A REVIEW OF FEDERAL BIOTERRORISM PREPAREDNESS PROGRAMS FROM A PUBLIC
HEALTH PERSPECTIVE
=======================================================================
HEARING
before the
SUBCOMMITTEE ON
OVERSIGHT AND INVESTIGATIONS
of the
COMMITTEE ON ENERGY AND COMMERCE
HOUSE OF REPRESENTATIVES
ONE HUNDRED SEVENTH CONGRESS
FIRST SESSION
__________
OCTOBER 10, 2001
__________
Serial No. 107-70
__________
Printed for the use of the Committee on Energy and Commerce
Available via the World Wide Web: http://www.access.gpo.gov/congress/
house
__________
U.S. GOVERNMENT PRINTING OFFICE
WASHINGTON : 2002
_____________________________________________________________________________
For Sale by the Superintendent of Documents, U.S. Government Printing Office
Internet: bookstore.gpo.gov Phone: toll free (866) 512-1800; (202) 512-1800
Fax: (202) 512-2250 Mail: Stop SSOP, Washington, DC 20402-0001
COMMITTEE ON ENERGY AND COMMERCE
W.J. ``BILLY'' TAUZIN, Louisiana, Chairman
MICHAEL BILIRAKIS, Florida JOHN D. DINGELL, Michigan
JOE BARTON, Texas HENRY A. WAXMAN, California
FRED UPTON, Michigan EDWARD J. MARKEY, Massachusetts
CLIFF STEARNS, Florida RALPH M. HALL, Texas
PAUL E. GILLMOR, Ohio RICK BOUCHER, Virginia
JAMES C. GREENWOOD, Pennsylvania EDOLPHUS TOWNS, New York
CHRISTOPHER COX, California FRANK PALLONE, Jr., New Jersey
NATHAN DEAL, Georgia SHERROD BROWN, Ohio
STEVE LARGENT, Oklahoma BART GORDON, Tennessee
RICHARD BURR, North Carolina PETER DEUTSCH, Florida
ED WHITFIELD, Kentucky BOBBY L. RUSH, Illinois
GREG GANSKE, Iowa ANNA G. ESHOO, California
CHARLIE NORWOOD, Georgia BART STUPAK, Michigan
BARBARA CUBIN, Wyoming ELIOT L. ENGEL, New York
JOHN SHIMKUS, Illinois TOM SAWYER, Ohio
HEATHER WILSON, New Mexico ALBERT R. WYNN, Maryland
JOHN B. SHADEGG, Arizona GENE GREEN, Texas
CHARLES ``CHIP'' PICKERING, Mississippi KAREN McCARTHY, Missouri
VITO FOSSELLA, New York TED STRICKLAND, Ohio
ROY BLUNT, Missouri DIANA DeGETTE, Colorado
TOM DAVIS, Virginia THOMAS M. BARRETT, Wisconsin
ED BRYANT, Tennessee BILL LUTHER, Minnesota
ROBERT L. EHRLICH, Jr., Maryland LOIS CAPPS, California
STEVE BUYER, Indiana MICHAEL F. DOYLE, Pennsylvania
GEORGE RADANOVICH, California CHRISTOPHER JOHN, Louisiana
CHARLES F. BASS, New Hampshire JANE HARMAN, California
JOSEPH R. PITTS, Pennsylvania
MARY BONO, California
GREG WALDEN, Oregon
LEE TERRY, Nebraska
David V. Marventano, Staff Director
James D. Barnette, General Counsel
Reid P.F. Stuntz, Minority Staff Director and Chief Counsel
______
Subcommittee on Oversight and Investigations
JAMES C. GREENWOOD, Pennsylvania, Chairman
MICHAEL BILIRAKIS, Florida PETER DEUTSCH, Florida
CLIFF STEARNS, Florida BART STUPAK, Michigan
PAUL E. GILLMOR, Ohio TED STRICKLAND, Ohio
STEVE LARGENT, Oklahoma DIANA DeGETTE, Colorado
RICHARD BURR, North Carolina CHRISTOPHER JOHN, Louisiana
ED WHITFIELD, Kentucky BOBBY L. RUSH, Illinois
Vice Chairman JOHN D. DINGELL, Michigan,
CHARLES F. BASS, New Hampshire (Ex Officio)
W.J. ``BILLY'' TAUZIN, Louisiana
(Ex Officio)
(ii)
C O N T E N T S
__________
Page
Testimony of:
Baughman, Bruce P., Director, Planning and Readiness
Division, Federal Emergency Management Agency.............. 88
Brinsfield, Kathryn, Director of Research, Training, and
