006

                               __________

                           Serial No. 109-61

                               __________

       Printed for the use of the Committee on Homeland Security
                                     
                   [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
                                     

  Available via the World Wide Web: http://www.gpoaccess.gov/congress/
                               index.html

                               __________

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36-035 PDF                 WASHINGTON DC:  2007
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                     COMMITTEE ON HOMELAND SECURITY

                   Peter T. King, New York, Chairman

Don Young, Alaska                    Bennie G. Thompson, Mississippi
Lamar S. Smith, Texas                Loretta Sanchez, California
Curt Weldon, Pennsylvania            Edward J. Markey, Massachusetts
Christopher Shays, Connecticut       Norman D. Dicks, Washington
John Linder, Georgia                 Jane Harman, California
Mark E. Souder, Indiana              Peter A. DeFazio, Oregon
Tom Davis, Virginia                  Nita M. Lowey, New York
Daniel E. Lungren, California        Eleanor Holmes Norton, District of 
Jim Gibbons, Nevada                  Columbia
Rob Simmons, Connecticut             Zoe Lofgren, California
Mike Rogers, Alabama                 Sheila Jackson-Lee, Texas
Stevan Pearce, New Mexico            Bill Pascrell, Jr., New Jersey
Katherine Harris, Florida            Donna M. Christensen, U.S. Virgin 
Bobby Jindal, Louisiana              Islands
Dave G. Reichert, Washington         Bob Etheridge, North Carolina
Michael T. McCaul, Texas             James R. Langevin, Rhode Island
Charlie Dent, Pennsylvania           Kendrick B. Meek, Florida
Ginny Brown-Waite, Florida

                                 ______

      SUBCOMMITTEE ON PREVENTION OF NUCLEAR AND BIOLOGICAL ATTACK

                     John Linder, Georgia, Chairman

Don Young, Alaska                    James R. Langevin, Rhode Island
Christopher Shays, Connecticut       EdwarD J. Markey, Massachusetts
Daniel E. Lungren, California        Norman D. Dicks, Washington
Jim Gibbons, Nevada                  Jane Harman, California
Rob Simmons, Connecticut             Eleanor Holmes Norton, District of 
Bobby Jindal, Louisiana              Columbia
Charlie Dent, Pennsylvania           Donna M. Christensen, U.S. Virgin 
Peter T. King, New York (Ex          Islands
Officio)                             Bennie G. Thompson, Mississippi 
                                     (Ex Officio)

                                 ______

     SUBCOMMITTE ON EMERGENCY PREPAREDNESS, SCIENCE, AND TECHNOLOGY

                 Dave G. Reichert, Washington, Chairman

Lamar S. Smith, Texas                Bill Pascrell, Jr., New Jersey
Curt Weldon, Pennsylvania            Loretta Sanchez, California
Rob Simmons, Connecticut             Norman D. Dicks, Washington
Mike Rogers, Alabama                 Jane Harman, California
Stevan Pearce, New Mexico            Nita M. Lowey, New York
Katherine Harris, Florida            Eleanor Holmes Norton, District of 
Michael McCaul, Texas                Columbia
Charlie Dent, Pennsylvania           Donna M. Christensen, U.S. Virgin 
Ginny Brown-Waite, Florida           Islands
Peter T. King, New York (Ex          Bob Etheridge, North Carolina
Officio)                             Bennie G. Thompson, Mississippi 
                                     (Ex Officio)

                                  (II)

                            C O N T E N T S

                              ----------                              
                                                                   Page

                               STATEMENTS

The Honorable John Linder, a Representative in Congress From the 
  State of Georgia, and Chairman, Subcommittee on Prevention of 
  Nuclear and Biological Attack..................................     1
The Honorable James L. Langevin, a Representative in Congress 
  From the State of Rhode Island, and Ranking Member, 
  Subcommittee on Prevention of Nuclear and Biological Attack....     2
The Honorable Dave Reichert, a Representative in Congress From 
  the State of Washington, and Chairman, Subcommittee on 
  Emergency Preparedness, Science, and Technology................     4
The Honorable Bill Pascrell, Jr., a Representative in Congress 
  From the State of New Jersey, and Ranking Member, Subcommittee 
  on Emergency Preparedness, Science, and Technology.............     5
The Honorable Bennie G. Thompson, a Representative in Congress 
  From the State of Mississippi, and Ranking Member, Committee on 
  Homeland Security..............................................     6
The Honorable Donna M. Christensen, a Delegate in Congress From 
  the U.S. Virgin Islands........................................    50
The Honorable Bob Etheridge, a Representative in Congress From 
  the State North Carolina.......................................    52
The Honorable Nita M. Lowey, a Representative in Congress From 
  the State if New York..........................................    57
The Honorable Edward J. Markey, a Representative in Congress From 
  the State of Massachusetts.....................................    59
The Honorable Eleanor Holmes-Norton, a Delegate in Congress From 
  the District of Columbia.......................................    55

                               Witnesses

Mr. Ernest Blackwelder, Senior Vice President, Business Force, 
  Business Executive for National Security:
  Oral Statement.................................................    30
  Prepared Statement.............................................    32
The Honorable David B. Mitchell, Secretary, Department of Safety 
  and Homeland Security, State of Delaware:
  Oral Statement.................................................    16
  Prepared Statement.............................................    18
Ms. Frances B. Phillips, RN, MHA, Health Officer, Anne Arundel 
  County, Maryland Department of Health:
  Oral Statement.................................................    23
  Prepared Statement.............................................    26
Dr. David C. Seaberg, Department of Emergency Medicine, 
  University of Florida:
  Oral Statement.................................................    36
  Prepared Statement.............................................    38
Dr. Tara O'Toole, Chief Executive Officer and Director, Center 
  for Biosecurity, University of Pittsburgh Medical Center:
  Oral Statement.................................................     8
  Prepared Statement.............................................    11

  PROTECTING THE HOMELAND: FIGHTING PANDEMIC FLU FROM THE FRONT LINES

                              ----------                              

                      Wednesday, February 8, 2006

             u.s. House of Representatives,
                    Committee on Homeland Security,
              Subcommittee on Prevention of Nuclear
                             and Biological Attack,
                                     joint with the
                    Subcommittee on Emergency Preparedness,
                                   Science, and Technology,
                                                    Washington, DC.
    The subcommittees met, pursuant to call, at 2:11 p.m., in 
Room 2237, Rayburn House Office Building, Hon. John Linder 
[chairman of the Subcommittee on Prevention of Nuclear and 
Biological Attack] presiding.
    Present: Representatives Linder, Reichert, Rogers, Dent, 
Langevin, Pascrell, Thompson, Markey, Lowey, Norton, 
Christensen, and Etheridge.
    Mr. Linder. [Presiding.] The Committee on Homeland 
Security's Subcommittee on Prevention of Nuclear and Biological 
Attack and the Subcommittee on Emergency Preparedness, Science 
and Technology will come to order.
    The subcommittees are meeting today to hear testimony on 
protecting the homeland in fighting pandemic flu on the 
frontlines. I would like to welcome and thank our distinguished 
panel of witnesses for appearing today before this joint 
hearing of these two subcommittees.
    Imagine this scenario. On September 29, seven deaths were 
reported in Washington. By October 2, there had been a total of 
35. By the middle of October, 60 to 90 people were dying each 
day.
    By then, the city's commissioners had taken drastic steps, 
first closing the schools, then prohibiting any large indoor 
public gatherings, including church services. The Red Cross 
nurses were caring for the sick, who were flooding area 
hospitals, or worse, suffering unattended in their homes. 
Disposal of bodies became a particular problem. On October 12, 
the U.S. Capitol shut its door to visitors.
    Ladies and gentlemen, this is an account of life in the 
fall of 1918 here in Washington, D.C., reported in The 
Washington Post. The United States, like most of the rest of 
the world, was gripped with a pandemic of Spanish influenza. 
With over 50 million deaths worldwide, it was the third-largest 
epidemic in recorded history, and the largest since the Middle 
Ages.
    Today, the possibility exists that the world may face yet 
another deadly outbreak, this time from an avian influenza 
strain known as H5N1. While the virus has not yet evolved into 
a form easily transmissible between humans, should it acquire 
that capability, it is similar to the 1918 pandemic. Estimates 
show that between 30 million and 384 million people worldwide 
would be afflicted.
    To combat this potentially devastating scenario, President 
Bush announced on November 1 of last year a national strategy 
for pandemic influenza, which provides a framework for U.S. 
government planning efforts.
    The goals of the national strategy are: first, to stop, 
slow or otherwise limit the spread of a pandemic to the United 
States; second, to limit the domestic spread of a pandemic and 
mitigate disease, suffering and death; and third, to sustain 
infrastructure and mitigate the impact of a pandemic to the 
economy and society.
    I look forward to working with the executive branch to 
implement this initiative in the coming months.
    The national strategy recognizes, however, that preparing, 
implementing and responding to a pandemic cannot be viewed as a 
purely federal responsibility. Our nation must have a system in 
place at all levels of government and all sectors of society to 
address the pandemic threat.
    Medical countermeasures such as vaccines and antiviral 
drugs are vital. At present, the strategic national stockpile 
only has approximately 3 million bulk courses of an unfinished 
H5N1 vaccine. The vaccine has not even yet been filled in 
vials. Antivirals like Tamiflu are limited as well. There are 
only enough doses on hand to cover about 1 percent of the U.S. 
population.
    Furthermore, effectiveness of the H5N1 vaccine and 
antiviral drugs in preventing and mitigating the effects of the 
strain of the influenza that sparks a pandemic are unknown. In 
the absence of an effective vaccine or antiviral, nonmedical 
countermeasures and intervention strategies are critical.
    Surveillance and early warning systems are essential tools 
for the non-medical-based pandemic strategy that will afford us 
more time to intervene and implement control measures to 
mitigate the virus' spread.
    Strengthening our public health infrastructure will 
increase our ability to identify, diagnose and treat those 
needing care, deliver information quickly to those local, state 
and national health officials and physicians to be of most 
help, as well as improve our overall surge capacity.
    Extending efforts to most of these areas will certainly not 
be a waste. It will instead provide benefits beyond preventing 
and preparing for and responding to an influenza pandemic. 
Clearly, if we are successful in implementing these strategies, 
our nation will be better equipped to face the threat of 
biological terrorism.
    I am now pleased to yield for an opening statement to my 
friend from Rhode Island, Mr. Langevin.
    Mr. Langevin. Thank you, Mr. Chairman.
    I would like to welcome our witnesses here today.
    This hearing is on a very important topic. Influenza 
pandemic is looming, and we need to know how prepared we are.
    Just a few months ago, Hurricanes Katrina and Rita struck 
the Gulf Coast. Response on nearly every level was disgraceful. 
In the case of these hurricanes, we had several days of 
warning. We should have been better prepared and ready to 
respond.
    In the case of a potential avian flu outbreak, we have 
already had at least 1 year of warning and we probably have at 
least another year to get ready. There really is no excuse for 
failing to be prepared.
    The Spanish flu epidemic of 1918 to 1920 is believed by the 
CDC and other health experts to be a similar model of what we 
can expect in an H5N1 outbreak. The Spanish flu killed 
approximately 675,000 Americans and more than 20 million people 
around the world.
    Based on such a model, an epidemic of H5N1 avian influenza 
could cause nearly 2 million deaths in the U.S. and up to 300 
million deaths worldwide. That epidemic was nearly 90 years 
ago. Our knowledge of viruses has increased dramatically and we 
have many more tools at our disposal.
    Last month, Secretary Leavitt was in Rhode Island to 
promote the administration's response plan. While I appreciate 
the fact that he is reaching out to states early, the message 
from the meeting was that states need to fight the pandemic on 
their own, with minimal federal assistance. Well, the flu does 
not abide by state lines. We need a well-coordinated national 
response if we are to be successful in slowing the spread of 
disease and saving the lives of Americans.
    Our goals must be realistic. We will not be able to keep 
avian flu from our shores if it is to mutate into easy human-
to-human transmission. Unfortunately, people will get sick and 
many could die. We must control the spread of the disease 
enough to ensure that our health care system is not overwhelmed 
and that our economy is not crippled.
    I am concerned that the president's national strategy on 
pandemic influenza could fail us because it puts too much 
emphasis on vaccines and antivirals. The national strategy, 
which was released in November, proposes $7.1 billion to 
prepare for avian flu, 85 percent of which is focused on 
vaccines and antivirals that the U.S. does not currently have 
the capacity to produce.
    At the same time, the national strategy provides only $251 
million to detect and contain outbreaks and $644 million to 
ensure that all levels of government are prepared to respond to 
a pandemic outbreak. Even if cell-based vaccine production 
technology were available today, the time from virus isolation 
to vaccine production would be approximately 6 months. During 
that time, no vaccine would be available. Using the present 
technology, it would take between 14 to 18 months to 
manufacture a vaccine.
    An antiviral such as a Tamiflu will present a slightly more 
optimistic story because they can be produced today. However, 
the production process is difficult and takes approximately 6 
to 8 months. Moreover, Tamiflu only treats the symptoms of the 
flu, rather than preventing the spread of the virus, and it 
must be taken within a few days of initial infection in order 
to have any effect at all.
    I am interested to hear from our witnesses today if they 
feel the president's plan is a good one, or if they agree that 
it relies too much upon drugs and not enough on simple public 
health practices such as hand washing and limiting social 
contact. We know that these methods, if practiced correctly, 
can be effective.
    I know that people such as our witnesses are trying their 
best to prepare for a pandemic. One thing that would be 
important is consistent and steady leadership, though, from the 
federal government.
    I am concerned that the national response plan might not be 
executed properly because the White House and the Department of 
Health and Human Services have created separate plans and 
people do not know which plan to follow. So I am interested to 
hear to whom you are looking to for guidance, and what kind of 
leadership and cooperation you are receiving from the 
Department of Homeland Security, as well as the Department of 
Health and Human Services.
    Ladies and gentlemen, right now, we have time to do what is 
right, and to do this right overall in terms of response and 
our planning. I am pleased to see that we are taking oversight 
responsibility seriously by ensuring that we are prepared.
    Mr. Chairman, I want to commend you for convening this 
hearing today.
    Thank you very much, Mr. Chairman. I yield back my time.
    Mr. Linder. I thank the gentleman.
    The Chair now recognizes the chairman of the Subcommittee 
on Emergency Preparedness, Science and Technology, the 
gentleman from Washington, Mr. Reichert, for the purpose of 
making an opening statement.
    Mr. Reichert. Thank you, Mr. Chairman.
    Welcome. Thank you for taking time out of your schedules to 
be with us this afternoon. I am looking forward to hearing from 
you. We appreciate your appearance before us today at this 
joint hearing on our nation's preparedness to deal with a 
potential avian flu pandemic.
    Before we start, I would like to commend my colleagues, 
Chairman John Linder and Ranking Member Jim Langevin on the 
Subcommittee on Prevention of Nuclear and Biological Attack, 
for their hard work on this complex and pressing issue. I 
appreciate your willingness to hold this joint hearing with the 
Subcommittee on Emergency Preparedness, Science and Technology, 
which I chair with the able assistance of my good friend Mr. 
Pascrell.
    As a former sheriff from the Seattle area, I approach this 
issue from the perspective of a first responder. Avian flu may 
never strike the United States, but if it does, this country 
must be prepared. Pandemics affect every sector of our society, 
not just our nation's health care system. It has the potential 
to severely disrupt our way of life, cause devastating loss of 
life, and have staggering effects on the international economy.
    As usual, we will rely heavily on the nation's law 
enforcement, firefighters, emergency medical services and other 
health service workers to serve on the frontlines at grave 
risk. These dedicated, caring men and women will not only be 
required to care for the sick. They will also be required to 
ensure the continuation of essential services, maintain public 
order, distribute drugs and medical supplies, food, water and 
enforce quarantines and isolations.
    Given the unique nature of a pandemic, the federal 
government will not be able to respond to every hot spot. 
Unlike a natural disaster, even one as catastrophic as 
Hurricane Katrina, a pandemic knows no geographical or temporal 
bounds. It can spread around the globe in the course of months 
or years, usually in waves, and affect communities of all sizes 
and compositions.
    That is precisely why our nation needs to ensure that every 
level of government is adequately prepared. It is my hope that 
this hearing will give the subcommittees a better sense of 
state and local government and private sector pandemic flu 
preparedness and how the federal government can support such 
efforts.
    I want to thank again the witnesses for their testimony 
today, and our colleagues on the Prevention Subcommittee for 
holding this joint hearing with us. Thanks.
    Mr. Linder. I thank the gentleman.
    The Chair now recognizes the ranking minority member of the 
Subcommittee on Emergency Preparedness, Science and Technology, 
the gentleman from New Jersey, Mr. Pascrell, for the purpose of 
making an opening statement.
    Mr. Pascrell. Thank you, Mr. Chairman.
    I want to preface my remarks, my opening statement with 
some questions I would ask the panel, and thank you for your 
service to your country.
    I want to preface the following questions. We know that the 
national response plan declares that the Department of Homeland 
Security is the lead agency, and that the Secretary of Homeland 
Security is the principal federal officer if an incident of 
national significance is declared. Do you have clear lines of 
communication with the department so that you will know what 
the Secretary is advising in such a case?
    My next question--and you are going to have your testimony, 
but I would like you to keep this in mind when you are 
presenting it. From all we have seen so far, the 
administration's national strategy for pandemic influenza is 
highly tilted towards pharmacological countermeasures, vaccines 
and antivirals, and 85 percent of the funding requested in 
support of the plan goes to these measures. Do you agree with 
that approach?
    And finally, what do you feel is the proper role for the 
federal government in providing resources for pandemic 
preparedness and response? What are your expectations from us?
    I want to thank Chairman Linder and Chairman Reichert for 
holding the hearing. The threat of a global influenza pandemic 
is real. It is not exaggerated. There is no hyperbole that I 
have seen. The possible effects of an actual outbreak could be 
catastrophic.
    Another very real fear exists, the fear that we still 
remain completely unprepared. Hurricane Katrina exposed our 
complete lack of coordination and preparedness to address a 
catastrophic storm, even when we had several days notice. The 
pandemic flu scenario is affording us much more time to 
prepare, but as of today it appears that the nation is poised 
to repeat a grave error by not heeding the lessons learned from 
Katrina.
    For example, while the president released his national 
strategy for pandemic influenza in November 2005, the plan 
contains no operational details; makes very broad mention of 
vaccines and antivirals, foreign and domestic monitoring, and 
response and mitigation. Agency-specific additions to this plan 
were to be completed by each federal agency by February 1, 
2006.
    Mr. Chairman, those plans are not available yet. This is an 
inauspicious start, to say the least.
    Allegedly, the overriding plan could be followed in the 
case of a declared incident of national significance, including 
certain biological events like a pandemic flu, is the national 
response plan. But the level of knowledge and familiarity of 
the different entities responsible for pandemic influenza 
response within the national response plan varies widely. Many 
state and local entities have simply never read the document, 
even though they are expected to develop plans that complement 
the document.
    Interestingly, 8 days ago, the GAO, the Government 
Accountability Office, released its preliminary observations 
regarding preparedness and response to Katrina and Rita, and 
found that the Department of Homeland Security failed to 
implement the NRP or designate a key federal point of contact. 
This is a real problem. I am not convinced that there is 
appropriate leadership in place to address the issue. Its 
current state is simply unacceptable for everybody on this side 
of the table.
    We know the dangers are enormous. Don't take my word for 
it. On October 27, 2005, Health and Human Services Secretary 
Michael Leavitt said the following: ``If the pandemic hits our 
shores, it will affect almost every sector of our society, not 
just health care, but transportation systems, workplaces, 
schools, public safety and more. It will require a coordinated 
government-wide response, including federal, state and local 
governments and it will require the private sector and all of 
us as individuals to be ready.''
    We are not ready, but we can do better as a nation. I am 
thankful that the two subcommittees within the Homeland 
Security Committee are taking on this issue. We need to examine 
and explore the ways best to consolidate and coordinate the 
actions of the federal, state and local actors. We need to 
ensure that a lack of federal leadership is remedied, and 
examine how best to combat problems of strained resources.
    We have a good panel before us, and I welcome them. I am 
very interested in hearing from our witnesses about their 
dealings with DHS, as well as their preparation, coordination, 
and incident command plans to address what many describe as an 
event certain to happen.
    I thank the chairman.
    Mr. Linder. I thank the gentleman.
    The Chair now recognizes the ranking member of the full 
committee, the gentleman from Mississippi, Mr. Thompson, for 
the purpose of making an opening statement.
    Mr. Thompson. Thank you very much, Mr. Chairman.
    I would like to welcome our witnesses here today, and I 
look forward to their testimony.
    I am pleased that these two subcommittees are turning their 
attention to the issue of pandemic flu preparedness and 
response. I am also looking forward to the hearing in the full 
committee on this subject, which as I understand at this point 
will feature Secretary Chertoff and Secretary Leavitt as 
witnesses.
    In a full-scale pandemic situation, federal, state, local 
and private entities will all need to cooperate effectively for 
a response to be successful. The thousands of state and local 
health departments are working hard to plan for pandemic flu, 
but they have been hampered by a lack of money and guidance 
from the federal government.
    In the president's national strategy for pandemic 
influenza, the bulk of federal research funding is going for 
drug research and vaccines. The president requested only $100 
million for state and local preparedness. While Congress 
appropriated $350 million in the emergency appropriation this 
past December, it still pales in comparison to the $6 billion 
that the president requested for vaccines and antivirals.
    I am also concerned that the various flu response plans 
that are being developed by federal agencies do not complement 
the national response plan, which is supposed to guide the way 
we manage domestic emergencies. We have many questions to 
answer. Who is in charge of response operations at the federal, 
state and local levels? Who gets vaccines first? Where should 
we urge citizens to wear masks or stay home? When should we 
close schools? How will hospitals handle the surges of 
patients?
    As I have spoken in recent months to local physicians, 
hospital administrators, public health officials and first 
responders, it has become clear to me that we do not yet have 
the answers to these questions. I hope this hearing will help 
us begin to answer them. Although we cannot be certain, many 
experts predict we have a year or longer before a full-scale 
outbreak of avian flu may occur. In that time, we must ensure 
that a coherent nationwide response is ready, and that is and 
will be properly executed when we need it.
    Thank you, Mr. Chairman.
    Mr. Linder. I thank the gentleman.
    We are pleased to have before us a distinguished panel of 
witnesses on this important topic.
    Let me remind the witnesses that their entire written 
statement will be made part of the record. We would ask you to 
keep as best you can your testimony to no more than 5 minutes.
    Dr. Tara O'Toole is the chief executive officer and 
director of the Center for Biosecurity at the University of 
Pittsburgh Medical Center. She has served on numerous 
government advisory committees, including panels of the Defense 
Science Board, the National Academy of Engineering's Committee 
on Combating Terrorism, and the National Academy of Science's 
Working Group on Biological Weapons.
    Secretary David Mitchell is the secretary of the Department 
of Safety and Homeland Security in the state of Delaware. 
Secretary Mitchell has over 3 decades of law enforcement 
experience. Prior to his recent appointment, he was 
superintendent of the Maryland State Police.
    Ms. Frances Phillips is a health officer in Anne Arundel 
County, Maryland. In addition, she is the vice chair of the 
Bioterrorism and Emergency Preparedness Committee of the 
National Association of County and City Health Officials, and 
past president of the Maryland Association of County Health 
Officers.
    Mr. Ernest Blackwelder is the senior vice president of the 
Business Executives for National Security, or BENS. Mr. 
Blackwelder oversees the organization's Business Force 
activities, including operations in New Jersey, Georgia, 
Missouri, Kansas, Iowa, Nebraska and California. Prior to 
joining BENS, Mr. Blackwelder was chief operating officer of 
ArsDigita, an Internet software and professional services firm.
    Dr. David Seaberg is with the Department of Emergency 
Medicine at the University of Florida. He serves as the 
president of the Florida College of Emergency Physicians. He 
also serves on the board of directors for the American College 
of Emergency Physicians and the Emergency Medicine Learning and 
Resource Center.
    We thank you all for being here.
    Dr. O'Toole?

