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85–343PS 2003

LEGISLATIVE HEARING ON BIOTERRORISM,

H.R. 3253 AND H.R. 3254

HEARING

BEFORE THE

SUBCOMMITTEE ON HEALTH

OF THE

COMMITTEE ON VETERANS’ AFFAIRS

HOUSE OF REPRESENTATIVES

ONE HUNDRED SEVENTH CONGRESS

SECOND SESSION

APRIL 10, 2002

Printed for the use of the Committee on Veterans’ Affairs

Serial No. 107–24

(
COMMITTEE ON VETERANS’ AFFAIRS

CHRISTOPHER H. SMITH, New Jersey, Chairman

BOB STUMP, Arizona

MICHAEL BILIRAKIS, Florida

TERRY EVERETT, Alabama

STEVE BUYER, Indiana

JACK QUINN, New York

CLIFF STEARNS, Florida

JERRY MORAN, Kansas

HOWARD P. (BUCK) MCKEON, California

JIM GIBBONS, Nevada

MICHAEL K. SIMPSON, Idaho

RICHARD H. BAKER, Louisiana

ROB SIMMONS, Connecticut

ANDER CRENSHAW, Florida

HENRY E. BROWN, JR., South Carolina

JEFF MILLER, Florida

JOHN BOOZMAN, Arkansas

LANE EVANS, Illinois

BOB FILNER, California

LUIS V. GUTIERREZ, Illinois

CORRINE BROWN, Florida

JULIA CARSON, Indiana

SILVESTRE REYES, Texas

VIC SNYDER, Arkansas

CIRO D. RODRIGUEZ, Texas

RONNIE SHOWS, Mississippi

STEPHEN F. LYNCH, Massachusetts

SHELLEY BERKLEY, Nevada

BARON P. HILL, Indiana

TOM UDALL, New Mexico

SUSAN A. DAVIS, California

PATRICK E. RYAN, Chief Counsel and Staff Director

SUBCOMMITTEE ON HEALTH

JERRY MORAN, Kansas, Chairman

CLIFF STEARNS, Florida,

HOWARD P. (BUCK) MCKEON, California

JIM GIBBONS, Nevada

MICHAEL K. SIMPSON, Idaho

RICHARD H. BAKER, Louisiana

ROB SIMMONS, Connecticut

ANDER CRENSHAW, Florida

HENRY E. BROWN, JR., South Carolina

JEFF MILLER, Florida

JOHN BOOZMAN, Arkansas

BOB FILNER, California

RONNIE SHOWS, Mississippi

SHELLEY BERKLEY, Nevada

CIRO D. RODRIGUEZ, Texas

LUIS V. GUTIERREZ, Illinois

VIC SNYDER, Arkansas

STEPHEN F. LYNCH, Massachusetts

(II)
(III)

C O N T E N T S

April 10, 2002

Page

Legislative Hearing on Bioterrorism, H.R. 3253 and H.R. 3254 ......................... 1

OPENING STATEMENTS

Chairman Moran ..................................................................................................... 1

Hon. Bob Filner ....................................................................................................... 2

Hon. Steve Buyer ..................................................................................................... 3

Hon. Cliff Stearns .................................................................................................... 7

Prepared statement of Congressman Stearns ................................................ 46

Hon. Lane Evans, ranking democratic member, Full Committee on Veterans’

Affairs .................................................................................................................... 9

Prepared statement of Congressman Evans .................................................. 47

Hon. Stephen F. Lynch ............................................................................................ 10

Prepared statement of Congressman Lynch .................................................. 47

Hon. Shelley Berkley ............................................................................................... 13

Hon. Ciro D. Rodriguez, prepared statement of .................................................... 46

Hon. Jeff Miller, prepared statement of ................................................................ 47

Hon. Henry E. Brown, Jr., prepared statement of ................................................ 48

Hon. Christopher H. Smith, prepared statement of ............................................. 49

WITNESSES

MacKay, Jr., Leo S., Deputy Secretary, Department of Veterans Affairs; accompanied by Robert H. Roswell, M.D., Under Secretary for Health, and

Kristi Koenig, M.D., Director, Emergency Management Strategic

Healthcare Group ................................................................................................. 5

Prepared statement of Dr. MacKay ................................................................ 51

Yeskey, Kevin, M.D., Director, Bioterrorism Preparedness and Response Program, Centers for Disease Control and Prevention, Department of Health

and Human Services; accompanied by Maureen Lichtveld, M.D., Associate

Director, Public Health Practice and Program Office, Deborah Powell, M.D.,

Executive Dean, School of Medicine, University of Kansas, and Stephen

F. Wintermeyer, M.D., M.P.H., Associate Professor of Clinical Medicine,

Indiana University ............................................................................................... 19

Prepared statement of Dr. Yeskey .................................................................. 56

Prepared statement of Dr. Powell ................................................................... 70

Prepared statement of Dr. Wintermeyer, with attachment, ......................... 75

MATERIAL SUBMITTED FOR THE RECORD

Bills:

H.R. 3253, a Bill to amend title 38, United States Code, to provide

for the establishment of emergency medical preparedness centers in

the Department of Veterans Affairs ............................................................ 33

H.R. 3254, a Bill to amend title 38, United States Code, to provide

for a partnership between the Department of Veterans Affairs and

the Department of Defense to develop and disseminate education and

training programs on the medical responses to the consequences of

terrorist activities ......................................................................................... 42

Statements:

The American Legion ....................................................................................... 79

AMVETS ........................................................................................................... 83

Disabled American Veterans ........................................................................... 85
Page

IV

Statements—Continued

Paralyzed Veterans of America ....................................................................... 89

Veterans of Foreign Wars ................................................................................ 92

Vietnam Veterans of America ......................................................................... 94

Written committee questions and their responses:

Chairman Moran to Hon. Leo S. Mackay, Jr., Ph.D. .................................... 98

Chairman Moran to Kevin Yeskey, M.D. ....................................................... 102

Chairman Moran to Deborah E. Powell, M.D. ............................................... 104

Congressman Filner to Deborah E. Powell, M.D. .......................................... 107

Chairman Moran to Stephen F. Wintermeyer, M.D. ..................................... 108
(1)

LEGISLATIVE HEARING ON BIOTERRORISM,

H.R. 3253 AND H.R. 3254

WEDNESDAY, APRIL 10, 2002

HOUSE OF REPRESENTATIVES,

SUBCOMMITTEE ON HEALTH,

COMMITTEE ON VETERANS’ AFFAIRS,

Washington, DC

The subcommittee met, pursuant to notice, at 3 p.m., in room

334, Cannon House Office Building, Hon. Jerry Moran (chairman

of the subcommittee), presiding.

Present: Representatives Moran, Stearns, Brown, Miller,

Boozman, Filner, Berkley, Rodriguez, and Lynch.

Ex officio present: Representative Evans.

Also present: Representative Buyer.

OPENING STATEMENT OF CHAIRMAN MORAN

Mr. MORAN. The subcommittee will come to order. I’m glad to

convene us once again. Good afternoon, everyone. I appreciate the

attendance of the folks here today.

The topic before the subcommittee, what role do we want, as

Members of Congress, do we want to define the VA in our national

effort to combat terrorism is the issue before us. No longer is it a

question of academics, or theory, but the emergency, and it’s an

issue that’s important to all Americans.

The attacks of September 11 are vivid in our recollection, and we

have entered a new phase in the United States for our role in the

world with heightened concerns about personal, institutional, and

national security.

In the wake of those suicide attacks on the World Trade Center

and the Pentagon, and the anthrax that landed here in the halls

of Congress, the Congress and the Nation have begun to ask questions about the best approaches for government to take for our Nation to prevent such future attacks.

Congress has acted rapidly in some cases, particularly last fall

to approve emergency supplemental appropriations to provide

funds to repair the physical damage and compensate the thousands

of victims and take other actions to restore our Nation.

Since that time this committee has examined ways the Department of Veterans Affairs can deal with these urgent national

needs.

Our full committee Chairman Smith will join us today, and has

introduced H.R. 3253, the National Medical Emergency Preparedness Act of 2001. This Act will move the VA in a new direction in
2

the Nation’s fight against terrorism, and Chairman Smith will be

here to further describe its purpose in a few moments.

Our friend and colleague, Mr. Buyer, Chairman of the Subcommittee on Oversight and Investigations, is going to introduce

H.R. 3254, the Medical Education for National Defense in the 21st

Century Act. And we’re pleased that Mr. Buyer joins our subcommittee here today to describe his bill and its packages.

Before we begin these matters, let me turn to my colleague, our

ranking member, the gentleman from California, Mr. Filner, for

any opening remarks he may wish to make.

OPENING STATEMENT OF HON. BOB FILNER

Mr. FILNER. I thank the Chairman, and I thank you for pursuing

this subject of great importance to our Nation.

I’d like to introduce to you a staff person who will be with us for

3 or 4 months. Our regular staff person is out on maternity leave.

Kathleen Greve, from the Office of the VA Secretary, has experience in health matters and is going to be filling in for her.

I was going to welcome her, but she comes from the Secretary’s

office. I wonder if she was sent to tell the Secretary what the

Democrats are doing. (Laughter.)

This is a confidential relationship—I want it on the record here,

confidential and difficult. (Laughter.)

Did you get the short end by being here?

(Laughter.)

Again, Mr. Chairman, this is obviously a really important issue,

and the creation of the Chairman’s legislation for VA Emergency

Medical Preparedness Centers is a very interesting and important

proposal.

As we know, the VA, without having these organizational

changes, was front and center in the aftermath of the events that

took place in New York and in the other attacks.

The years of experience in treatment of post-traumatic stress disorder was extremely helpful to New York City and right here in

our back yard. And we thank the VA for that.

We heard follow-up testimony from the VA about the many supportive leadership roles the department has played, and continues

to play, at the local and the national level in bio-terror research,

education, and, of course, homeland security.

And certainly—and I hope we continue this in the budgets that

we pass—VA research has long been recognized as ground-breaking

in medical, scientific, and academic circles, with benefits that extend far beyond just the VA and the community itself.

I’m very proud that a recent development was done in San Diego,

in fact, where the VA has announced the development of what

looks like a promising new drug to treat smallpox. The thought of

a smallpox epidemic is obviously very worrisome to anybody, and

it’s a real bioterrorist threat to this Nation.

Dr. Carl Hostetler, of the VA in the San Diego healthcare system, has been directing this research, which is now being tested

further by researchers at the U.S. Army Medical Research Institute

of Infectious Diseases.

This is the kind of effort that we look to from the VA, and that

it has been able to provide us. And the formation of Medical Emer-
3

gency Preparedness Centers of Excellence, maybe we should call

them, makes good sense. We want to take advantage of the existing

infrastructure and build on it.

I’m sure you will join me in this, Mr. Chairman. Any money that

we devote to this has to come from other than the existing programs that we are trying to fund in the VA! We don’t want to create a new program, and dilute older ones. We want to get some

new money in our efforts to do that.

So I look forward to the testimony and the eventual reports pursuing this subject of great importance.

Mr. MORAN. Mr. Filner, thank you very much, and I do share

your sentiments in regard to the appropriations and budget issues

with regard to both of these issues.

Mr. Buyer, we appreciate you joining us today, a man of passion

on these issues, and we’ll be happy to have you describe for the

committee your legislation.

OPENING STATEMENT OF HON. STEVE BUYER

Mr. BUYER. Thank you, Mr. Chairman, and ranking member Mr.

Filner. If you’ll indulge me, I am going to read this statement, because it has legislation that I have authored.

And I want to thank both of you for holding the hearing today,

and also let me take a moment to pause and recognize Mr. Danny

Devine, who used to work for this committee, left the legislative

branch, and then went into the private sector, and is now working

on the executive side of the House. Where is Danny Devine? Standing in the back. Thanks for coming back into the family.

The first bill, H.R. 3253, the National Medical Emergency Preparedness Act of 2001. This is legislation introduced by our Chairman, Chris Smith, of which I’m proud to be a co-sponsor.

Chairman Smith’s bill would establish at least four emergency

preparedness centers at VA hospitals, and this reiterates the fourth

mission of the VA. And I’m very pleased that both the ranking

member and the chairman were active participants to remind everyone about the fourth mission of the VA.

The second bill, H.R. 3254, the Medical Education for National

Defense in the 21st Century, is legislation that I introduced.

The purpose of my legislation is to authorize funds to enable the

VA Veteran’s Health Administration, and DOD’s—the F. Edward

Hebe ́rt School of Medicine of the Uniformed Services University of

the Health Sciences to develop in partnership a series of model

education and training programs.

These programs can then be made available to all healthcare professionals, students, graduate medical education trainees, and practitioners across the country about diagnosing and treating victims

of biological, chemical, and radiological attacks and incidents.

The ‘‘American Association of Medical Colleges Reporter’’ article

in December, 1998, quotes an issue of Military Medicine that says,

‘‘Even military physicians, who should be more prepared than civilian doctors, aren’t sure about their capability of handling such a

situation. The June, 1998 issue of Military Medicine reported that

only 19 percent of military physicians were confident about providing care in NBC situations.’’ NBC, meaning nuclear, biological, and

chemical.
4

‘‘The majority of those confident few—53 percent—were USUHS

graduates of that military medical school.’’

The combination of DOD’s expertise in the field of teaching and

treating casualties resulting from an unconventional attack, and

the VA’s infrastructure of 162 medical centers, 800 outpatient clinics, extensive satellite broadcasting capabilities, and a preexisting

affiliations with 107 medical schools as teaching hospitals, will enable the current and future medical professionals in this entire

country to become knowledgeable and medically competent in the

treatment of casualties of weapons of mass destruction and other

disasters.