Quality Improvement, Boston Emergency Medical Services and
Deputy Medical Commander, National Disaster Medical
System's International Medical and Surgical Response Team-
East....................................................... 34
Heinrich, Janet, Director, Health Care--Public Health Issues,
U.S. General Accounting Office............................. 93
Lillibridge, Scott R., Special Assistant to the Secretary on
Bioterrorism Issues and for National Security and Emergency
Management, U.S. Department of Health and Human Services... 83
O'Leary, Dennis, President, Joint Commission on Accreditation
of Healthcare Organizations................................ 47
Peterson, Ronald R., President, Johns Hopkins Hospital, on
behalf of the American Hospital Association................ 42
Smithson, Amy E., Director, Chemical and Biological Weapons
Nonproliferation Project, Henry L. Stimson Center.......... 17
Stringer, Llewellyn W., Jr., Medical Director, North Carolina
Division of Emergency Management........................... 38
Waeckerle, Joseph F., Chairman, Task Force of Health Care and
Emergency Services Professionals on Preparedness for
Nuclear, Biological and Chemical Incidents, on behalf of
the American College of Emergency Physicians............... 26
Young, Frank E., former Head, Office of Emergency
Preparedness, U.S. Department of Health and Human Services. 53
Material submitted for the record by:
Ataxia: The Chemical and Biological Terrorism Threat and the
US Response, report by Amy E. Smithson and Leslie-Anne Levy 164
Bioterrorism: An Even More Devastating Threat, The Washington
Post, September 17, 2001................................... 191
Commissioned Officers Association of the U.S. Public Health
Service, prepared statement of............................. 192
Daniels, Deborah J., Assistant Attorney General, Office of
Justice Programs, Department of Justice, prepared statement
of......................................................... 103
Hospital Preparedness for Mass Casualties, report entitled... 107
Hospital Preparedness for Victims of Chemical or Biological
Terrorism, report entitled................................. 185
(iii)
A REVIEW OF FEDERAL BIOTERRORISM PREPAREDNESS PROGRAMS FROM A PUBLIC
HEALTH PERSPECTIVE
----------
WEDNESDAY, OCTOBER 10, 2001
House of Representatives,
Committee on Energy and Commerce,
Subcommittee on Oversight and Investigations,
Washington, DC.
The subcommittee met, pursuant to notice, at 10:15 a.m., in
room 2322, Rayburn House Office Building, Hon. James C.
Greenwood (chairman) presiding.
Members present: Representatives Greenwood, Stearns, Burr,
Bass, Tauzin (ex officio), Deutsch, Stupak, Strickland, and
Rush.
Also present: Representatives Ganske and Buyer.
Staff present: Tom DiLenge, majority counsel; Peter Kielty,
legislative clerk; and Edith Holleman, minority counsel.
Mr. Greenwood. The hearing will come to order.
Good morning. We welcome you all and apologize for the
slight delay. The Chair recognizes himself for an opening
statement.
Today's hearing is part of this subcommittee's long-
standing interest and oversight of bioterrorism issues which
led to the unanimous passage of the Bioterrorism Prevention Act
of 2001 by the full committee just last week.