                 STATEMENT OF DR. TARA O'TOOLE

    Dr. O'Toole. Thank you, Mr. Chairman. It is a pleasure to 
be with you today.
    I am going to address three specific issues amongst the 
panoply of very serious and scary matters you outlined in your 
opening remarks. I am going to talk about the health care, 
specifically hospitals' response to a possible pandemic and 
what that would mean, and what it is going to take to get 
through it without collapsing our health system and endangering 
the faith of the American people, not to mention their lives.
    I am then going to talk a little bit about disease 
containment, and the prospects for protecting the well, for 
stopping the spread of disease in a flu pandemic; and finally 
the very important topic of engaging the people as 
collaborators in our response to flu.
    Before I do that, I am going to say a few words about the 
current situation. We have no idea on a scientific basis when 
or if a pandemic might break out. We do not know why 1918 
happened. We do not understand the genetics of that virus, 
which we have now replicated. We do not understand why it was 
so virulent or why it spread or why it literally popped up out 
of nowhere. So we cannot predict when or if the avian flu that 
is now endemic through Eurasia will become transmissible.
    But it is very important to understand that the current 
situation is historically unprecedented. There are now millions 
and millions of wild birds throughout Southeast Asia and Asia, 
and today we learn that there are poultry outbreaks of H5N1 in 
Nigeria, who are carrying this very lethal virus as they 
migrate around the world. The more birds that carry the virus, 
the greater the chances that this virus would become 
transmissible. It might happen a year from now. It might happen 
tomorrow. There is absolutely no way of predicting.
    Hopefully, we will be given the gift of time to get 
prepared, but whenever it happens, getting through this is 
going to be a traumatic event for America and an existential 
event for some countries and certainly for some economies. We 
are only going to get through this intact if everybody works 
together. That is all sectors, not just public, but also 
private at all levels.
    How do we do that? Let's talk about hospitals, because they 
are the linchpin of the U.S. health care system in many ways, 
and they are where Americans expect to go if they or their 
family are very sick. It is true that there are a lot of things 
to worry about beyond hospitals and health care, but the irony 
of the situation is that hospitals and health care, because 
they are a private sector enterprise, have been left out of 
most emergency preparedness, bioterrorism preparedness, or flu 
preparedness exercises in thinking.
    That is hard to believe, but that is the case. Most 
hospital administrators have not read the flu plan, and they 
are not going to. In most hospitals, the person in charge of 
disaster preparedness is a low-level assistant professor who 
has this as an add-on assignment. Hospitals are already very 
overburdened. They have responded to the financial pressures of 
the last decades by cutting staff, by going to just-in-time 
supply chains, et cetera, et cetera.
    The first thing to know, and this is not going to change, 
in all likelihood, is that if a 1918-type pandemic broke out in 
America, most Americans would have no access to the health care 
system. I am not just talking about hospital admissions. I am 
talking about the ability to talk to or to visit a physician. 
We have to educate the American people to this reality, and we 
have to organize ourselves so that the health care system we 
have can be as expandable and as agile as possible. That is 
going to take a lot of work.
    Let me give you some specifics. CDC has put out a computer 
model that allows each hospital to calculate how much it would 
have to surge in a 1918 pandemic or in a smaller 1968-type 
pandemic. Let me give you the figures for the Atlanta metro 
region if we had a 1918-type flu. All of the hospitals together 
in Atlanta would have to increase their current pre-epidemic 
hospital bed capacity by 300 percent just to care for flu 
patients. Now, beds are not the problem. The real problem is 
the staff to take care of the patients in the beds. This 300 
percent does not include the people that you would need to take 
care of heart attacks and patients not related to flu. Atlanta 
would have to increase its intensive care unit capacity by 700 
percent. It would need nearly four times as many ventilators as 
it is using today just to care for flu patients.
    This is not feasible. You cannot get there from a kind of 
marginal, incremental increase over what we have done. 
Hospitals can probably get prepared to surge maybe 20 percent 
over their current capacity. But what we are talking about here 
is a fundamental shift in how we deliver health care and what 
we mean by health care.
    Within your purview, within the purview of the Department 
of Homeland Security, lies the National Disaster Medical System 
and the DMAT, the Disaster Medical Assistance Teams. These are 
going to be of very little use in a pandemic. There is a 
terrific report out that was commissioned by Secretary Ridge 
that critiques the NDMS and the DMAT quite carefully and 
accurately, that is worth your while, done by a Dr. Lowell. The 
essence of it is that we have a very fragmented federal 
response system when it comes to health care. We have to get 
that much more coherently organized.
    We definitely need to plan, but I would suggest that there 
is no way we are going to be able to come up with explicit 
protocols and procedures for how we would react to a pandemic. 
We are not going to know when we are going to close schools in 
advance. We are not going to know who is going to get the 
ventilators. What we have to do, and what the main point of 
planning is, as we have learned in all of the emergency 
preparedness done so far, is that we have to start talking with 
each other.
    In an emergency, the NDMS, which is intended to transport 
patients from the disaster area to another region that has 
available hospital beds, is not going to make sense. We are not 
going to be transporting contagious people around the country, 
besides which everyone is going to be overloaded or fearful of 
being overloaded and unlikely to be willing to accept new 
patients.
    Now, flu is very, very contagious. We are not going to be 
able to stop the spread of a transmissible flu if it breaks 
out. This notion that if we see it early, if we catch the first 
30 people who are spreading it from person to person, and then 
fly lots of Tamiflu in and give it to the one village that was 
first the victim of this transmissible gene, is worth pursuing 
because we ought to do anything we can to quench this pandemic, 
but has a very low probability of success. We are probably not 
going to see this breakout if it happens in Kurdish Iraq or in 
the Urals somewhere until it is well under way, and then it 
will be everywhere.
    There are some important things to know about flu. Every 
disease spreads slightly differently and the public health 
measures you use to control the spread of disease differ from 
one pathogen to the next. You can be contagious with flu before 
your symptoms. In fact, you usually are. In fact, in a normal 
flu season, half of the people who are infected are never 
symptomatic, but can spread the disease. So it is going to be 
almost impossible to actually contain the disease or to stop 
the spread.
    What we want to do is slow it down so the consequences are 
spread out over time and we have a better chance of responding. 
We need the cooperation of the American people in succeeding 
with this. They have to understand that if they get sick, they 
need to stay home. Provisions have to be made to make that 
possible, which means a whole bunch of things, from the 
capacity for employees to work from home, to delivering food to 
the doorstep, to keeping good movies on television so you can 
keep the teenagers from going to the mall. A lot of the action 
is going to happen at a very local level.
    We have to keep as many people as possible out of the 
hospitals so the hospitals can tend to the very ill. At some 
point, the hospitals will become overrun and we are going to 
have to shift to this complete paradigm change in health care. 
That ought to be a decision that is made by leaders of the 
community, not just elected officials. New organizations are 
going to have to be formed that will make it possible for very 
competitive hospitals who on a normal day would try and steal 
each other's patients, to work together and make joint 
decisions that are going to mean life and death for their 
communities.
    It is quite possible that interventions intended to prevent 
the spread of disease will make things worse. It is quite 
possible that we could worsen the CBO's estimates of a 5 
percent drop in GDP if we were to have a 1918 pandemic, by 
trying to stop travel; by trying to limit the flow of goods; by 
basically doing things that mess around with the economy, but 
are not going to get you much in terms of stopping the spread 
of disease.
    So all elected officials have to be very informed about how 
flu spreads and what works and what does not work with respect 
to public health interventions.
    Mr. Linder. Doctor, if you go on too long, I will have to 
stop you, before my glee at what you are speaking about just 
overwhelms me. We will be back with questions for you.
    Dr. O'Toole. Could I say one thing?
    Mr. Linder. Sure.
    Dr. O'Toole. We can do this. We have absolutely 
extraordinary scientific and technological prowess that we are 
not using well. We have a huge coast-to-coast health care 
system that we can organize, and we have a private sector that 
I think is willing to pitch in, but we need a better vision of 
how we get through it.
    [The statement of Dr. O'Toole follows:]

               Prepaed Statement of Tara O'Toole, MD, MPH

    Mr. Chairman, distinguished members of the committee, thank you for 
the opportunity to appear before you today to discuss the nation's 
preparedness to deal with a possible influenza pandemic.
    My name is Tara O'Toole. I am the Director and CEO of the Center 
for Biosecurity of the University of Pittsburgh Medical Center and a 
professor of medicine at the University of Pittsburgh Medical School. 
The Center for Biosecurity is a non-profit, multidisciplinary 
organization which includes physicians, public health professionals and 
biological and social scientists located in Baltimore. The Center is 
dedicated to understanding the threat of large-scale lethal epidemics 
due to bioterrorism and to natural causes. My colleagues and I are 
committed to the development of policies and practices that would help 
prevent bioterrorist attacks or destabilizing natural epidemics, and, 
should prevention fail, to mitigating the destructive consequences of 
such events.
    Last year, my colleagues and I had the privilege of participating 
in this committee's retreat at Wye River, where we held an interactive 
table-top based on Atlantic Storm, a ministerial exercise conducted in 
January 2005 which was designed to illuminate the kinds of issues that 
world leaders would confront in the wake of a bioterrorist attack using 
smallpox.
    Over the past 18 months, the Center for Biosecurity has focused its 
attention on the threat of pandemic influenza and the capabilities 
needed to respond to such an event. I will focus my testimony on two 
aspects of pandemic response: containing the spread of influenza and 
the role of hospitals in pandemic preparedness and response. First, 
however, I will describe the current situation with respect to H5N1 and 
the potential impacts on hospitals were a flu pandemic to occur in the 
next year or two.

        Background: The Likelihood and Implications of Pandemic 
        Influenza

Current Situation--
    The current situation in Asia and parts of Europe--namely, the 
infection of millions of wild, migratory birds and poultry with the 
H5N1 strain of influenza, and the infection of over 100 people--is 
unprecedented. H5N1 is an especially virulent type of flu against which 
no humans have immunity. More than half of all humans known to be 
infected have died. H5N1 is clearly endemic in wild birds, and cannot 
now be eradicated. Moreover, as the birds migrate to winter feeding 
grounds, they are spreading the virus into wild and domestic birds 
across Asia and into Europe. The World Health Organization (WHO) warned 
in 2005 that the evidence point towards the likelihood of an influenza 
pandemic, which could sicken one of four people on the planet, and kill 
millions.
    Recently, bird flu has been found in domestic poultry in Turkey and 
in Kurdish Iraq. Peregrine falcons in Saudi Arabia have also been 
infected. Infection with avian flu continues in domestic flocks across 
wide expanses of Indonesia, and southeast Asia. At least XXXX human 
cases of bird flu have been confirmed, although no human-to-human 
transmission has been observed.
Potential Impacts--
    The WHO estimates that once the next human pandemic begins, it will 
be found on all continents (but not necessarily in every country) 
within three months and will spread across the world within 12 months. 
Recurrent outbreaks would be expected over subsequent winter and spring 
seasons. The specific pattern of spread is impossible to predict and 
will depend on the properties of the pandemic strain (how lethal, how 
contagious, how closely it could move around the planet).
    The Congressional Budget Office (CBO) has estimated that in a 1918 
scale pandemic, about 90 million people would become sick and 2 million 
would die in the US alone [Congressional Budget Office, ``A Potential 
Influenza Pandemic: Possible Macroeconomic Effects and Policy Issues'', 
Dec. 8, 2005]. The CBO estimates that a pandemic of this scale would 
lower real GDP by about 5%compared to the level it would have reached 
had there not been a pandemic. The CBO notes that ``Improving the 
capacity of the health care system to care for many people in all parts 
of the country who are sick at the same time stands out as a priority. 
. . .'' [CBO, page 2].
    There is no scientific way to predict whether an influenza pandemic 
will occur this year or next or several years from now or how severe it 
will be. That there will be an influenza pandemic in this century is 
certain; flu pandemics have occurred throughout history, about three 
times each century. The ``good news'' is that there is much that can be 
done to mitigate the death, suffering and economic and social 
disruption caused by epidemics--if preparations are made in advance. Of 
course the preparations that could be put in place were a pandemic to 
occur in the next few months would differ considerably in scale and 
scope from what could be accomplished if we had 18 months or years to 
get ready. My colleagues and I are deeply concerned that the current 
pace and intensity of pandemic preparedness activities, including the 
search for effective vaccines, are still very inadequate given the 
possible consequences of this threat.

Importance of Vaccine--
    Having adequate amounts of an effective vaccine changes everything. 
Global supplies of a pandemic vaccine and the ability to distribute it 
could transform these grim scenarios decisively. Today, there are more 
than 20 projects to develop a vaccine against H5 type influenza viruses 
underway, pursued by private sector biopharma companies and the NIH but 
results to date have been disappointing. The recent Congressional 
appropriation for flu vaccine research and development is welcome and 
necessary, but still falls far short of what is warranted by the nature 
of this threat. The scientific basis of the effort is sound, but there 
is, as yet, no national strategy to pool America's prodigious 
scientific and pharmaceutical industry capacity in the context of an 
overall strategic plan. I realize this issue is beyond the usual scope 
of this committee, but the matter is of such overriding importance that 
all of Congress should be aware of the situation.

  Caring for the Sick During a Flu Pandemic or Mass Casualty Bioattack

US Health Sector is Unprepared to Meet Surging Pandemic Health Care 
Needs
    In the event of a 1918-scale flu pandemic, most Americans would be 
unable to access the health care sector because demand will exceed 
supply by large factors that cannot be bridged by incremental, marginal 
increases in health care capacity.
    Hospitals would be flooded with desperately ill people seeking 
care. Most hospitals routinely operate at or near full capacity, 
however and have limited ability to rapidly increase services. During 
an epidemic, the health care workforce would be greatly reduced. Health 
care workers would face a high risk of infection because of contact 
with infected patients; many would need to stay home to care for sick 
relatives, and in the absence of vaccine, others might fear coming to 
work lest they bring a lethal infection home to their families The 
provision of critical, non-flu medical services would be adversely 
impacted in most communities. .
    In addition, because hospitals have adopted just-in-time supply 
chains, there would be an almost immediate shortage of critical 
supplies such as ventilators, masks and gowns, antibiotics, etc. The 
shortages of supplies and staff would likely worsen over time as 
critical components of supply chains are lost due to attrition and 
absenteeism in the US and overseas. (During the 2003 SARS outbreak, a 
single Ontario teaching hospital used 18,000 N95 masks per day).
    All three TOPOFF exercises convincingly demonstrated that hospitals 
are among the most fragile components of mass casualty response. 
Hospitals have little money of their own to spend on stockpiling 
supplies or planning for catastrophes. The US health care delivery 
sector is financially pressured, and highly competitive. One third of 
US hospitals do not meet operating costs; among non-profit hospitals 
which are in the black, operating margins average only 3%. In a 
pandemic, hospitals would be forced to close clinics, cancel surgery 
and defer most money making services to care for the volume of flu 
victims. Many hospitals may be forced to close down due to lack of 
staff and/or lack of revenue.
    Hospitals do not have the funds to pay for pandemic preparedness 
planning or to purchase stockpiles of equipment or train staff. Federal 
funds for hospital preparedness began only in FY 2002 and have remained 
at low levels. The federal appropriation for FY 2006 was only enough to 
cover the salary of a single nurse at each of the country's 
approximately 5000 hospitals for one year.
    Within the medical community, there are widespread expectations 
that the military would quickly provide significant resources 
(personnel, mobile hospitals, equipment) during a mass casualty event. 
The military maintains that its medical resources are limited and that 
force support needs would be the priority.

CDC Flu Surge Projections: Pandemic Demands Would Overwhelm Most 
Hospitals
    It is important to have a clear picture of what the pressures of 
pandemic flu would mean. CDC has create ``Flu Surge'', a software 
program that allows one to project the patient demands that would be 
levied on hospitals of different types and sizes if the pandemic attack 
rates and severity of illness mimicked those of 1918.
    For example, in a 1918 type pandemic, in the Atlanta metro area, 
that region would require 300% of its current (pre-epidemic) hospital 
bed capacity to care for flu patients (and the necessary clinical staff 
to care for this increase in patients); 700% of Atlanta's pre-epidemic 
Intensive Care Unit capacity and nearly four times as many ventilators 
to care just for the flu patients.
    These demands do not take into account the resources that would be 
required to meet normal ongoing critical medical needs (care of heart 
attack victims, etc.).

   The US lacks a national strategy for providing health care surge 
                 capacity in mass casualty emergencies.

    The NDMS, DMAT teams and uniformed public health service would be 
of little practical use in such an emergency. These organizations lack 
the necessary operational scale and skill sets and will be needed in 
their home communities.
    In a large-scale flu pandemic or bioterror attack, the National 
Disaster Medical System (NDMS) and the Disaster Medical Response Teams 
(DMATs) would be of little practical use. An analytic report of the 
Department of Homeland Security's readiness to respond to national 
medical emergencies (January 2005) stated:
        ``A National healthcare system-wide strategy for providing 
        surge capacity does not exist. . .Numerous Federal programs 
        (e.g. NDMS, Commissioned Corp Readiness Force, and the Medical 
        Reserve Corps program) exist to enhance surge capacity, but 
        they are fragmented and not incorporated into the national 
        response effort.''
        [Lowell, J. ``Medical Readiness Responsibilities and 
        Capabilities: A Strategy for Realigning and Strengthening the 
        Federal Medical Response'', Jan. 3, 2005; accessed at http://
        wid.ap.org/documents/dhsmedical.pdf, 2/3/06.]
    NDMS was designed to identify empty hospital beds beyond the area 
affected by an emergency to which casualties could be sent. However, in 
a pandemic, all areas of the country would be affected more or less 
simultaneously, or to fear that they will be hit next.
    Moreover, the crucial need is not for hospital beds, but for 
medical staff to care for the patients in the beds. The central premise 
of NDMS--that empty hospital beds imply the capacity to care for 
patients--is outdated. Similarly, the deployment of Disaster Medical 
Support Teams (DMATs), which consist of volunteers from around the 
country, would be impractical in contexts in which team members are 
needed in their home communities.
    Following 9/11, the Medical Reserve Corp (MRC) was founded. This 
component of the Citizen Corps is located within the office of the 
Surgeon General in HHS. Still considered a pilot program, the MRC 
currently has 55,000 volunteers in 330 local MRC units who are intended 
to supplement local medical resources in times of need. MRCs have no 
uniform structure and volunteers are not necessarily medical 
professionals.
    The US health care sector is highly fragmented, competitive and 
largely private. In most locales, there is no ``Organizing Authority'' 
with the capacity to establish a regional pandemic plan that would 
obligate hospitals to collaborate in a manner designed to optimize 
health care delivery during a pandemic.
    Aside from a handful of cities such as New York, Minneapolis and 
Seattle, there are no well defined or practiced plans for mobilizing 
hospitals, HMOs and other sources of patient care during a mass 
casualty emergency. Public health agencies typically have not taken on 
this task, nor do most public health agencies have the personnel, funds 
or legal power to direct, manage or coordinate hospitals in crisis.
    The ability to identify and contact health care professionals and 
support staff is essential to hospitals' capability to respond to 
emergencies. There is an urgent need to create regional data bases of 
health care workers that would allow rapid identification of and 
contact with professionals with certain credentials and skill sets. 
Further, provisions to credential clinicians at multiple hospitals in a 
region (ahead of an emergency), and to ensure that professionals and 
the institutions in which they work have adequate liability protection 
are essential. Some states have established Mutual Aid pacts or other 
provisions with neighboring jurisdictions to address such concerns. Yet 
few regions have successfully built the data bases needed, or solved 
all the legal problems to ensure that qualified health care 
professionals can practice across state and institutional lines in 
times of emergency.
    Collaboration among hospitals and other patient care institutions 
will require near-real time ``situational awareness''. Yet most 
hospitals do not have electronic connections with other hospitals in 
their region or links to their local or state public health agencies. 
This will make it difficult for decision-makers to understand which 
hospitals are able to receive patients, where vital equipment is 
located or needed, what supplies are running low or where the public 
should be told to take those who are desperately ill.
    The Federal government has failed to propose a coherent strategy 
for pandemic hospital response; has failed to adequately fund even 
minimal hospital preparedness activities. Responsibility and 
accountability for hospital preparedness within DHS and HHS are 
diffuse, confused and grossly under funded and understaffed.
    The HHS Pandemic Flu Plan contains a lengthy list of items 
associated with hospital preparedness. However, the FY06 appropriation 
for pandemic preparedness contains no funds for hospitals. Accordingly, 
it would not be possible for any hospital to implement everything 
suggested by the HHS list, partly because of cost and partly because 
individual hospitals lack the authority to accomplish much of what is 
recommended.
    It is unclear who in the federal government--or indeed which 
agency--is in charge of medical response in a mass casualty emergency. 
The HHS missions and skill base more closely match the need than do the 
assets currently found in DHS. The National Disaster Medical System 
(NDMS), transferred to DHS upon its creation, had its management 
personnel reduced from 144 to 57, leaving the NDMS without a staff 
physician, medical planner or logistician [Lowell, ibid. p. 6].

         Containing the Spread of Disease During a Flu Pandemic

Not All Interventions to Prevent Disease Spread are Worth the Costs
    Most disease containment interventions are logistically difficult 
to implement, of imperfect or uncertain effectiveness, and may have 
significant adverse economic and social consequences. It is important 
that decision-makers understand the ``return on investment'' of various 
interventions.
    When considering possible interventions to stop or slow the spread 
of influenza--or of any contagious disease--it is important to consider 
both the possible benefits of the intervention as well as the costs. 
The interventions that are likely to produce a reasonable ``return on 
investment'' are likely to differ, depending on the specific disease 
and the context. It is critical that elected officials understand how 
flu spreads and carefully consider the trade-offs involved in various 
disease containment measures. Some public health interventions will 
cause more harm than good.
    Influenza is a highly contagious disease. In normal flu seasons, 
each infected victim passes the infection to at least two others. What 
makes flu so contagious however is the speed at which people are 
infected. One becomes contagious within 24 to 72 hours after being 
infected. Thus, flu can spread from one person to the next before 
symptoms occur. In normal flu seasons as many as half the cases may 
never show any symptoms but can still be contagious. Infectious 
pandemic flu patients can be expected as well.
    This means that screening interventions--for example, screening 
airline passengers for fever or for cough and other symptoms--will not 
be effective. This was apparent during the SARS outbreak of 2003. Both 
Canadian and Chinese authorities, in careful studies, concluded that 
such screening was of no value although requiring a great deal of time, 
effort and cost.

Possible Interventions to Control the Spread of a Contagious Disease:
    Vaccine--having sufficient supplies of an effective pandemic flu 
vaccine changes everything. An effective vaccine is by far the single 
most important component of pandemic preparedness. If available in time 
and in sufficient quantities vaccine would make a decisive difference.

    Therapies which can be used in treatment--Tamiflu is proposed for 
use although little information is yet available regarding its actual 
effectiveness. Given within 36 hours after symptoms begin, it would be 
expected to reduce growth of the virus and perhaps reduce the 
likelihood of a fatal outcome. However, virus resistance to this drug 
is expected and supplies of the drug are limited

    Therapies which may prevent spread--Tamiflu decreases the amount 
(``load'') of virus in the patient's throat and hence may prevent 
disease and, as well, diminish the likelihood of transmission. 
Prevention with this drug, however, would require daily administration 
of the drug throughout the course of an epidemic. The quantities of 
drug required and the cost, let alone complications of the drug itself 
recommend against its general use.

    Isolation of sick individuals--This is an essential component of 
all influenza containment strategies. Especially in health care 
settings, isolation of infected patients is critically important to 
limiting disease spread. However, health care workers are at special 
risk and thus, appropriate isolation of infected patients and use of 
``barrier controls'' (gowns, face masks, gloves) and hand-washing are 
essential.
    It would also be highly desirable to isolate individuals who are 
sick with flu but not so desperately ill that they need to be 
hospitalized. It is likely that many people will remain at home, though 
some communities are making provisions to equip sports arenas and other 
large spaces with beds to accommodate those who cannot be cared for at 
home. To the extent possible, patients should be encouraged to stay at 
home from the first signs of illness and to stay out of close contact 
with others until they are no longer contagious.
    The resources needed to enforce compulsory isolation or quarantine 
are enormous and the likelihood of failure is high. Cooperative rather 
than compulsory measures are to be preferred.
    There are significant challenges associated with isolation of 
infected persons, whether they are restricted to their homes or 
isolated in some central facility. Arrangements must be made to provide 
people with food and medical services (including medicines for chronic 
illnesses

    Quarantine--Historically, quarantine referred to sequestration of 
large groups of people who are without symptoms--some of whom may have 
been infected with a disease, some not--until it was certain that all 
who might have been infected were past the point of being able to 
spread the illness. Large scale quarantine requires vast resources, 
most likely including the use of force. Experience shows that it has 
seldom proved to be effective and, in some cases, has led to 
suppression of reports of disease and of persons fleeing or escaping 
the restricted area. Rarely does it succeed in limiting spread of the 
disease.

    Social Distancing--this involves voluntary avoidance of close 
contact (3-6 feet) with others. Social distancing could include 
cancellation of schools or large public gatherings such as sports 
events or business conventions. It could also include asking employees 
to work from home, urging people to avoid coming within 3 feet of 
others, forgoing handshakes and other forms of direct contact.

    Use of Personal Protective Equipment--such as masks, respirators, 
gowns, gloves.
    These are of value for use of health care personnel in preventing 
their acquisition of infection. Masks are of uncertain value for public 
use.