One of the witnesses that we will hear from today is from my

own State of Indiana. We would like to extend a warm welcome to

Dr. Stephen F. Wintermeyer. Dr. Wintermeyer is an Associate Professor at Indiana University School of Medicine, and chair of that

school’s Task Force on Bioterrorism.

Prior to joining the Indiana School of Medicine, Dr. Wintermeyer

served in the Gulf War, and is currently a member of the medical

staff at Roudebush VA Medical Center in Indianapolis. We look forward to Dr. Wintermeyer’s testimony.

Last November, the VA Subcommittee on Oversight and Investigations, which I chair, held a hearing that revealed our inability

to diagnose and treat casualties resulting from biological toxins,

chemical agents, or radiological agents from attacks and possible

other incidents.

One of the most compelling pieces of testimony we heard was

from Dr. Carlos Omenaca. He was an attending physician who successfully treated the second case of inhalation anthrax in Miami,

FL. Dr. Omenaca was not just a doctor. Excuse me. But he was

also a specialist of internal medicine with a sub-specialty in infectious disease.

As part of his diagnosis, he referred to a 1904 text book. He said,

‘‘You do not diagnose what you do think of, and you do not think

of what you do not know about.’’

What initially looked like a flu-like illness was later confirmed

as a second case of inhalational anthrax, and the third case in 25

years in the United States. At the hearing Dr. Omenaca also stated, ‘‘Our medical personnel, including myself, do not have the

training to recognize illnesses that have not occurred in this country in decades.’’

Since September 11, we cannot afford to assume that our country

will never have to experience a massive biological, chemical, or radiological attack. We must act to ensure that if the worst of our

fears are realized, our medical professionals will be ready and able

to effectively respond to the fallout.

It is not the intent of this legislation to create new community

standards of medical practice. We must recognize that diseases

such as smallpox, botulism, and plague are not normally seen and

treated except by a few clinicians in the world.

It is also imperative that in carrying out the intent of this legislation that we work with HHS to ensure that we include other Federal healthcare systems that are responsible for supporting medical

research and public health.
5

The Washington Post ran an article last Sunday entitled: ‘‘U.S.

Health Care System Grapples With New Role.’’ In that article,

Julie Casani, head of the Maryland Department of Health and

Mental Hygiene’s new Bioterrorism Division, was quoted as saying,

‘‘The CDC was hampered because of scientific understanding of

how finely milled anthrax spores behave was sketchy and changed

during the outbreak.’’

She went on to say that, ‘‘Various federal officials sometimes offered contradictory advice that confused doctors and patients.’’ She

further stated, ‘‘There was no doctor who stood up and said, ‘this

is what we have to do, and this is what we’re going to do,’ she said.

‘We needed a Dr. Giuliani.’’’

MEND for the 21st Century provides healthcare workers with

the capability needed to identify and treat these lesser known

deadly diseases to mankind.

I thank you, Mr. Chairman, for yielding me time to read my

statement. I yield back the time.

[H.R. 3253 and H.R. 3254 appear on pp. 33 and 42.]

Mr. MORAN. Mr. Buyer, thank you very much, and thank you for

joining us today, and for being here to support and explain your

legislation.

We have our first panel in front of us, and that panel consists

of the Deputy Secretary MacKay; Dr. Roswell, the Under Secretary

for Health; and Dr. Koenig, and we would welcome all of you to our

subcommittee, and in particular welcome Dr. Roswell for his first

appearance. We look forward to a long and fruitful relationship

with this subcommittee, Congress, and the Department of Veterans

Affairs.

Dr. MacKay, if you would like to begin your testimony, we’d be

delighted to hear from you.

STATEMENTS OF LEO S. MACKAY, JR., DEPUTY SECRETARY,

DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY

ROBERT H. ROSWELL, M.D., UNDER SECRETARY FOR

HEALTH, AND KRISTI KOENIG, M.D., DIRECTOR, EMERGENCY

MANAGEMENT STRATEGIC HEALTHCARE GROUP

Dr. MACKAY. Thank you, Mr. Chairman. Good morning—good

afternoon, rather. I am pleased to appear before you today to discuss the Department of Veterans Affairs in its role in homeland security.

The VA plays many roles in the Nation’s healthcare system. It’s

the largest integrated healthcare system in the country, and we

have a potential to play an even greater part in procuring America’s security, and we welcome that opportunity.

Our resources are significant. We are at the forefront of medical

research, we’re an integral part of our Nation’s healthcare system,

and a key member of its emergency response team.

We are the largest pre-deployed asset in our country’s public

healthcare arsenal, and I can assure you we will be prepared and

ready to serve America wherever we are at. We will do this consistent with the evolving federal strategy on homeland security.

The two pieces of legislation under discussion this morning

would substantially add to the VA’s ability to help the medical
6

community prepare for the acts of terrorism against the United

States.

Let me say that VA strongly supports the bills of both H.R. 3253

and H.R. 3254. However, we do have concerns. Chief among them

is that without dedicated funding to support the proposed two missions, VA’s ability to fully meet its primary responsibility to veterans may be compromised.

As you are aware, our medical care accounts are stretched to the

limit. As well, I would also urge that any new spending be accommodated for in the President’s overall discretionary budget.

The proposed bills would accomplish two very important goals.

First, they would accelerate efforts to train VA and non VA

healthcare providers. And, second, they would enhance the VA’s

ability to sponsor research for the prevention, containment, and

treatment of injuries related chemical, biological, and radiological,

or CDR warfare injuries.

It’s important to note here that the pharmaceutical caches we

manage for the Department of Health and Human Services provide

the backbone of America’s ability to respond to chemical and biological attacks.

Weapons of mass destruction have a potential to inflict serious,

widespread, and sustained injury to the American population. It is

therefore essential that the Nation’s healthcare providers have the

tools they need—that is, the education and training that they

need—to successfully treat Americans who will one day be exposed

to unconventional warfare agents. In response, the largest medical

education and health professionals training program in the entire

United States, the VA, is well-positioned to provide medical instruction of this nature.

The VA also welcomes the opportunity for an expanded role in

medical preparedness research, education, and assistance. Our extensive research program has long been a vanguard on the cutting

edge of medicine. In particular, our involvement with biological and

chemical warfare research is significant and predates the events of

September 11.

In short, the VA is well-equipped to serve the homeland security

force multiplier. With our Federal partners we are already addressing broad based issues like threat assessment and incident management, medical and public health, research and development, as

well as plans, training, exercises, and evaluation.

Clearly the demand for enhanced support of homeland security

is one of our greatest short term challenges, and one of our greatest

opportunities.

I’m confident the VA can meet the challenge and maximize the

opportunities they hold not only for better national security, but for

better health for all Americans. The Department of Veterans Affairs supports the proposed legislation and looks forward to sharing

our expertise with the Nation at large.

Thank you, Mr. Chairman.

[The prepared statement of Dr. MacKay appears on p. 51.]

Mr. MORAN. Mr. Secretary, thank you very much. I appreciate

your testimony, and I would give Mr. Filner the first opportunity

to ask any questions.
7

Mr. FILNER. Thank you, Dr. MacKay, it’s good to meet you. You,

too, Dr. Roswell, and welcome to the friendly confines of this House

committee. Do you have any suggestions if this bill passed? Would

you give the President any suggestions for funding? Your concern

was similar to mine.

Dr. MACKAY. Yes, sir. I think you said it very well.

Mr. FILNER. We’re going to have to work directly with the Appropriations Committee on this because you’re already stretched to the

limits as far as I can see. Everywhere I look you don’t have the resources to do a job that we keep giving you more to do, and the

nature of your population gives you more to do.

So I think we have to work very closely with Appropriations, Mr.

Chairman, and the chairman of the VA full committee is obviously

very involved in that. Will he be here to talk about that?

Mr. Moran. Yes, sir.

Mr. FILNER. Because this is obviously a key issue.

You have done a lot of things before this, and this is a natural

fit for you to contribute to the national effort.

I can’t resist putting a little dig in here. You referenced today a

very comprehensive homeland security policy. I wish the Director

would come to Congress and talk to us about it!

We need to work together if we’re going to do this. To figure out

where the money is coming from because we can’t add this on to

you without the resources, and I think we need to keep that in

mind, Mr. Chairman.

Mr. RODRIGUEZ. Will the gentleman yield?

Mr. FILNER. Please.

Mr. RODRIGUEZ. Mr. Chairman, I apologize I have no comment

for the committee meeting at the present, but I would like to submit some written comments for the record if possible.

Mr. MORAN. Without objection, so ordered.

Mr. RODRIGUEZ. Thank you, Mr. Chairman.

[The prepared statement of Congressman Rodriguez appears on

p. 46.]

Mr. MORAN. Mr. Stearns.

OPENING STATEMENT OF HON. CLIFF STEARNS

Mr. STEARNS. Thank you, Mr. Chairman, I’m delighted to be

here, and of course I was just recently out in Snowmass, Colorado

with Dr. Roswell meeting with the Disabled Veterans Sports Clinic.

And both he and I addressed roughly 400 veterans, amputees, spinal cord injury, and veterans who were out there to compete and

sweat and to provide tremendous inspiration for both Dr. Roswell

and I.

And I urge all my fellow colleagues if they can to go out once a

year and see the disabled veterans tackle the ski slopes, and to

come down successfully. It’s an inspiration. I think, first of all, Mr.

Chairman, I just want to make my opening statement as part of

the record quickly.

[The prepared statement of Congressman Stearns appears on p.

46.]

Mr. MORAN. Without objection, so ordered.

Mr. STEARNS. And, of course, I want to congratulate Dr. Roswell

on his Under Secretary appointmentship. He was, of course, the di-
8

rector in Florida, and that is a very challenging job to satisfy people in Florida because there is always new people coming down

from north and northeast, the west, and so forth, so that Florida

has a challenge for accommodating all of the veterans’ services that

are required.

Dr. MacKay, refresh my memory. How much do you think this

is going to cost out of discretionary funding for these bills? Can we

just run through that again, definitively how much the first year,

the second, so forth?

Dr. MACKAY. We had a—in the testimony, we have a first year

estimate of about five and a half million dollars for 3254. And

roughly about five and a half million dollars a year, for a 10-year

total of about $55 million, Congressman. And the bill itself, 3253, has provisions for $20 million a year,

and also provisions for us to be able to reprogram money out of

other accounts at the discretion of the Secretary to bolster, or fill

out these efforts. We are working on a detailed estimate for 3253,

and we don’t have a complete estimate for that at this time.

Mr. STEARNS. So 3254 is going to cost $20 million——

Dr. MACKAY. Five and a half million a year in funding over 10

years.

Mr. STEARNS. Where does the $20 million come from?

Dr. MACKAY. The $20 million is mentioned in the language of

H.R. 3253.

Mr. STEARNS. Okay. So the bills together would cost?

Dr. MACKAY. Twenty-five million, to $26 million a year.

Mr. STEARNS. So that would be roughly a quarter of a billion dollars over 10 years.

How much, Dr. Roswell—I know you’re just on the job, but, you

know, it’s always been a problem getting payments on loans, and

getting outstanding debts that are due to Veterans. That’s been one

area that we’ve always tried to tweak to try to get more money

back.

Is that an area that would be helpful to get this funding for those

two bills?

Dr. MACKAY. I’m not sure that that type of recovered funds could

be reprogrammed, but it’s certainly something that we would be

happy to look into as a source of some funds.

Mr. STEARNS. These recovered funds have always been enormous,

and they have been—you know, unsuccessful in getting payment

back. And I’d just—I think everyone on the Vets Committee wants

to see these bills, but they don’t want you folks to come up and say,

oh, yes, we like the idea, but it’s going nowhere because we don’t

have the money.

And I think many of us would like to see if we internally what

could be done within the Veterans’ Affairs to increase productivity,

lower expense, and provide a better service. And so, in turn, on a $50 billion budget, to come up with some

of this money to take on this. So what your offices will always say

is we like the idea, but it costs too much money, and the bill goes

nowhere.

And so the sponsors of this, including my own healthcare bill, we

all sit here and let the bills pass, but we don’t get the funding for

it. So it’s a disappointment for us. So, you know, it would be nice
9

if you folks would also come up here and give us ideas on how we

could fund this.

So, Mr. Chairman, my comment really is to throw the ball back

at them because they’re throwing it on us and saying, well, you’ve

got to fund it, Congress, and we like the idea, but there’s no funding. So we’re not sure if we can do that. I would throw it back at

them and say if they come up with some areas that they could

show us where they could increase productivity, decrease expenses,

and help fund this themselves.

Mr. MORAN. Thank you, Mr. Stearns. We’re glad to have Mr.

Evans, the ranking member of our full committee, with us. Lane,

welcome.

OPENING STATEMENT OF HON. LANE EVANS, RANKING DEMOCRATIC MEMBER, FULL COMMITTEE ON VETERANS’

AFFAIRS

Mr. EVANS. Thank you, Mr. Chairman. I appreciate your holding

this hearing; it’s very appropriate that we air these issues. But it

also concerns me that perhaps this Nation’s people think that the

VA itself is under that current state of increased funding for its

core programs. The VA, of course, provides medical assistance, but

does not have the resources to do more than its core program. The

VA has been involved, of course, with its medical system and other

resources, along with the DOD and the military. And I think all

we can do is press our government to move as quickly as possible

with the resources that it can apply to this situation, and try to improve it, so we can get this done. I’m concerned about it, and I appreciate your coming up here to testify before Congress.