Today, we turn our attention to an acutely critical area,
our Nation's preparedness to deal with the threat of
bioterrorism. Since May of this year, members of the committee
and committee staff have been busy investigating the capacity
of Federal, State and local public health officials to respond
to these kinds of threats and dangers.
When this subcommittee announced 5 weeks ago its intent to
hold a hearing on September 11 to examine the effectiveness of
Federal bioterrorism preparedness from a local public health
perspective, a concern at that time was that too little
attention was being paid to improving the ability of our local
health care communities to detect, contain, treat and
effectively manage a terrorist attack using deadly biological
agents, or for that matter, any naturally occurring disease
outbreak or disaster with mass care consequences.
The evil that was visited on our country and the world on
September 11 has changed all of that. It is now clear that the
people who perpetrated this deed are unconstrained by any sense
of morality. The only restraint on their form of ideologically
inspired madness is the limit of the technology that they can
acquire. And though the weapons of choice on that day were
jetliners filed with innocent passengers and not anthrax or the
plague, September 11 prompted this Nation to seriously
reexamine how we prepare for all types of terrorist attacks,
including bioterrorism.
There is much anxiety. Some of it is fueled by the almost
daily stories on the networks and in our major newspapers
detailing our lack of preparedness for bioterror assaults.
Congressional committees are also busy holding hearings to
examine this potential threat and the efforts to combat it.
The detection of the anthrax bacterium in a Florida
workplace and in two workers at that site, one of whom already
has died, has raised the temperature on this issue even higher.
Nevertheless, while there is legitimate reason to be anxious,
it is the duty of Congress to confront and reduce that anxiety
by making sound public policy choices. And big questions remain
unanswered about how best this Nation should approach
bioterrorism defense.
Our mission today is to engage in a dialog with the public
health officials who would be in the vanguard of any response
to bioterrorism, so that we in Congress build the right kind of
working partnership between all levels of government, as well
as assemble the necessary Federal resources that will best
enable them to address this threat. I hope to accomplish
several objectives with continuing, indeed increasing,
importance.
First, as we embark upon what most likely will be an major
new Federal initiative to improve our bioterrorism
preparedness, I think it is critically important that Congress
hear directly from the health care front lines--the hospitals,
the physicians, the emergency medical personnel about how they
view the existing Federal preparedness programs and what some
of the past barriers have been to successful preparedness
programs in the health care community.
Too often the concerns and needs of these groups which will
constitute our first line of defense in any real bioterrorist
incident have been overlooked or ignored in our race to do
something about terrorism. Hopefully, our hearing today will
help to change that.
Second, and just as important, I believe it is essential
that we at all levels of government approach bioterrorism
preparedness from a broader public health perspective. This
makes good sense for several reasons, but most of all because
it will be difficult to justify the costs or sustain
accomplishments over the long run if we focus too narrowly on a
threat that many in the health care community may rightly
perceive as small when compared to the tremendous daily
challenges facing our health care systems.
While there is a considerable debate about the likelihood
of a mass casualty biological terrorist attack, there was near
universal agreement that our public health infrastructure
itself is in need of CPR.
What do we mean when we use the term ``public health''? The
basic elements are pretty straightforward: clean water, a
plentiful and uncontaminated food supply, clean air, wastewater
treatment, and the ability to respond and control epidemics.
Unfortunately, in recent decades, we have allowed the
capability of our public health departments, laboratories, and
hospitals to deal with major disease outbreaks to stagnate or
even deteriorate. Between 1981 and 1993, for example, State
public health budgets declined as much as 25 percent. To now
ask them to take up the additional burden of responding to
bioterrorism without substantial new resources and direction
would be to risk a breakdown of the entire system.
Last, we need to take a good, hard look at how we are
spending and will continue to spend Federal dollars in this
area to ensure better allocation of existing and future
resources devoted to this purpose. Everyone gives lip service
to the idea that our local communities are and will remain the
principal responders to terrorist events. Yet most of the
billions of dollars spent each year on combating terrorism
never finds its way beyond the Capital Beltway.