         Possible Congressional Actions to Improve US Hospital

         Response During a Pandemic or Mass Casualty Situation

     The Secretary of HHS is the nation's leader on pandemic 
preparedness and Secretary Leavitt's commitment to this issue is 
evident and commendable. Given the breadth and urgency of preparedness 
activities, it seems essential that someone be appointed who can be 
fully devoted to overseeing flu preparedness strategy across all 
agencies. The federal government must clearly identify someone who is 
knowledgeable and has both authority and resources to assume direction 
of pandemic preparedness programs and to enlist appropriately trained 
staff to address the array of problems posed by a potentially 
catastrophic pandemic. Of special importance are the problems posed by 
the need to provide medical care to an unprecedented number of victims.
     In spite of the often heroic efforts of individual, highly 
expert federal employees, the federal agencies do not now include the 
full range and depth of talent and experience required to develop and 
implement a pandemic flu plan or a strategic defense against 
bioterrorist attacks. There is a pressing need to immediately acquire a 
staff of 50-100, including senior professionals and executives who 
could assist in establishing pandemic response policies and programs.
     There should be a federal/state task force charged with 
designing a plan to deliver medical care during a pandemic or mass 
casualty event. This group should focus on options for dealing with 
surges in medical demand comparable to those predicted by Flu Surge 
models for a 1918 type pandemic. Every effort should be made to work 
directly with the hospital community as well as with governors and 
mayors to address these urgent problems. HHS should be directed to work 
with hospital and health care leaders as well as local officials on the 
state and local level and members of Congress to devise ``organizing 
authorities'' that could effectively coordinate medical services during 
mass casualty emergencies. Funds to institute such authorities should 
be appropriated
     HHS should distinguish which specific pandemic 
preparedness are the responsibility of individual hospitals, and for 
what functions states or the federal government are accountable and 
create mechanisms to fund and oversee these functions.
     The Congress should appropriate sufficient funds, on an 
ongoing basis, to allow hospitals to execute specific, clearly 
identified and measurable preparedness activities. It should charge HHS 
with responsibility for designing processes, possibly in collaboration 
with the Joint Commission on Accreditation of Health Care 
Organizations, for ensuring that these activities are implemented and 
adequate.
     It would be highly useful for the Administration and the 
Congress to orchestrate a public ``call to service'' to the medical 
care community, to clearly communicate the gravity of the threat of 
mass casualty events and the need for immediate action on the part of 
hospitals, health care organizations and providers.
     Federal financing to spur the development of hospital 
electronic medical records should be considered a national security 
priority. Federal funds should be contingent on hospitals linking 
health information systems to other hospitals in their region and to 
public health authorities.
     Congress should immediately consider the possibility of a 
large-scale pandemic and hold public hearings on the need to enforce 
``eminent domain'' type authorities over health care assets should such 
a crisis arise as well as mechanisms to ensure that people who lack 
health insurance are not denied care or shunted to public or not-for- 
profit hospitals.
     Congress should establish legal provisions to ensure that 
hospitals who must forgo routine revenue flows to care for mass 
casualty victims will remain financially viable throughout the crisis.
     The single most important preparation in coping with a 
pandemic is education of the public. It will be critical that people 
understand what they can do to protect themselves and others during a 
pandemic. In particular, members of the public need to clearly 
understand that in a pandemic many people will find it difficult to 
access the health care system and should not expect to visit their 
doctors unless absolutely necessary.
     The Congress--and elected officials--should be educated on 
the basic facts about flu and participate in a nation-wide education 
campaign to prepare the public for a potential epidemic. In particular, 
leaders should acquaint themselves with the potential advantages and 
downsides of various interventions intended to contain the spread of 
flu and be prepared to explain why certain measures are necessary or 
unfounded. There will be great temptation to ``do something'' in the 
emergency. The probable benefits and longer term costs of such measures 
should be clearly articulated to the public and the cost-benefit of 
instituted measures should be carefully monitored.
     Employers should be encouraged and incentivized to plan 
for a major pandemic and in particular to prepare to enable employees 
to work from home and to avoid the workplace if they are ill. People 
should be encouraged to prepare to voluntarily remain at home--get 
themselves out of circulation--at the first sign of flu like symptoms 
or if they know they were in close contact with someone with flu.

    Mr. Linder. Thank you very much.
    Dr. O'Toole. Thank you. Sorry to be so long.
    Mr. Linder. Secretary Mitchell?

   STATEMENT OF THE HONORABLE DAVID B. MITCHELL, SECRETARY, 
 DEPARTMENT OF SAFETY AND HOMELAND SECURITY, STATE OF DELAWARE

    Mr. Mitchell. Thank you, Mr. Chairman.
    Chairman Linder, Chairman Reichert, ladies and gentlemen of 
the committee, I bring greetings on behalf of Governor Ruth Ann 
Minner from the First State, the state of Delaware. She brings 
her greetings, and I, along with my governor, thank you for the 
opportunity to discuss this most important topic with you here 
today.
    We in Delaware are not unfamiliar with the concept of H5N1 
bird flu. There are two issues here. One is avian flu, and one 
is pandemic flu. On any given day, today for example, on the 
Delmarva peninsula, we have 110 million chickens. In fact, 
Sussex County, Delaware, is the greatest poultry producer of 
any of the counties in the United States. We did in fact have 
an outbreak of avian flu several years ago, and we were very 
successful. It was a low-grade flu that infected two poultry 
farms. We were very successful in containing that. I have to 
say, that thanks to Secretary Mike Scuse, one of my colleagues, 
and DDA in the state of Delaware, were very sophisticated in 
our preparation for that. Our relationship with the poultry 
industry, I have to say, is second to none.
    When it comes down to pandemic influenza, fighting from a 
homeland security perspective, one of our accomplishments in 
Delaware was to prepare for what some say may happen, others 
say will happen, with the enactment of our Emergency Health 
Powers Act. It gives the Division of Public Health and the 
Department of Safety and Homeland Security the authority to 
obtain quarantine and isolation orders in an expedited manner.
    It also contains provisions protecting the due process 
rights of individuals who are subject to a quarantine or an 
isolation order. By ``isolation,'' I am saying that in fact we 
know you are infected with H5N1 bird flu, and so we will, if 
necessary, isolate you, if necessary against your will, for the 
better good of our community. By ``quarantine,'' I am saying 
that you have been exposed, and I am not sure if you have it, 
but we will isolate you until that determination is made.
    That type of isolation and quarantine has been tested in 
our Third Circuit of the federal judiciary. It has passed 
muster constitutionally, provided that there is a due process 
opportunity, which raises all kinds of issues. How do you bring 
someone before a member of the judiciary if they are infected 
with H5N1 bird flu? Well, I had that discussion with our 
Supreme Court and other members of the bench in Delaware just 
last week. We proposed to do it by video, but even that brings 
up all kinds of issues about whether or not. We certainly do 
not want to contaminate an inmate population. We are working 
through these issues, in fact, as we speak.
    The Intrastate Mutual Compact that we have is another major 
accomplishment. It gives us the opportunity across 
jurisdictional lines within our state and between states, to 
help one another out. With our proximity being that close to 
Maryland, New Jersey and Pennsylvania, we do rely on each 
other, as well as in the great state of Virginia.
    With regard to federal funding, resources have supported 
many of our objectives, including effective communications. We 
heard, as we know in Katrina, the issue, as is often the case 
in any crisis, is our ability to talk to one another. Thank you 
for your federal support to our 800 MHz system. We do have 
coverage that is about 99 percent effective throughout our 
great state. Our in-building coverage is about 66 percent, well 
on its way to becoming 85 percent in compliance, so that we 
will have not only coverage outside of any structure, but 
inside of any structure. When I say ``coverage,'' I am talking 
about transportation systems talking with the police, 
firefighters, emergency responders and others.
    We also have benefited from your support to the Delaware 
Information and Analysis Center, which is a hub that collects 
not only intelligence from our local officers up through and up 
to the Department of Homeland Security, but it receives 
information from the Department of Homeland Security and our 
federal resources that we disseminate locally. It is our hub 
where have situational reports given the threat that we face, 
that we would put that information out daily and so forth.
    We hope that enhancing the federal-state partnership will 
be the order of the day. Our line of communication with the 
Department of Homeland Security, I have to say, is very clear. 
I have an outstanding relationship with my colleagues on the 
federal level, and we are very fortunate. I cannot speak for 
all the other states, only for the state of Delaware, probably 
because of our proximity, that we are in contact so frequently.
    But we need to continue to foster and support that 
partnership. Our federal partners need to continue to hold 
public meetings and summits to keep the lines of communication 
open. Delaware looks forward to a federal partnership that 
highlights best practices. That is something the federal 
government can do, tell us what best practices are occurring 
where, so that we can consider on a local level what might work 
in our state, recognizing that one size does not necessarily 
fit all.
    We also need continued federal funding to increase our 
ability to gather accurate information and to disseminate that 
information, in fact, to the public. Our success depends on 
that coordination and cooperation. We are here to extend a hand 
to continue that partnership with our federal allies. We 
support the president's vision as to whether or not 85 percent 
should go to the issue of pharmaceuticals. That is an issue 
that is well beyond my realm of expertise.
    I am here to say that our line of communications is open; 
that we have an outreached hand; we look forward to continuing 
to work with our federal partners.
    We thank you for the opportunity to be here today.
    [The statement of Mr. Mitchell follows:]

      Prepared Statement of the Honorable David B. Mitchell, J.D.

INTRODUCTION
    Good afternoon, Chairman King and members of the Subcommittees. I 
am David B. Mitchell, Secretary of the Delaware Department of Safety 
and Homeland Security. On behalf of Governor Ruth Ann Minner, I am 
honored to be here today to address the important issue of homeland 
security as it relates to pandemic influenza. I would like to thank you 
for your support of the many initiatives now in place that have 
enhanced homeland security and emergency preparedness at the federal 
and state level.
    The most recent concern of avian influenza mutating into a form 
that leads to a human pandemic is a topic not unfamiliar to Delaware, 
since we are a leading poultry producing state. I would like to open my 
statement today with an explanation of Delaware's experiences with 
avian influenza prevention and response in our animal or poultry 
population. I will then move on to discuss with you our response to 
human pandemic influenza and how we can enhance our federal-state 
partnership and allocate resources wisely.
    Each year, Delaware poultry growers produce approximately 240 
million chickens. Tyson Foods, Inc., Perdue Farms, Inc., Mountaire 
Farms, Inc., and Allen Family Foods are the major poultry companies 
with growers or facilities in Delaware. However, there are also 
numerous other smaller commercial and non-commercial poultry producers 
in Delaware. On any given day, there are approximately 110 million 
chickens on the Delmarva Peninsula. As one of the largest poultry 
producing states in the nation, the risk of exposure to avian influenza 
within the poultry industry is high. Of even greater significance is 
the risk of exposure within the human population of an influenza 
pandemic. The avian influenza virus presents two potential crises with 
serious consequences to the State of Delaware. First, an outbreak of 
the avian influenza virus within the State's poultry population may 
have a severe negative impact on Delaware's economy. Secondly, and of 
greater significance, is the possibility of an influenza pandemic which 
would have grave consequences for the public health in Delaware.
    In recognition of its unique situation, the Delaware Department of 
Safety and Homeland Security (DSHS) and its Divisions, Delaware 
Emergency Management Agency (DEMA) and the Delaware State Police (DSP), 
have succeeded in creating close partnerships and working relationships 
with the Delaware Department of Agriculture (DDA), the Department of 
Health and Social Services and its division, the Division of Public 
Health (DPH), local law enforcement, the Delaware National Guard and 
the Dover Air Force Base in an effort to develop a seamless 
preparedness and emergency response plan.

AVIAN INFLUENZA--IMPACT ON DELAWARE'S POULTRY INDUSTRY
    In February 2004, the DDA and several Delaware agencies joined 
forces to contain a low pathogenic avian flu virus identified in flocks 
at two Sussex County farms. At the time of the initial outbreak, the 
DSHS, through its Division, DEMA, already had in place the Delaware 
Emergency Operations Plan (DEOP) for emergencies arising from natural 
or human-made disasters. The DDA immediately implemented its emergency 
support functions under the DEOP and another division of DSHS, the 
Delaware State Police, came in to support the DDA in its efforts to 
contain the avian flu virus. Further, the Delmarva Poultry Industry 
Inc. (DPI), a nonprofit industry association, had already created an 
emergency disease task force in response to an avian influenza outbreak 
that occurred in the early 1980s in Lancaster, Pennsylvania. A 
Memorandum of Understanding creating a partnership between the DDA, DPI 
and other states within the Delmarva Peninsula enabled the DDA to also 
convene the DPI's Emergency Disease Task Force. Because the outbreak 
did not involve a bird-to-human or human-to-human transmission, DDA 
acted as the managing agency. The Delaware State Police, in conjunction 
with local private security officers, was immediately mobilized to 
assist the DDA in setting up a quarantine of the infected farms, 
setting up a barrier to prevent reporters and other curiosity seekers 
from trespassing onto the farm, and providing lines of communications 
between the DDA, the press and the public about the status of the 
crisis.
    Despite the quarantine order and admonitions by the DDA and the 
Delaware State Police that it was necessary to stay away from the 
infected farms to prevent spread of the virus, reporters attempted to 
enter the quarantined area through any means available. Some flew 
helicopters to gain access to the farms; others trespassed at night 
with night vision equipment to photograph poultry, houses and growers. 
Through coordination between DSHS, DDA and DPI, efficient 
implementation of the DEOP, and effective communications between DDA, 
the Delaware State Police, DPI and the public, Delaware successfully 
quarantined the two farms and contained the virus.
    Delaware's success in containing the virus in 2004 has earned it 
national attention as a leader in how to respond to avian influenza as 
it pertains to poultry. Under the DDA's poultry regulations, all 
commercial or non-commercial premises where live poultry is kept must 
be registered with geo-referenced coordinates of all chicken coops. 
Vehicles, crates, coops and footwear used for sale or transfer of 
poultry out of state must be in a completely clean condition prior to 
leaving or returning to Delaware and is subject to inspection. The DDA 
requires all poultry growers to maintain detailed records of their 
poultry.
    Producers are required to participate in several testing programs 
to ensure their flocks are free from any potentially hazardous forms of 
avian influenza. Thanks to a partnership between the DDA and the 
University of Delaware, the DDA is able to conduct onsite testing of 
every flock and receive test results within 3 to 4 hours. At present, 
the test can quickly identify the potential harmful ``H'' factor of the 
avian flu, but additional testing must be conducted in order to 
identify the ``N'' factor. Any flock found to have avian influenza is 
immediately depopulated and disposed of onsite in an environmentally 
acceptable manner and the coops disinfected for reuse.
    Delaware is one of five states to implement an Indemnity Program 
which utilizes state and federal funds to reimburse poultry producers 
for flocks lost due to depopulation by DDA. This permits the State of 
Delaware to immediately respond to the threat of the spread of an avian 
flu virus without delays and, as an additional benefit, encourages 
poultry growers to report an infected flock in a timely manner. The 
continued success of its program is dependent upon efficient 
recognition and reporting of an emergency poultry disease. Because 
Delaware is one of the largest poultry producing states in the nation, 
continued funding from the federal government is necessary to ensure 
that Delaware can continue its research to completely and expeditiously 
identify a highly pathogenic avian flu virus with the potential to 
mutate to a form adaptable for human to human transmission. Further, 
federal funding is also necessary to ensure the viability of Delaware's 
Indemnity program. From a homeland security perspective, fighting the 
pandemic influenza from the frontlines includes, in large part, 
preventing the spread of avian influenza through the development of 
strict regulations, rigorous testing and an effective emergency 
response plan as it pertains to Delaware's poultry industry.

    PANDEMIC INFLUENZA_FIGHTING FROM A HOMELAND SECURITY PERSPECTIVE
    The U.S. Department of Health and Human Services' (HHS) Pandemic 
Influenza Plan recognizes the important role that Homeland Security and 
state and local law enforcement agencies have in the overall success of 
the plan and offers detailed guidance to local law enforcement 
regarding their involvement in the execution of their state and local 
pandemic influenza plans.
    In September 2005, with the guidance of the HHS Pandemic Influenza 
Plan, Delaware completed its Pandemic Influenza Plan. In recognition of 
the important role of the Department of Safety and Homeland Security 
and State and local law enforcement play in a pandemic influenza 
situation, DSHS and state and local law enforcement agencies, with the 
Delaware National Guard, DEMA and other state agencies have conducted 
extensive drills, table top exercises and incident command training 
geared towards early, quick and effective response to a pandemic 
influenza event and allocation of resources in the most effective and 
efficient manner.
    In November 2005, more than 100 participants gathered to take part 
in a Pandemic Influenza Table Top Exercise tackling tough issues like 
isolation and quarantine, continuity of essential services and 
businesses, medical surge capacity, infrastructure security, mass 
fatality and public education. The exercise was a great opportunity for 
Delaware's agencies to coordinate their individual roles, exchange 
information and concerns, network and review emergency plans. Delaware 
will hold its Pandemic Influenza Summit on February 21, 2006 with 
Governor Ruth Ann Minner and other local and federal representatives, 
including keynote speaker U.S. Surgeon General Richard Carmona. The 
Summit will give Delaware the opportunity to discuss Delaware's 
Pandemic Influenza Plan and to exchange information with its federal 
partners to ensure the continued development of a seamless, flexible 
and practical preparedness and emergency response plan.

    A. The Emergency Health Powers Act
    The Department of Safety and Homeland Security, Delaware State 
Police, DEMA, Division of Public Health, Delaware National Guard, and 
the Dover Air Force Base are actively working together to develop an 
effective quarantine and isolation plan. One of Delaware's 
accomplishments has been the enactment of the Emergency Health Powers 
Act, which gives the Division of Public Health and the Department of 
Safety and Homeland Security the authority to obtain quarantine or 
isolation directives and orders in an expedited manner during an 
influenza pandemic. Prior to a Declaration of a State of Emergency by 
Governor Ruth Ann Minner, the Public Health Authority under DPH may 
obtain a quarantine or isolation order if it has been established that 
a person or persons pose a significant risk of transmitting a disease 
to others with serious consequences. Once a State of Emergency has been 
declared, the Public Safety Authority under DSHS has the authority to 
obtain quarantine and isolation orders. Both the Public Health 
Authority and the Public Safety Authority have the ability to request 
that an order be granted on an ex parte basis and both have the 
authority to issue directives permitting state and local law 
enforcement to detain the person or persons pending the issuance of an 
isolation or quarantine order. Further, the Emergency Health Powers Act 
contain important provisions protecting the due process rights of 
individuals who are subject to a quarantine or isolation order, such as 
ensuring that persons quarantined or isolated under an ex parte order 
receive a hearing within 72 hours.
    Currently, the Delaware Department of Safety and Homeland Security 
and Division of Public Health are working with Delaware's state courts 
to create form petitions for ex parte quarantine and isolation orders 
to help expedite the process of obtaining orders under which law 
enforcement can legally act. The goal is to create petitions easily 
recognizable to a judge or clerk of the court as urgent. Furthermore, 
both agencies are working with the courts to establish a judge-on-call 
who can act as the primary responder to an emergency petition to 
quarantine or isolate as well as a set policy and procedure for 
responding to an influenza pandemic.
    Although the judges in Delaware are not considered first 
responders, they play an important role in determining what legal 
authority law enforcement has to enforce a quarantine or isolation 
order and to the extent of that legal authority. It is further expected 
that judges will continue to play a role during a pandemic as they will 
be asked to issue other orders, such as orders of contempt against 
those persons who violate the quarantine or isolation orders or to 
determine law enforcement's authority to, for instance, restrict travel 
across State borders. Currently, efforts are being made to protect 
judges from being exposed to the virus when they are called upon to 
preside over hearings related to quarantine and isolation orders. For 
example, Delaware is looking at the possibility of conducting hearings 
from a remote location through videoconferencing or providing judges 
with protective gear when conducting such hearings.

    B. The Delaware Emergency Operations Plan and Pandemic Influenza 
Plan
    The Incident Command System has been incorporated into the Delaware 
Emergency Operations Plan. The Department of Safety and Homeland 
Security and the Delaware State Police are the primary agencies in 
command of security and law enforcement and in charge of communications 
when there has been a declaration of a state of emergency. Delaware's 
Pandemic Influenza Plan, issued in September 2005, also provides that 
the Delaware State Police shall act as a supporting agency in the way 
of crowd control, traffic control for vaccination clinics, enforcement 
of quarantine and isolation orders and directives, and transportation 
of shipments of vaccines to designated receiving sites. Until there has 
been a declaration of a State of Emergency, the Delaware State Police 
shall only act as a supporting agency to the local jurisdiction in 
which a quarantine or isolation order has been issued by the Division 
of Public Health. The Delaware State Police will only assist when help 
is requested by that local jurisdiction. DSHS, the Delaware State 
Police and local law enforcement also have the ability to enter into 
mutual aid agreements if the emergency escalates.

    1. The Intrastate Mutual Aid Compact
    As part of Delaware's incident command training and its efforts to 
minimize local jurisdictional lines during an emergency, Delaware 
recently enacted the Intrastate Mutual Aid Compact which creates a 
system of intrastate mutual aid between participating political 
subdivisions and fire, rescue and emergency medical service provider 
organizations in Delaware. The Compact provides for mutual assistance 
in the prevention of, response to, and recovery from, any disaster that 
results in a formal state of emergency in a participating political 
subdivision. The Compact has also created a committee to review the 
progress and status of statewide mutual aid, assist in developing 
methods to track and evaluate activation of the system and to examine 
issues facing participating political subdivisions and fire, rescue, 
and emergency medical service provider organizations regarding 
implementation.
    From a homeland security perspective, the Intrastate Mutual Aid 
Compact permits state and local law enforcement to cross in-state 
jurisdictional lines to provide or receive aid from neighboring local 
jurisdictions and promotes integration and intra-operability between 
state and local law enforcement resources as a cohesive and fluid 
process.
    Once there has been a declaration of a State of Emergency, the 
Delaware State Police creates a task force comprised of representatives 
from each of the local law enforcement agencies, which then convenes to 
coordinate emergency law enforcement response, allocation of resources, 
communications and assignments of personnel. It is imperative that 
intra-operability, information gathering, analysis and dissemination 
between agencies and the public be transparent, fluid and efficient. 
Delaware recognizes that intra-operability between first responders and 
other necessary emergency personnel is key to the success of any 
emergency preparedness plan. Federal funds are always necessary to 
assist Delaware in acquiring and maintaining state-of-the-art 
technology which would promote continuity of operations during an 
emergency involving the containment of a lethal virus or disease.

    STATE ALLOCATION OF FEDERAL RESOURCES
    Federal funding and resources have supported many of Delaware's 
main homeland security objectives including effective communication 
between first responders, information gathering, analysis and 
dissemination, intra-operability between local jurisdictions, agencies 
and the business and private sector, and public education and 
awareness. Funding received from the federal government has also 
enabled the Department of Safety and Homeland Security to make 
significant strides in the development of an ``all hazards'' approach 
to our preparedness and emergency response plans. Funding at the 
federal level is necessary to ensure that Delaware can continue to 
develop plans which are flexible enough to adapt to different types of 
emergencies, yet specific enough to effectively and efficiently respond 
to those emergencies. Finally, fighting the pandemic influenza from the 
frontlines means maintaining a strong focus on prevention and response. 
Delaware must place its efforts in preventing the virus from entering 
its State borders and on ensuring success in the execution of an 
immediate, effective and proficient emergency response plan.
    DSHS understands the importance of being able to equip Delaware's 
first responders and state and local law enforcement with the tools 
necessary to successfully fight an influenza pandemic from the 
frontlines. A substantial amount of federal funds Delaware has received 
has been allocated to the purchase of decontamination equipment, 
protective suits and masks, communications equipment, all terrain 
vehicles for rescue and recovery in extremely rough terrain, chemical 
detection kits, security cameras and night vision equipment. State and 
local law enforcement agencies are working with the Delaware Division 
of Public Health to ensure that they, as first responders, and their 
families receive antiviral vaccinations that should offer protection 
against the virus. Further, the DSHS, in conjunction with DEMA and the 
Delaware State Police are designated as the primary agencies for 
keeping the lines of communication open between agencies and the public 
and disseminating accurate information to the agencies and the public 
as a pandemic unfolds.
    The Department of Safety and Homeland Security is using state of 
the art telecommunications technology to create a 24 hour, 7 day a 
week, center from which information and intelligence data may be 
received, analyzed, processed, and disseminated to the private and 
public sector in a consistent and reliable manner. The Delaware 
Information Analysis Center (DIAC) will be key in maintaining open 
lines of communication between state and local law enforcement and 
other first responders. It will also serve to expand DSP's intelligence 
capabilities allowing a host of law enforcement agencies including the 
FBI, State and local police to share information regarding possible 
terrorist and bioterrorist threats. As part of the DIAC, DSHS is 
developing a geographical information system (GIS) and looking at the 
option of installing global positioning system (GPS) and automatic 
vehicle locator (AVL) devices in all modes of transportation used by 
first responders.
    As a result of federal funding, Delaware has been able to enhance 
its 800 MHz Digital Trunked Radio System to improve intra-operability 
for all state, county and local government agencies, fire, police and 
emergency medical services and to improve communications within 
buildings through the use of vehicular repeater systems. Currently, 
there are over 40 different agencies on the system, using approximately 
12,000 mobile and portable radios and making over 115,000 calls on a 
typical day. The 800 MHz System also provides interoperability in the 
jurisdictions surrounding Delaware that have systems which are 
compatible with Delaware's system. Delaware's goal is to enhance the 
system to resolve current system deficiencies. This $52 million project 
will provide in-building coverage throughout the State, through the use 
of tower sites, bi-directional amplifiers, and vehicular repeater 
systems. It will also expand the number of dispatch consoles from 54 to 
123 while standardizing and improving redundancy within and between all 
911 Centers, upgrade the radio systems platform to extend its 
lifecycle, enhance intra-operability with agencies that are not on the 
800 MHz system today, such as Public Works, and enhance 
interoperability with jurisdictions surrounding the State who use 
systems which are not compatible with Delaware's system. The State 
would like to also expand the microwave network that connects the radio 
system so that it can support the traffic and reliability needs for 
other telecommunications services requirements in the state. While the 
$52 million allocated for this project will help to upgrade systems 
currently being used by Delaware for emergency response, additional 
federal funding over the next 5 to 7 years will be necessary to meet 
the prevention and emergency response needs of Delaware as it strives 
to keep pace with ever evolving technology.Sec. 
    Delaware has also been involved in other projects to enhance the 
state's ability to stay informed of events as they unfold throughout 
the state and to allocate resources where they are most needed. 
Recently, Delaware State Police and Kent County Emergency Services 
purchased new high-tech Mobile Command Centers which have been fully 
customized with state of the art technology and telecommunications to 
assist those who need help as quickly as possible at the scene of an 
emergency. Additionally, the Delaware State Police enhanced their 
medical transport service with the purchase of new aircraft to provide 
24-hour, 7-day a week emergency helicopter transport statewide.
    Educating the public prior to the onset of this crisis is crucial. 
The Department of Safety and Homeland Security is providing an all 
hazards personal preparedness message to Delawareans by promoting the 
U.S. Homeland Security Ready campaign. Residents are encouraged to 
create a plan, make a kit and know potential threats. DEMA also 
provides personal preparedness training in communities statewide 
through its Citizen Corps program. Delaware has earmarked the Phase 1 
Federal Pandemic Influenza funds it has received for public education. 
The Division of Public Health has implemented a public outreach program 
to educate Delawareans about pandemic influenza and personal 
preparedness. One component of the program is a series of public 
informational meetings hosted in communities throughout the state. 
Public Health officials will also provide citizens with information on 
assembling a personal emergency kit with the essential items including 
health supplies, food and water. Brochures have been created for the 
special needs population in Delaware on how to prepare for and respond 
to general emergencies. The brochure advises people with disabilities 
and other special needs to maintain a contact list of medical 
suppliers, pharmacies, doctors, family members and friends they can 
rely on during an emergency. It also provides information on how to 
create an emergency preparedness kit.