[The prepared statement of Congressman Evans appears on p.

47.]

Mr. FILNER. If the ranking member would yield.

My good friend, Mr. Stearns, and I represent the differences in

the way the two sides of the aisle view the situation. For me, it’s

always waste, fraud and abuse. And, of course, the Democrats always want to spend more. We’ve been dealing with the VA budget

for quite some years together, and we have given them increased

responsibilities. Your very good Millennium Healthcare Act, adds

very great responsibilities. And yet the budget has gone down in

real terms over a decade. We’ve managed to get it up a little bit

over the last couple of years, and now it’s flat lined again.

And as I understand it—Craig, tell me if I’m right on this, Dr.

MacKay, Dr. Roswell. That there is a provision in the new supplemental for the VA. Is there money that the President is requesting

in the supplemental? Several hundred million? What is that figure?

Dr. MACKAY. It’s $142 million that’s——

Mr. FILNER. That’s requested. Well, I see figures anywhere between $400 million and $800 million that you’re really out of synch

with in your existing budget.

And so we can’t even give the veterans who have served us the

proper care now. And you know from, your chairmanship of this

committee, Mr. Stearns, better than anybody, what the needs are,

and what we want to do, and should do. And yet the money is not

there. But to think that they are going to try to find more money

by, only looking for waste and abuse is mistake. If I went into your
10

office I’d find a few minutes that some staff member was goofing

off——

You haven’t seen Stearns’ office! We could find abuse anywhere.

You know, we could—but they’re under incredible pressure that we

have helped put them under. And, of course, the aging population

that they’re serving, I think we have to give them some credit for

trying to do more with less over the last decade.

I think it’s up to us to come up with the money, and not assume

that there is somehow money in there.

I know you’re very anxious, Mr. Stearns, so I’ll yield to you.

Mr. STEARNS. I thank the gentleman. But, you know, the many

years I have served on the Veterans Committee rarely have I have

heard either administration come forward with a plan to provide

extra money because of higher productivity, or because of cutting

of waste, or duplication, or repetition.

And so—— Mr. FILNER. Actually, they have. They have come forth.

Mr. STEARNS. Well, I would say it’s not the routine. And so, you

know, like any government agency it’s always good to try and urge

them to come forward with an initiative which shows how they

could save money.

Mr. FILNER. I agree, I see I’m defending your administration!

Mr. MORAN. Thank you. Mr. Evans? Mr. Miller?

Mr. Miller. Thank you, Mr. Chairman. I do have a statement

that I would like to enter into the record, and at this time will

waive any questions.

[The prepared statement of Congressman Miller appears on p.

47.]

Mr. MORAN. Without objection, so ordered. Mr. Lynch.

OPENING STATEMENT OF HON. STEPHEN F. LYNCH

Mr. LYNCH. Thank you, Mr. Chairman. Mr. Chairman, I just

want to commend you on your good work on behalf of our veterans,

and also I do want to say that I am supportive of both these legislations that are being offered today.

However, I am concerned, as has been voiced earlier by the ranking member on our side, about whether or not we would also be

looking at additional money, or whether we are simply trying to do

something with resources that are currently dedicated toward the

core, the other three missions, I guess, of the VA.

And if I could be satisfied that we were not going to draw from

those other core missions of the VA, I would be most happy to support this—these pieces of legislation.

And I guess just as a general question to our guests, I would ask

what specific proposals do you have in terms of I think undertaking

a more vigorous pursuit of the VA’s fourth mission?

Dr. MACKAY. I will begin to answer you, Congressman, and then

I’ll invite the Under Secretary.

We are working very closely with the Office of Homeland Security and the White House. In fact, we are part of the effort to provide the homeland security strategy which hopefully will be delivered to the President in July.

Gen. McKickliter, who has been—is actually our representative

to the process. I sit on, of course, the Deputy’s committee of the
11

homeland security process. That has served a senior review group

for many of the policies and other planning that’s gone on. So we

have been very much involved.

We are also part of policy coordinating agreements for medical

and public health, research and development for exercises and

plans, and also for domestic response and incident management. So

we’re fully involved in the homeland security process.

Additionally, we have taken a number of steps on our own. We

have identified funding that would—is very top priority funding,

and made those needs known to the Office of Homeland Security.

On our own recognizance we have formed a consolidated office of

operations, security and preparedness. A centralized place where

all our planning and execution for these types of things happen inside the department.

I’ll let Dr. Roswell continue, but just some of the things that we

have done; an emergency management academy that had been contemplated even before September 11 has been started where we deliver education and training over our own internal knowledge network to both our own, but also partner agencies that have access

to that network.

We have initiated a new telecommunications plan, and a new

cyber security plan that will give us a robustness to resist cyber attacks. We have also revamped, and refreshed our continuation of

continuity of operations for our continuity of government.

We have more robust, hardier, and more numerous operation

centers and plans so that we would be a harder target, and we

would be better in the face of a terrorist incident in delivering benefits and services to the veterans that come to us. And also in safeguarding our own employees.

So we have not been still. We have not been static. We have done

things that we could within our own resources. We have identified

very modest, but also, we hope, very effective pharmaceutical

caches that have been positioned in some 20 facilities around the

VHA network. These are all, you know, to protect our own employees and veterans that come to us.

We have exercised our decontamination capabilities, and we also

had a very real world exercise with regard to the Olympics that

were held out in Salt Lake City. The Olympic Stadium was about

1,500 yards from the Salt Lake City VMAC, and during that—the

course of the Olympics, the Salt Lake City VMAC was the headquarters for the bulk of the Federal forces that were deployed

there.

In fact, one building was taken over by one federal entity that

had overall responsibility for coordinating the federal effort out

there.

So we were an integral part of that. We have a 24 by 7 capability

now in our operation center that constantly keeps the Secretary

and myself apprised of events that are going on around the network and heightens our ability to respond and protect our assets,

our veterans and employees.

I don’t think I’ve left much time for you, Mr. Under Secretary.

Dr. ROSWELL. Thank you. If I may, Dr. MacKay has given a very

exhaustive list of some our responses. I think the point here is that

our role is inevitable. With, or without funding, with our without
12

these bills. Our role in a significant domestic terrorist event is

inevitable.

Literally within hours of the first diagnosis of anthrax in south

Florida the VA was responding. The VA was using its extensive

communication capability to send out clinical guidance to over

15,000 physicians throughout our health system.

Within days we had distributed guidance from the Department

of Defense, the Army Surgeon General’s guidance, the CDC guidance. We were able to disseminate that to all 1,300 locations of

care nationwide.

When patients were evaluated by the Centers for Disease Control

in the West Palm Beach area and Fort Lauderdale area, they were

referred to the VA for assistance with CIPRO, a prophylactic medication and the antibiotic necessary to treat anthrax.

So we had a major response early on. Our role is inevitable.

With regard to Mr. Stearns’ earlier statement about funding,

these are national programs. They should be national programs. If

I’m not mistaken, I believe there is a statutory requirement for

monies collected by the Department of Veterans in private insurance to be retained at the facility where it’s collected.

So I certainly don’t mean to abrogate on our obligation, or absolute requirement to improve the efficiency with which we deliver

care. We are doing that, and are making concerted efforts. But by

the same token I think a national program such as this should not

be funded from the MCCF collection program.

Mr. LYNCH. May I just ask one follow-up question?

Mr. MORAN. Yes, Mr. Lynch.

Mr. LYNCH. Dr. Roswell, you mentioned the work that you’re

doing so far. Is there some coordination with local first responders

and the Emergency Management Academy?

Dr. ROSWELL. Yes.

Mr. LYNCH. I mean the local first respondents?

Dr. ROSWELL. The VA’s role is not a first responder role, but we

do coordinate with community and State officials. We have a very

effective role in coordinating that response.

Dr. Koenig, our consultant of emergency medicine, can describe

very briefly that—how that response is activated, and how it was

activated in New York and Washington and report.

Dr. KOENIG. To answer your question directly, the Emergency

Management Academy was set up first and foremost to train VA

providers across the entire Nation as a cost effective way of using

satellite broadcasts and web based training.

So it is not currently used for first responders, although that infrastructure could be expanded for that role if we have the appropriate authorization and funding to do so.

We do coordinate on the local levels, as Dr. Roswell said, with

all healthcare providers, including first responders.

Mr. LYNCH. Thank you. Thank you, Mr. Chairman.

Mr. MORAN. Thank you, Mr. Lynch. Mr. Brown.

Mr. BROWN. Mr. Chairman, I don’t have any questions, but I do

have an opening statement I would like to turn in.

[The prepared statement of Congressman Brown appears on p.

48.]

Mr. MORAN. Without objection, so ordered. Ms. Berkley.
13

OPENING STATEMENT OF HON. SHELLEY BERKLEY

Ms. BERKLEY. Thank you, Mr. Chairman, and thank you for

being here. I’m sorry that I didn’t hear the bulk of your testimony,

but I’m sure my staff member is going to advise me. She was briefing me while we were sitting here.

Let me tell you my concern, because it’s—I represent a district

where we don’t have a VA hospital. Our clinic is getting condemned

because of structural damage—and, by the way, the—it was first

built and dedicated in 1997.

I don’t have a cemetery, I don’t have an old age home, I don’t

have a nursing care facility, and half of my homeless are veterans

that are lining the streets with no place to go. Now, it concerns me

that there is yet another mission for the VA when, quite frankly,

they’re not doing much of a mission and not fulfilling the mission

you’ve got for my veterans. And, as everybody knows here, I’ve got

the fastest-growing veterans population in the United States.

I don’t know where these monies are going, but I feel a little bit

awkward going back to my vets and saying you’ve got no hospital,

you’ve got to go to Long Beach. You—we’re closing the clinic, we’re

going to have you throughout the city in various facilities because

we don’t have a place for you to go for the basic needs that you

have.

I don’t have a cemetery. There is no long term care, so if you get

really sick and you’ve got no family, I don’t know what the heck

you’re going to do. And half of my homeless are lying down in the

streets with no place to go, and we’ve cut the funding for the homeless, even though we passed the Heather French Homeless Act last

year.

So tell me what I can go back and tell my veterans, because this

bioterrorism, I don’t know, I have a whole bunch of—my sheriffs,

my FBI, and the hospitals and everything else, the VA wasn’t

there. And I’m not sure that that should be your role if we’re not

fulfilling the role the we’ve got already, with all due respect.

How do I go back and tell my vets I’m supporting this more

money for another mission for the VA?

Dr. MACKAY. Congresswoman, I think you—though I can tell you

better—we share your concern about the veterans’ health, and we

absolutely promise you that in the Department of Veterans

Affairs——

Ms. BERKLEY. You know what, after 3 years of sitting on this

committee and being in Congress, my vets don’t want to hear that

you feel their pain. They want to see something productive from

the VA, and so far we don’t see anything.

And I’m uncomfortable voting for more funds for yet another mission when the VA doesn’t seem to be fulfilling any of the basic missions that it has for the veterans I represent. So——

Dr. MACKAY. I can only reiterate that the veterans’ healthcare

is job number one in the Department of Veterans Affairs. And we

have been very clear, my testimony is very clear, the Secretary has

been very clear, that over and above missions—and this would be

an over and above mission, it’s not currently within the scope of

the things that the department does—requires over and above

funding. So we are absolutely and a hundred percent in accordance

with you about the primacy of that issue.
14

With regard to the situation, and it is an unfortunate situation

in Las Vegas with the clinic. I know you and the Secretary have

had many conversations about this.

You know, that we have been monitoring very closely the situation with the structural integrity of the unit. That we are planning

actively. As you know, medical care in that region of the country

is fully subscribed, as you have accurately characterized.

We are going to find an alternate facility. We are going to move

the veterans to that alternate clinic, and we are going to execute

our CARES process—capital asset realignment for enhanced services—we’re going to look at situations that have demographic drivers like in Las Vegas and Nevada. And we are going to shift our

resources to accommodate them.

You know, these are dynamic demographics within the medical

community. I have no qualm, I have no problem with anything you

said. You have made some very accurate statements. Some of them

are hurtful, but I understand the truth of the things you said.

You have the Secretary’s commitment. I know that you have our

commitment, the whole department commitment that we know, we

understand, and we are working as hard as possible to alleviate

both the immediate situation you have with respect to the clinic

issue. And the long term situation you have with respect to the

growing veteran population.

You are absolutely correct, and I could add nothing more to what

you have said, only our commitment. We do understand you.

Ms. BERKLEY. Well, let me ask you something. If I’m not mistaken, you’re going to want—you want funding for this additional

mission for the VA.

How can I vote for that when I need the additional funding to

do the work that you already aren’t doing in my district?

Mr. FILNER. They’re being nice here in their testimonies. You

know, they probably want to say what you just said.

Ms. BERKLEY. Okay. Then let me address this to you.

Mr. FILNER. That would be good.

Ms. BERKLEY. Why are we giving them an additional mission if

they can’t fulfill the mission they’ve already got?

Mr. FILNER. Ask Mr. Buyer. It’s his bill.

Ms. BERKLEY. And help me out here to understand whey we’re

burdening them with more when they can’t do what they’ve already

been assigned to do, and what we’ve already promised our veterans

for years, and years, and years that we will provide for them.