We need to change that reality, particularly given that all
of the Federal assets and specialty teams that have been
created for this purpose make two fundamental assumptions in
their response plans: first, that timely surveillance and
detection activities will be made at the local level; and
second, that the local response teams possess the resources and
capabilities to effectively manage an emerging crisis within a
critical 12 to 72 hours before Federal assistance arrives on
the scene.
As we will hear today, those are two big assumptions.
Before I conclude, I also want to announce that this
subcommittee plans to hold another hearing on this topic on
October 25 to explore the related and equally important issue
of public health surveillance and detection systems, and how
technological advances in these areas can help in our battle
against bioterrorism, as well as against naturally occurring
disease outbreaks.
I thank our witnesses today and now recognize the ranking
member of this subcommittee, Mr. Deutsch, for his opening
statement.
Mr. Deutsch. Thank you, Mr. Chairman.
Last Thursday, I had, I guess, just certain difficulty, as
this meeting was originally scheduled for September 11, with
meeting with the county chairperson of Palm Beach County, the
county chairperson of Broward County, and the mayor of Miami-
Dade County in the early afternoon. At that point, they were
actually up here in terms of the potential supplemental bill
and in terms of talking about issues related to it. And in the
course of our discussion, you know, we were talking about other
issues. And I was talking about our committee and our
jurisdiction.
As many of you are well aware, our committee has
jurisdiction over the CDC, and we were talking about issues of
threats of bioterrorism. And I proceeded to go through what I
was aware of at the time, the sort of plan that exists and how
good that plan is, and how CDC is supposed to move in
automatically and provide all sorts of resources.
And as it so happens, unbeknownst to me at the time, but
beknownst to the chairperson from the County of Palm Beach, an
anthrax case was diagnosed in Palm Beach County. And the three
heads of the three counties in South Florida, where the
population is close to 6 million people, they didn't go into
outbreak laughter, but they basically said that what I was
describing was not reality.
And it was not reality at that moment in Palm Beach County,
and it was not reality of what could exist in Broward or Miami-
Dade Counties. And, you know, we understand--and the Secretary
of HHS has been on television on several occasions since last
Thursday telling the American people, don't worry, relax, we
are ready, we can deal with this.
Based on this sort of empirical thing of the leadership of
the three counties in South Florida, I have real concerns, and
I expect that we will have testimony today that will
essentially substantiate that.
This issue, though, is obviously much different since
September 11. I think all of us are much more knowledgeable
about not just terrorism in general, but bioterrorism,
bioterrorism in particular. It is no longer theory; it is a
reality in many ways; and I think, just to put on the table at
the start of the hearing, chemical weapons were used over 10
years ago by both Syria and Iraq. And I think there is
absolutely no reason to think that terrorists don't have
available those weapons today; and the only restricting factor
could be a delivery system.
So we are no longer talking about some esoteric,
theoretical issue; we are talking about a practical issue. As
awful as the horrific events that occurred at the World Trade
Center were, I think all of us understand that the potential is
far in excess of those events in a direct attack.
Now, the good news is, there are things that we can do in
terms of intelligence and also in terms of public health to
prevent that. And that clearly has become the highest, or as
high a priority as any that this Congress faces.
I yield back the balance of my time.
Mr. Greenwood. The Chair recognizes for an opening
statement the chairman of the full committee, Mr. Tauzin.
Chairman Tauzin. Thank you, Chairman Greenwood, for holding
this very critical and timely hearing on how this Nation can
best prepare for the possibility, however small, of any kind of
major bioterrorist event. I believe this committee, as the
principal public health committee on this side of the Capitol,
must take the lead to ensure that the Nation can, in fact,
tackle this very difficult issue.