ENHANCING THE FEDERAL-STATE PARTNERSHIP
    Delaware will continue to look to the federal government for 
guidance and support during the development of its plans to manage an 
influenza pandemic. It is important that our federal partners continue 
to hold public meetings and summits to keep the lines of communication 
open. Public meetings are needed in each state to share information 
with local residents. Delaware looks forward to a federal partnership 
to highlight best practices. It is vital that we learn from each other. 
Sharing expertise and lessons learned can save states valuable time and 
money. Delaware also needs federal funding to implement these best 
practices, which may include the purchase of state-of-the-art equipment 
and technology or the institution of innovative programs designed to 
prepare its agencies, the private and business sector and its citizens 
for a worst case emergency scenario. Fiscal restraints should not 
interfere with the States ability to take appropriate safety measures 
to protect its citizenry. In the face of the varying messages from 
different facets of the media, federal funding and support continue to 
be necessary to increase Delaware's ability to gather accurate 
information and disseminate that information to the public. Our 
citizens rely on state officials to provide them with timely accurate 
information. Providing funds to develop the Delaware Information 
Analysis Center and 800 MHz System will promote accurate dissemination 
of information to the public and enhance rumor control. Finally, 
support from our federal partners should come in the form of ongoing 
joint summits and federal and state exercises and drills. Exercises 
help states form invaluable relationships with state and federal 
contacts important in emergencies. Experiences gained during drills and 
exercises will prove beneficial in the event of emergency.
    The success of the Delaware Pandemic Influenza Plan, and any other 
pandemic influenza plan, depends on the cooperation and coordination 
between law enforcement and other agencies on the national, state, and 
local level. Effective forms of communication and accurate 
dissemination of information as the pandemic progresses will lessen the 
chance of overstating or understating the risks inherent in this type 
of a crisis. One thing is for certain: we must stay ahead of the H5N1 
avian flu virus. Constant preparation, planning, testing, and 
development of Delaware's Emergency Operating Plan and Pandemic 
Influenza Plan will result in an effective and meaningful preparedness 
and emergency response plan to the pandemic flu.

    Mr. Linder. Thank you, Secretary Mitchell.
    Ms. Phillips?

STATEMENT OF FRANCES B. PHILLIPS, HEALTH OFFICER, ANNE ARUNDEL 
             COUNTY, MARYLAND DEPARTMENT OF HEALTH

    Ms. Phillips. It is my pleasure, Chairman Linder and 
Chairman Reichert and distinguished members, to address you 
today on the vital role that local health departments and our 
community partners play on the frontlines in pandemic influenza 
planning and response.
    Local health departments hold the potential to minimize the 
impact of a pandemic, and in fact local public health action 
can determine the initial and perhaps ultimate impact of such a 
crisis in the United States.
    What I would like to do is very briefly describe what it is 
that local health departments across the country are now doing, 
and the crucial link between this public health work and our 
public safety agencies. I will base my remarks on my experience 
in Anne Arundel County.
    As you may know, Anne Arundel County is in the Baltimore-
Washington corridor, a county in Maryland, home to just over 
500,000 county residents, as well as our historic capital, 
Annapolis. Our county is also home to many very important 
federal landmarks, such as the United States Naval Academy, 
Fort Meade Army base, the National Security Agency, and other 
federal installations, the Chesapeake Bay Bridge, and of 
particular interest for this topic is the Baltimore-Washington 
Thurgood Marshall International Airport.
    In my experience, over 13 years as a health officer in Anne 
Arundel County, our department has faced a number of local 
public health crises, certainly ranging from the full 
mobilization on 9/11, and then the subsequent anthrax attack in 
2001. We have had severe weather emergencies, smallpox 
preparedness, as well as the SARS emergency in 2003.
    We have also dealt with more moderate public health crises, 
including hepatitis, tuberculosis, and West Nile outbreaks, as 
well as the national seasonal flu vaccine shortage in 2005. And 
then on a day-to-day basis, we face urgent public health issues 
such as well water contamination, respiratory outbreaks in 
nursing homes, and meningitis cases among schoolchildren.
    I had the opportunity in 2004 to have a very rewarding 
opportunity, I should say, to serve as an interim fire chief 
for my county. In making this appointment, the County Executive 
reflected on the number of instances in our county where the 
health department and the fire department jointly addressed 
local emergencies, and how both agencies share a common 
commitment to the protection of the public safety of our 
residents. I found in my tenure with this large metropolitan 
fire department, I found more in common between the two 
agencies than that which is different.
    With regard to pandemic planning, not only must we take an 
all-hazards approach, but we must definitely plan for the 
integration of local, state, federal and nongovernmental 
response agencies. Fundamental to this organization, this 
integration, is the shared command and management framework 
which the National Incident Management System provides. This is 
the common underpinning across public health and public safety.
    In my department, with a staff of over 850, every single 
person in my health department has been trained in basic 
preparedness, using the NIMS model, some much more skilled than 
the basic level. Readiness for the possibility of a 24/7 
emergency call-up is a condition of employment in my health 
department. So every school nurse, for example, every 
addictions counselor, every restaurant inspector has a basic 
understanding of what their role would be in an emergency. We 
have both exercises, and we have had real-time experience with 
this call-up.
    I would like to name just four areas of unique local public 
health activity with regard to pandemic preparedness. The first 
has been mentioned, and that is disease surveillance. We need 
and we have a system across the country of surveillance so that 
when an astute clinician either diagnoses or suspects a case, 
that suspicion can be reported to a public health authority 
able to interpret and to respond on that report. That is the 
basic infrastructure and local health departments are the boots 
on the ground, so to speak, with regard to our nation's 
surveillance system. Every year, my department receives 4,000 
communicable disease reports, which then trigger over 2,100 
disease investigations.
    A different kind of surveillance is demonstrated by an 
incident that occurred within the last 2 weeks at BWI airport. 
On a commercial carrier, the pilot radioed ahead that there was 
a sick passenger on board and that that passenger had had 
extensive Southeast Asian travel. What occurred at the point of 
landing was a very rapid response where, taking isolation for 
caution, the patient was evacuated to a nearby hospital for 
emergency evaluation. Within the hour, about two dozen state, 
local, federal and representatives of the commercial carrier 
were convened, and a response plan initiated.
    Surveillance is one. The second unique role that I would 
like to briefly mentioned, and has been mentioned, community 
awareness and self-sufficiency. Pandemic is going to involve 
all sectors, as has been said. It is a pan-societal crisis. In 
my department, we have been briefing over the past several 
months every sector in our county, certainly our other public 
safety and other county agencies. We have been working very 
closely with personnel from the Naval Academy, from Fort Meade, 
from NSA, working on their contingency plans; our school 
systems, our hospitals, our church and faith-based 
organizations, and I have to say our business community. Large 
employers in our county are very anxious to understand more 
about pandemic influenza preparedness so that they can put 
forth their continuity of operations plans.
    Thirdly, community infection control. When we think about 
an outbreak of this kind of infection, certainly the issue of 
isolation and quarantine comes forward. As has been mentioned, 
many states have beefed up the legal underpinnings to take some 
unprecedented actions with regard to ordering individuals and 
to taking control of private property. At my level, we are 
right now working on an inventory of alternative housing for 
individuals who would need to be in respiratory isolation, as 
well as working on the social and the medical support that 
these people would need to stay homebound.
    We had a little bit of experience with this with the SARS 
emergency. We had some people who were in a voluntary home 
isolation. We had 100 percent compliance, but we certainly 
believe that that may not be the future with pandemic and we 
need to rely on our public safety partners for security.
    Lastly, mass vaccination and medication distribution. The 
role of local health departments, when a vaccine is available, 
an effective vaccine, is to take delivery of that vaccine and 
to distribute it to all county residents. In our county, we 
have not had, of course, the experience with pandemic, but last 
year in 2005, with the flu vaccine crisis, we had a situation 
where thousands and thousands of residents were very anxious 
for their flu shots. We mobilized, with the help of our EMS and 
our police department. High-school-based mass clinics, using 
all of our staff, were able to vaccinate on two Saturdays, 
6,800 people at a rate of 670 doses an hour.
    In conclusion, as far as federal leadership, I do commend 
the federal government for this proactive approach and 
engagement on the issue of pandemic flu. I have submitted some 
written recommendations with regard to the federal role. 
Suffice it to say that it is key that there is a collaboration 
at the very highest levels of the federal government, because 
for us on the ground it is very important that that 
collaboration result through state and local grantees in a 
reinforced and consistent message. I urge the Department of 
Homeland Security, for example, to engage with us, local public 
health practitioners, as they go forward with their pandemic 
flu plan.
    So on behalf of the National Association of City and County 
Health Officials and our membership, I commend you for your 
leadership on this topic. Thank you.
    [The statement of Ms. Phillips follows:]

               Prepared Statement of Frances B. Phillips

    It is my pleasure, Chairman Linder, Chairman Reichert, and 
distinguished Members, to address you today concerning the vital role 
of local health departments and their community partners in homeland 
security on the front lines in pandemic influenza planning and 
response.
    The combined efforts of local health departments and our colleagues 
in first response will determine the initial, and in many ways, the 
ultimate impact of an influenza pandemic in the United States. In my 
presentation, I will describe how local health departments are planning 
our response to a worldwide influenza outbreak, with an emphasis on how 
the success of those plans relies on the crucial linkages that have 
been built between local public health departments and a range of 
community partners.
    For nearly 13 years I have directed a large local health department 
serving a population of about 500,000, including residents of our 
historic state capital, Annapolis. Anne Arundel County is also home to 
many national landmarks such as the U.S. Naval Academy, Fort Meade Army 
Base, the National Security Agency and other federal installations and 
the Chesapeake Bay Bridge. In terms of pandemic flu, the landmark about 
which I am most concerned is the Baltimore Washington Thurgood Marshall 
International Airport. Collectively, these landmarks have resulted in a 
relatively high ``vulnerability index'' of security threats to the 
county.
    Heightened awareness of the potential vulnerabilities is something 
all the response entities in our jurisdiction share. For years, we have 
been engaged with our police, fire and rescue, emergency management and 
other counterparts in planning and exercising for local emergencies. As 
in the rest of the country, this type of cooperative work intensified 
after September 11, 2001, building on the mutual understanding that we 
all have our part to play in any unfolding emergency.
    In 2004, I had the unique and rewarding opportunity to serve as 
Acting Fire Chief for an interim period in my county. In making this 
decision, the County Executive reflected on the number of instances in 
which both fire and health departments had jointly addressed local 
emergencies, and how a common commitment to protecting the safety of 
county residents was central to the appointment. So often we hear about 
the differences that exist among the emergency disciplines--but this 
core mission that we share is key.
    I found more that was common to public health during my tenure with 
this large metropolitan fire department than was different. There were 
areas where each agency could--and did--benefit from an exchange of 
expertise. For example, learning from public health's proficiency in 
prevention and outreach to diverse communities, including those with 
special needs, was a gain for the fire department. Likewise, the fire 
department's expertise in incident management and chain of command 
accountability has proven to be of great utility within the health 
department in a range of emergency situations.
    My department, with a staff of about 850, has experienced a wide 
array of emergencies, just in recent years. We have had direct 
experience mobilizing emergency operations in the face of the 9/11 
attacks and subsequent anthrax attacks of 2001, severe weather 
situations, tuberculosis and hepatitis outbreaks and the SARS emergency 
of 2003. We have also faced more moderate, but nonetheless challenging 
events, such as the West Nile Virus outbreak and the national flu 
vaccine shortage of 2005. And of course, on a daily basis we are 
confronted with localized but urgent public health issues such as well 
water contamination, respiratory outbreaks in nursing homes and 
meningitis cases among school children. All of these experiences are 
vital to building a workforce prepared to respond in the face of a 
prospect as daunting as pandemic influenza. My remarks today are based 
on lessons learned from these real world events.

    Pandemic Influenza Preparedness Must be Integrated into All-Hazards 
Preparedness
    Local emergency preparedness is based on an `all-hazards' approach. 
This approach requires communities to assure the essential capabilities 
necessary to respond to a wide range of emergencies: intentional or 
naturally occurring infectious disease outbreaks; chemical, explosive 
or radiologic accident or attack; weather-related disaster; or other 
emergency.
    Since 2001, with the elevated awareness of the country's 
vulnerability to intentional attacks with biological agents, there has 
developed a better understanding of public health's unique role in 
protecting the homeland in this kind of scenario. Whether the 
communicable disease threat is a novel influenza virus, smallpox, 
anthrax, West Nile Virus, SARS, or other emerging pathogen capable of 
causing widespread illness and death, there are a core of universal 
public health response capabilities for which local health departments 
across the country are planning, training and exercising.
    However, those health departments do not and cannot stand alone. 
All planning and response must be integrated with other local entities, 
most notably public safety first responders, but also state, federal 
and non-governmental partners. Fundamental to such integration is a 
shared command and management framework. With its strong foundation in 
the Incident Command System, the broader National Incident Management 
System (NIMS) developed under Homeland Security Presidential Directive 
5 provides this common underpinning for all public health and public 
safety preparedness. Over time, adoption of NIMS will continue to 
facilitate the integration of language, mental models and even certain 
cultural aspects of public safety by public health professionals.
    Pandemic influenza planning is a section of our county's Health/
Medical Annex--the ``ESF (Emergency Support Function) #8 Chapter''--
within the county's all-hazards plan. This is typical and it 
demonstrates the integration of the influenza response into an all-
hazards approach. Although it is located in the Health/Medical Annex, 
which contains the core response elements for a disease outbreak, the 
roles in executing the response span the gamut of other emergency 
disciplines, as they do for any other targeted scenario within an all 
hazards plan.

Key Elements of Front Line Pandemic Influenza Preparedness
    1. Disease Surveillance
    The purpose of a strong surveillance system is to create time in 
which to intervene and eliminate or mitigate threats. In local public 
health, practical disease surveillance means a system by which 
clinicians in private practice or in hospital settings can detect and 
report a novel flu virus or a suspect case to a public health authority 
capable of receiving, interpreting and responding to such a report. 
Ultimately, the country may reach a point where electronic medical 
records and associated systems will enable automatic reporting of 
diseases or suspicious symptoms, but such capability will be immensely 
challenging in this intensely diverse and complex national environment. 
We cannot wait, nor can we depend solely on technology when so much is 
at stake. Our greatest strength is in our American workforce--our 
astute clinicians, our trained healthcare professionals, our alert 
hospitals--and the effective partnerships that are forged between this 
community and capable local public health departments. It is important 
not to underestimate the immediate and important utility of this model 
of disease surveillance.
    Local health departments are the `boots on the ground' elements of 
our nation's disease surveillance system. In my department, we receive 
4000 communicable disease reports each year from our partner hospitals 
and physicians. Typically, these reports involve infectious diseases 
such as tuberculosis, AIDS, or measles. These reports generate over 
2100 disease investigations conducted by public health, with our staff 
conducting patient interviews, performing contact tracing and, where 
indicated, beginning prophylactic treatment of persons who have been 
exposed.
    One less typical but important example of public health 
surveillance recently occurred when the flight crew on a commercial 
aircraft bound for BWI airport reported a sick passenger returning from 
extensive travel in Asia. Upon arrival, the individual was immediately 
transported to a nearby hospital for evaluation. Within the hour, 
nearly two dozen local, state and federal agency personnel, along with 
representatives of the carrier, had been alerted and a response plan 
initiated.

    2. Community Awareness and Self-Sufficiency
    As the BWI incident demonstrates, planning with a broad range of 
partners meant than when a real situation arose, the right people were 
there quickly. In the specific case of pandemic influenza, there is a 
continuing need for not only governmental, but also corporate and 
community sectors to be informed about pandemic influenza and to 
understand their potential roles in a response.
    At a local level, the health department is regarded as the source 
for reliable and practical information, specific to the community. For 
months my department has conducted continual `customized' education 
sessions on avian and pandemic influenza to all sectors, beginning with 
our police, fire, emergency management and pubic works departments. We 
have held ongoing briefings with the Naval Academy, Ft. Meade and NSA 
personnel; our school system, hospitals, and nursing homes. The 
business sector, faith-based and community-based organizations have all 
sought our information and guidance on preparing for a major flu 
outbreak.
    My department serves a key consultant to county government and 
several large corporations in developing their continuity-of-operations 
plans to address prolonged and widespread absenteeism. We have a cadre 
of trained presenters, as well as a very active website, public sector 
cable television channel and strong media relationships to assist with 
these broad communications efforts.
    We are not alone in conducting such education. Across the country, 
some innovative partnerships between public health departments and the 
private sector are emerging. Whether it is educating their employees 
through distributing information on preventive measures or volunteering 
to coordinate points of dispensing on corporate campuses, some 
companies are showing interest in playing a part in the larger 
response.
    There is a tremendous desire for information regarding pandemic 
influenza across all sectors and a great deal of work ahead for local 
health departments in spreading the word, but this effort will be worth 
the return if we can reduce panic and increase creative response 
options if the need ever arises.

    3. Community Infection Control
    Over the past several years, the legal foundation required for 
public health to adequately protect the public in a catastrophic health 
emergency has been significantly strengthened in many states. Both 
state and local health departments have closely examined our respective 
responsibilities to isolate or quarantine persons; to control private 
property or otherwise intervene in private activities. All these would 
be unprecedented actions, requiring enormous pre-planning. In my 
county, for example, we are developing an inventory of alternative 
housing suitable for persons requiring respiratory isolation. We are 
identifying sources for the medical and social supports should large 
numbers of people be confined at home. These partners will be a major 
part of the success of any critical effort to minimize the spread of 
disease.
    Our experience with placing a few SARS suspects in home isolation 
has been instructive. We experienced 100% compliance, but recognize a 
pandemic circumstance could be radically different. In such situations, 
we may call on our public safety partners to assist with security. We 
recognize the importance of making sure they are educated about risks 
and are knowledgeable about what prophylaxis is available and the need 
for any personal protective equipment.

    4. Mass Distribution of Vaccines and Medications
    Timely development of an effective vaccine, in sufficient quantity 
to immunize the population against a novel virus, is a huge challenge 
that the Federal government has taken important steps to confront. 
Local health departments are responsible on the ground for accepting 
delivery of the Strategic National Stockpile in which such a vaccine or 
anti-viral medications would be stored. Mindful that we do not now have 
the ability to manufacture sufficient quantities of such 
countermeasures, we must still have in place all the planning, staffing 
and public information systems necessary to promptly distribute them to 
all priority populations in the county.
    While we've not experienced a pandemic, local health departments 
have had parallel experiences and exercises that have tested our 
ability to provide mass vaccine and medication distribution. In our 
case, in October 2001, we rapidly mobilized mass clinics to distribute 
ciprofloxacin to U.S. Postal Service or U.S. Senate employees 
potentially exposed to anthrax while working. During the 2004 seasonal 
flu vaccine shortage, with delayed shipments causing the public to 
become extremely anxious to get their flu shots, our department gave 
over 6800 doses in two days, at a rate of 670 doses an hour.
    This effort demonstrated the value of a thoroughly trained and 
responsive public health workforce. In my department, every staff 
person, from school nurse to addictions counselor to restaurant 
inspector, is required to be trained, at a minimum, in basic emergency 
preparedness using the NIMS model.
    Yet again, we could not have managed this mobilization without the 
full support of our police and fire departments, who provided security, 
essential traffic control, and necessary emergency medical transport 
capacity at the high school-based mass clinics. These are no minor 
feats in a mass setting, especially in a real life situation where 
emotions are running high and the chance of panic is never far away. 
The public already has benefited greatly from the collaboration between 
public health and public safety agencies. Only through a highly 
coordinated and very broad ``pan-social'' approach will we achieve 
maximum homeland security in the face of an influenza pandemic.

Federal Leadership
    It is a positive step that so many in this country are paying 
attention to pandemic influenza before we find that threat a reality. 
We often tend to focus on the last event, but in this case the focus 
has been on being proactive--a fact which is evidenced by the very 
existence of this hearing. Your leadership on this issue is 
appreciated.
    However, there doesn't always appear to be the same sort of 
cooperation and coordination occurring at the Federal level among the 
various agencies involved in pandemic influenza preparedness as there 
is even in Anne Arundel County. Leadership questions in the event of a 
biological attack have been debated by Federal agencies in the press. 
Should the Department of Homeland Security (DHS) be at the forefront or 
should the Department of Health and Human Services (HHS) play the 
leading role? If DHS is in charge, how will they draw on public health 
expertise and resources to guide the Federal response?
    The same question frequently arises when setting up an incident 
command at the local level for a biological incident. Is the public 
health officer the incident commander? The answer is sometimes yes, 
sometimes no. The answer depends on the health department, it depends 
on the community and it depends on the event. The decision should be 
made based on a clear understanding of needs and capabilities. Most 
often at the local level, the understanding is that if public health is 
not the incident commander in a public health emergency, whoever does 
assume that role will rely heavily on the public health officer to 
provide the guidance and situational awareness necessary for decision-
making.
    Thus far, the Department of Homeland Security has made progress in 
understanding and integrating public health in fits and starts. Initial 
efforts toward fulfilling HSPD-8 showed limited understanding of what 
public health even was and how it would mount a response in an 
incident. As I described above, pandemic influenza response will 
require much more than medical care and hospital beds. To its credit, 
DHS later reached out to public health practitioners for input on 
documents like the Universal Task List and the National Preparedness 
Goal. DHS and HHS appear to have improved their communication somewhat, 
but there is still much room for improved coordination between these 
two agencies.
    For example, the interdisciplinary cooperation I have described 
that will be so valuable in the event pandemic influenza arrives in 
Anne Arundel County appears not to be a high priority in the current 
Federal approach. Congress has appropriated some much-needed additional 
funds, $350 million, for local and state health departments, and new 
guidance for those efforts is on its way. Yet, little discussion is 
taking place regarding the non-CDC grantees vital to the success of a 
pandemic influenza plan. Can DHS grantees use their funds for 
collaboration on this sort of planning? Should they be required to do 
so?
    Federal agencies need to collaborate at the highest level of 
government to send coordinated and reinforcing messages to all grantees 
at state and local levels that multidisciplinary cooperation is a high 
priority. Through the structure of grant programs and the guidance 
provided, DHS and HHS can either facilitate local efforts in that 
regard or hinder them with inconsistent guidance. Both agencies should 
include local public health practitioners, the ones who will be key 
responders on the ground, in their consultations. It is not enough for 
DHS to rely exclusively on HHS for public health input.
    Another way that those at the Federal level can help to make our 
national response to emergencies like pandemic influenza more unified 
is to remember the professional diversity of their audience when 
rolling out national programs. Local emergency response agencies are 
being required to absorb and integrate a continual stream of new 
initiatives, ranging from NIMS and the National Response Plan to the 
Target Capabilities and the National Preparedness Goal. Training 
courses are introduced through FEMA and the Emergency Management 
Institute. Yet the local audiences grappling with all these new 
programs--while continuing their day-to-day workload serving their 
communities--need to understand just how these programs are relevant to 
their roles in an emergency. When a federal contractor with a fire 
service background conducts a basic Incident Command System training 
for public health workers, the concepts are correct, but the anecdotal 
examples don't resonate. In terms of public health, there are a wealth 
of solid examples of departments that have integrated ICS into even 
their day-to-day operations. Courses that reference those familiar 
experiences are more likely to have an impact. Unfortunately, such 
courses are hard to find.
    Finally, while much time is spent asking local and state emergency 
personnel to understand how the national plan is structured, we need to 
remember that no matter how serious the emergency, the response always 
begins locally. And in the case of pandemic influenza, the 
effectiveness of that early response will determine how the emergency 
unfolds. Standardization is important to the extent that it can be 
realized, but national plans also must support a response in every 
corner of this diverse country. A one-size-fits-all approach simply 
will not be successful.
    Whether pandemic influenza or some other disaster afflicts our 
nation, there is no shortage of dedicated Americans at every level of 
government working hard on homeland security. Continuing to promote, 
support, and build local partnerships among public health, health care, 
public safety, emergency management, and a host of private sector 
partners will only improve our ability to protect the health and safety 
of our communities.