Not that I don’t think all of this stuff is very important, but even

a train stops. Where are we going to get it? Where are we going

to get the additional funds? If I’m being told by the VA we don’t

have funds for a clinic, we don’t have funds for a hospital, we don’t

have funds for a long term facility, we don’t have funds for the

homeless, but we’re going to find funds for bioterrorism.

Mr. BUYER. Ms. Berkley, when I was the chairman of the Personnel Committee on House Armed Services, I had jurisdiction over

the military health delivery system. I have been at Nellis.

The picture that you just drew is completely different from the

picture that I saw when I was at Nellis. I met with district commanders, the veterans’ service organizations. They described a dif-
15

ferent scene and a different picture than you just described in your

testimony.

So, I was sort of taken aback. I’m not going to dispute you, because it’s your district. I just know what I saw when I was there

and I spoke to the district commanders.

So, I cannot concur with what you just said.

Ms. BERKLEY. Well, then let me—come out to my district, because you don’t know what you’re talking about. I’m telling you

what’s happening on the ground in Vegas.

Mr. MORAN. The gentlewoman’s time has expired. I believe that

concludes this panel. Oh, I’m sorry, Mr. Buyer.

Mr. BUYER. Thank you. Now to answer your question. I can only

convey to you, ma’am, what was told to me by your district commanders that I had met with in Vegas. So I’m a little sensitive to

your personal attack toward me.

The second thing, did you vote for the bioterrorism bill that went

to the House floor? Did you? You did? Then you have voted for this

provision. So you should go back and defend your vote, because

you’ve already voted for this.

This bill, the reason we’re bringing it before this committee, is

that—we’ve got several things going on here at once, and this is

Steve Buyer’s blueprint. You aren’t going to read it anywhere, but

you have the prosecution of the war on terrorism going on.

We have preventive measures that we have to do, i.e., homeland

defense. We have consequence management that we have to do,

and then we have a judicial function which comes under the military commissions in how we treat terrorists.

So Ms. Berkley, you’re right. We’re doing all those other things,

and they’re suppressed in doing those things, but on top of it, the

country has turned to us, being the responsible individuals, to address America being attacked and how are we going to prevent future attacks. And how are we going to prepare first responders.

What are the consequences if those acts occur, and other things.

So when we coordinated with DOD, with the AMA, with medical

universities, with the Veterans Committee, with the Congressional

Committee, jurisdiction was waived from DOD and VA, and this

piece was put in the bioterrorism bill that passed the House, and

is presently in committee.

It was moving—everything, if you recall last fall, was moving

fast. And we didn’t know if these anthrax attacks were going to

occur, if there was going to be another wave coming; we didn’t

know.

And the President was putting together his request for funding

for the bioterrorism package, and I sent this over to the Senate,

but, you know, the Senate is a little different. And they didn’t get

their opportunity to chill it, I guess, and do their own approach to

it. So they left it out and it’s presently at conference.

Now that we’ve had some time, what I want to make sure is that

we don’t put it together in haste. Yes, we took 5, 6 weeks to put

this together, but we also have some time now.

CDC is going to be testifying today, and they’ve got their ideas.

In their testimony the VA just said, ‘‘we like this idea that you’ve

put together, is it in complement thereof.’’
16

The funding mechanisms are in place. What I have asked this

committee today is to mark up this bill separately. In the House,

we’ve sent a very strong message to the conferees, who have already been assigned to bioterrorism, and that conference is already

occurring, to keep the education piece in the bioterrorism bill.

And what’s unfortunate here is, to all my colleagues is, I thank

you for permitting me to be a part of your subcommittee, and I

wish I could explain that ahead of time to all of you, but I had to

go last in my remarks.

And I am very eager to have a conversation, a sidebar, with you,

ma’am. Julia Carson and I chair the oversight and investigations

subcommittee of this committee. We are sensitive to what’s occurring in this population shift to southern Nevada, and whether or

not they’re being responsive to your veterans. That’s what brought

me out there.

You know, Johnson took me and said you’ve got to see this. And

if the picture is changing that rapidly, I want to know about it because when I was there it was 4 years ago. You’re saying, Steve,

what happened 4 years ago, today is so much different. Please, I

want to have that conversation with you and if we need to go out

there and see some things and be responsive, ma’am, that’s what

the oversight function of this subcommittee is for.

Mr. FILNER. But, Mr. Buyer, could you yield for a second?

Mr. BUYER. Sure.

Mr. FILNER. What Ms. Berkley was painting of her district is, because of the demographic changes, much more dramatic in her district. But the same is true in every district in terms of veterans not

getting proper treatment and care.

They’re waiting months for appointments. You know, and on, and

on, and on.

Mr. BUYER. Well, I understand.

Mr. FILNER. So you tried to dismiss her situation as if you

haven’t been on this committee for a decade.

Mr. BUYER. I find that insulting. I reclaim my time.

I would like to know, in your preparation for the Olympics, the

coordination that you had with CDC in the training of first responders, what occurred? Can you tell us what occurred out there

in the field?

Dr. ROSWELL. Yes. The Bay Pines VA Medical Center in Florida

operates a hazardous material decontamination team. That team

was mobilized at the request of the Secretary’s office to provide a

contingent decontamination capability.

The HAZMAT team deployed, and set up on the grounds of our

Salt Lake VA Medical Center for the opening ceremonies of the

Olympics and was prepared to receive casualties in the event that

there had been some type of chemical, or biological warfare attack

at the opening ceremonies.

This was not an exercise. They were deployed and prepared to

execute their mission. The team then redeployed for the closing

ceremonies, and also was prepared to execute—in the event of any

actual casualties.

So this was a response that took advantage of expertise and capability in the Department of Veterans Affairs. It was supported by

our VA Medical Center in Salt Lake City.
17

If I could add, Mr. Buyer, that our emergency management infrastructure is extensive. In fact, our very ability to respond to structural deficiencies for the southern Nevada healthcare system exercised our emergency management response, and our ability to validate comprehensive plan to relocate the staff and patients at that

clinic in the Congresswoman’s district was in large measure a result of the emergency management infrastructure that we have in

the VA healthcare system.

So, again, I would submit to you that our role, albeit unfunded

at present, is an inevitable one, and we will be a participant when

called to task.

Dr. MACKAY. And it’s unfortunate that Congressman Stearns

isn’t here. We took the opportunity when we deployed the decontamination team from Bay Pines—which is the senior decontamination unit, to exercise with a team that was there in Salt Lake City.

I was actually on site when the exercise occurred, and watched

the learning between the two teams. And the Salt Lake team,

which is just being started, learned from the Florida decontamination teams. They went back to redeploy for the closing ceremony,

but they also left in place a residual capability. In Salt Lake the

decontamination team was much better off for being able to exercise with and learn from a team that had been together and had

developed and garnered expertise for a long time.

Mr. BUYER. Thank you, Mr. Chairman.

Mr. MORAN. Mr. Filner.

Mr. FILNER. Ms. Berkley, I think, put a very important question

before us, and whether or not we voted for the Bioterrorism Act,

as Mr. Buyer said, we have had now 6 months to see if we’re working out the details, or we’re seeing what can happen if, those details get enacted.

And her question I think has to be dealt with by this committee

as we move forward. She said are we going to add a new mission

when we have—we’re not doing the present mission, the primary

mission, satisfactorily. And, again, this is because we haven’t had

the resources to do that.

And that’s the question. There’s no wrong or right on it. It’s

something this committee has to grapple with, and that’s the purpose of these hearings, it’s the purpose of the mark-ups.

Because we voted for one act doesn’t mean that the consequences

of that act have been presented to us. We have to deal with it and

fund it properly.

So we have to work together on this, and I thank the gentle lady

for bringing up this issue. She has been a very firm advocate for

her district, and we should applaud that, because what she’s actually saying is for all our districts as we all feel the same thing in

some way, or another.

So it’s an issue, and we appreciate your testimony. And if you

want to address the issue as Mr. Berkley put it, please do.

Dr. ROSWELL. Healthcare has changed significantly in this country since September 11. We’re a healthcare provider. We’re a

predeployed Federal healthcare provider. But we have already of

necessity spent scarce resources, which I fully admit are scarce, to

maintain the integrity of our ability to provide and respond to the
18

needs of our veteran patients should this country have another terrorist attack.

We have already, with appropriated funds, purchased pharmaceutical caches that Dr. MacKay spoke of to safeguard our employees and the patients they treat at all of the locations around this

country.

What I’m saying, sir, is that healthcare is different today. It’s not

a choice of accepting the mission, we can’t continue to do our current mission of providing comfort and healthcare veterans in this

new environment, post 9/11, without additional resources.

So it’s really not a choice of accepting a new mission. It’s whether

or not we choose to fund a mission that is an essential part of delivering healthcare in the 21st century, and it’s an inevitable role

that the VA will play as the largest Federal pre-deployed

healthcare responder in this Nation.

Mr. FILNER. I appreciate it, that was a very good statement of

the issue. This is for funding.

Mr. BUYER. Mr. Chairman.

Mr. MORAN. Mr. Buyer.

Mr. BUYER. As I understand, when we passed the bioterrorism

bill, and what has gone into conference, what was going to be

worked out is between $3 billion and $4 billion.

That’s money that we have already sent. All right. So if this

piece stays in the bioterrorism bill, then future funding comes out

of the HHS appropriations. If this piece is not in the bioterrorism

bill, and this becomes a stand alone through us, then the funding

is by us.

That’s what I wanted to share here.

Mr. MORAN. Thank you, panel, very much for giving us the opportunity to make a number of statements and have debate among

ourselves, and we appreciate your time with us, Mr. Secretary.

We’ll call for the second panel. Thank you.

Dr. MACKAY. Thank you.

Mr. MORAN. Dr. Kevin Yeskey, Director of Bioterrorism Preparedness and Response Centers for Disease Control and Prevention, also Dr. Deborah Powell, who is the Executive Dean of the

University of Kansas School of Medicine, and Dr. Stephen

Wintermeyer, the Associate Professor of Clinical Medicine at Indiana University.

Dr. Wintermeyer is a Persian Gulf veteran, and a leader of the

bioterrorism task force. So the subcommittee has a special privilege

in welcoming him, and we appreciate the testimony of all our expert witnesses today. And I would call Dr. Yeskey.
19

STATEMENT OF KEVIN YESKEY, M.D., DIRECTOR, BIOTERRORISM PREPAREDNESS AND RESPONSE PROGRAM, CENTERS

FOR DISEASE CONTROL AND PREVENTION, DEPARTMENT

OF HEALTH AND HUMAN SERVICES; ACCOMPANIED BY

MAUREEN LICHTVELD, M.D., ASSOCIATE DIRECTOR, PUBLIC

HEALTH PRACTICE AND PROGRAM OFFICE, DEBORAH POWELL, M.D., EXECUTIVE DEAN, SCHOOL OF MEDICINE, UNIVERSITY OF KANSAS, AND STEPHEN F. WINTERMEYER, M.D.,

M.P.H., ASSOCIATE PROFESSOR OF CLINICAL MEDICINE, INDIANA UNIVERSITY

Dr. YESKEY. Thank you, sir. Good afternoon, Mr. Chairman, and

members of the committee. I’m Dr. Kevin Yeskey, Director of the

bioterrorism preparedness and response program in the National

Center of Infectious Diseases of the CDC.

I’m also a graduate and longtime adjunct faculty member of the

Uniformed Services University School of Medicine.

With me today is Dr. Maureen Lichtveld, Associate Director of

the workforce development of the Public Health Practice and Program office of the CDC.

Thank you for this opportunity to discuss CDC’s public health response to the threat of bioterrorism. Recent events highlight the

need for increased vigilance and preparedness of unexplained illnesses and injuries as an essential part of the public health network to protect the American people against bioterrorism.

The CDC outlined necessary steps for strengthening public

health and healthcare capacity to protect the Nation against bioterrorist threats in its April 21, 2001, Morbidity and Mortality

Weekly Report release of Biological and Chemical Terrorism: Strategic Planning for preparedness and response, Recommendations of

the CDC’s strategic planning work group.

This report reinforces the work CDC has been contributing to

this effort since 1988, and lays a framework from which to enhance

public health infrastructure. In keeping with the message of the report, five key focus areas have been identified which provide the

foundation for local, State, and Federal planning efforts; preparedness and prevention, detection and surveillance, diagnosis and

characterization of biological and chemical agents, response, and

communications. These areas capture the goal of CDC’s bioterrorism preparedness and response program for general bioterrorism

preparedness.

My written statement details the ongoing efforts of these five

areas, and so I would like to spend the balance of my time highlighting some of our current focus areas.

In the area of preparedness and prevention, CDC has been working to ensure that all levels of the public health community, Federal, State, and local, are prepared to work in coordination with the

medical emergency response communities to address the public

health consequences of biological and chemical terrorism.

CDC has created diagnostic and epidemiological guidance for

State and local health departments, and will continue to help

States conduct drills and exercises to assess local readiness for bioterrorism.

The next area is detection and surveillance. Since the initial detection of a biological terrorist attack will most likely occur at the
20

local level, CDC is providing terrorism related training to epidemiologists, laboratories, infection control personnel, emergency

responders, emergency department personnel, and other front line

healthcare providers, as well as health and safety personnel.

The CDC is also working with partners such as Johns Hopkins

Center for Civilian Biodefense Studies and the Infectious Diseases

Society of America to develop training and education materials for

incorporation into medical and public health graduate and postgraduate curricula.

Third, CDC continues to invest in the public health communications infrastructure through the Health Alert Network, or HAN.