Given what we read in the newspapers, what we see on
television, the American people understandably are concerned
about the threat of bioterrorism. It is true that--as we will
hear today, that we need to do more. So we need to do more to
fully prepare our Nation for this kind of a possibility.
It is also true, after September 11, that we have all, I
think, underestimated the evil and the sophistication of our
enemies, unfortunately, at our own peril.
That said, we should not allow undue public concern or
worry to develop over what most experts believe is a relatively
remote threat and one that is technically very difficult to
carry out. That is why it is imperative that we approach this
issue in a very thoughtful and a very measured way. I am glad
to see that that is exactly the approach that you, as chairman,
and the subcommittee have agreed to take.
Let me expand quickly on three points that Chairman
Greenwood has raised. First, we need to start a serious public
debate about some of the big questions that he alluded to, the
questions that remain unanswered today: What are we preparing
for, and what is the measure of our preparedness? In other
words, what are we trying to achieve and how do we know when we
have achieved it? How do we know that we have reached the point
where we can assure the American public that we are prepared,
and that we are prepared not only to assure their safety, but
to react in the worst case?
Our staff hears over and over about the health care front
lines, that the people who operate those lines, what is not
happening, where direction is not being given, where guidance
from Federal experts to properly prepare for a bioterrorism
event might, in fact, be helpful.
We need to change that. We need to make sure the lines of
communications are clear and that people understand guidance
and direction in this area as clearly as anything else as we
face these threats.
Second, this is not, as some would think, just a question
of more money. There is a reason that today's hearing is before
the oversight committee. We have already spent at the Federal
level billions of dollars in this area and more than $200
million annually on health-related programs alone. Secretary
Thompson says he needs at least $800 million more for
bioterrorism preparedness, probably more in the future. That is
not small change, and it is incumbent upon this committee to
make sure that both existing funds and new funds are used in
the most effective and measured way.
Again, that means the big questions need to be addressed:
Where should we be spending our money for the most safety and
security?
And third, I want to echo Chairman Greenwood's comments
regarding the importance of really listening to our brethren in
local jurisdictions around the country, particularly those in
the health care community. As one of our witnesses today states
so well in her written testimony, it is the local emergency
medical personnel, the hospitals, the health department
administrators, the doctors and nurses and support staff in the
communities where we live who are going to be the people whose
actions and decisions will determine just how contained or how
damaging any bioterrorism incident ultimately will be.
There are people who will detect an outbreak and treat
their fellow citizens often putting themselves at risk as well
as, and they should not be ignored by the Federal Government
that so often focuses too much on itself when devising
responses to bioterrorism.
One final thought: Our full committee has been briefed very
deeply by Secretary Thompson on the nature of those potential
threats. We are not about to join the leakers around town who
talk about things we shouldn't talk about. But I want you to
know that as we went into that briefing, my concern levels and,
I think, the concern levels of every member of this committee
were extraordinarily high; all of us felt more assured after
that briefing than before we had it.
Secretary Thompson and his department are aggressively
working and private sector components of the effort to prepare
this country are aggressively working not only to beef up the
already deployed stocks of vaccines and other pharmaceuticals
that are important for us to be able to respond to any such
threat, but also to make sure that there are new quantities and
new, appropriate steps taken to protect our citizens not simply
from the advent of the incident, but equally important, to take
care of our citizens should the worst ever happen.
Now, look, I got a call from a doctor at home. I am sure
you all did. And people were calling them because they have
heard stories and they want to know about what they can do
personally to prepare themselves.
The best preparation we can all have in this area, as in so
many areas, is to be the best citizens we can be, to be on our
guard, to go about our lives and to conduct our businesses--as
the President said, to hug our children, but also to be on our
guard, to be good citizens and to be helpful and supportive of
the agencies of our government that are trying to make sure
nothing like this ever happens in this country again, or
anything like it should happen in the future.