    Mr. Linder. Thank you very much, Ms. Phillips.
    Mr. Blackwelder?

  ERNEST BLACKWELDER, SENIOR VICE PRESIDENT, BUSINESS FORCE, 
           BUSINESS EXECUTIVES FOR NATIONAL SECURITY

    Mr. Blackwelder. Good afternoon, Chairman Linder, Chairman 
Reichert, ranking members, distinguished members of the 
committee. It is an honor to be here today to address some of 
the ways in which the private sector can help our country 
better prepare for and respond to pandemic influenza.
    I am here on behalf of Business Executives for National 
Security, or BENS, a national nonpartisan, nonprofit 
organization, comprised of more than 500 business executives 
committed to volunteering their time and talents to improve the 
nation's security.
    Mr. Chairman, when facing the threat of pandemic flu or any 
catastrophic event, businesses have two kinds of 
responsibilities. First is saving themselves, and the second is 
helping their communities. Self-preservation or business 
continuity planning includes developing emergency response 
capabilities to protect employee health and safety, as well as 
taking steps to make business operations resilient enough to 
survive a catastrophic event. Business preparedness helps 
protect critical infrastructure, ensure availability of 
urgently needed goods and services, and strengthen economic 
stability.
    Businesses are creating contingency plans to help reduce 
their economic risk in the event of pandemic flu, including 
stockpiling supplies, improving virtual work programs such as 
telecommuting, implementing travel restrictions, cross-training 
employees, reallocating work activities, and reconfiguring 
shifts, to limit exposure to coworkers.
    While business continuity planning is critical, there 
remain huge gaps in our preparedness and response capabilities 
nationwide that neither business nor government can fill alone. 
Increasingly, communities recognize the need to bring the best 
of business and government together to meet these challenges. 
Three years ago, BENS began to leverage private sector 
resources and know-how to work in concert with state and local 
government to strengthen regional homeland security and 
disaster response capability. I would like to share some of the 
lessons we have learned and the promise they hold for saving 
lives.
    Through regional public-private partnerships we call the 
Business Force, BENS has mobilized businesses to help state and 
local government on a pro bono basis to prepare for and respond 
to catastrophic events.
    Mr. Chairman, I would like to describe four Business Force 
initiatives that illustrate the potential for American 
businesses to work in partnership with government, specifically 
to address the threat of pandemic flu.
    The first involves mobilizing business volunteers to assist 
in the dispensing of the strategic national stockpile. In July 
of last year, BENS worked in partnership with state and local 
public health leaders in Georgia and the metro Atlanta region 
to mobilize 1,200 private sector volunteers for a live 
bioterrorism exercise. Our members facilitated a 9-month design 
effort, during which business volunteers helped state and local 
health officials modify their existing exercise plans to 
incorporate significant business participation. That exercise 
included utilizing corporate facilities as a point of 
dispensing, or POD.
    Following the exercise, BENS members worked with state and 
local public health leaders to create a model that calls for 
large employers in a given urban area to dispense vaccines or 
medications to their employees and their families, with the 
understanding that a predefined group of employees would then 
volunteer to go to designated public schools and help treat the 
general population. This model has the potential to provide a 
substantial portion of the thousands of volunteers that would 
be needed in any major urban area in the wake of a biological 
or chemical attack.
    Furthermore, this model can be modified for use in an 
influenza pandemic by tapping the expertise of the private 
sector in such areas as logistics, supply chain management, 
human resources, and in fact creating a public-private sector 
disease management and monitoring program.
    The second initiative is what we call the Business Response 
Network, Web-based regional databases of pledged business 
resources that state and local emergency management leaders and 
public health officials can call upon during a catastrophe. 
Both 9/11 and Hurricane Katrina highlighted the need to create 
in advance a system that effectively utilized the overwhelming 
offers of support from the private sector. The total value of 
business resources we have registered to date is about $700 
million, but the potential exists to register tens of billions 
of dollars in pledged business resources nationwide.
    Now, some of the search capacity requirements of the 
pandemic, including facilities, transportation, and 
communications equipment, can be identified and pre-pledged, 
while other needed supplies might be solicited on the fly 
during an event. The Business Response Network is an efficient 
and effective tool for doing both.
    The third initiative is the Workplace Sentinel Program. 
BENS has recently partnered with the New Jersey Public Health 
Department to design a Web-based reporting system that will 
enable large employers to report spikes in absenteeism to state 
and local epidemiologists.
    Finally, in addition to building these three specific 
capabilities, business and government leaders must learn to 
communicate effectively and make sound decisions during an 
event. To this end, BENS is facilitating the integration of 
business representatives into state and local emergency 
operation centers and intelligence and information fusion 
centers.
    Mr. Chairman, business does not have all the answers, but 
it is clear, especially during times of crisis, that our nation 
needs the vast resources, expertise and capabilities of the 
private sector. We cannot overstate the value of building trust 
and creating a study bridge between business and government in 
advance. BENS will continue to work with our government 
partners to strengthen prevention, preparedness and response 
capabilities.
    Mr. Chairman and members of the committee, thank you for 
your courtesies. I look forward to your questions.
    [The statement of Mr. Blackwelder follows:]

              Prepared Statement of Ernest A. Blackwelder

    Good afternoon, Chairman Linder, Chairman Reichert, Ranking 
Members, and distinguished Members of the Committee. It is an honor to 
appear before you today, to address some of the ways in which business 
and the private sector can help our country better prepare for and 
respond to the threat of a pandemic influenza.
    My name is Ern Blackwelder. I am here on behalf of Business 
Executives for National Security (BENS)--a national, non-partisan, non-
profit organization comprised of more than 500 business executives--
committed to volunteering their time and talents to improve the 
nation's security.
    Since its inception in 1982, BENS has worked on nuclear non-
proliferation initiatives and the application of best business 
practices into Pentagon support functions. With the turn of the 
century, BENS' focus expanded to include the growing threats of 
terrorism. After 9-11, our members agreed there would be important 
roles for the private sector in homeland security as well and quickly 
recognized the wisdom of an all hazards approach.
    When facing the threat of pandemic flu, or any catastrophic event, 
the business community has responsibility in two important areas.
    The first is business continuity planning--a term that often 
includes developing emergency response capabilities to help ensure 
employee health and safety, as well as making sure that the business 
survives a catastrophic event. Business preparedness also serves to 
protect critical infrastructure, ensure availability of urgently needed 
goods and services, and strengthen economic stability. These challenges 
would be especially severe in a flu pandemic, where companies could 
experience absenteeism rates of up to 30 or 40 percent for up to 
several months.
    Pandemic flu business continuity plans encompass a wide variety of 
activities like hand washing and social distancing, stockpiling 
supplies, monitoring and assisting the sick, improving virtual work 
programs such as telecommuting, implementing necessary travel 
restrictions, cross-training employees, reallocating work activities 
and reconfiguring shifts to limit disease spread. Large companies 
typically employ business continuity professionals, while smaller 
companies often ask operations managers to perform this function along 
with their other responsibilities.
    In December 2005, HHS Secretary Leavitt and DHS Secretary Chertoff 
co-signed a letter to business leaders containing a checklist to assist 
companies with pandemic flu business continuity planning 
(www.pandemicflu.gov and www.cdc.gov/business). In addition to advising 
businesses on how to prepare themselves for a pandemic, the Secretaries 
asked businesses to coordinate with external organizations to help 
their communities. I will focus the remainder of my prepared remarks on 
this second responsibility of business during times of crisis: that of 
providing civic leadership--sharing resources and expertise for the 
benefit of the community and the nation.
    While business continuity planning is critical, there are huge gaps 
in our preparedness and response capabilities nationwide that neither 
business, nor government can fill alone. We saw those gaps on 9-11, and 
more recently with Hurricane Katrina. Increasingly, communities 
recognize the need to bring the best of business and government 
together to meet these challenges.
    Three years ago, BENS began to leverage private sector resources 
and know-how to work in concert with state and local government to 
strengthen regional homeland security and disaster response capability. 
I'd like to share some of the lessons we've learned and the promise 
they hold for saving lives.
    Through regional public private partnerships we call the Business 
Force, BENS has mobilized member businesses on a pro bono basis to help 
state and local government leaders prevent, prepare for, and respond to 
catastrophic events--including acts of terrorism, natural disasters, or 
public health emergencies. These partnerships can help reduce loss of 
life and economic disruption from such events by implementing specific 
preparedness and response initiatives that tap the expertise and 
resources of the private sector and build trust between business and 
government.
    Through early collaboration with state and local public health 
leaders and with the Center for Disease Control (CDC) in Atlanta, we've 
identified four Business Force initiatives of particular value in 
addressing the threat of a flu pandemic, or other public health 
emergencies. They include:
        1) mobilizing business volunteers to assist in the dispensing 
        of the Strategic National Stockpile;
        2) building Business Response Networks--web-based registries of 
        pledged business resources that can be called upon by public 
        officials in response to a catastrophic event or public health 
        crisis;
        3) launching the Workplace Sentinel program--enlisting large 
        employers to report anomalous rates of employee absenteeism to 
        provide public health officials early indicators of disease; 
        and
        4) integrating business into state and local emergency 
        operations and intelligence fusion centers.

Strategic National Stockpile (SNS) Dispensing
    BENS worked in partnership with state and local public health 
leaders in Georgia and the Metro-Atlanta region to mobilize 1,200 
private sector volunteers for a live bio-terrorism exercise in July 
2005. Our members facilitated a nine-month design effort, during which 
business volunteers helped state and local public health officials 
modify their exercise plans to incorporate significant business 
participation. During the exercise, business volunteers served as both 
patients and logistics observers at three dispensing sites--two public 
schools and a private manufacturing facility.
    The Atlanta exercise illustrated that local public health 
districts, responsible for dispensing the SNS, used approximately 40 
percent of their personnel to process a patient volume equal to less 
than five percent of the patient volume expected following an actual 
airborne anthrax attack. In other words, had this been an actual 
attack, public health would have had about 10 percent of needed 
personnel. Similar shortfalls exist under other biological or chemical 
attack scenarios, although specific personnel requirements would vary.
    Following the exercise, BENS worked with state and local public 
health leaders to create a model that calls for large employers in a 
given urban area to dispense vaccines or medications to their employees 
and families, with the understanding that a pre-defined group of 
employees would then volunteer to go to designated public schools to 
assist in dispensing to the general public.
    This model has the potential to provide a substantial portion of 
the thousands of volunteers that would be needed in any urban area in 
the wake of biological or chemical attack. Furthermore, this model can 
be modified for use in an influenza pandemic by tapping the expertise 
of BENS members and staff--in areas such as logistics, volunteer 
recruitment, and building trust between business and government 
partners--to create a public-private disease monitoring and management 
program.
    Beyond Georgia, public health leaders have expressed interest in 
implementing this model in each of the regions where BENS has 
operations--including the states of California, Kansas, Missouri and 
New Jersey, and the Kansas City and Santa Clara County urban areas 
selected for emergency preparedness pilots by the Centers for Disease 
Control and Prevention (CDC).

Business Response Network (BRN)
    Hurricane Katrina demonstrated how a catastrophic event can 
overwhelm government's ability to respond. Katrina also highlighted the 
need to create, in advance, a system for effectively utilizing the 
overwhelming offers of support from the private sector. BENS has 
implemented a web-based system to meet this need called the Business 
Response Network, or BRN. The BRN is a regional web database of pledged 
business resources (warehouse or office space, trucks, equipment, 
skilled personnel, etc.) that emergency management and public health 
leaders can call upon in a catastrophe or public health emergency. 
(www.businessresponsenetwork.org)
    BENS has implemented permanent BRN's in New Jersey, Missouri and 
Kansas, and a temporary BRN for the state of Massachusetts prior to the 
2004 Democratic National Convention. The total value of business 
resources registered to date is approximately $700 million; however, 
the potential exists to register tens of billions of dollars in pledged 
business resources nationwide. Multiple state BRN's could be 
coordinated through the states' mutual aid program known as EMAC 
(Emergency Management Assistance Compact). The EMAC system currently 
applies to public sector resources, however BENS is exploring 
opportunities to include private sector resources as well.
    BENS builds the BRN at the state or regional level for two reasons: 
1) state and local governments have primary accountability for first 
response under the National Response Plan; and 2) it is easier to build 
trust between business and government at the state and local level.
    Until there is a uniform federal standard, concerns about liability 
protection must be addressed at the state and local level, where laws 
vary widely. While some businesses may not participate in their state's 
BRN due to liability concerns, many others have chosen to participate--
even with imperfect Good Samaritan laws. These companies recognize that 
sitting on the sidelines will only lead to higher casualties and 
greater risk--to the economy, their communities, and their businesses.
    The BRN system applies to ``all hazards'', but would be especially 
useful in the event of a pandemic, given its potential scope and 
duration. Some of the surge capacity requirements of a pandemic--
including facilities, transportation, or communications equipment--can 
be identified and pre-pledged, while other needed supplies might be 
solicited on-the-fly during an event. The BRN provides an efficient and 
effective tool for doing both.

Workplace Sentinel
    BENS has recently partnered with New Jersey public health leaders 
to design a web-based reporting system that will enable large employers 
to report spikes in absenteeism that can alert state epidemiologists. 
This system, which is planned for implementation in mid-2006, calls for 
each company to establish a baseline absenteeism rate. When absenteeism 
exceeds a certain number of standard deviations above baseline, 
companies will report that information online. Employer data will be 
anonymously aggregated by county, and then forwarded to state and 
affected county public health agencies to help identify causes and 
determine appropriate response.

Business Integration into Emergency Operations and Information Fusion 
Centers
    The SNS Dispensing, BRN and Workplace Sentinel initiatives can all 
be implemented and exercised in advance, to dramatically improve the 
response to any catastrophic event or public health emergency. In 
addition to building these specific capabilities, business and 
government leaders must learn to communicate effectively and make sound 
decisions during a crisis. To this end, BENS is facilitating the 
integration of business representatives into state and local Emergency 
Operations Centers and Intelligence/Information Fusion Centers.
    Establishing a formal business presence at these centers and 
performing exercises to test the effectiveness of business-government 
communication will strengthen teamwork and build trust--making it 
easier to work together effectively during a crisis. BENS is developing 
pilot programs in Georgia, Metro Kansas City, New Jersey, and in Los 
Angeles and Orange Counties, and has also been asked to support 
implementation of similar initiatives in other states.
    Mr. Chairman, there is no single model, nor comprehensive program 
that will fill all the nation's needs in the event of pandemic flu. It 
is clear, however, that especially during times of crisis, our nation 
needs the vast resources, expertise, and capabilities of the private 
sector. BENS is highly confident in the value of building trust and 
creating a sturdy bridge between business and government, and we will 
continue to work with our government partners to strengthen prevention, 
preparedness and response capabilities.
    Mr. Chairman, I look forward to answering your questions.

                                                      BENS
                                                 BUSINESS FORCE
                                    Business Executives for National Security
                                              Programs and Regions
----------------------------------------------------------------------------------------------------------------
                  Initiative                               Description               NJ   GA   KC   SF   LA   MA
----------------------------------------------------------------------------------------------------------------
ASSETS
----------------------------------------------------------------------------------------------------------------
 Business Response Network                     * Businesses make needed resources     X    X    X    X    X    X
                                                (e.g., trucks, warehouses, people
                                               with certain skills) available on a
                                                  pro bono basis via web database
----------------------------------------------------------------------------------------------------------------
VOLUNTEERS
----------------------------------------------------------------------------------------------------------------
Strategic National Stockpile Partnership       * Businesses assist in distribution    X    X    X    X    X
                                                   and dispensing of vaccines and
                                                other medical supplies in a major
                                                                medical emergency
----------------------------------------------------------------------------------------------------------------
Emergency Preparedness Training                * BENS recruits companies to create    X         X
                                               Community Emergency Response Teams
                                                                          (CERTs)
----------------------------------------------------------------------------------------------------------------
INFORMATION
----------------------------------------------------------------------------------------------------------------
Intelligence/Information Fusion                   * Business assist government in     X    X    X    X    X
                                                 implementation of Fusion Centers
                                                that include active participation
                                                            of the private sector
----------------------------------------------------------------------------------------------------------------
Critical Infrastructure Protection               * Business assists government in          X    X         X
                                                            implementing critical
                                                   infrastructure risk assessment
                                                     tools, and provide advise on
                                               protecting critical infrastructure
----------------------------------------------------------------------------------------------------------------
Public TV/Radio Partnership                          * BENS recruits companies to     X
                                                receive satellite ``datacasting''
                                                     feeds during times of crisis
----------------------------------------------------------------------------------------------------------------
Knowledge Portal                                     * BENS creates a ``knowledge          X    X
                                                management portal'' to facilitate
                                                sharing of best practices between
                                                    state government and business
----------------------------------------------------------------------------------------------------------------
Agricultural Early Warning System                * Agricultural businesses report          X    X
                                               animal sickness or contamination to
                                                    public health agencies (early
                                                                           stage)
----------------------------------------------------------------------------------------------------------------
STRATEGIC SUPPORT
----------------------------------------------------------------------------------------------------------------
Exercises                                             * BENS designs and conducts     X    X    X    X
                                                    exercises to identify program
                                                 opportunities and to ensure that
                                                each program is operational. Also
                                               hosting a major TOPOFF3 exercise in
                                                                       New Jersey
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Ad Hoc Projects                                      * Operating Groups of senior     X    X    X    X
                                               business and government leaders in
                                               each region enable collaboration on
                                               an as-needed basis (e.g., response
                                               to flu vaccine shortage; serving on
                                               state homeland security committees)
----------------------------------------------------------------------------------------------------------------

        * Regions
        NJ: New Jersey--started February 2003
        GA: Georgia--started October 2003
        KC: MidAmerica (Missouri, Kansas, Nebraska, Iowa, based Kansas 
        City)--started October 2004
        LA: Los Angeles and Orange Counties--management agreement 
        Homeland Security Advisory Council began January 2006
        SF: San Francisco Bay Area--start-up planned for 2005
        MA: Massachusetts--DHS project for Democratic National 
        Convention in 2004

    Mr. Linder. Thank you, Mr. Blackwelder.
    Dr. Seaberg?
    Dr. Seaberg. Mr. Chairman and members of the subcommittees, 
I want to thank you for allowing me to testify today on behalf 
of the American College of Emergency Physicians. ACEP is the 
largest specialty organization in emergency medicine, with over 
23,000 members.
    Emergency departments act as our nation's health care 
safety net. Unlike any other health care provider, the 
emergency department is open for all patients who seek care, 24 
hours a day, 7 days a week, 365 days a year. We provide care to 
anyone who comes through our doors regardless of their ability 
to pay.
    At the same time, when factors force an emergency 
department to close, it is closed to everyone and the community 
is denied a vital resource. As the frontline of emergency care 
in this country, emergency physicians are particularly 
sensitive to the devastating impact an avian flu pandemic would 
have on our patients and our communities. According to CDC 
estimates, a medium-level pandemic in the U.S. could affect 
between 13 percent and 35 percent of the population, with an 
economic impact between $71 billion and $166 billion.
    As I mention in my written statement, avian influenza could 
proliferate rapidly throughout the United States. As the virus 
spreads exponentially from person to person, the strain will 
cripple our nation's emergency departments, which are already 
operating at or over critical capacity.
    Over the last decade, emergency department visits have 
risen by 26 percent. However, the number of emergency 
departments have decreased by 14 percent. Additionally, 
hospitals have lost over 103,000 staff beds and 7,800 intensive 
care unit beds. As a result, fewer beds are available for 
admissions from the emergency department. Once the emergency 
departments have filled all their beds, there is no reasonable 
way to expect that the stressed systems will be able to 
suddenly create the surge capacity necessary to effectively 
manage an event.
    When crowding becomes so severe, ambulances must be 
diverted to other hospitals, reducing patient safety. In a 
study that was just released on Monday, an ambulance is 
diverted to a different hospital on average every minute in the 
United States. These findings show a clear lack of capacity in 
the emergency medical care system.
    Protection of a disaster, act of terrorism or epidemic will 
only be effective if appropriate preparations have been made at 
all levels. In most disasters, the emergency department is the 
frontline. History has shown that during a disaster, nearly 80 
percent of patients simply go to the nearest emergency 
department, bypassing ambulance transport. Even if hospitals 
had sufficient warning of a pandemic outbreak, most emergency 
departments have limited isolation units. Once the emergency 
physicians and nurses have contracted the disease, their 
ability to provide care for their patients would be severely 
diminished.
    Since 9/11, we have appropriately spent billions on 
preparedness, but emergency departments have received virtually 
none of that support. Lack of overall capacity may lead to a 
breakdown of the health care safety net when we need it most. 
If we are unable to effectively respond to a disaster or 
pandemic, people will suffer needlessly and some will die. We 
must take steps now to avoid a catastrophic failure of our 
medical infrastructure, and we must take steps now to create 
capacity, alleviate overcrowding, and improve surge capacity in 
our nation's emergency departments.
    We present this 10-point plan to achieve these goals. One, 
we must increase the surge capacity of our nation's emergency 
departments by ending the practice of boarding admitted 
patients in emergency departments because no in-patient beds 
are available.
    Two, we must collect and monitor real-time data for 
syndromic surveillance, hospital and emergency department 
capacities, and ambulance diversion status.
    Three, homeland security agencies need to understand that 
emergency departments are part of the community's critical 
infrastructure.
    Four, we must require hospitals and communities that are 
severely affected by a disaster to postpone elective admissions 
until the crisis has abated.
    Five, command and control of disaster medical response must 
be more coordinated across federal, state and local agencies.
    Six, we must develop and refine national medical 
preparedness priorities and standards that are consensus-driven 
and evidence-based.
    Seven, we must provide federal and state funding to 
compensate hospitals and emergency departments for the 
unreimbursed cost of meeting the critical public health and 
safety net roles, to ensure that emergency departments remain 
open.
    Eight, we must establish a sustainable funding mechanism 
for disaster preparedness for hospitals, emergency departments, 
and emergency management that is tied to national benchmarks 
and deliverables.
    Nine, Congress should continue to include emergency 
physicians and nurses in any definition regarding first 
responders to disaster.
    And ten, Congress should pass H.R. 3875, the Access to 
Emergency Medical Services Act, which provides incentives to 
hospitals to reduce overcrowding and provides reimbursement and 
liability protection for EMTALA-related care.
    Let me close by assuring you that in any local, regional or 
national disaster epidemic, the nation's emergency physicians 
and emergency nurses will be there to do their jobs, as was 
evident during Hurricane Katrina. Every day, we save lives 
across America. Please give us the capacity and the tools we 
need to be there for you when you need us, today, tomorrow and 
when the next major disaster strikes the citizens of this great 
country.
    Thank you.
    [The statement of Dr. Seaberg follows:]

    Prepared Statement of David C. Seaberg, M.D., C.P.E., F.A.C.E.P.