HAN is a nationwide program to establish the communications,

information, distance-learning, and organizational infrastructure

for a new level of defense against health threats, including

bioterrorism.

For response to events another integral component of the public

health preparedness, CDC has developed a national pharmaceutical stockpile. The CDC maintains an interagency agreement

with the National Acquisitions Center for the Department of Veterans Affairs in order to facilitate the procurement of pharmaceuticals, medical supplies, and antidotes that comprise the NPS.

This partnership allows CDC to take advantage of a four billion

dollar annual pharmaceutical buying power of the VA to analyze

various markets and then develop the need and very favorable contractual agreements for the stockpile program.

These contracts provide the acquisition of pharmaceuticals and

other material, inventory rotation, and maintenance, and emergency transport. CDC’s partnership with the VA also permits the

stockpile program to access the VA’s current vendor for pharmaceuticals and medical/surgical supplies under very favorable terms.

CDC’s goal in education and training is for the entire public

health system to maintain a public health work force fully capable

of delivering the essential public health services during routine and

emergency operations. As one of the Nation’s largest providers of

health care, the VA is a partner in CDC’s efforts.

CDC and the VA collaborate through a number of different training and education mechanisms, including: the Public Health Training Network, laboratory training activities, and the Association of

American Medical Colleges, or AAMC, their bioterrorism initiative

First Contact, First Response.

Since October, of 2000, 79 VA Medical Centers have participated

as satellite down link sites of PHTN presentations. The National

Laboratory Training Network provides clinical, environmental, and

public health laboratory training forces with six regional offices to

identify training needs, deliver courses, and evaluate NLTN training programs.

Last year alone, the NLTN delivered more than 226 courses to

an audience of more than 6,200 students. Since 1997, NLTN has

trained 359 students from the VA. In the year 2000, CDC established a national system of Centers for Public Health Preparedness

to strengthen State and local work force capacity to respond to bioterrorism and to support CDC prevention programs in general.

The Centers have developed over 180 bioterrorism-related training programs, short courses, seminars, public meetings, media
21

interviews, and national satellite broadcasts to address local and

regional concerns of preparedness.

The AAMC designed an educational plan with CDC to address

the preparedness of the work force in both the near and distant futures by including specific educational experiences for medical students, resident physicians and practice physicians. Specifically, regional medicine-public health education centers will be established

to facilitate this preparedness education activities and foster collaboration between medical schools and State and local public

health agencies.

CDC will collaborate with the VA, Department of Defense,

FEMA, FDA and other Federal partners, State and local governmental agencies, as well as medical societies, and national professional organizations in implementing the Centers for Preparedness

and other education and training programs targeting clinicians and

other public health and healthcare professionals.

In conclusion, CDC continues to work with other Federal agencies and partners, as well as State and local public health departments to ensure the health and medical care of our citizens. A

strong and flexible public health infrastructure is the best defense

against any disease outbreak.

Thank you very much for the invitation to present today. I’ll be

happy to answer any questions you may have.

[The prepared statement of Dr. Yeskey appears on p. 56.]

Mr. MORAN. Thank you, Doctor, very much. Dr. Powell, the University of Kansas, I especially welcome my—your home town, at

least home state. Thank you very much for joining us here today.

Dr. POWELL. Thank you, Mr. Chairman, for giving me the opportunity to testify today and strongly support H.R. 3253 and H.R.

3254. The University of Kansas VA affiliation is one of the oldest

VA affiliations in the country, and they’re somewhat unusual because they’re affiliated with four VA Medical Centers within our

VISN: Kansas City, Wichita, Topeka, and Leavenworth.

We also are unusual in that our primary VA Hospital, 15 minutes away from our medical school, is in Kansas City, MO. We

have a bi-state partnership with the VA.

The Veterans’ Affairs Medical Centers are a critical part of our

educational efforts for our 700 medical students, and almost 400

resident physicians in training, and the VA provides almost a hundred residency positions in primary care and specialty fields to the

University of Kansas School of Medicine.

I believe today I’m speaking in support of the second very important mission of the VA, which is the educational partnerships with

the School of Medicine. And the events that the Chairman referred

to of September 11 has made medical schools acutely aware of the

gap in our curriculum, and the need to fill those gaps, and it’s entirely appropriate that the Department of Veterans Affairs and the

Department of Defense take a leadership role in partnering with us

to address the needs.

I wanted to just summarize a few points, and not read my testimony. The first point I’d like to make is that I think these initiatives should be ones of partnership and inclusivity. I hope that the

important partnership of the VA and the AAMC will not be deducted. The CDC has already referred to the exciting new collabo-
22

rations with the AAMC and CDC to establish medical school of

public health regional education centers, which I think could be

very important collaborative units for the VA in this partnership.

But the partnership can’t be confined to medical schools alone.

All health professionals have to be educated to recognize and treat

the results of terrorist activities. So the partnership has to extend

beyond the schools of medicine and public health to include schools

of pharmacy, dentistry, nursing, and allied health through our academic health centers.

It also must include our resident physicians, who have a somewhat different, but real educational needs, and our practicing physicians throughout the country who have educational needs as well,

particularly through the American Board of Medical Specialties

and continuing medical education.

A second point I would like to make is that those of us in medical

education are struggling with information overload, and how to

teach our students to access, rather than memorize information. It

is impossible in 4 years of medical school and 3 to 7 years in residency for a practitioner to learn all that they are going to require

in 40 plus years of practice.

So all of the educational materials that have come out of this

proposed legislation should be designed with the idea of providing

accessible information that can be readily accessed by practitioners

of all different levels.

Thirdly, I would like to just mention the need in these times of

national crisis to develop systems for rapid information sharing.

We need to develop systems to share data, and to build information

linkages across boundaries such as State lines, to our medical centers, hospitals, health departments, et cetera.

We need to start with our emergency rooms and urgent treatment centers since these are the primary access to our systems by

individuals.

The VA has been a leader in medical information systems, but

we need to find better ways to link our systems to the VA, and to

each other across State lines and regions, and this is the challenge

of all of us.

Finally, I think we cannot neglect agriculture. Kansas is one of

only six State nationally which operates a combined department of

health and environment. And we have active collaborations with

our Land Grant Institution at Kansas State University.

Issues of bioterrorism in many forms also involve the agricultural

community, and we must find ways to connect with them as well.

Finally, I just want to say that I am extremely supportive of any

effort that can be found to strengthen the historic partnerships between the Veterans’ Affairs Medical Centers and our health professional schools, particularly our schools of medicine. These historic

partnerships could be re-strengthened and re-energized in this time

of national crisis, and I think this represents an opportunity the

University of Kansas will be very happy to play whatever role we

can in assuring the success of these partnerships and initiatives.

[The prepared statement of Dr. Powell appears on p. 70.]

Mr. MORAN. Thank you, Doctor. Dr. Wintermeyer.

Dr. WINTERMEYER. Chairman Moran, members of the committee,

good afternoon. I am Dr. Stephen Wintermeyer, Associate Professor
23

of Clinical Medicine in the Division of Pulmonary, Allergy, Critical

Care and Occupational Medicine at the Indiana University School

of Medicine. Dean D. Craig Brater of the IU School of Medicine has

asked me to represent the school at the hearing today.

Let me speak briefly about myself and the IU School of Medicine.

I know the VA system well. I have been a medical student in a VA

hospital. I have served as a resident and fellow in a VA hospital.

I am presently a member of the medical staff at the Richard L.

Roudebush Veterans’ Affairs Medical Center in Indianapolis.

Equally important, I have been a patient in the VA, and I have

been a family member of a patient in the VA. I have tremendous

respect for the VA health system.

I also know something about biological, chemical, and nuclear

weapons. As a physician on active duty in the U.S. Army for 6

years I was deployed to the Middle East for 6 months during Operations Desert Shield and Desert Storm. As chief of medicine and

ambulatory care for the 46th Combat Support Hospital during

these operations, among other things I made a decision along with

my hospital commander to start our troops on pyridostigmine, a

nerve agent prophylactic medication.

At the present time, in addition to giving talks on bioterrorism,

I am the Associate Chair of the IU School of Medicine Task Force

on Bioterrorism.

The IU School of Medicine is the second largest medical school

in the country. At IU, we enjoy a mutually beneficial and appreciated affiliation with the Richard L. Roudebush Veterans’ Affairs

Medical Center. Our school’s primary effort regarding bioterrorism

is our Task Force on Bioterrorism, created by Dean Brater right

after the 9/11 tragedy.

This task force is chaired by Dr. Rose Fife, our Associate Dean

for Research, and includes members from our Schools of Medicine,

Nursing, Dentistry, the VA Medical Center, including several faculty members who are also veterans; our County and State Departments of Health, the Indiana Poison Control Center, the University

environmental health and safety department, and other primary

teaching hospitals.

I should like to emphasize that the VA is a very important participant on this task force. We have been dealing with issues of

training, personnel mobilization, emergency transport, general education, and so on. As an example of one area of immediate interest

for the task force, I enclose with my testimony a draft course outline for a ‘‘crash course’’ that we are developing on emergency preparedness for medical students, nursing students, residents, and

other trainees and faculty.

The group developing the course includes members of our County

Department of Health, the Indiana Poison Control Center, and fulltime School of Medicine faculty members for the Departments of

Emergency Medicine, Medicine, and Obstetrics/Gynecology.

Additionally, Dr. Fife and other members of the school’s task

force, including our VA representative, serve on a task force organized by the Mayor of Indianapolis to deal with disaster preparedness. This group has been working on innovative measures, including emergency credentialing of physicians and hospitals other their

home hospital in the event of disasters to ensure that medical per-
24

sonnel will be distributed throughout the city, and, indeed, region

as needed.

They have also been dealing with issues such as networking

among hospitals such as building a common electronic medical

record, emergency transportation, quarantine facilities, access to

drugs, and care of mass casualties, to list a few.

The activities of the task force are examples of what can and

should be done cooperatively among hospitals and institutions to

improve our ability to withstand any future attacks or other disasters. The VA’s participation as a major member of this task force

ensures that programs developed by the VA in this arena can be

readily deployed throughout the community.

I am here today to speak in support of both H.R. 3253, the National Medical Emergency Preparedness Act of 2001, and H.R.

3254, the Medical Education for National Defense in the 21st Century Act. H.R. 3253 establishes emergency preparedness centers

within the VA. Such centers would involve strong collaboration

with qualified medical schools, public health schools, and other research and educational entities.

With the VA’s national network and affiliations with medical

schools, such as ours, and its recent integral role in educating both

the medical and lay communities about bioterrorism, VA hospitals

are in an excellent position to work with these medical schools to

expand research in medical emergency preparedness and to further

enhance the training of healthcare professionals in this area.

H.R. 3254 creates a joint program between the Department of

Veterans Affairs and the Department of Defense in which a series

of model education and training programs on the medical response

to the consequences of terrorist activities are developed and disseminated. Again, the long history of collaboration between VA hospitals and medical schools puts the VA in an excellent position to

get this valuable job done.

H.R. 32543 and H.R. 3254 are valuable initiatives that work in

synergy to address critically important educational and research

needs in the area of emergency preparedness. This synergy is leveraged even more through partnering with the Uniform Services University of Health Sciences, and VA affiliated medical schools.

In closing, let me reinforce our support for these laudatory initiatives, but also emphasize that they will require new resources for

the VA system. Existing resources should not be reassigned for this

proposal, rather additional resources should be added for to this

specific program. To do otherwise would jeopardize other valuable

VA programs. Indeed, the programs that would be created by these

two pieces of legislation require a stable foundation on which to

build. The stable foundation is a solid and vibrant VA medical

health system.

I thank you for this opportunity to present to you today.

[The prepared statement of Dr. Wintermeyer, with attachment,

appears on p. 75.]

Mr. MORAN. Doctor, thank you very much for your testimony. I

thank the entire panel.

Dr. Powell, you have the opportunity to at least explain to me

in a way that I can understand it, because I’m familiar with the

University of Kansas School of Medicine. I’m familiar with the
25

Kansas/Missouri line. I’m familiar with our VA hospitals in Kansas

City and Leavenworth, and Topeka and Wichita.

And if you could just generally help me understand the consequences of this legislation? If it’s passed, what would change,

how would things be different, and in addition to that would you—

since September the eleventh have the—has the University of Kansas School of Medicine, and other schools of medicine changed their

curriculum? Is there continuing medical education for physicians

that’s now different? What is it that we’re doing today, and what

would this legislation help us accomplish?

Dr. POWELL. Well, I think, Congressman, what we are—we have

made some attempts to introduce new topics related to bioterrorism

and chemical warfare and radiological terrorism into our curriculum, but our faculties are not well prepared to do this in many

instances.

In the fourth year of our school of medicine, we have a required

course called The Health of the Public, and this is the venue for

us to introduce the course materials for the medical students.

But this legislation, I believe, would help in the generation of

new courses, such as being—are being put in place by the Uniformed Services University, which would provide us with expertise

that may be lacking in our own faculties to introduce the kinds of

materials that we could use for the education of our students.

We have core courses for our residents as well. Our cost is important, so surgery, medicine, pediatrics, neurology, psychiatry residents area all—all have a core curriculum, and we would hope that

this legislation could help introduce courses as well that would

allow us to incorporate them into our core curriculum for our residents. Continuing medical education, at least in our state, has not

emphasized as yet courses related to bioterrorism and chemical

warfare for our practicing physicians, and I think this is a huge

need. I think our physicians in practice need to have access to data

in a timely fashion, and, also, updated information because these

are the pieces, events, medical contingents that we have not experienced often many of us in our practice life times.