And the second thing is to have what I have--what I am
beginning to have in greater degree: a great deal of faith in
the notion that everybody at this level is working day and
night to ensure that our preparedness is at its top, its best;
and the money we will allocate and spend will have been
directed, as the chairman said, to the most important places
where our country needs to be prepared.
This Nation has come together very well. And Mr. Chairman,
this hearing, I hope, will be another effort to make sure that
the country knows that its government is not sleeping, that we
will not rest until we are sure that the American public and
this Nation are as protected as we can make them and as
prepared as much as we can for the worst of circumstances,
should we ever experience them again.
Thank you, Mr. Chairman.
Mr. Greenwood. The Chair thanks the chairman for his
opening statements and for his presence, and recognizes for an
opening the statement the gentleman from Michigan, Mr. Stupak.
Mr. Stupak. Thank you for holding today's hearings on the
subject that I have been interested in working on for the past
few years. Bioterrorism has suddenly taken center stage, and we
welcome comments from today's participants on this topic.
Last year, Congressman Burr and I cosponsored a public
health and emergencies act, which was rolled into the health
omnibus bill. It is the logical next step to evaluate our
Nation's preparedness.
As a former law enforcement officer, I am well aware of the
logical difficulties in implementing a country-wide or county-
wide public health response; and I am eager to hear today's
witnesses and their advice on how best to build on what Mr.
Burr and I started last year.
I was especially pleased and gratified to see Secretary
Thompson recently invoking the law that Mr. Burr and I worked
so hard to pass last year, specifically relating to
bioterrorism. It is my understanding Secretary Thompson was
able to ship medical supplies and assistance to the victims of
the September 11 terrorist attack in New York City as easily as
he did because of the language that we inserted in our
legislation last year.
The logistical elements of coordinating our efforts are
staggering, to stay the least. Effective communications mean
establishing links among public law enforcement, local health
departments, clinics and hospitals, so that critical data in an
emergency situation can identify, contain, and respond to an
emergency efficiently. However, we lack the personnel and the
resources to do this.
For example, if a bioterrorism attack occurred on Friday
afternoon after office hours, there would be no one to report
it to until Monday morning. The way most health departments are
currently set up, that would be the situation.
No one wants to spread unnecessary fear or alarm, but I
have to question, just how organized is the Nation's public
health system to respond to bioterrorism? No hospital or
geographically contiguous group of hospitals can effectively
manage even 500 patients demanding sophisticated medical care
and supplies, as would be required in a case of the outbreak of
anthrax.
The Bush administration's head advisor on bioterrorism
testified yesterday morning in front of a Senate panel. He said
in the event of a contagious disease outbreak such as smallpox,
far fewer patients could be handled, testified the expert, Dr.
Donald Henderson, Director of Johns Hopkins's Center for
Civilian Biodefense Studies. That is a good fact to know and a
compelling factor to consider in our deliberations today.
Mr. Chairman, I thank you for holding this hearing and for
holding a future hearing on October 25, and I look forward to
hearing from our experienced panels of witnesses on this issue
today. Thank you.
I yield back the balance of my time.
Mr. Greenwood. The Chair thanks the gentleman and
recognizes for an opening the gentleman from New Hampshire, Mr.
Bass.
Mr. Bass. Thank you, Mr. Chairman; and I appreciate your
holding this important hearing. As the distinguished chairman
of the committee has mentioned, the issues here are what we are
preparing for and what measure of preparedness should we take.
Over 2 years ago, the Intelligence Committee had a public
hearing on this very subject. I had the pleasure of
participating in that hearing, and suffice it to say that there
has been awareness and action undertaken both on the military
and on the civilian side to prepare for this kind of
eventuality.
I think, however, it is important, as we consider the
issues here, not to scare people or create mass paranoia, but
to inform and educate the people so that we can be alert and
aware of what we need to look out for, not for Congress to
overreact--or government, for that matter--but develop and
implement good, effective public policy that will be in the
best interests of the American people.