Introduction
    Mr. Chairmen and members of the subcommittees, I want to thank you 
for allowing me to testify today on behalf of the American College of 
Emergency Physicians at this joint hearing entitled, ``Protecting the 
Homeland: Fighting Pandemic Flu From the Front Lines.''
    ACEP is the largest specialty organization in emergency medicine, 
with over 23,000 members who are committed to improving the quality of 
emergency care through continuing education, research, and public 
education. ACEP has 53 chapters representing each state, as well as 
Puerto Rico and the District of Columbia, and a Government Services 
Chapter representing emergency physicians employed by military branches 
and other government agencies.
    Emergency departments act as our nation's health care safety net. 
Unlike any other health care provider, the emergency department is open 
for all patients who seek care, 24 hours a day, 7 days a week, 365 days 
a year. We provide care to anyone who comes through our doors, 
regardless of their ability to pay. At the same time, when factors 
force an emergency department to close, it is closed to everyone and 
the community is denied a vital resource.
    As the frontline of emergency care in this country, emergency 
physicians are particularly sensitive to the devastating impact an 
avian flu pandemic would have on our patients and our communities. To 
put this in perspective, I would like to share with you the findings of 
the Centers for Disease Control and Prevention:
        ``In the absence of any control measures (vaccination or 
        drugs), it has been estimated that in the United States a 
        'medium-level' pandemic could cause 89,000 to 207,000 deaths, 
        314,000 to 734,000 hospitalizations, 18 to 24 million 
        outpatient visits, and another 20 to 47 million people being 
        sick. Between 15% and 35% of the U.S. population could be 
        affected by an influenza pandemic, and the economic impact 
        could range between $71.3 and $166.5 billion.''\1\
---------------------------------------------------------------------------
    \1\ Centers for Disease Control and Prevention. January 17, 2006 
``Pandemic Flu: Key Facts''
---------------------------------------------------------------------------
    As this statement indicates, if the avian flu pandemic, which has 
been the focus of world attention over the past several months, should 
begin spreading from human to human and then reach our shores, the 
consequences to the United States would be catastrophic. What makes a 
potential avian influenza pandemic so deadly is that, like some 
biologic agents, it would be transmissible from person to person and 
could spread rapidly in an urban environment or through mass 
transportation. Optimally, treatment must be initiated as quickly as 
possible, although contracting avian flu would not result in obvious 
characteristics that would distinguish it from the normal flu 
initially. Therefore, detecting it, even when symptoms occur may be 
difficult.
    The state of readiness in our nation's emergency departments and 
the ramifications of patients who have been infected with the avian flu 
virus appearing at hospital emergency departments around the country 
are what I will explore in my testimony today.
Patient X
    Let me give you an example of what could be a typical avian 
influenza outbreak scenario. Patient X unknowingly contracts the avian 
flu while on a business trip in Europe immediately prior to boarding a 
plane for Atlanta. Not only will this person infect the passengers of 
this plane and anyone else who comes into contact with this individual 
at one of the busiest airports in the world, but the passengers who 
have final destinations outside Atlanta will also carry the infection 
to other passengers, and so on, as the disease begins to spread 
exponentially. Of course, it will take several days for this person to 
feel sick enough that they go to their local emergency department.
    This infected patient now sits in a typically overcrowded emergency 
department spreading the infection to everyone else in the waiting room 
and they, in turn, will either eventually be admitted to the hospital 
or treated and released to go home and spread the infection to their 
family and neighbors. Even once they are admitted to the hospital, the 
majority of patients still remain in the emergency department (also 
known as ``boarding'' a patient in the emergency department) waiting 
for an inpatient bed for more than four hours, with nearly 20 percent 
of those patients waiting in the emergency department for more than 
eight hours,\2\ which would continue to expose these infected 
individuals to other emergency department patients, as well as patients 
throughout the hospital due to the high-volume of air recirculation.
---------------------------------------------------------------------------
    \2\ General Accounting Office. GAO-03-460. March, 2003 ``Hospital 
Emergency Departments: Crowded Conditions Vary among Hospitals and 
Communities.''
---------------------------------------------------------------------------
    While it is common practice to ensure a patient who enters the 
emergency department with a cough or fever wears a mask while waiting 
to be treated, it may take over an hour before a triage nurse has an 
opportunity to see that individual if the emergency department just 
received multiple ambulances and the waiting room is already saturated. 
In addition, the patient may require oxygen treatment and a nebulizer, 
making the use of a mask irrelevant, and it was the use of nebulizers 
that caused SARS to spread so rapidly through emergency rooms in 2003.
    Without sufficient warning, emergency physicians and nurses would 
be unprepared to place arriving avian flu patients in isolation until 
it was too late. Since most hospitals only have one isolation unit, 
there would be no way to isolate the next patient infected with avian 
flu. By this time, the emergency physicians and nurses have also been 
in contact with avian flu and, unless they have been previously 
inoculated, would be at high-risk of contracting the disease 
themselves, potentially diminishing their ability to provide care for 
incoming patients.

    Overcrowding and Lack of Surge Capacity
    As the disease begins to spread rapidly among the population, the 
strain will cripple America's 4,000 hospital emergency departments as 
the majority of the nation's emergency departments are already 
operating either at or over critical capacity. Emergency department 
visits rose more than 26 percent in a decade--from 89.8 million in 1992 
to 114 million in 2003. At the same time, the number of emergency 
departments decreased by 14 percent.\3\ In addition, between 1990 and 
1999, hospitals lost 103,000 staffed, inpatient medical/surgical beds 
and 7,800 Intensive Care Unit (ICU) beds.\4\ As a result, fewer beds 
are available for admissions from the emergency department. Once the 
emergency departments have filled all of their beds, there is no 
reasonable way to expect that these stressed systems will be able to 
suddenly create the surge capacity necessary to effectively manage a 
pandemic, natural disaster, terrorist attack or other mass-casualty 
event.
---------------------------------------------------------------------------
    \3\ Centers for Disease Control and Prevention Advance Data from 
Vital and Health Statistics ``National Hospital Ambulatory Medical Care 
Survey: 2003 Emergency Department Summary.'' No 358. May 26, 2005.
    \4\ ``Emergency Departments: An Essential Access Point to Care,'' 
AHA Trendwatch 3, no. 1 (2001): 1-8.
---------------------------------------------------------------------------
    When crowding becomes so severe that patient safety could be 
jeopardized, ambulances must be diverted to other hospitals, 
potentially causing precious time to be lost. In 2001, two-thirds of 
emergency departments diverted ambulances to other hospitals. Because 
overcrowding is most severe in areas with large populations (where the 
potential spread of infectious disease poses the greatest risk), nearly 
one in 10 hospitals reported being on ambulance diversion 20 percent of 
the time (more than four hours per day).\5\

    \5\ General Accounting Office. GAO-03-460. March, 2003 ``Hospital 
Emergency Departments: Crowded Conditions Vary among Hospitals and 
Communities.''

Need for Effective Syndromic Surveillance
    Knowing about an avian flu outbreak elsewhere in the world or here 
in the United States could significantly improve preparations and 
reduce diagnosis time. For this reason, it is essential that our nation 
have a real-time syndromic surveillance system linking emergency 
departments across regions with state public health departments and 
nationally with the Centers for Disease Control and Prevention to serve 
as an early warning system for epidemics. Existing data collection 
systems are currently limited in their capacity and ability to provide 
information to health authorities and the public. Until such time that 
we do have an effective means of data collection and dissemination, 
emergency physicians and nurses will serve as critical components of 
the nation's human syndromic surveillance system.

Planning and Preparedness
    Detection of a disaster, act of terrorism or epidemic will only be 
effective if appropriate preparations have been made at all levels of 
government and the private sector. In most disasters, the emergency 
department is the frontline. History has shown that during a disaster, 
such as 9/11 or the anthrax scare here in the nation's capital, nearly 
80% of patients simply go to the nearest emergency department, 
bypassing ambulance transport. In fact, only a small percentage of 
patients are actually managed by EMS. Emergency department personnel 
are the forgotten first line of response in disasters.
    Since 9/11 we have appropriately spent billions on preparedness. 
But emergency departments have received virtually none of that support. 
Policymakers and the public have assumed that the nation's emergency 
departments will be able to meet their vital safety net function. 
However, lack of overall capacity may lead to a breakdown of the health 
care safety net when we need it most. If we are unable to effectively 
respond to a disaster or pandemic, people will suffer needlessly and 
some will die.
    The private sector also will play an important role before and 
during an avian flu pandemic. In addition to providing goods and 
services to the public and medical personnel, workplace policies that 
diminish the potential spread of infectious diseases are critical. 
Establishing an ethic of infection control in the workplace that 
includes options for working offsite while ill, systems to reduce 
infection transmission and worker education are vital.

ACEP Recommendations
    We must take steps now to avoid a catastrophic failure of our 
medical infrastructure and we must take steps now to create capacity, 
alleviate overcrowding and improve surge capacity in our nation's 
emergency departments.
    My colleagues and I at the American College of Emergency Physicians 
present this 10-point plan to achieve these goals and we urge Congress 
to enact these measures in order to effectively manage a pandemic, 
natural disaster, terrorist attack or other mass-casualty event.
        1. We must increase the surge capacity of our nation's 
        emergency departments by ending the practice of ``boarding'' 
        admitted patients in emergency departments because no inpatient 
        beds are available. This will require changing the way 
        hospitals are funded to allow for inpatient and intensive care 
        unit surge capacity to manage this burden.
        2. We must implement protocols to collect and monitor real-time 
        data for syndromic surveillance, hospital inpatient and 
        emergency department capacities and ambulance diversion status. 
        Collection of this data is vital to developing appropriate 
        protocols.
        3. Homeland Security agencies on the Federal, State, and Local 
        levels need to understand that hospitals and Emergency 
        Departments are part of the community's Critical 
        Infrastructure. We can not have response and recovery in a 
        disaster without fully functioning, protected, and connected 
        health resources.
        4. We must require hospitals and communities that are severely 
        affected by a natural or man-made disaster, or even a severe 
        influenza outbreak, to postpone elective admissions until the 
        crisis has abated. We must develop a way to compensate those 
        facilities for their loss of revenue.
        5. Command and control of disaster medical response must be 
        more coordinated across federal, state and local agencies and 
        departments.
        6. We must establish a committee of stakeholders and disaster 
        medicine experts from the public- and private-sectors and 
        academic institutions to develop and/or refine national medical 
        preparedness priorities and standards. We must change the 
        national preparedness culture to one which is consensus-driven 
        and evidence-based.
        7. We must provide federal and state funding to compensate 
        hospitals and emergency departments for the unreimbursed cost 
        of meeting their critical public health and safety-net roles to 
        ensure these emergency departments remain open and available to 
        provide care in their communities.
        8. We must establish a sustainable funding mechanism for 
        disaster preparedness for hospitals, emergency departments and 
        emergency management that is tied to national benchmarks and 
        deliverables.
        9. To ensure emergency physicians and nurses play a primary 
        role in disaster planning and are considered in any national 
        allocation of resources and protective measures, Congress 
        should continue to include them in any definitions regarding 
        first responders to disasters, acts of terrorism and epidemics.
        10. Congress should pass H.R. 3875, the ``Access to Emergency 
        Medical Services Act,'' which provides incentives to hospitals 
        to reduce overcrowding and provides reimbursement and liability 
        protection for EMTALA-related care.

Conclusion
    While adopting crisis measures to increase emergency department 
capacity may provide a short-term solution to a surge of patients 
suffering from the flu, ultimately we need long-term answers. The 
federal government must take measures necessary to strengthen our 
resources and prevent more emergency departments from being permanently 
closed. In the last ten years, the number and age of Americans has 
increased significantly. During that same time, while visits to the 
emergency department have risen by tens of millions, the number of 
emergency departments and staffed inpatient hospital beds in the nation 
has decreased substantially.\6\ This trend is simply not prudent public 
policy, nor is it in the best interest of the American public.
---------------------------------------------------------------------------
    \6\ Centers for Disease Control and Prevention Advance Data from 
Vital and Health Statistics ``National Hospital Ambulatory Medical Care 
Survey: 2003 Emergency Department Summary.'' No 358. May 26, 2005.
    ``Emergency Departments: An Essential Access Point to Care,'' AHA 
Trendwatch 3, no. 1 (2001): 1-8
---------------------------------------------------------------------------
    Let me close by assuring you that in any local, regional or 
national disaster or epidemic, the nation's emergency physicians and 
emergency nurses will be there to do their jobs, as was evident during 
Hurricane Katrina. If the avian flu pandemic were to spread throughout 
America before appropriate safety measures could be implemented, then 
it's reasonable to expect a 20% loss of emergency department personnel 
due to death or disability. America's emergency departments are already 
operating at or over capacity. This loss of emergency department 
personnel is unsustainable and would cripple this nation's health care 
safety net and the quality of patient care would be severely 
jeopardized.
    Every day we save lives across America. Please give us the capacity 
and the tools we need to be there for you when you need us. . . today, 
tomorrow and when the next major disaster strikes the citizens of this 
great country.