And we need to have concise, well developed materials to access

for our practitioners, for our residents, and for our students. One

of the things that I think that we really need to do is provide the

ground work with the basic forces, but then have access to information so that people can immediately have that. They cannot remember everything. If you have to have things that you can access if

you need to if you’re in the emergency room, and on the wards——

Mr. MORAN. Let me follow up with that, because I think that

what you just said is true and important that we have a quick response in position, or a nurse practitioner who knows what to do

when someone presents in the office lobby, or in the waiting room

at the hospital complaining that they’ve come in contact with anthrax, or smallpox.

And my guess is that we’re not yet at the point of—in most instances, of knowing what that response is supposed to be. Nor is

there—is there someone at the University of Kansas School of Medicine to call and say someone claims to have some biological agent

contact, what do we do?
26

Dr. POWELL. I think we learned—at least speaking from my—we

aren’t at that point yet. And I think there are two problems. First

of all, we have a number of specialists. You can call someone in radiation biology, you can call someone in infectious diseases, but we

haven’t gotten coordinated effort.

And then, secondly, I think unless there is a mass emergency, if

there are isolated attacks, people aren’t going to come to an emergency room and say I have been exposed to anthrax, or I have been

exposed to smallpox.

And that is part of our problem as we saw in the events following

September 11, that the patients don’t come in with labels with for

us. And may very well give them the scenarios that many of them

will not come to us that way.

And, therefore, we need to educate our students, our residents,

and physicians across the State. And I think particularly paying attention to the emergency room and urgent treatment physicians as

to how patients may present. And that, I don’t think, we have done

yet.

Mr. MORAN. Doctor, why the VA? And my explanation, at least

to myself, is that you have a long, continuing, ongoing relationship

with the Veterans Administration and its hospitals.

Is that why this makes sense to you?

Dr. POWELL. I think this makes sense to me for two reasons. The

VA and the Department of Defense ought to be the entities, the

agencies, that have the most direct experience with biological warfare, or chemical warfare because it’s more practical for the people,

the patient populations that they treat, for the kinds of physicians

in the case of the Uniformed Services University that they are

preparing.

We are preparing general physicians to enter residency programs

in all different specialties. But particularly the Uniformed Services

University is preparing physicians, military physicians. And the

VA physicians at least have a mission of treating military personnel. We don’t have that concentrated mission.

Also, the VA has this longstanding educational partnership. So

we know how to work with the VA. We have worked with the VA

for over 50 years in training medical students. So we’re comfortable

with the VA as an established relationship.

So those are the two reasons why this makes sense to me.

Mr. MORAN. Thank you very much. Dr. Wintermeyer, I have a

question for you, but maybe in the second round. Let me turn the

opportunity over to Mr. Filner.

Mr. FILNER. Mr. Filner reserves his time.

Mr. MORAN. Mr. Boozman.

Mr. BOOZMAN. I’m just anxious to hear your second question.

Mr. MORAN. Mr. Buyer.

Mr. BUYER. I’d like to thank you for putting this panel together.

Let me compliment you, Dr. Powell. You are very articulate, not

that doctors aren’t, but you are very articulate. Do you have a military background at all?

Dr. POWELL. No, I don’t. My brother was killed in Vietnam. So

I have a close affinity to the military.

Mr. BUYER. Yes.
27

Dr. POWELL. And, also, I trained also as a medical student in a

VA hospital, and my husband was a practicing physician in VA

hospitals for 20 years.

Mr. BUYER. I detected something. The Chairman asked a perfect

question; why the VA. And obviously I was pleased with how you

answered, but I can share with you why I came up with this. And

maybe it’s also on my background.

When we have to prepare doctors in the arena of military medical readiness, and if we are giving our military anthrax inoculations because the threat is real, then we must prepare—and you’re

on the staff of USUHS. So you’re preparing these doctors to treat

those casualties.

Well, the VA has got to get with it, too, because they’re going to

be shipped to the VA. What we have attempted to do is to prepare

the VA to receive this, the nexus is already in place with the teaching—as a teaching hospital for the medical universities.

And I just saw a win-win. So when you talked about partnership

in my mind I kept thinking about the nexus, but it’s all win-win

here. We prepare the military medical readiness, you’ve got the expertise. The country’s asking us to prepare a response, and I just

saw it all as a win-win.

Now, you did catch me by surprise in your testimony when you

said I like it so much we’ve got to extend it to nursing, pharmacy,

allied health, dentistry. I agree, but, you know, we can—I’ll agree

with Mr. Filner here, whoa, wait.

Whoa, I don’t know how this is all going to happen, but at first

when we put this together last fall, beginning last winter, it was

about the first responder groups.

And that was my immediate concern, and I also notice CDC. As

a health agency, Congress was working with you on the bioterrorism bill. I noticed some within HHS wanted to protect some of their

turf.

You know, I don’t care about that. What I care about is that if

this is the right nexus, then let’s do it. If we disagree, then say,

Steve, this isn’t the right way to do this. Then what’s the best way

to do it?

If someone says, oh, let’s just let HHS and CDC do it, fine, but

I guess we have to do this anyway. Right? We have to prepare the

military because it’s going to happen on the battle field, and we

have to prepare the VA because they’re going to be the recipient.

They’re going to receive these patients, and we’ve got to prepare

the public because we never even found out who released this biological toxin called anthrax.

This nut case could release it anywhere, or at an arena, and

shame on us if the country has given us time to prepare, and we

sent the money to the President and for whatever reason we

haven’t done it.

So I just wanted to add my two cents. And, Mr. Chairman, you

asked a really key question here. But the HHS, correct me if I’m

wrong, there is no turf battle here is there? You want to work in

coordination and in partnership as Dr. Powell has mentioned, and

also Dr. Yeskey?

Dr. YESKEY. That’s absolutely correct. We encourage cooperation,

and we want to work in a cooperative way and in coordination with
28

other Federal, State, and local agencies in preparing for bioterrorism.

Mr. BUYER. Dr. Omenaca testified, and his testimony really got

my attention. ‘‘A greater degree of coordination between doctors directly involved in the management of patients suffering from a bioterrorist attack, and official institutions is needed.’’ Now this is an internal medicine and an infectious disease guy.

And if he’s struggling and trying to figure this stuff out—he mentioned someone else who is a family doctor, an intern, or an emergency room doctor. Who then calls—as the Chairman said, the University of Kansas, or calls one—their professors. You know, they’ve

got relationships.

Then he said, ‘‘I detected potential deficiencies in communications between clinicians, health departments, and perhaps even the

CDC.’’ So that’s what we’ve got. I mean you’ve got one of these experts that everybody turns to and he then has to turn to somebody,

and he’s getting all this conflicting information.

And so hopefully what we’re doing here on this ‘‘education piece,’’ we have practicing physicians. We have people that we have to prepare for first response, but in the process we also, as we bring more

docs on line, we just want to be able to think outside the box. Do

you agree?

Dr. POWELL. Absolutely, I do.

Mr. BUYER. Thank you, Mr. Chairman.

Mr. MORAN. Mr. Filner. Mr. Boozman.

Mr. BOOZMAN. I’m anxious to hear your question.

Mr. MORAN. You certainly did, and the pressure is really on; in

some ways I might change the topic here, although something occurred to me as Mr. Buyer was speaking.

Is there any role model elsewhere in the world, perhaps in medical education, regarding this topic? Are we truly creating a program from scratch?

Dr. WINTERMEYER. Is that me?

Mr. MORAN. That is not the question. I’ll be happy to have you

answer.

Dr. WINTERMEYER. Okay. I wasn’t sure if that was the question

you had been saving for me.

In my mind I would make reference to BCLS, Basic Cardiac Life

Support System, and ACLS Advance Cardiac Life Support. These

are advanced life support modules, which the various organizations

have developed, such as the American Heart Association, and are

generally taught in two, or three day periods of time. In my mind

this is a topic that would fit into that sort of model.

When I was deployed over to Saudi Arabia during the Gulf War,

the people at Fort Detrick came over to multiple facilities in the

Gulf and gave their chemical casualty care course, in which they

took a week long course and condensed it into about 2 days for

those of us over there.

So that’s sort of model I think would be a reasonable model, if

we’re trying to develop something like that at IU School of Medicine to provide to our students and faculty as well.

I think that this sort of model is useful, but it’s only part of the

picture. As we all acknowledge, this sort of thing fortunately

doesn’t happen very often. It catches everybody’s attention, and
29

then people, physicians in particular, go back to their usual

routine.

We need to expose the students, we need to expose the practicing

physicians to these topics, but we also need to make sure that they

have ready access to that information so that 3 or 4 months down

the road if a patient comes into their waiting room and the patient

has smallpox or anthrax, the student or physician knows how to

deal with it.

So I would very much encourage web based resources to be out

there, even modules for Palm Pilots and that sort of thing, so that

people can have access to them.

They’ve seen the big picture a few months ago, and now they’re

getting details that they need at that moment. So it’s a two

pronged picture as I see it.

Mr. MORAN. I also serve on the Transportation Committee, and

we have looked at Israel, for example, as a role model here on safety. And I was interested if there was another country such as

Israel that has been down this path.

If this question is a prelude to the question that I really wanted

to explore with you, although it’s—it’s very much related at this

point. I was curious as to whether or not your answer would be the

Department of Defense. Whether our military hospitals, and doctors, healthcare professionals, are they within the military

healthcare system further along, well advanced, knowledgeable,

and trained in regard to the kind of issues we’re talking about that

may face the general public?

And, Doctor, first of all, let me thank you for your service to our

country, and tell you that because of the experiences that you encountered I am very much interested in any thoughts that you may

have in regard to the circumstances that our deployed men and

women today face in Afghanistan, or elsewhere, as a result of biological or chemical agents.

The kind of experiences this subcommittee has taken of course

of looking at what occurred during the Persian Gulf War in hopes

that we can learn something from that to prevent the same kind

of circumstances being presented to the VA by the men and women

who return from Enduring Freedom.

And either now, or subsequent to this meeting, I would be very

interested in any thoughts that you might have based upon your

experiences and understanding of application of military health.

What have we learned from your experience, the experience of

many veterans like you, from our Persian Gulf days, events, such

that we are going to more likely returning men and women to the

United States in much more healthy condition than we did a decade ago?

Dr. WINTERMEYER. I think you have a multi-faceted question.

Mr. MORAN. It was built up by my colleagues that I was

reluctant——

Dr. WINTERMEYER. You couldn’t let them down. I think the first

part of your question is why is the Department of Defense the most

appropriate model, at least in this country. I think I would answer

that by making a reference to the fact that I was a medical student

at a private university in New England. I was a resident at an

Army facility just in the northern part of the District, at Walter
30

Reed. And then I was a fellow at a public university in California,

and now I’m a faculty member at a public university in the midwest.

So I have seen a lot of different medical centers. Clearly the best

education I ever got on this topic was when I was on active duty

in the Army. The people that trained me were all faculty members,

an adjunct faculty members at USUHS, and—I can’t think of a better facility to develop a model curriculum if we’re going to develop

a model curriculum and try to disseminate it.

Looking back at the medical school I was at, and the other facilities I have been at, there is no group or critical mass of people on

faculty that have the expertise to develop that. And that’s part of

the issues and mission at USUHS and they have the personnel

there. So I’m comfortable with that.

Mr. MORAN. Let me follow up with that point. If you put two

physicians side by side, one who has served in the military, and

one who is a civilian in practice, one trained military aspects of

healthcare, and one not, would we find a difference in the education and training level between those two physicians to address

the issues of preparedness for a biological or chemical agent—an

act of terrorism?

Dr. WINTERMEYER. As a basic general rule, yes. I did my residency in the Army. I did not go to medical school at USUHS, but

I did my residency in the Army, and part of our training as an intern was to spend 4 days at Fort Sam Houston in the Combat Casualty Care Course, outdoor activity primarily dealing with battlefield casualties. And I certainly had training in dealing with NBC

type exposures that people might have.

I have never had anything like that in the civilian world. Shortly

after the events happened last fall, our Department of Medicine decided there were a lot of people in our department who didn’t know

much about anthrax. We needed to have a Ground Rounds and

teach the people about anthrax.

The chief resident coordinated it and spoke to our Chief of Infectious Disease, who is a very reasonable person to speak to. Eventually he contacted me because he knew that I had some military

background and dealt with or had been trained in dealing with

these biological agents. Fortunately, I did not have to deal with any

directly myself when I was over there.

So my impression is, yes, that military physicians do have a better training and expertise on that topic.

Mr. MORAN. Thank you very much, Doctor. Mr. Filner. Mr.

Boozman. Mr. Buyer.

Mr. BUYER. Thank you. I just have one follow-up question for

Dean Powell and Dr. Wintermeyer. For the purpose of legislative

history, I would like to establish that this bill is not intended for

there to be a Federal mandate of specific curriculum on medical

universities.

That testimony from Health and Human Services about coordination, the testimony from Dr. Wintermeyer referencing USUHS as

the experts, and that he’s comfortable with regard to their curriculum and how that can be coordinated with the medical universities,

and in cooperation with the CDC, is what we envision.
31

Secondly, this legislation does not have a specific purpose to establish new community standards of medical practice. These chemical agents and biological toxins and radiological agents are still uncommon, and therefore should not be used by trial lawyers to establish grounds of community standards for the purpose of medical

malpractice.