This hearing is a good beginning. I look forward to hearing
the testimony from the distinguished witnesses.
I yield back.
Mr. Greenwood. The Chair thanks the gentleman and
recognizes the gentleman from North Carolina, Mr. Burr.
Mr. Burr. Thank you, Mr. Chairman.
We are here today to look at bioterrorism preparedness. We
are probably a little late, in all honesty. But what we find
when we examine the issue is, we find a number of entities
within the Federal Government, a number of different agencies
with funding and with efforts to address our preparedness--some
because of the oversight restrictions of committees that fund
duplicative programs, some where one committee might determine
that the money is directed in the right place. We see the
participation of other agencies in the same area.
And now, since September 11, we have begun to look at it in
its entirety and, in many cases, with a microscope.
Let me suggest, had we held this before September 11, we
would have highlighted one thing today, and we will at this
hearing: What we had put in place as it relates to the national
medical response network of four private sector entities that
could be called up at any time, given that there was threat of
a bioterrorism attack. Had we had the hearing before September
11, I am not sure that we would have looked as closely at our
response capabilities federally and locally like we do today.
So I think for the American people the benefit of us having
this hearing post-September 11 is tremendously advantageous.
Mr. Chairman, we have got a challenge. As a member of the
Intelligence Committee--Ms. Harman is on the Commerce
Committee--we understand the efforts that are under way, we
understand the challenges that we will place on health care
professionals in every community across this country.
The only way that Congress can fall down on their job is to
make sure that the resources that we make available do not get
to the entities that need the equipment and that need the
training to respond in a timely fashion to a threat that exists
somewhere in America.
Our ability to pinpoint that threat does not exist and will
not exist, but our capabilities to respond to the threat and to
minimize the effects exist today. If the Congress of the United
States can find a way to coordinate the resources, the existing
resources and the potential future resources, we will have a
tremendous opportunity with the confirmation of Governor Tom
Ridge in his newly designed post.
And, Mr. Chairman, I hope that we will learn a lot about
our health preparedness and our response capabilities today;
and I hope that all members will begin to think, and those
entities that are here to testify will begin to think, how it
is that we help design this new post for Governor Ridge, so
that he has the budgetary authority to make sure that the
dollars are directed where they can do the most good for the
threat that we perceive and for the comfort of the American
people.
Even though we are an oversight arm of the Commerce
Committee, we are limited to a great degree by the efforts of
Health and Human Services and to--to their dollars that they
spend on health. Given that there are eight Federal agencies
and eight committees of jurisdiction where we don't have
collaboration between oversight committees, the only way that
we can function with the degree of confidence that we need to
have to make sure that American people are, in fact, protected
and that our response capabilities are the best, is to make
sure that we have an entity within the Federal Government, like
Governor Ridge, who is in charge of making sure that every
agency is held accountable for every dollar that goes into our
preparedness and our response capabilities.
I look forward to the panel that the committee has before
us today. And with that, I yield back.
Mr. Greenwood. The Chair thanks the gentleman and
reiterates that this hearing was originally planned for July,
and we decided to wait for the GAO study. And of course, the
great irony is that we noticed the hearing for September 11.
The issues remain the same, only the urgency has changed.
The Chair thanks the gentleman and recognizes the gentleman
from Iowa, Mr. Ganske.
Mr. Ganske. Thank you, Mr. Chairman. I ask consent to
submit for the record my full statement.
Mr. Greenwood. Without objection.
Mr. Ganske. Which would be about 30 to 40 minutes and I am
sure----
Mr. Greenwood. I am sure there are no objections.
Mr. Ganske. I think some of the remarks that have been made
so far bear repeating briefly; and that is that we should not
scare people, but we need to be responsibly concerned about the
threat of bioterrorism, and it is something that this Congress
has been working on in the past few years.