    Mr. Linder. Thank you, Dr. Seaberg.
    I want to thank each of you for your hopeful and uplifting 
comments.
    Dr. Seaberg, do the emergency rooms have paperless 
activities so that they can be on computer and let that 
information go immediately to the Board of Health or something 
when you see a spike?
    Dr. Seaberg. There are very few emergency departments right 
now that are on paperless systems, probably less than 10 
percent in the country right now. None of those systems that I 
am aware of are right now hooked up to the health department. 
There are some states that are looking at developing this, but 
currently there are very few paperless systems across the 
country.
    Mr. Linder. Dr. O'Toole, is that what we need?
    Dr. O'Toole. Yes.
    Mr. Linder. I understand Pennsylvania is working toward 
that, in testimony we had, I believe, yesterday.
    Dr. O'Toole. Yes, some hospitals, about 15 percent of 
hospitals have electronic records in one way or another. Many 
of them are not as robust as one would wish, and very, very few 
of them have links to public health. As we spend money, we 
ought to try and invest in solutions instead of stopgaps 
wherever possible.
    Much better than surveillance systems designed for this 
disease or that disease, or this problem and that problem, 
would be a true integrated electronic health network to take 
care of patients on a routine day, but would also give you 
real-time situational statistics during an epidemic. That is 
going to be a ways off.
    Mr. Linder. Secretary Mitchell, who has the authority to 
instigate quarantines in Delaware?
    Mr. Mitchell. As the point person, I have the overall 
command of an emergency such as what we are discussing.
    Mr. Linder. That rests with you?
    Mr. Mitchell. Yes, it does rest with me. However, we would 
petition the court in cases where we could. That is not where 
we are that concerned. We are concerned where someone comes in 
to an emergency room, and heaven forbid, and there are many 
undocumented workers here, as you know. If they are diagnosed 
with bird flu and told that they are going to have to be 
quarantined, they are probably going to leave the hospital 
immediately and they are probably going to disappear.
    Which brings up the case, it is almost like an arrest-
without-warrant situation. When can a police officer detain 
without a judicial order? We can, in Delaware, provided that a 
physician, based on clear and convincing evidence, says that 
that patient in fact is infected and is a danger to the health 
of our community. Based on that clear and convincing evidence, 
a police officer can detain against one's will.
    Mr. Linder. Ms. Phillips, do you have that same power?
    Ms. Phillips. We have a slightly different arrangement in 
the state of Maryland. Two years ago, the legislature enacted 
the Catastrophic Health Emergency Powers. The power to 
quarantine and isolate individuals rests with the governor, who 
may designate that authority to the state health secretary to 
issue the quarantine and isolation orders. It is the role of 
the local health department to carry out those orders, to find 
suitable arrangements for these individuals, and to provide the 
support necessary for their term of either isolation or 
quarantine.
    Mr. Linder. I am impressed by the training that you do with 
your 800 people. Most of us think of local health departments 
as being sort of sleepy backwaters. Is it your experience that 
many counties across the country are doing what you are doing?
    Ms. Phillips. It is. From my work nationally with NACCHO, I 
am seeing that there is a tremendous infusion of an 
understanding of NIMS, incident command, and the kinds of 
infrastructure that we take for granted on the public safety 
side, to the public health community. The kinds of 
opportunities for a clear chain of command and accountability 
during in an emergency are clearly advantages that the public 
health community is picking up, as well as the 24/7 response.
    What we do not share with the public safety folks is three 
shifts. Public health typically is a one-shift-a-day operation 
so that we are drawing on a workforce that in a sustained 
emergency would be very stretched.
    Mr. Linder. Dr. O'Toole, I do not want to sound like a 
cliche, but is it true that this is not a matter of if, it is a 
matter of when?
    Dr. O'Toole. There is no scientific way to answer that. I 
am very worried. I think it would be the height of 
irresponsibility to bet on a miracle. In 1918, the mortality 
rate was 1 to 2 percent. We are seeing a mortality rate of 
about 50 percent right now. Even if it drops down to half that, 
and there is no reason to suppose it would, we are talking 
about quite a cataclysmic event.
    If I could, I would like to say a couple of things about 
quarantine. ``Quarantine'' should be banned from use as a word 
because it is a very confusing word. It comes from the 1400s. 
It had to do with taking ships that you thought were coming 
from plague-infested waters and putting them in a corner of the 
harbor until everybody on the ship was either dead or still 
living, until they were not contagious. I do not think, aside 
from that special situation of possibly seeing the first 
village that gets transmissible flu, I do not think it is 
possible to implement a quarantine in the modern world.
    Secondly, I do not think you are going to want to, if what 
you are going to do is take people who may have been exposed, 
but are not yet sick, and house them together until they are 
through the incubation period. The way to think about disease 
containment is as a return on investment judgment. Even if you 
could quarantine Annapolis, where I live by the way, would you 
really want to? Is that how you are going to want to be 
spending your resources in an epidemic? Probably not.
    Sam Nunn said something very wise during a bioterrorism 
exercise years ago, when he was being urged to federalize the 
National Guard. He said, there is no force on earth that can 
make the American people do something they do not believe is in 
their own best interest and the best interest of their 
families. It is very important to keep that in mind. If this 
breaks out, we are not going to have time to use video to go 
through due process and so forth. We are going to have one out 
of four Americans infected. It is going to be overwhelming.
    The other thing that I would mention is a recent Harvard 
study that shows that in surveys, Americans are much more 
willing to be isolated at home or in the type of facility Ms. 
Phillips talked about, if they cannot stay at home, if it is 
not compulsory. If it is compulsory, they get a lot less 
willing to participate. We saw that in China during SARS. When 
Beijing authorities decided things were so bad in one big 
apartment complex they were going to quarantine it, keep 
everybody in. Before they could get the police over there, 
everybody had fled, worsening the situation.
    So we should not talk about quarantine. We should talk 
about isolation. We should be, especially you all in leadership 
positions, should be very precise in use of your terms as a way 
of educating Americans so that they understand what would be 
expected of them.
    Mr. Linder. Thank you. My time has expired.
    Mr. Langevin?
    Mr. Langevin. Thank you, Mr. Chairman. I want to thank you 
again for convening this hearing.
    I want to thank all of our witnesses who testified. It has 
been very enlightening.
    Let me begin with Dr. O'Toole, if I could. You said, if I 
heard you right--and I guess I can speak for the whole panel--I 
should say that I did not hear a real ringing endorsement of 
the national response plan, so hopefully you will have a chance 
to comment further.
    Dr. O'Toole, you said that, as I heard it, that most 
hospital administrators have not read the national response 
plan and they are not going to. Can you discuss this further? 
How do we get them more engaged?
    Further, you stated in your testimony that there has 
traditionally been a wide gulf between the public health 
community and the medical care provider community. Can you 
elaborate on that and in what ways that gulf can be bridged?
    I would also like to hear from Ms. Phillips and Dr. Seaberg 
after your answer.
    Dr. O'Toole. I think what Secretary Leavitt is doing in 
going from state to state is a good start in getting the 
attention of hospital authorities. It has been our experience, 
and we have worked on hospital response issues for about 4 
years now in the context of bioterrorism.
    We are deeply involved in flu response with hospitals right 
now as well. It has been our experience that the hospitals do 
not necessarily think of themselves as part of the national 
response plan. They do not think of themselves as part of an 
incident command system. They certainly do not think of 
themselves as being under the orders of the public health 
system on most days.
    So what you are talking about is a different cultural 
attitude about what their mission and responsibilities are. One 
of the problems with the pandemic flu plan that the president 
set forth, which I do think is a good beginning, although I do 
not think it spends nearly enough on vaccine or nearly enough 
on everything else, is the list of things hospitals should do.
    The problem is it is an overwhelming list. There is not a 
hospital in the country that could actually implement 
everything on that list. It is not prioritized. There are some 
things on that list that are not within the purview of an 
individual institution, such as fix all the legal problems 
involved with sharing staff at your other hospitals.
    What we need is a prioritized, very specific list that says 
every hospital in America has to be able to do the following. 
And then you need to send money. Okay? Hospitals do not have 
the funds to do this. Really, truly, they do not. It is not 
going to happen unless we figure out some kind of coherent 
system for getting the money and getting it to them, not in 
just one tranche, but over time.
    I would suggest, though, back to the invest in solutions, 
not stopgaps, we have to make that list of what they have to do 
specific enough so that you can enforce against it. You have to 
hook it not just to the carrot of money, but to some kind of 
stick that they will pay attention to, because these people are 
very busy trying to survive until next week.
    On your public health care sector gulf, I think that is 
improving because of the efforts of people like Ms. Phillips 
and others, and because of the growing awareness of flu and 
bioterrorism. It is still a very big gulf. They really have 
very different jobs. These are very different cultures. Neither 
community actually has the resources to do a lot of outreach, 
the kind of table-tops, the kind of exercises that Mr. 
Blackwelder was talking about. Anything that gets people in the 
same room is a good thing, but it is going to take time. My 
choice for what to invest in first would be electronic health 
records that have an immediate connection to public health.
    Mr. Langevin. And you do not feel that right now the public 
reporting system in the public health system is robust enough 
to get real-time monitoring?
    Dr. O'Toole. It is not even close. Most emergency 
departments have to go through each shift with a pencil and 
figure out, well, what did we see that Fran might be interested 
in, and then call it in. Since 9/11, in those entities that 
actually dealt with anthrax, that has gotten a little bit 
better and there are more electronic exchanges of information. 
But then, most public health authorities have to go through and 
say, am I going to investigate this or not. I mean, half of 
what got called in as emergencies did not warrant an 
investigation. It is a very laborious process right now.
    The problem has been misconstrued to some extent. I do not 
think detection is as big a problem as management in the 
situation we are in during an epidemic. For that, we need real-
time electronic health records.
    Mr. Langevin. I agree.
    Ms. Phillips?
    Ms. Phillips. Yes, a couple of points to follow up on the 
surveillance discussion.
    In Maryland, we have a beginning of a system that links 
what is happening in hospitals, particularly emergency rooms, 
with the public health sector, with the emergency responders, 
the EMTs. It is very basic, but it is an electronic system, so 
that in my office I can see the volume of activity in the 
emergency rooms in my county. I can see the volume of patients 
coming in who are likely to need ventilators. But I do not get 
anything close to the kinds of surveillance indicators that I 
would need to understand what is going on in terms of 
interpreting that.
    I do believe that our system is a little bit ahead because 
of our experience with anthrax in Maryland. We have a ways to 
go on surveillance. So right now the surveillance system we 
rely on is the relationships between hospitals, the physicians, 
and the public health system and telephone and fax and 
postcards. So that is what we are working with.
    Coming back to the issue of the plan, from a public health 
perspective, the direction, the guidance that we get on 
pandemic flu planning comes from the CDC. So that is a pipeline 
that, as you know, has released a document in December, I guess 
it was January, that was extremely welcome to all public health 
agencies across the country, to look at the federal guidance on 
planning for a pandemic.
    I want to emphasize that in my remarks, I did try to 
emphasize that the role locally that I play is really a bridge 
with the public safety folks. I do not see through their 
pipeline, which is our state emergency management agency, FEMA, 
as well as the Department of Homeland Security on a federal 
level, I do not see that level of pandemic flu preparation 
training. So that I am the one now to do all of this work with 
our 600 firefighters and our 700 police officers.
    So the request, I guess, that I made as far as coordination 
at the top level is that the kind of guidance that CDC is 
pushing out to the public health community be replicated on the 
public safety side so that we get some assistance. Right now, 
it is based on coordination and it is working at a local level, 
but it is working against some of those barriers as far as 
funding.
    Mr. Reichert. [Presiding.] The gentleman's time has 
expired.
    The Chair recognizes himself for 5 minutes.
    Thank you again for being here. I want to just make a 
couple of comments, and I have a few questions.
    The point that you were making, Ms. Phillips, is one that I 
struggled with as a sheriff in trying to work with public 
health officials back in Seattle, and the law enforcement 
community not understanding their role in this new 
responsibility. I know that the secretary can identify with 
that same struggle.
    What I hear, though, is really some good things are 
happening. There has been a lot of progress made in building 
partnerships. We have business represented here, where in the 
past when I was first assigned to a police car was handle the 
burglary, do not talk to the people, and just take care of 
business and on you go. Those so-called separations and silos 
were all in effect, and everybody had their own 
responsibilities. Now, today, we realize we all have to work 
together. So all of us are here.
    What I have noticed, though, in your testimony, all of you 
together, first I would like to address a couple of frightening 
things that I heard. First, Dr. O'Toole, you said that the 
surge capacity would increase, for beds, by 300 percent, if we 
were hit by it?
    Dr. O'Toole. If you use the CDC models on what it would 
take to deal with a 1918-type pandemic, and you plug in the 
current number of beds, in the Atlanta metro region, just as an 
example, then you need 300 percent of your current beds.
    Mr. Reichert. And 700 percent increase in patients.
    Dr. O'Toole. A 700 percent increase in ICU capacity.
    Mr. Reichert. ICU capacity.
    Dr. O'Toole. And you would need four times as many 
ventilators as one has on hand now.
    Mr. Reichert. And a 20 percent surge is acceptable?
    Dr. O'Toole. Well, I think a 20 percent surge is a 
reasonable goal that you could ask hospitals to strive for. It 
is a stretch.
    Mr. Reichert. And then Dr. Seaberg says there is a 26 
percent average increase of patients, and a 14 percent drop in 
hospital emergency rooms. Is that correct?
    Dr. Seaberg. That is correct.
    Mr. Reichert. And then the last statement that you made, 
Dr. O'Toole, was, and you asked Chairman Linder, can I just say 
one more thing, and you said, we can do this. If you could just 
maybe explain for a couple of minutes some of your thoughts 
along the lines of, with those big numbers, how can we do this?
    Dr. O'Toole. Well, first of all, the way to solve the 
problem is to get a vaccine. I know that is not directly within 
your purview, but everybody ought to understand that we are not 
doing what we ought to be doing if you really think vaccine is 
the answer, as I do. That would transform everything, if we had 
an effective vaccine, and we had enough and we had it in time.
    But suppose we do not have a vaccine. If we do not have a 
vaccine, then going to the hospital will not help you get 
through the flu in most cases. We are not going to have enough 
Tamiflu. It is not clear that Tamiflu is even going to be 
effective if we did have it on hand. So what you are talking 
about for most people is what we all do with flu. You go home 
and you go to bed; you take fluids; you rest; et cetera, et 
cetera. And you do not run around contaminating other people.
    What we need to do is get that message across so that the 
people who seek medical care are those who are the desperately 
ill, and there are three or four ways that people are going to 
be desperately ill with flu, as far as we understand it. I can 
go into that, but you do not really care.
    Those are the people who ought to go into hospitals. 
Everyone else ought to either stay at home, or if they cannot 
stay at home for whatever reason, they ought to be cared for in 
the type of facilities Ms. Phillips was describing, you know, 
gymnasiums where they are basically getting home care. It is 
not going to be alternative hospital care. As we saw in 
Katrina, a hospital is not just doctors and nurses and beds. It 
is a significant infrastructure. It is gases, oxygen, et 
cetera, et cetera. It is a whole infrastructure that you are 
not going to replicate in a gymnasium or a sports arena.
    Mr. Reichert. Is this process taking place today?
    Dr. O'Toole. No.
    Mr. Reichert. Nowhere?
    Dr. O'Toole. There is no master plan.
    Mr. Reichert. Does anybody on the panel have a comment?
    Dr. Seaberg. This is not occurring. The problem with the 
federal response is it takes time to coordinate that. So what 
is going to happen is initial response is all going to have to 
be local. Compared to police, fire and public health, the 
hospitals and health care workers are clearly the weakest link 
in any health care response to this, without a doubt. They have 
not been prepared. Health care workers and hospitals have been 
unwilling to participate due to lack of funds. My hospital 
alone is nearly $1 million for a 1-hour training course.
    So the number-one concern, if you asked health care 
workers, is surge capacity. We can barely handle what we have 
now, let alone a pandemic. In Florida, we are looking at ways 
to perhaps retrofit non-clinical space such as auditoriums, 
cafeterias, conference rooms, so that they can be surged up to 
clinical space, because until all this is set up by public 
health and federals, I am sorry, they are going to be coming to 
the hospital. The worried well will be coming to the hospital 
and to the emergency departments.
    So we need to look at creating non-clinical space into 
clinical space. We need to reduce overcrowding, and H.R. 3875 
is a step in the right direction. We need to train the hospital 
and health care workers to more long-term pandemic scenarios. 
And then we need to take these lessons learned, the best 
practices and lessons learned, and disseminate. We are spending 
a lot of money in each state to train people, but at least in 
the health care workforce, these lessons are not being 
disseminated. You have each state creating standard core 
competencies for hospitals. We should have national core 
competencies that everyone trains to. Yet, we are working on 
that through the American College of Emergency Physicians, but 
we do not have that yet. We need to have better coordination 
between federal, state and local.
    Mr. Reichert. Thank you.
    My time has expired. The Chair recognizes the ranking 
member of the Subcommittee on Emergency Preparedness, Mr. 
Pascrell.
    Mr. Pascrell. Thank you, Mr. Chairman.
    Dr. O'Toole, what is the main reason we have not developed 
the necessary vaccines?
    Dr. O'Toole. It is hard and it is expensive. There are 
about 20 companies, as well as NIH, trying to develop a 
pandemic flu vaccine. There are not many expectations that they 
are going to make money out of that.
    Mr. Pascrell. Is there a sense of urgency?
    Dr. O'Toole. I think there is a sense of urgency, but I do 
not think that has been translated into a strategic approach to 
how the world could get together and make a vaccine that works 
and in sufficient quantities. For example, there are things we 
ought to be doing in parallel that we are doing in serial. We 
just found out that the H5N1 vaccine that NIH has been working 
so hard on, we discovered last summer requires an enormous 
amount of the antigen, which is the stuff that gets grown in 
eggs that we have a very limited supply for and we cannot make 
more.
    We were hoping that adding an adjuvant, which is a kind of 
immune booster to that vaccine would allow us to make more 
doses. It did not work. We should have done the adjuvant 
studies simultaneously with the antigen studies. We are doing a 
lot of things that we ought to do in a more organized fashion. 
We are kind of running the H5N1 trials, as far as I can tell, 
and one of the peculiarities, it is very hard to get the 
science. It is taking months and months to publish it. There 
ought to be a much more real-time exchange of information among 
the scientists involved.
    As far as we can tell, it is being run pretty much like a 
normal research process. People are working hard, do not get me 
wrong, but with more money and more organization that is beyond 
the reach of the people in charge right now, we could do 
better.
    Mr. Pascrell. Let's take the example of Tamiflu. Let's take 
that example, since you brought it up. I think it is a good 
example. We knew very early on that there was some hope and 
possibilities. Whether at this particular time in history, 
February 8, we think maybe Tamiflu is not the answer. Anyway, 
the companies who make Tamiflu, particularly there is one major 
company, had no real signal from the federal government, as I 
understand it, to move forward with the research and 
development.
    Am I mistaken, Dr. O'Toole?
    Dr. O'Toole. I think it is more complicated than that, 
unfortunately.
    Mr. Pascrell. Okay.
    Dr. O'Toole. We need a very robust process for figuring out 
what we are going to invest in scientifically. One of the 
truisms of vaccines and drugs is that they are really difficult 
to make. You have to get a long way into a very expensive 
process before you know if it is going to work or not. Last 
August, the New York Times said the problem is solved; the H5N1 
vaccine that NIH is making works. All right?
    Now, the government thus far has been very reluctant to 
invest gigantic sums of money, and we are talking billions of 
dollars here, in stuff that we might not need and might not 
work. What we need is a more open and much more robust process 
for understanding what is out there that might work.
    Mr. Pascrell. Yes, but what do we need to do that? We have 
heard that before, Dr. O'Toole. Let's get to the point. Let's 
get to the meat and potatoes here.
    Dr. O'Toole. Okay, let's do.
    Mr. Pascrell. What are you suggesting we are not doing now 
in order to facilitate this research so that we avoid 
duplicity, so that we avoid research that is going to come up 
with nothing. What do we need?
    Dr. O'Toole. The government needs to form a process that 
engages the intellectual firepower of the private sector, of 
the bio-pharma community and the university researchers.
    Mr. Pascrell. Isn't that what NIH is supposed to be doing 
or the Center for Disease Control supposed to be doing?
    Dr. O'Toole. No, it is not what they are doing.
    Mr. Pascrell. Then what are you calling for, another 
agency? Are you calling for, what?
    Dr. O'Toole. What I would call for is first of all put 
somebody in charge of pandemic preparedness across the 
agencies.
    Mr. Pascrell. Okay. That would be one thing that would 
advance this.
    Dr. O'Toole. That would be one thing that would advance 
this, because you can see it is very complicated. There are 
things that are definitely in the lane of more than one agency. 
DHS and HHS are the big players. So is DOD.
    Secondly, you have to find ways to really engage the 
private sector. The U.S. government at the federal level does 
not at this point have the talent it needs in sufficient 
numbers to handle this problem. That is not to say that people 
are not working their hearts out and are not competent. They 
are. Okay? But we do not have in the federal government in 2006 
a lot of biopharmaceutical experts. We do not have a lot of 
epidemiologists. We do not have people with the skill sets we 
need. This is a new problem. You have to hire about 100 people.
    You also have to pick off what the problems are that you 
need to focus on. One person cannot do hospital preparedness 
and public health preparedness and build a vaccine. It is too 
hard. I think Secretary Leavitt has done a great job, but he is 
one guy and he has a huge portfolio beyond the flu. This is 
really big. We have to do something that is very extraordinary 
and very non-routine here.
    Mr. Pascrell. Okay. You answer I think is very clear, very 
focused--if I may conclude, Mr. Chairman?
    Mr. Reichert. Yes, sir.
    Mr. Pascrell. It is very clear, very focused. I gather from 
all these hearings, we do not have a sense of urgency. And 
secondly, we do not have a sense of direction, which is just as 
important. I mean, you could be, let's do this; we have to get 
this done right away, and not have any direction once they are 
going.
    You have provided very clear direction. Is the federal 
government listening? I do not know. We are listening. We need 
to do something different than what we have been doing. We 
should be further down the line, is what I am saying. I do not 
know if you agree or disagree with me. We should have been 
further down the line. We are doing a disservice to the 
American people. I have heard all of these discussions before. 
We are doing a disservice to the American people. We are not 
moving the ball forward. We are relying on past strategies to 
deal with the major problems that exist right now.
    Mr. Reichert. The gentleman's time has expired.
    Mr. Pascrell. Thank you, Mr. Chairman.
    Mr. Reichert. The Chair recognizes the gentlelady from the 
Virgin Islands, Ms. Christensen.
    Mrs. Christensen. I did not realize I was up already.
    I want to thank the chairs of the subcommittees for holding 
this hearing because health care has not really gotten the kind 
of attention that it has needed since this committee has been 
formed and actually since the department has been formed.
    I have had the opportunity to be very much involved with 
the Katrina efforts, in trying to restore the health care 
infrastructure there. It has been a nightmare. If we did not 
believe the state of unreadiness of our health care system to 
withstand a natural disaster or a manmade disaster, I think we 
have seen it in full swing.
    I had a lot of questions, some of which have been answered. 
I have heard several of you say that we need one person who is 
directing, a director of pandemic, or something like that, I 
think you called it, Dr. O'Toole. We have an assistant 
secretary at the Department of Health and Human Services for 
Emergency Preparedness and Response. I believe his name is Mr. 
Simmons. What has his role been with Delaware, with Maryland, 
or with the University of Pittsburgh Medical Center?
    It seems to me that there is someone at the department that 
should be filling it. There is a position that is filled at 
that department and I would like to know what your experience 
has been with that office.
    Ms. Phillips. I do not know that particular position. I do 
know that the unit within CDC that is responsible for pandemic 
flu guidance is, I guess they are working very hard; we are 
waiting for the guidance, with respect to the funding. There 
has been a lot of discussion about the funding for development 
of pharmaceuticals. I suppose the other 15 percent of that pie 
goes to the preparedness, in terms of certainly distributing 
the pharmaceuticals, as well as a lot of the other planning 
work.
    The difficulty from a public health perspective, and also 
public safety perspective, is that that is not something you 
buy. That is not a piece of heavy equipment. That is staff. 
That is a workforce. And so the problem with categorical 
funding that is about to come down, I suppose, is that it is 
short term and it is categorical, so that it is very tough in 
my department to take a grant, a small grant that is time 
limited, and to hire staff on that. Really, when you think 
about the response to get a vaccine from the strategic national 
stockpile, and then administer it to the population, that is 
not something I can buy though a contract arrangement as a one-
time-only.
    I did ask a ranking individual at CDC, how is it that a 
local health department can take this categorical one-time-only 
funding and best use it. I was told two things. I was told to 
buy a plan and to do a drill. You know, I feel that the kind of 
relationships that we need locally to sustain an all-hazards 
response is not something that an external contractor can 
provide for us.
    Mrs. Christensen. I was going to ask you, because you 
talked about the importance of the federal, local, state 
collaboration. I was wonder. I was going to ask you what your 
experience has been in terms of having that collaboration. You 
have gone through several events, as you mentioned at the 
beginning of your opening statement. What was your experience 
relating to the federal government, or coordinating with the 
federal government? What improvement might you have seen since 
that time?
    Ms. Phillips. We do look to the CDC. We look to the CDC for 
standardized, authoritative guidance on infectious disease.
    Mrs. Christensen. When you are in the middle of an 
anthrax--
    Ms. Phillips. When we are in the middle of an event, we go 
to that Web site. We pull of what is the most recent, the 
clinical protocols for testing for avian flu or for influenza 
type-A. We look to that.
    Mrs. Christensen. Do they back you up, to work with you?
    Ms. Phillips. We have had experiences where CDC, yes, where 
CDC does send special officers. In the BWI incident that I 
mentioned, we had quarantine officers that were involved with 
us with regard to the commercial carrier. So CDC has tremendous 
capabilities, as does our state, but oftentimes there is that 
lag of time between the time we get the notification and the 
time that we can get effective assistance.
    Mrs. Christensen. Go ahead.
    Dr. Seaberg. The Department of Homeland Security has also 
recently nominated a medical director, who is also looking at 
the medical aspects of disaster. Particularly, we saw with 
Katrina that there was a lack of communication and coordination 
with national FEMA, national NDMS, and the local and state 
response. So he is looking at trying to coordinate that 
response much better, and also looking at the areas of hospital 
training.
    Mrs. Christensen. Mr. Blackwelder, we have met, probably, 
or some people from BENS had breakfast with us. I was really 
impressed. I have had the experience of talking with you and 
also been a Project Impact recipient in my district, which is 
basically what you are doing.
    There were some experiences. After Katrina, for example, 
you offered communications vehicles that were turned down, and 
then they wanted to buy them from you. We are now approaching 6 
months afterwards. Have there been some discussions with the 
federal government?
    I know from experience how important it is setting up the 
business expertise, or the coordination before-hand, even being 
able to expand the personnel for administering medication or 
whatever. Has there been any discussion since we met back a few 
months ago?
    Mr. Blackwelder. Yes. We have been in discussions with the 
Department of Homeland Security and the CDC. They are 
interested in expanding this kind of capability. Frankly, we 
are moving as fast as our resources allow us to move. We do 
believe we are just scratching the surface, really, in terms of 
mobilizing the business community. I gave some examples. We 
have partnerships in place in five regions around the country.
    For example, when I spoke about response during Katrina, we 
did not have any kind of partnership in place there, nor did 
anybody else. So what you saw post-Hurricane Katrina was a 
pretty disjointed and haphazard business response effort. 
Literally thousands of businesses that wanted to help and tried 
to help, could not plug into the system. We know in major 
catastrophes, particularly in the case with pandemic flu, that 
there is not enough surge capacity in the government anywhere, 
federal, state or local, to meet the need.
    We also know that business is willing to help. And finally, 
we know that business cannot plug into the system at game time. 
You cannot just show up on the field without having practice, 
without having gotten to know the players, without having 
written some plays and practiced them. So this is what we are 
trying to do as fast as we can.
    It is important, we find, to build these kinds of teams and 
to do this kind of practicing at the state and local level. DHS 
and CDC are supporting what we are doing. We make sure that we 
are integrating with the national response plan and NIMS. We 
provided input to the private sector portion of the NRP, but 
really these relationships and the kind of trust that needs to 
be built between business and government needs to happen at the 
state, local and regional level. That is really where the 
action is.
    Mr. Reichert. The gentlelady's time has expired.
    The Chair recognizes the gentleman from North Carolina, Mr. 
Etheridge.
    Mr. Etheridge. Thank you, Mr. Chairman.
    Let me thank you for being here. I think you have 
recognized that the committee is interested, the public 
frightened, and looking for answers. Let me ask you to comment. 
I am going to try to zero in very quickly in 5 minutes.
    If we go back to 1918 and the pandemic, as bad as it was, 
the world was an entirely different place. People did not 
travel like they travel today. They lived in rural areas. 
Communication, at best, was newspapers; no TV; no Internet; all 
the stuff we see today.
    Yesterday, I had the opportunity to participate with some 
of my colleagues in a table-top exercise, along with 
administration officials, on this very issue. It focused on the 
federal response to the emerging flu pandemic. Most of the 
participants agreed that we are not prepared. We are not ready. 
A number of things came out of it, one of which is education, 
communication, coordination, a focus on what we are going to 
get to, the very things you have talked about, because the 
first thing that is going to happen is somebody is going to 
have a TV camera in someone's face and they will have to answer 
the question.
    So I have a couple of questions, and I will get to them, 
because I think that is the critical piece. You know, we picked 
up today what is happening in Nigeria. That will be on the news 
tonight, and no one will really be paying attention yet, but 
some are. I am frustrated that we cannot get the federal 
officials working with the state officials in coordination 
across agencies.
    I was state superintendent of schools for the state of 
North Carolina before my service here. One of the real 
challenges we had was getting people to work together across 
disciplines. That is not easy.
    You can appreciate that, Mr. Mitchell.
    The key is you have to make it happen. I think we have to 
do it here, because lives are at stake, and a lot of lives 
possibly.
    Do you feel the information the public gets through the 
media about the impending situation, number one, is accurate? 
Number two, what are your most trusted sources of information?
    I am only going to ask a couple of you that, because I will 
not have time. Ms. O'Toole, I want to ask you first how you 
would respond, and Mr. Mitchell, since you have statewide 
responsibilities.
    Dr. O'Toole. Well, it depends on which media.
    Mr. Etheridge. I agree with that, but there is so much out 
there, we have to try to reach.
    Dr. O'Toole. Yes. It has been very difficult to get 
information about what is happening on the ground. For example, 
it takes the WHO about 10 days using the best labs on the 
planet to figure out if the sick person in Turkey actually has 
H5N1. So there is a lag period between when you see something 
happening.
    Mr. Etheridge. The first information to close-out.
    Dr. O'Toole. Closing that gap would be helpful in general. 
What the public is not getting from the media is what they need 
to do to protect themselves and their family in a crisis. 
Generally, people do not listen to that kind of information 
until the crisis is upon them. That is a tenet of public health 
education. You have to be ready to go the moment something 
breaks. Anything we can do beforehand in workplaces and in 
schools, and indeed in the U.S. Congress. I hope you all go 
home and tell your constituencies what you know. It would help.
    We have to be ready to actually just kind of cover the 
media if this really happens. People have to know what they 
need to do themselves.
    Mr. Etheridge. Mr. Mitchell?
    Mr. Mitchell. The information I rely on comes from our 