I invite comment from Dean Powell and Dr. Wintermeyer on

these two points.

Dr. POWELL. Well, I’m grateful for your analysis and clarification

because I think those are both very important points. Certainly

across the medical schools it would be I think unfortunate if there

were expected standards of curriculum that were imposed on the

medical schools.

So I welcome that very much. I think we all—you know, that we

need to address these important issues, and doing it in a spirit of

partnership and cooperation without coercion is very important.

Also, I think your second point is absolutely essential to the practitioners of this country and graduates. And I appreciate your clarification.

Dr. WINTERMEYER. I would concur with the Dean specifically regarding your second issue, albeit the events of last fall have generated great publicity and physicians throughout the country know

a lot more about anthrax now than they did back in September, or

early October, last fall.

The reality is that those physicians had never seen anthrax. If

they were asked to show a picture of anthrax, they probably

couldn’t find one and they would have to refer a book dated 1904,

or something like that. Or search the CDC web site.

So to expect that the accurate diagnosis of anthrax should be a

standard of care is unrealistic. It is important that anthrax usually

presents initially as a very nonspecific illness. So it’s not like—and

someone made reference earlier, it’s not like these people come in

with a post card on their head saying that they have anthrax. It’s

not an easy diagnosis to make rapidly, and the fact is that most

physicians haven’t seen it. So to expect rapid diagnosis is not

realistic.

Mr. BUYER. Thank you very much for your testimony, and I also

want to take the opportunity to complement HHS for all the work

the men and women have done and how they responded to September 11. Please accept my compliments.

Dr. LICHTVELD. Thank you.

Dr. WINTERMEYER. Thank you.

Mr. MORAN. Thank you, Mr. Buyer. Dr. Lichtveld, just to give

you the opportunity so that you can say anything you would like,

I would like to grant you the microphone if there is anything you

would like to say.

Dr. LICHTVELD. Thank you, Mr. Chairman. We’re here at the

pleasure of the subcommittee, and we’re pleased to coordinate with

the VA.

Mr. MORAN. Thank you. Thank you for your attendance. Our

subcommittee has been provided with the testimony by six veterans organizations that will be placed in the record if there is not

objection. And, also, Chairman Smith has submitted his statement

for the record, and will be ordered to be included.
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[The prepared statement of Chairman Smith appears on p. 49.]

Mr. MORAN. I believe this just about concludes this hearing, and

we anticipate that these bills will be considered by the subcommittee for mark up prior to the recess in May.

So based upon the statements here today we ought to see if there

are some issues that need to be resolved because the intention of

the full committee is to have these two items on the agenda.

Again, I appreciate both panels for being with us today, and for— particularly the experts taking time out of their schedules. I’m always reluctant to intrude upon doctors when you ought to be saving lives. Perhaps by what we do today that can occur.

So, again, I appreciate your attendance, and this subcommittee

is adjourned.

[Whereupon, at 4:50 p.m., the subcommittee was adjourned.]
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A P P E N D I X
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PREPARED STATEMENT OF HON. CIRO D. RODRIGUEZ

TALKING POINTS

Opening Remarks for HVAC Health Subcommittee Hearing on H.R. 3253,

Emergency Preparedness Act

H.R. 3254, Medical Education for National Defense in the 21st Century Act

• I am happy that we have the opportunity to have a hearing on these two pieces

of legislation.

• The events of September 11th and the anthrax attacks have forced us to reevaluate our ability to respond to chemical, biological, and radiological contingencies.

• We had a hearing a few months ago on the status of the VA’s preparedness as

a third line responder.

• The news was not very good.

• VA is the nation’s largest health care system, it engages in some of the most

promising research, and it provides first-rate medical training and education.

• Considering all the VA does, I see no reason why the VA cannot be positioned

as a first responder in the event of a biological or chemical attack.

• Many VA medical centers, including the Audie Murphy Hospital in my district,

already have shared teaching and research arrangements with medical schools

and the ability to attract high-level scientists in fields relevant to bio-chemical

and radiological threats.

(Audie Murphy has relationships with the University of Texas Health

Science Center in San Antonio, University Hospital, the University of

Houston School of Public Health, Southwest Research Foundation,

Southwest Foundation for Biomedical Research as well as military medical institutions).

• I am excited about the prospect of National Emergency Preparedness Centers

which would not only engage in research to develop methods of detection, inoculation, and treatment but also coordinate research with universities and federal

agencies and disseminate the latest information to healthcare workers at public

and private hospitals.

• I believe the VA, through the creation of these National Emergency Preparedness Centers, can become a key partner in our nation’s homeland defense efforts.

• I look forward to this development.

• Thank you, Mr. Chairman.

PREPARED STATEMENT OF HON. CLIFF STEARNS

VA’S ROLE IN COMBATING BIOTERRORISM

I want to thank Chairman Moran for holding this hearing. I welcome our witnesses, especially Dr. Roswell, who recently departed as the Medical Director for my

VISN 8, in Florida: Congratulations on your confirmation.

As an original cosponsor of both of these pieces of legislation, I do believe that

VA can play an invaluable role in combating bioterrorism. For HR 3254, We know

that we have a tremendous resource here, with our over 1,000 facilities, affiliation

with 100 medical and other health profession schools, and tens of thousands of dedicated employed health care professionals.

Equally, the Department of Defense offers an unparalleled training regimen at its

Uniformed Services University of the Health Sciences. As we learned at the hearing

October 15, at no other medical school in the United States is one taught to recognize exposure to as broad a panel of biological weapons as are the DOD medical students. Similarly, USUHS students are foremost in learning efficiencies in contamination and minimizing exposure to chemical and radiological materials.

For HR 3253, again, VA has the capabilities and framework to support research,

education and assistance in the bioterrorism field. I do understand from Dr.

Mackay’s testimony that VA must implement any responsibilities of these new four

preparation centers within the framework of the Office of Homeland Security’s upcoming overall plan, due this July. Also, I want to reiterate a concern I have expressed that any new responsibilities we ask of the VA must not compromise the
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VA’s first, second and third missions. Most importantly, the VA must continue its

priority of caring for our nation’s veterans who have done so much for so many.

PREPARED STATEMENT OF HON. LANE EVANS

Good afternoon. I applaud the Chairman and Ranking Member for convening this

legislative hearing on the two bio-terrorism bills before us today.

The events of September 11th served as a wake-up call for us. It sent a very clear

message about the threat of terrorism and the danger associated with not taking

that threat seriously.

The VA is neither a law enforcement agency nor an intelligence agency. As such,

we do not look directly to the VA to stop a terrorist attack. We do however, look

to the VA to lessen the consequences of a full array of catastrophic events that

threaten the lives of our citizens—including terrorist attacks such as the one experience on September 11th.

The two bills before us today—H.R. 3253 and H.R. 3254 are aimed at expanding

VA’s capabilities to respond to bio-terrorism. Bio-terrorism poses a very serious

threat and I think it is appropriate that we address this issue.

I welcome the witnesses this afternoon and I look forward to your testimony. Your

views on these legislative proposals will help us in our attempts to ensure that the

VA is poised to appropriately respond to bio-terrorism attacks.

Again, I thank the Chairman and Ranking Member.

PREPARED STATEMENT OF HON. JEFF MILLER

HEARING TO EXAMINE VA ROLE IN EMERGENCY PREPAREDNESS

Thank you Mr. Chairman.

I am pleased to be with you today. I would like to thank the distinguished members of the panels present today. Your input is invaluable to us as we work toward

what is right and best for our veterans and our nation. I also want to join my colleagues in specifically recognizing Dr. Rob Roswell, the recently confirmed Under

Secretary for Health. I look forward to working with you sir.

With over 200,000 employees, the VA operates the largest integrated healthcare

system in the United States, and is therefore one of our greatest resources in responding to potential chemical and biological attacks. This is something that we

should be very proud of and a resource that we should be eager and willing to use

in order to address the challenges that our nation currently faces. That being said,

it is vital that we find a viable funding stream that will provide the foundation for

this extension of the VA mission. This Committee has worked tirelessly to gain additional funding devoted to health care, the primary mission of the VA, and we

should take no actions that would be detrimental to this effort, whether it be in

funding or in focus. I want to commend Chairman Smith and Chairman Buyer for

introducing this legislation and the VA for their desire to do their part at this difficult time in our nation’s history.

Again, I thank you for your testimony today and for your assistance as we do our

duty for our nation’s finest.

PREPARED STATEMENT OF HON. STEPHEN F. LYNCH

Good afternoon and thank you Mr. Chairman for your courtesy.

Firstly, Mr. Chairman, I would like to commend you and all the good work that

you do for our nation’s veterans that we are here today to discuss. All of us, I think,

can agree that the VA does a great job with sometimes little and inadequate resources. Our VA takes care of our veterans’ health care needs, education and training, and our VA also is a place where extensive medical research is happening.

September 11th has impacted all of our lives in very profound ways. As a nation,

our priorities have necessarily changed. We have all awoken from a sweet dream

of complacency and innocence that has ended.

In the days since the terrorist attacks, anthrax, smallpox and bioterrorism have

become part of every household’s vocabulary. As a nation, we must now take a closer look at our emergency preparedness.

In much the same way, the VA must also take a closer look at its mission. As

we are all aware, stated within its fourth mission, the VA must serve as a backup

to the DOD health system in a time war or other emergencies, to support our communities following domestic terrorist incidents and other major disasters.
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What is the best use of the VA and all of its resources to accomplish this mission?

The two bills before us today, are, good starting points.

The history of medical research undertaken by our VA places it in a unique position to address questions that have arisen around bioterrorism. This expertise can

be used for measures outlined in Mr. Smith’s bill. Medical emergency preparedness

centers will allow the VA to brings its expertise to these areas.

By addressing terrorist threats to public health and safety with research, training,

treatment disciplines and standards to prevent or deal with biological, chemical, and

radiological attacks, these new centers will become an important national resource.

Additionally, Mr. Buyer’s bill to establish national education and training programs for health care professionals responding to terrorist activities is a natural fit

for the VA. The VA does a good job training America’s healthcare professionals with

more than 85,000 being trained annually at our VA healthcare facilities.

Though in principle I fully support the concepts of both pieces of legislation, I do

have one serious concern.

Mr. Chairman, I am concerned about the possible funding streams available to

implement this mission. In establishing these national medical preparedness centers, as well as the proposed medical education programs, the VA must receive specific earmarked appropriations that are separate from the VA’s standard healthcare

funding. We must not jeopardize the health of our veterans by targeting already

strapped health care resources.

Additionally, I would like to hear more generally about the plans put in place by

the VA in order to undertake its fourth mission. I appreciate the Deputy Secretary

appearing before us today to explain to us the machinations of this system. For instance, I would like to know how many VA beds would be available today in the

event of a national incident? What infrastructure does the VA already have established?

Once again, thank you Mr. Chairman for the opportunity to comment today. I look

forward to hearing from our witnesses and in working with the committee on these

issues.

Thank you.

PREPARED STATEMENT OF HON. HENRY E. BROWN, JR.

Mr. Chairman, thank you for holding this Subcommittee Hearing today. In light

of the dangerous world that we all face today, it is our responsibility to safeguard

the American people from every potential biological, chemical, radiological or nuclear hazard that we may have to face in the future. I believe that the key is preparation, and this preparation includes training and educating medical and health professionals to identify these hazards and then to be able to respond and treat patients before it is too late. I hope that these two bills, H.R. 3253 and H.R. 3254,

can bring us closer to that reality.

However, I think we should also move cautiously in this area. First, we must ensure that these new roles for the V A do not degrade the primary mission of the

V A which is to provide first class health care services to our veterans who have

given so much to this nation. I am also concerned about the funding for these bills.

We may be able to fund these measures through emergency appropriations for

homeland defense efforts this year, but where will the money come from in the future? With the current strains on our budget as a result of the war on terrorism

and veterans health care increases, and hopefully concurrent receipt, we must exercise fiscal restraint wherever possible. Lastly, we must be weary of duplication of

effort here. Both the Departments of Defense and Health and Human Services along

with State and local agencies have dedicated resources to this effort since September 11. We need to take a close look at what these bills will accomplish and coordinate our efforts.

In Charleston within my district, the Ralph H. Johnson V A Medical Center is

a busy facility which offers all levels of inpatient and outpatient care to veterans.

It enjoys a successful affiliation with the Medical University of South Carolina. As

a result of this partnership, it has one of the leading open-heart surgery programs

in the Southeastern United States and conducts major research in diabetes, heart

disease, kidney disease, fetal alcohol syndrome, rheumatology and other areas.

Hopefully, these experiences can be transferred to success in new partnerships between the VA and the academic community in areas of bioterrorism.

Mr. Chairman, thanks again for holding this hearing today and thank you to all

of the witnesses for educating us on this important subject.
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PREPARED STATEMENT OF HON. CHRISTOPHER H. SMITH

EXPANDING THE VA’S ROLE IN HOMELAND SECURITY (H.R. 3253)

Mr. Chairman, I commend you for holding today’s hearing to consider legislation

that would expand the VA’s role in fighting biological and chemical terrorism.

While it will not be a surprise to most of the people in this room, I suspect that

the vast majority of Americans do not realize that the Department of Veterans Affairs has the world’s largest integrated health care network, with over 200,000

health care professionals, 163 medical centers, more than 800 outpatient clinics, 115

medical research programs, affiliations with over 100 schools of medicine and a $25

billion annual budget.

Dedicated to providing health care to the America’s military veterans, the VA is

now the federal government’s leading provider of direct medical services, with over

4.5 million patients treated last year. From providing top quality medical care to

veterans, to performing comprehensive, cutting edge research, such as for prosthetics and Alzheimer’s, the VA health care system has become a unique national re- source. That’s why we fought so hard to increase their health care budget for next year, which I am pleased to say has been increased by $2.8 billion in the budget resolution approved by the House last month.

As you know, Mr. Chairman, the VA already has some defined roles in both the

National Disaster Medical System (NDMS) and the Federal Response Plan (FRP)

in the event of national emergencies. Among its specialized duties are conducting

and evaluating disaster and terrorist attack simulation exercises; managing the nation’s stockpile of pharmaceuticals for biological and chemical toxins; maintaining

a rapid response team for radiological releases; and training public and private

NDMS medical center personnel around the country in properly responding to biological, chemical, or radiological disasters.

Yet despite the VA’s capacity, experience and expertise in public health matters,

it is almost routinely overlooked when it comes to discussions of homeland security,

even those concerning bio-terrorism. In the Administration’s budget submission, al- most $6 billion was requested to prevent bio-terrorism, including $2.4 billion for additional research, yet not one dollar was earmarked for the VA. In fact, if you look

at the Administration’s latest strategy document on Homeland Security, which can

be found on their webpage, the VA is not even mentioned once. The VA can and

must be asked to do more.

Last October, I proposed legislation (H.R. 3253) to create four National Medical

Preparedness Centers to be operated by the Department of Veterans Affairs, two for

dealing with chemical and biological threats, and two for dealing with radiological

threats. In coordination with the Department of Defense, HHS, FEMA, CDC, NIH,

and other agencies or organizations with appropriate expertise, these Centers would

research and develop new methods to detect, diagnose, vaccinate and treat potential

victims of chemical, biological, and radiological terrorism. The Centers would serve

both as direct research centers and as coordinating centers for ongoing and promising new research at other government agencies and research universities.

Furthermore, these Centers would serve as training resources for the thousands

of community hospitals that would be first responders to future bio-terror attacks.

Finally, the Centers would be charged with establishing state-of-the-art laboratories

to help local health care authorities quickly determine the presence of dangerous biological and chemical toxins, such as anthrax.

Mr. Chairman, I also need to emphasize that my legislation provides that the cost

of these new centers would be taken from additional funds provided to combat terrorism, and not taken from the already hard-pressed VA health care system.

There is ample precedent and experience within the VA for undertaking this expanded mission. Through their extensive medical research programs, the VA has

documented expertise in diagnosing and treating viral diseases with devastating

health consequences, such as their groundbreaking work on HIV and hepatitis C.

And just last month, Dr. Karl Hostetler and his VA colleagues in San Diego developed a new oral treatment for smallpox, one of the most deadly bio-terror threats

confronting the world today.

In addition, the VA already operates two War-Related Illness Centers tasked with

developing specialized treatments for illnesses and injuries related to combat. In essence, these new National Medical Preparedness Centers would similarly study illnesses and injuries most likely to come from a terrorist attack, and develop new

treatments and protocols to mitigate their dangers.

Mr. Chairman, I believe it is appropriate for the VA to playa larger role in homeland security and the legislation I have proposed is one way to take advantage of
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its expertise while continuing to meet their primary mission of taking care of our

veterans.
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PREPARED STATEMENT OF DR. STEPHEN WINTERMEYER

TESTIMONY OF STEPHEN F. WINTERMEYER, M.D., M.P.H., INDIANA

UNIVERSITY SCHOOL OF MEDICINE

Chairman Moran, members of the committee, good afternoon. I am Dr. Stephen

Wintermeyer, Associate Professor of Clinical Medicine in the Division of Pulmonary,

Allergy, Critical Care and Occupational Medicine at the Indiana University School

of Medicine. Dean D. Craig Brater of the IU School of Medicine has asked me to

represent the school at this hearing today.

Let me speak briefly about myself and the IU School of Medicine. I know the VA

system well. I have been a medical student in a VA hospital. I have served as a

resident and fellow in a VA hospital. I am presently a member of the medical staff

at the Richard L. Roudebush Veterans Affairs Medical Center in Indianapolis.

Equally important, I have been a patient in a VA and have been a family member

of a patient in a VA. I have tremendous respect for the VA health system. I also

know something about biological, chemical and nuclear weapons. As a physician on

active duty in the U.S. Army for six years, I was deployed to the Middle East for

six months to serve in Operations Desert Shield and Desert Storm. As Chief of Medicine and Ambulatory Care for the 46th Combat Support Hospital during these operations, among other things, I made the decision, along with my hospital commander,

to start our troops on pyridostigmine, a nerve agent prophylactic medication. At the

present time, in addition to giving talks on Bioterrorism, I am the Associate Chair

of the IU School of Medicine Task Force on Bioterrorism.

The Indiana University School of Medicine is the second largest medical school

in the country. At IU, we enjoy a mutually beneficial and appreciated affiliation

with the Richard L. Roudebush Veterans Affairs Medical Center. Our school’s primary effort regarding Bioterrorism is our Task Force on Bioterrorism, created by

Dean D. Craig Brater right after the 9/11 tragedy. This Task Force is chaired by

Dr. Rose Fife, our Associate Dean for Research and includes members from our

Schools of Medicine, Nursing and Dentistry, the Veterans Affairs Medical Center

(including several faculty members who are veterans themselves), our county and

state departments of health, the Indiana Poison Control Center, the university environmental health and safety department services, and our other primary teaching

hospitals.

I should like to emphasize that the VA is a very important participant on this

Task Force. We have been dealing with issues of training, personnel mobilization,

emergency transport, general education, and so on. As an example of one area of

immediate interest for the Task Force, we enclose with this testimony a draft course

outline for a ‘‘crash course’’ that we are developing on emergency preparedness for

medical students, nursing students, residents, and other trainees and faculty. The

group developing the course includes members of our county department of health,

the Indiana Poison Control Center and full-time IUSM faculty members from the

Departments of Emergency Medicine, Medicine and Obstetrics/Gynecology.

Additionally, Dr. Fife and other members of the School’s Task Force, including our

VA representative, serve on a Task Force organized by the Mayor of Indianapolis

to deal with disaster preparedness. This group has been working on innovative

measures including emergency credentialing of physicians at hospitals other than

their home hospital in the event of disasters to ensure that medical personnel will

be distributed throughout the city, and, indeed, region, as needed. They also have

been dealing with issues such as networking among hospitals such as building a

common electronic medical record, emergency transportation, quarantine facilities,

access to drugs, and care of mass casualties, to list a few. The activities of the Task

Force are examples of what can and should be done cooperatively among hospitals

and institutions to improve our ability to withstand any future attacks or other disasters. The VA’s participation as a major member of this Task Force ensures that

programs developed by the VA in this arena can be readily deployed throughout the

community.

I am here today to speak in support of both H.R. 3253, the National Medical

Emergency Preparedness Act of 2001 and H.R. 3254, the Medical Education for National Defense in the 21st Century Act. H.R. 3253 establishes Emergency Preparedness Centers with the VA. Such centers would involve strong collaboration with

qualifying medical schools, public health schools and other research and educational

entities. With the VA’s national network and affiliations with medical schools, such

as ours, and its recent integral role in educating both the medical and lay communities about bioterrorism, VA hospitals are in an excellent position to work with

these medical schools to expand research in medical emergency preparedness and

to further enhance the training of health care professionals in this area. H.R. 3254
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creates a joint program between the Department of Veterans Affairs and the Department of Defense in which a series of model education and training programs

on the medical response to the consequences of terrorist activities are developed and

disseminated. Again, the long history of collaboration between VA hospitals and

medical schools put the VA in an excellent position to get this valuable job done.

H.R. 3253 and H.R. 3254 are valuable initiatives that work in synergy to address

critically important educational and research needs in the area of emergency preparedness. This synergy is leveraged even more through partnering with USUHS

and VA-affiliated medical schools.

In closing, let me reinforce our support for these laudatory initiatives but also emphasize that they will require new resources for the VA system. Existing resources

should not be reassigned for this proposal; rather additional resources should be

added for this specific program. To do otherwise would jeopardize other valuable VA

programs. Indeed, the programs that would be created by these two pieces of legislation require a stable foundation on which to build. The stable foundation is a solid

and vibrant Veterans Affairs Health System.

I thank you for this opportunity to present to you today.
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CHAIRMAN MORAN TO DEPARTMENT OF VETERANS AFFAIRS
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CHAIRMAN MORAN TO CENTERS FOR DISEASE CONTROL AND

PREVENTION
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CHAIRMAN MORAN TO DR. DEBORAH POWELL
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CONGRESSMAN FILNER TO DR. DEBORAH POWELL
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CHAIRMAN MORAN TO DR. STEPHEN F. WINTERMEYER

INDIANA UNIVERSITY,

Indianapolis, IN, April 25, 2002

Hon. JERRY MORAN

Chairman, Subcommittee on Health,

Committee on Veterans’ Affairs,

House of Representatives, Washington, DC.

DEAR MR. CHAIRMAN: I hereby present responses to your questions in your letter

to me dated April 12, 2002.

1. Dr. Wintermeyer, you testified you served in the U.S. Army during Operations

Desert Shield and Desert Storm and that you personally made a major medical

decision concerning the troops deployed under your care. Was your decision, to

administer pyridostigmine bromide, known as PB, to your troops in the field,

based on the information you received before deployment, or information you received during your deployment—or did other factors justify it? In other words,

was the decision to use the PB based on your military training prior to deployment or information available to you in the combat area?

My decision to instruct the members of my unit, the 46th Combat Support Hospital, to start taking pyridostigmine bromide (PB) by mouth was made in conjunction with my commander, Colonel Theodore Raia, Commander, 46th Combat Support Hospital. The decision was made based on both information

learned prior to our deployment and to information received in the combat theatre.

I had some general knowledge of chemical weapons (diagnosis, decontamination, treatment) and biological weapons (diagnosis, decontamination, treatment)

prior to deployment. This information was obtained primarily through reading

manuals that were provided to me in the weeks preceding deployment. Most

of the knowledge I received regarding chemical and biological weapons was obtained by attending a 3 day Chemical Casualty Care Course. This course was

put on by U.S. Army personnel at a number of sites in Saudi Arabia during

Operation Desert Shield. I attended the course along with a number of my colleagues from the 46th CSH. The final information on which Colonel Raia and

I based our decision was the knowledge that Operation Desert Storm had just

started. Colonel Raia and I did not know at that time whether or not our unit

might be exposed to chemical weapons. Thus, we chose to start our troops on

pyridostigmine as a preventive measure.

2. I assume that you are familiar with the biohazards training program at the F.

Edward Hebe ́rt School of Medicine in Bethesda. In your judgment, is this a

good model that can be made portable to other health professionals training

venues?

At the present time, I cannot say I am very familiar with the biohazards training program at the F. Edward Hebe ́rt School of Medicine at the Uniform Services University of the Health Sciences in Bethesda, Maryland. I did my internal

Medicine residency at Walter Reed Army Medical Center from 1985 to 1988.

From 1986 to 1988, I was a teaching fellow at USUHS. However, I have not

been associated with USUHS since that time.

However, based on my knowledge of USUHS and the fact that it includes education of chemical and biological weapons more so than other medical schools,

I suspect their program is significantly better than that offered at other medical schools.

I would be being very happy to evaluate the USUHS program if I were provided a copy of it or another opportunity to do so.

3. Dr. Wintermeyer, you submitted a mock course description that would implement the essence of the Buyer bill, H.R. 3254, and I appreciate your effort to

do so. How do you envision a training program based on this bill to be disseminated to health professions schools like Indiana University and University of

Kansas?

H.R. 3254 provides for a model program to be disseminated to medical schools

via the VA.
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For medical students to get this training, the following would need to be accomplished:

1. Basic curriculum development

2. Curriculum revision to reflect local conditions/resources

3. Provision of time in the curriculum for such training

4. Provision of resources

a. Faculty

b. Teaching site

c. Equipment

H.R. 3254 would allow for the formation of the basic curriculum. I envision the

American Association of Medical Colleges (AAMC) requiring that member medical schools provide such curriculum training in their curriculum. I believe that

this would be necessary for such training to be performed. There are so many

demands on the medical school curriculum that without a formal requirement

from AAMC, such training would likely not make it into the curriculum.

One should also consider graduate medical training (residents/fellows). Such

training should be required by the American Council for Graduate Medical

Education (ACGME). If ACGME did not require such training in residencies,

it also would likely not be provided. I feel that the following residency programs should have significant training in biological and chemical weapons:

1. Internal medicine

2. Emergency medicine

3. Public health

4. Preventive medicine

Residency programs in other fields should at least contain information regarding the appropriate decontamination of patients to insure the safety of other

patients and health care providers.

Since H.R. 3254 provides for the dissemination of the model curriculum

through VA’s in association with medical schools, there would need to be a

point person at each VA Hospital that would take the curriculum from USUHS.

That person would be a faculty member at the affiliated medical school. That

person should be in charge or work closely with someone in charge of implementing this material into the curriculum. The medical school would need to

come up with the faculty time, training site and equipment necessary to implement this training.

I hope my answers are informative to you and other members of your Subcommittee.

Sincerely,

STEPHEN F. WINTERMEYER, M.D., M.P.H.,

Associate Professor of Clinical Medicine, Division of Pulmonary, Allergy, Critical

Care and Occupational Medicine, IU School of Medicine

Æ