state health secretary and our director of public health, Gus 
Rivera. That information comes to us in Homeland Security on a 
daily basis. On the statewide response, we are working very 
well together, between Homeland Security, as well as the 
Departments of Health and Agriculture.
    We are not relying so much on a federal response, if you 
will, as much as we are what do we need to do for ourselves. Of 
course, the federal response in the way of financing is very 
generous and very helpful, and very necessary in planning and 
getting information out to the community, about 30 days worth 
of food supplies so that you can self-quarantine in your home; 
basic hygiene measures that we should all be doing nonetheless; 
as well as encouraging the business community in particular to 
consider telecommuting, and for all of our state agencies for 
telecommuting. How do we maintain our state operations and how 
do we maintain commerce from remote locations, if you will.
    Mr. Etheridge. Thank you.
    I think all of you heard, and I don't think anyone 
disagrees, during the Katrina exercises that there was a 
disaster. People worked hard. There's no question there was at 
all levels, and we do not need to go there.
    What level of confidence do you have that the appropriate 
agencies now are refocusing, because they are doing so many 
other things, but this issue is so critical that we are paying 
attention to things we ought to be paying attention to? I know 
we are here having a hearing. We want to get it moving, but 
that the resources that are being put in the right pots, so 
that we get the biggest bang for the buck. Dr. O'Toole, you 
have already indicated we probably are not doing that.
    So tell us what we need to do very quickly. You have shared 
some ideas. What do we need to be doing now to be prepared? 
There are those who would say, well, you know, we are spending 
all this money and we may not need it. Well, in our national 
defense, during the Cold War, we spent a lot of money on 
nuclear weapons and a lot of other things and never used them, 
thank God, but we had them there just in case. If we never have 
this, that would be a great benefit to the American people.
    Mr. Blackwelder. I offer three things that the government 
can do to mobilize more of the private sector, where after all 
over 80 percent of the critical infrastructure resides. The 
first is to improve and make more consistent Good Samaritan 
laws, to protect liability of people who help. Now, we know 
that business is willing to help despite that fact that Good 
Samaritan laws are imperfect, but we also know that some are 
sitting on the sidelines because of that fact. So I think 
strengthening and making more consistent Good Samaritan laws is 
one thing.
    Second, I encourage state and local government and business 
leaders to build these kinds of partnerships and create these 
kinds of relationships in advance. We know that with just 
modest investments, one or two full-time people to manage these 
sorts of public-private partnerships can deliver huge returns 
on investment.
    The third thing is just to continue to encourage DHS and 
the CDC and HHS to make business an integral part of their 
strategic planning process.
    Mr. Reichert. The gentleman's time has expired.
    The Chair recognizes the gentlelady from the District of 
Columbia, Ms. Norton.
    Ms. Norton. Thank you very much, Mr. Chairman.
    I appreciate that you called this hearing. We are working 
on this issue. I am particularly appreciative to today's 
witnesses because they have come from the various points of 
view that we most need to hear from. I am very concerned about 
the public response to the possible epidemic. It is as if they 
think we are crying wolf, and you are beginning to hear them 
say, you know, nothing is going to happen, and even some 
pundits and members of the press are saying this. I think post-
Katrina, we are doing exactly what we should do.
    I am not convinced. I must say I am very concerned after 
hearing your testimony. One of my major questions, having heard 
your testimony, is I do not for a moment think that we are 
remotely prepared to do what would be needed if in fact 
something that would be called an epidemic, as opposed to if 
one or two cases broke out. I just have no question about it, 
from your testimony and from other testimony in a number of my 
other committees.
    I am particularly interested, frankly, in what Dr. O'Toole 
or one of you called alternative institutions, because the 
notion of piling it on the hospitals or on clinics, I do not 
think anybody thinks would work.
    I must say, Dr. O'Toole, you focused me on a question that 
I have had for some time, just on the basic science. This plan 
focuses on that. I am not critical of that. I am critical of 
our failure to deal operationally, but I am not critical of the 
federal government focusing on the vaccine, because that is 
really the only institution that can do that. That is what your 
federal government is for.
    So I think they have to begin there. And then they have to 
look at what has happened with flu. You know, the flu we have 
right now, the flu that we have every year. We don't have any 
vaccine for that. So here we are talking about a vaccine for 
what is an unknown disease, and you expect the citizens of the 
United States to believe that we, the United States, can 
develop a vaccine for something that no one ever heard of until 
a couple of years ago.
    No wonder there is lack of confidence in the public in our 
capability. Well, 30,000 people die every year. We know they 
are going to die every year and we still do not know what to do 
about it. We had some of the same problems to arrive this year, 
just in distribution of that flu vaccine after what we had last 
year, and we are trying to convince the public that we can not 
only develop a vaccine, but we can distribute it, and do not 
worry, we are starting early, so you see the evidence of it.
    They will look at flu, the flu that their mother-in-law 
gets; the flu that they keep their children from getting, to 
measure whether or not we can do that. You know what? I think 
Congress ought to look there, too.
    And I heard Dr. O'Toole talking about electronic health 
retrievals. You know, we are ground zero there, too, so that is 
like beginning with the vaccine. Everybody considers that a 
frontier idea.
    Let me begin by asking this. The Spanish flu we all go back 
to as the marker. I cannot understand this coming pandemic, or 
if it will really be avian flu or something else that we really 
are not talking about. It ought to be much worse now. We have a 
global economy, everything moving at lightning speed. That is 
not what you had in 1918, the Spanish flu.
    Moreover, this should be facilitated by the fact that birds 
fly everywhere, and yet nobody has seen it here, and frankly 
the average American says, I hope you all work on something 
that I am really interested in, like the flu we get every year.
    So I do not understand why this is a first priority, as 
opposed to some other viruses that could come around the 
country. I do not understand, for example, whether or not this 
virus is anything like the AIDS virus. Did it linger in animals 
for some time and slowly move to human beings? Now, of course, 
it is a real epidemic. I do not understand how avian flu, which 
so far a bird gets, we can find no proof, no evidence of how it 
has even moved to the human being, or if after it moves to a 
human being, it has been spread to other human beings.
    So my concern is of the viruses that may be coming around 
the world, this is the one, if it hasn't been here yet, and if 
the flu that comes here every year, we cannot do anything 
about, I am still not sure why this is at the top of the list 
of the various kinds of viruses that could come, much as I 
believe we are correct to focus on this. I wish you would help 
me understand, you know, it has been since 1918, why we haven't 
gotten something already, and the question I pose.
    My time is already up. Please, Dr. O'Toole. I would also 
like to get something on alternative institutions, what kind of 
alternative institutions.
    Mr. Reichert. The gentlelady's time has expired.
    Ms. Norton. I am sorry. Could she at least be able to 
answer the question? I will not open my mouth again.
    Could I say that I did not realize I was taking all the 
time to ask a question, because I heard others, and I did not 
realize I was taking any more time than they were. But if I 
could ask the indulgence of the Chair, if she could just 
answer.
    Mr. Reichert. Dr. O'Toole?
    Dr. O'Toole. The question is why worry, and why worry about 
this, and why worry to the point where we are talking about 
spinning up the entire government and everybody else to get 
ready.
    We do not know why the 1918 pandemic happened, but here is 
what we do know. Influenza viruses of all different types 
circulate in wild birds all the time. They normally do not hurt 
the birds. Every once in a while because of the genetic 
propensity of the virus to re-assort its genes, you get a flu 
virus that is new and that has the ability to make humans sick. 
If it is a completely new virus to which we have no previous 
exposure and hence no immunity, you get a pandemic. Sometimes 
they are not a huge deal. In 1957 and 1968, we saw new types of 
flu. It was a pandemic and killed a lot of people, but did not 
perturb the world in a fundamental way.
    What is different here is that we have never seen, first of 
all, a new flu virus. This is a new flu virus we have never 
seen before, this H5N1, that makes birds this sick. It kills 
chickens in 24 hours and it is killing a lot of wild migratory 
fowl as well. So we have never seen one this virulent and we 
have never seen it in this many birds, who are spreading it to 
poultry that are in contact with humans.
    There are hundreds of millions of poultry in Asia who are 
in contact with these wild birds who are carrying H5N1, and 
those hundreds of millions of poultry are in direct contact in 
Asia and in the Urals, for example, with humans. They are 
backyard birds. If this were just happening in large blocs 
under corporate control, as is the case in Delaware, we could 
imagine controlling it. But we are not going to get rid of this 
H5N1 that is now in the wild birds, and there is no way really, 
practically to stop the wild birds from commingling and 
sickening the chickens.
    So the are gazillions of copies of this virus now literally 
flying around the planet, and this is a virus which normally, 
under normal circumstances, moves its genes around, takes new 
genes from other viruses that are circulating in the birds and 
in humans, and re-assorts and makes new viruses. If this virus 
learns how to transmit, we are talking about a pathogen that 
kills 50 percent of the people that it infects. Remember in 
1918, only 2 percent of infected people died. And as you point 
out, Congresswoman, everybody is moving around faster, further, 
et cetera, et cetera, and more routinely.
    So there is that possibility of a calamity. We do no know 
what it would take to make H5N1 transmissible, but it is 
moving. It is evolving and it is changing as we speak. So 
people who understand flu and who watch it are worried. I will 
only say that we could control seasonal flu. We just don't, but 
that is within achievable horizons.
    Mr. Reichert. Thank you.
    The Chair recognizes Ms. Lowey.
    Ms. Lowey. Thank you, Mr. Chairman.
    I also want to thank the ranking member as well, Mr. 
Chairman, for organizing this very important hearing.
    To segue from Dr. O'Toole's comments, some of us that serve 
on another committee, Labor HHS, the one that funds CDC and 
NIH, have been concerned about this for a very long time and 
have been expressing our strong feeling that this is an urgent 
situation.
    I remember a hearing in October 2004 where we had people 
testify and we talked about the fact that if in fact we 
expanded our seasonal vaccine supply, we would have the 
capacity to manufacture in this country additional vaccine 
which would address the avian flu. Of course, we didn't and we 
knew this, and I am sure the experts knew this before.
    Not being a physician, I believe the physicians who have 
been briefing us, we knew this in 2004, October. We have been 
talking about it, many of us, since. And the process is moving 
so slowly. I want to congratulate this panel for what you are 
doing locally in sounding the alarm. I just wish more people 
would listen.
    Dr. Seaberg, even addressing the surge issue, I believe you 
talked about that. In the president's pandemic plan, as you 
probably know, there is no money for surge capacity. This was 
discussed in the New York Times article.
    Many of us also served on this committee when BioShield was 
passed. In fact, there was another article, I believe it was 
the New York Times, talking about Stewart Simonson, the man who 
oversees Project BioShield. Before he was appointed to that 
position, he was a lawyer for Amtrak. There had been some 
questioning about his capability by both Republicans and 
Democrats. The example that was discussed on 60 Minutes was 
that a company, it is not important to even mention it, a 
biotech company was authorized to make a product that would 
deal with radiation. The company went ahead expecting to 
produce 10 million doses, and Stewart Simonson authorized 
100,000 doses. The company went broke, et cetera, et cetera, et 
cetera.
    For those of us who have been asking Dr. Fauci and Julie 
Gerberding about Tamiflu and vaccines and they are working on 
both, I said if Tamiflu is important, if you really think it 
will mitigate the disease by shortening the disease, then why 
are we covering 1 percent of the population, when England is 
covering 22 percent; France, 20 percent; and Canada, 17 
percent? And now we are trying to push the companies to 
manufacture more. And yet, as someone mentioned here, this 
company did not even get the signal for it to go ahead and 
manufacture. So now they won't even be ready to cover all the 
population by 2007.
    So we have had some real problems. There is a lack of 
funding. The localities complain about unfunded mandates in the 
latest plan that has been produced by the administration. They 
are asking localities to pay for 25 percent of the Tamiflu. 
Now, is health going to depend upon where you live? Or does the 
federal government have a responsibility, if they are sending a 
signal that this is a good thing, to make sure that we are 
producing enough on the federal level.
    It seems to me, we still do not know who is in charge. I 
have had many, many, many meetings, in addition to the 
hearings, on this issue; Homeland Security for some things; CDC 
for other things. We saw what happened with Katrina when no one 
was in charge. The military told us they were able to move the 
equipment in, but once it was in there, it was like Paul Revere 
brought back again. You heard stories of people throwing 
bottles down to tell people, others who were in charge, where 
to go.
    So I don't even know if I have a question at this point. If 
I am expressing frustration, having worked on this for a long 
time, sounding the alarm for a long time, I just appreciate 
what you are doing on the local level. I also want to say, if I 
have a minute or so left, I do not know where I am.
    Mr. Reichert. You are on yellow.
    Ms. Lowey. I am on yellow.
    I also serve on the Foreign Operations Committee. In this 
area, I support the president 100 percent. Fight it over there, 
and we are not fighting it over there adequately. There is not 
adequate surveillance. We are not working with the governments 
adequately to compensate the farmers to do adequate culling. 
They are paid such low wages anyway that we could certainly 
replace their income.
    So whether it is producing antivirals, whether it is the 
local plans in place. You are all exceptions. There have been 
many articles, which I do not have time to quote here, talking 
about how inadequate the planning is on the local level, 
because they are not getting adequate direction from the feds 
on communication, on surge capacity, on interoperability.
    So, once again, thanks to the chairman.
    I hope we can continue to work with you, and I hope that we 
can replicate your successes across the country, because there 
is sure a lot needed. I do believe this is coming, if not now, 
I hope it never does, but we should be ready and treat this as 
a national security issue, because frankly we do not use all 
the bombers that the military makes, but we all vote for that 
defense bill. We should be providing exactly what is needed.
    Thank you very much.
    Mr. Reichert. The Chair thanks the gentlelady for her 
statement.
    The Chair now recognizes the gentleman from Maine, Mr. 
Markey.
    Mr. Markey. Massachusetts.
    Mr. Reichert. I am sorry. Massachusetts.
    Mr. Markey. You know what? Maine was part of Massachusetts 
until the compromise of 1820, when letting Missouri be a slave 
state, we also broke off the top of Massachusetts, called it 
Maine and had two more anti-slave senators.
    [Laughter.]
    We are proud of it.
    According to the Department of Homeland Security's budget 
in brief, released earlier this week, the department's 
preparedness director is the focal point to build our nation's 
preparedness to respond effectively to attacks, major 
disasters, and other emergencies. Clearly, a bird flu pandemic 
would be a major disaster and public health emergency for our 
country, with an estimated 2 million deaths in the United 
States alone.
    Earlier this week, the Bush administration submitted its 
fiscal year 2007 budget request to Congress. It seeks $3.4 
billion, which represents a cut of $621 million compared to the 
funding level enacted in fiscal year 2006. This funding cut 
includes a $613 million reduction in funding preparedness 
grants and training for first responders and emergency 
officials in communities across the country.
    Dr. O'Toole, given the current lack of preparedness for a 
bird flu pandemic that you described in your testimony, should 
the federal government be cutting emergency preparedness grants 
to state and local emergency personnel by $613 million over the 
next year?
    Dr. O'Toole. No, but it should reorganize those grants.
    Mr. Markey. Excuse me?
    Dr. O'Toole. It should reorganize those grants.
    Mr. Markey. Even if you organize it, can you do a good job 
if you are taking $613 million away from emergency 
preparedness?
    Dr. O'Toole. I do not know what that $600 million is, 
Congressman Markey. I suspect it is a bad idea.
    Mr. Markey. Okay. Let me ask, has anyone else focused on 
the $613 million cut the Bush Administration is proposing in 
emergency grants? Yes, sir, could you please?
    Mr. Mitchell. Yes, we certainly are in Delaware. The money 
for law enforcement and terrorism, and so forth, has been cut. 
We are in the law enforcement arena feeling it very 
desperately, frankly. It is money that should not be cut.
    Mr. Markey. Okay, thank you. I agree with you. I just think 
that the Bush administration is nickel and diming homeland 
security, cutting emergency preparedness even as we are 
identifying that it is already an area of weakness. They are 
cutting it even further at the local and state level.
    Now, the Bush administration's budget also cuts Medicare 
payments to hospitals. In my home state of Massachusetts, the 
Bush administration would cut Medicare payments to hospitals in 
my state by $213 million over the next 5 years. Dr. Seaberg, 
how would that affect the local community's ability to respond 
in the event of a pandemic flu?
    Dr. Seaberg. Well, it would again increase the overcrowding 
of emergency departments. You would have less physicians 
wanting to take care of Medicare patients, and their only 
alternative is going to be coming to the emergency departments. 
I am in the response business. I believe avian flu is a serious 
threat, as is influenza, smallpox. I am in the response 
business primarily, and I need to decrease my overcrowding in 
the emergency department. I have to have better surge capacity 
in the hospitals.
    Mr. Markey. So Medicare cuts will undermine actually your 
ability to respond. Is that what you are saying?
    Dr. Seaberg. It could, yes.
    Mr. Markey. Okay.
    How about you, Ms. Phillips, do you agree with that, that 
cuts in Medicare funding will undermine hospitals' abilities to 
be able to respond?
    Ms. Phillips. Actually, the Medicare cuts are not ones that 
in public health that we have focused on.
    Mr. Markey. That's okay. Then this weekend The Washington 
Post reported that because our emergency departments are so 
overcrowded nationwide, an ambulance has to be diverted to a 
different hospital every minute in our country. Now, a couple 
of years ago there was an accident on Route 93 in my district. 
It basically overcrowded the emergency room, just a very small 
accident. This is in greater Boston, the medical capital of the 
United States.
    Dr. Seaberg, in your testimony you described the challenges 
currently faced by the approximately 4,000 emergency 
departments. In your opinion, about how many of those 4,000 
emergency departments are prepared today to respond to a 
pandemic flu outbreak in their communities?
    Dr. Seaberg. None.
    Mr. Markey. None.
    Dr. Seaberg. In a small disaster, a car accident, you know, 
I had one 2 weeks ago--
    Mr. Markey. No, I am talking about a pandemic. How many are 
prepared to respond today--
    Dr. Seaberg. None.
    Mr. Markey. Okay.
    Now, the president's budget set aside $2.3 billion to help 
prepare for pandemic flu. However, he has not specified how he 
would like that money to be used. Clearly, the $350 million 
provided last year is not enough, by your testimony. How much 
of this money to the states, the cities, and towns need to have 
in order to be prepared in the event of a pandemic in the view 
of Dr. Seaberg?
    Dr. Seaberg. I cannot give you an exact estimate. I may be 
able to get that information for the record. But right now, we 
can barely handle what comes in our departments today. We are 
overcrowded. Hospitals are at capacity. We cannot handle what 
we have today, let alone a pandemic.
    Mr. Markey. Okay. Now, after September 11 and the anthrax 
attacks, Congress passed the Public Health Security and 
Bioterrorism Preparedness and Response Act. This bill 
authorized $1.6 billion for states and towns to prepare for a 
public health emergency. In January of 2004, GAO found that 
while this Act improved our country's preparedness, we are 
still not prepared. Ranking Member Thompson and I have asked 
GAO to study the barriers to preparedness and provide 
recommendations to help us ensure that the funds provided for a 
pandemic influenza do more to improve our nation's safety.
    What do you think caused the Public Health Preparedness Act 
to fall short of its goal of preparing the public health system 
for a national emergency? Do you have any questions that you 
think the GAO should look at with regards to our public health 
preparedness?
    Secretary Mitchell, would you please respond to that, and 
the Ms. Phillips?
    Mr. Mitchell. Suffice it to say that we in the state of 
Delaware have enormous needs. On the one hand, we are a small 
state, only 800,000 people. On the other hand, we are large 
enough and we are within a metropolis of a four-state area that 
we are a great risk. The funding is needed to address the 
issues. How it is planned to be spent I think needs a lot of 
state and local coordination and recommendation. That is what 
we are about doing as we speak.
    Mr. Markey. Ms. Phillips?
    Ms. Phillips. Yes, I would like to make three points very 
quickly. First of all, the experience that we have had, 
unfortunately some of those grants have been very categorical, 
so we have been focusing on smallpox, and then we stopped 
smallpox. I would like to think that in the future it would be 
a more sustained, all hazards approach, rather than each agent 
by agent.
    Secondly, as I mentioned before, if it is not continuous 
funding, if I do not have confidence that I can meet a payroll 
with that grant next year, then I cannot hire the staff who 
will be on the other end of the call when a physician or 
emergency room makes a communicable disease report.
    Thirdly, a lot of problems have arisen with the 
jurisdictional specificity of some of this money. My county 
straddles Baltimore in the northern part and D.C. in the 
southern part. I am only one health department, but I am in two 
metropolitan areas and it is very tough to juggle zip codes as 
to which resident gets which grant funding.
    Those are three areas that I would like to see streamlined.
    Mr. Markey. I thank each of you. You are like latter-day 
Paul Reveres warning us that the bird flu is coming. I hope 
that the Bush administration listens to you. I do not think 
they can be cutting by $613 million emergency preparedness at 
this time. I think it is a bad decision, a terrible decision. I 
am going to make sure the Congress votes on restoring that 
money to the Bush budget. I just think it should be an 
additional $600 million, not less.
    We thank you so much for your guidance today.
    Mr. Reichert. Thank you, Mr. Markey. The gentleman's time 
has expired.
    Mr. Pascrell, you have an additional question?
    Mr. Pascrell. Thank you, Mr. Chairman.
    I have quickly two questions. I want to associate myself 
with the questions and answers of the gentleman from 
Massachusetts, soon to be a state, but within the United 
States.
    [Laughter.]
    Dr. Seaberg, I want to thank the panel for your boots-on-
the-ground responses because I look at it this way. Either the 
administration is in denial or they are playing with dire 
cynicism. I do not know which it is. This is all A, B, C, and D 
of the question. What are your protocols for epidemiological 
reporting? What are your protocols?
    Dr. Seaberg. We are part of the state Department of Health. 
They right now just collect our total census information, as of 
right now. We are going to look eventually to include 
diagnoses, now that we have an electronic medical record. Other 
than that, our information on epidemics and so forth comes 
through the state department of health through emails and other 
ways.
    Mr. Pascrell. Have you been asked by the CDC to report flu 
symptoms to them?
    Dr. Seaberg. We have not at this point been asked to report 
flu symptoms.
    Mr. Pascrell. Do you test patients presenting flu-like 
symptoms like H5N1?
    Dr. Seaberg. Obviously, if we suspect that, we would report 
it to our local department of health.
    Mr. Pascrell. Do you by law have to do that? Or are you 
doing this simply because--
    Dr. Seaberg. If we think it is avian flu, there is 
mandatory reporting for certain infectious disease in Florida, 
yes.
    Mr. Pascrell. And isn't there a relatively inexpensive 
urinalysis test, $20, that should be available to inform you, 
and therefore inform CDC as to what is going on?
    Dr. Seaberg. For avian flu?
    Mr. Pascrell. Yes.
    Dr. Seaberg. We do not have that. We do have the regular 
influenza test. We do not have avian flu.
    Mr. Pascrell. And by the way, did you get your stockpile 
that you were supposed to get for that?
    Dr. Seaberg. Vaccines?
    Mr. Pascrell. Yes, regular flu?
    Dr. Seaberg. Well, we have our supplies, our hospital did.
    Mr. Pascrell. And it was adequate?
    Dr. Seaberg. Yes. Actually, the department of health did 
get an adequate supply in Alachua County.
    Mr. Pascrell. Can I ask one more question, Mr. Chairman?
    Mr. Reichert. Yes, sir.
    Mr. Pascrell. One more question of Dr. O'Toole. Dr. 
O'Toole, what tools do we have to limit the influx of disease 
into our country from abroad? And how effective to you think 
these measures are?
    Dr. O'Toole. I do not think we have any effective tools. I 
think that for flu, not for all diseases, but for flu, 
screening incoming airline passengers is going to be very 
expensive and very low-yield.
    I also think that it does not make a lot of sense to screen 
airline passengers without screening people coming in via boats 
or over the border from Mexico or Canada, et cetera, et cetera. 
I think to do fever checks at all border crossings would have a 
very profound effect on commerce.
    If we are contemplating doing airline fever screening, for 
example, which again I do not think will work on flu because 
half of them are going to be contagious before they have a 
fever, but if we are contemplating doing that, before we do 
something that would be that intrusive of commerce, I think the 
CDC should really put together the evidence that says this 
makes sense. I have not seen that evidence. We have gone 
looking for it. We do not think it is there.
    I think because of how fast flu moves and because of the 
way the world works now, once it is out, it is going to be out. 
It is going to be pretty much everywhere within a few months. 
We are going to have a very limited time to respond. Then what 
we want to do is try and slow the spread of disease, and if we 
can keep people from getting sick. That is really going to 
depend on mass cooperation. It is going to depend upon doing 
things at the local level.
    Again, we ought to think of all of this as return on 
investment.
    Mr. Pascrell. Mr. Chairman, I thank you very much.
    Mr. Chairman, I would contend that this is even more 
evidence that chapter 12 of the 9/11 Commission's report on 
global strategy must be taken into account when we are trying, 
and every day there are examples. If we are not in 
communication. If we are not at the table with these nations, 
when we are not going to do what we have to do.
    I would think, Mr. Chairman, that that chapter 12 should be 
taken almost from memory by every member of Congress and 
anybody who is in the public realm to protect us. We cannot 
protect the citizenry of this country unless we have good 
relationships with the countries, or try to have good 
relationships with these countries, until they understand, too, 
how serious the subject is that we are talking about.
    Mr. Markey. Would the gentleman yield?
    Mr. Pascrell. Yes.
    Dr. Seaberg. Mr. Chairman, could I make one correction to 
my testimony? If we do have laboratory-confirmed information, 
that is reportable to the state. I misspoke.
    Mr. Pascrell. By law?
    Dr. Seaberg. Yes.
    Mr. Reichert. Mr. Pascrell's time has expired.
    Mr. Markey is recognized.
    Mr. Markey. I thank the chairman very much.
    Dr. O'Toole, I am actually on this subject preparing 
legislation that would encourage countries to comply with the 
World Health Organization's international health regulations 
and establish an annual country-by-country report on the degree 
to which nations are complying with the regulations' 
requirements, including prompt notice to the World Health 
Organization of diseases such as bird flu, SARS, and other 
diseases.
    Do you think such legislation could be helpful as a public 
health tool?
    Dr. O'Toole. Yes. If we can find a way to get countries to 
actually enforce and practice the international health 
regulations, which obliges them to report disease outbreaks, 
that would be very helpful. The rub, of course, is that it 
takes time to confirm, usually more time than the media needs 
to put it on the airwaves.
    Secondly, confirmation of a big disease outbreak is 
automatically an economic threat, a hit, really. So countries 
are understandably very reluctant to say we have a problem 
until they can prove they have a problem, and then there is a 
lot of national price, et cetera, et cetera, involved.
    So it is complicated getting it to happen, but that is what 
needs to go on. Everybody had to understand we are all in it 
together.
    Mr. Markey. You know, we are in a world now of trade and 
travel and tourism. In China and many other countries, they 
want desperately to be given entry to the World Trade 
Organization. They say it is central to their development. And 
yet, the more obviously that we trade with China and other 
countries, the higher the risk that diseases from those 
countries will come to our country and to the West generally.
    So you wind up in a situation where many of these countries 
want the benefit of free trade, the benefit of global tourism, 
but do not want the concomitant responsibility as a member of 
the World Health Organization to then report promptly diseases 
which could be much more easily transmitted across our world 
than could before this era of the World Trade Organization. So 
we now are in a situation where 2 million people cross 
international boundaries every day, and a lot of it because of 
this speeded-up world trade.
    So what recommendations would you have, Dr. O'Toole or 
anyone else on the panel, to build some teeth into a 
requirement that these members who are participants in this 
global trading regime now accept their responsibility to notify 
immediately, notwithstanding their national pride. They do not 
have too much pride to join the World Trade Organization. They 
do not have too much pride to send their products to our 
country. But you are saying that they have too much pride that 
they do not want to admit that they have a disease which can 
affect us and others in the West.
    So what recommendations do you have to us so that we can 
ensure that they understand their concomitant responsibility to 
give us the public health notice?
    Dr. O'Toole. That is me, Congressman?
    Mr. Markey. Yes, please, or anyone else.
    Dr. O'Toole. I would suggest two things. First of all, any 
hammers or sticks that you have that you think would actually 
work I think are certainly worth contemplating. I think if we 
built a rudimentary international disease surveillance system 
that was grounded in the health care and public health care and 
laboratory network, we would have to build the laboratory 
network, around the world, word would get out really quickly, 
regardless of what the governments wanted or tried to prohibit, 
because of the Internet and because of things like ProMED.
    We knew a lot about what was going on in China with SARS 
before the Chinese government told us. We know a lot about bird 
die-offs in western China in spite of the government saying 
nothing is happening, again because of the Internet. So if we 
build the surveillance system so that we can see the disease 
outbreaks, which we cannot in most parts of the world today, 
until they are really a forest fire, I think the tourist 
industry will make its own decisions.
    Mr. Markey. All right. Well, again, what you are saying is 
that the Internet can serve as an early warning system, but 
when you have situations where Microsoft is agreeing to 
cooperate with the Chinese government not to allow anything on 
their Internet on penalty of crime, then I think that is, 
honestly, a pretty weak place to be dependent, where time is of 
the essence in a public health situation, where this disease 
can spread so rapidly. So we need other drivers, other hammers 
here, that will put it through.
    Yes?
    Mr. Mitchell. In Delaware, we have a situation where 
because of our poultry industry we want immediate reporting. We 
made a decision to indemnify each grower that if a flock is 
infected, the state will buy the flock. So it takes out the 
economic scare, if you will, of losing a flock and so forth.
    Mr. Markey. So are you saying that we should insist that 
countries adopt policies that they will promise to indemnify 
any farmers or others who are affected by this?
    Mr. Mitchell. I am saying that in Delaware, that is what we 
did to encourage reporting, and also that we do not publicly 
report which poultry farm has an infection. We report that 
there is an infection, but we do not by law, and it was passed 
by our General Assembly. Whether or not that would work in 
another country, I do not know.
    The issue of the government telling our government, a 
foreign government telling our government about a disease is 
one issue. Whether or not farmers in that country are telling 
their government about a disease is another.
    Mr. Reichert. The gentleman's time has expired.
    Mr. Markey. Thank you, Mr. Chairman.
    Mr. Langevin. I want to thank you all for your testimony. 
This has been a long afternoon, but a fruitful discussion and 
your input has been invaluable.
    Just briefly, we had a discussion earlier, I think Dr. 
O'Toole, you were mentioning the work that CDC was doing in 
terms of trying to make a vaccine for the H5N1 virus. It is my 
understanding, and I just want to clarify it for the record, 
that what is going to be most effective, and one of the 
constraints that we have in terms of making vaccine is that we 
actually have to wait until the vaccine mutates to easy human-
to-human transmission before we can actually make a vaccine 
that is effective for H5N1. Is that a correct understanding?
    Dr. O'Toole. Maybe. It is possible. We and others are 
trying to make vaccines right now against H5N1. It may be that 
H5N1 ends up mutating into a pandemic and that the pandemic 
strain is close enough to the vaccine that we created today 
that it will still have some cross-reactivity.
    Mr. Langevin. But we do not really know that?
    Dr. O'Toole. We do not know that that will be the case. 
There are other strategic options that have a basis in science, 
such as trying to create a flu vaccine that would be good 
against all sub-types of flu. This would solve Congresswoman 
Norton's problem of every year we have to make a new flu 
vaccine. That science ought to be very heartily supported. It 
is getting minimal amounts of money right now.
    There are a variety of scientific strategies you could 
conceive of to speed up the process and to put your bets on 
more than one square, which we are not doing right now in what 
I would consider a robust fashion. But you are generally right. 
That is definitely a problem.
    Mr. Langevin. Thank you all.
    Mr. Reichert. Thank you.
    I want to thank the witnesses and thank the members for 
their questions.
    Members may have additional questions for the witnesses, 
and we will ask that you respond to them in writing. The 
hearing record will be open for 10 days.
    Without objection, the subcommittee stands adjourned.
    [Whereupon, at 4:33 p.m., the subcommittee was adjourned.]

                                 
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