A couple of years ago we passed a bill outlining a number
of ways in which to better combat a potential bioterrorism
attack. In that legislation, sums were authorized for Federal
expenditures. We need to fulfill those authorizations, and as
the chairman pointed out, probably expand those authorizations
and actual appropriations. Because we are dealing with the
situation, with bioterrorism, where the first line responders
will not be policemen or firemen, but they will be doctors and
nurses and hospitals and public health facilities; and there
are a number of things that we need do to bolster that public
health component.
For many years now, public health services have been not
funded, I think, at the levels that they should be. They need
to be better coordinated between Federal, State and local and
city units. That is something for Governor Ridge to work on and
for Congress to work on, too, in order to facilitate that.
We are going to hear something about smallpox and about
anthrax today. Smallpox, as a physician, I can tell you that
there is probably no one in this audience today who is
immunized against smallpox. The immunizations for that were
discontinued years ago, were effective for a period of time.
Then, we supposedly eliminated smallpox from the planet,
except that it was kept in two repositories, that were supposed
to be secure, both in the United States and in Russia. I think
it is fair to say that it is possible that there are smallpox
strains elsewhere in the world, for instance in Iraq, possibly
in other places in Russia.
There certainly is expertise among Russian scientists who
have worked on bioterrorism projects. That is available around
the world. And we know that the--we are facing increasing
levels of sophistication in terms of terrorist attacks, so
these are some things that we need to be concerned with.
Smallpox is extremely catchy, and it can be 30 percent
fatal in people who are not immunized. So we need to do things
about increasing supplies for vaccines, surveillance, things
like that.
Anthrax is a little harder to distribute, but it is more
fatal if you get it in the pulmonary form. I will be interested
in seeing or hearing testimony today about this strain in
Florida that, according to newspaper reports, can be traced to
an Iowa facility from the 1950's.
But I also want to talk about the bioterrorism attack in an
economic way, and that is something that I and members of the
Agriculture Committee have been concerned about for many, many
months, long before the September 11 attack; that is the foot
and mouth disease problem.
We have seen what has happened to agriculture in areas
around the world where--particularly Europe, where this has
hit. We have been concerned about proper USDA surveillance, CDC
surveillance, things like that for this disease. It is not
particularly harmful to humans, but the economic devastation on
our agriculture community could be incredibly, incredibly
devastating.
I know that there will be some farmers who will be
listening to my testimony right now that would probably not
want me talking about this, except for the fact that this has
now received front page and headline stories in major magazines
like Time magazine, so this is not something that is secret. We
need to be looking at ways to secure our agriculture in terms
of an economic attack on our country, as well.
And finally, I think that we can all hope and pray that we
do not see a massive epidemic. I think that with better
coordination, with better funding of our public health
services, we certainly could see some additional benefits in
our ways for our country, and I look forward to the testimony.
Thank you, Mr. Chairman.
[The prepared statement of Hon. Greg Ganske follows:]
Prepared Statement of Hon. Greg Ganske, a Representative in Congress
from the State of Iowa
Tuesday September 11th is forever seared into our minds. We will
never forget the images: airplanes flying into buildings and exploding,
people choosing to jump off buildings rather than burn to death,
buildings collapsing on rescuers, clouds of vaporized concrete, steel,
glass and thousands of humans rolling down the streets like a volcanic
eruption . . . the Stars and Stripes framed by the flaming crater that
was the pyre of 195 soldiers and civilians at the Pentagon. Our hearts
go out to the victims and their families.
We watched those images and they didn't seem real. The spectacle
almost disguised the human toll. At first the magnitude of this tragedy
made it hard for most Americans to grasp. But everyday the newspapers
now put faces on the victims and their families. The shock has worn off
and we are left with grief, the deepest grief. We read those obituaries
and find ourselves tearing up. I don't know about you, but I can only
read a few each day before I must stop.
We've learned the stories of the brave passengers on United Flight
93 who bid their loved ones farewell pledging that they were going to
go down fighting. Their plane crashed but those heroes saved many lives
in Washington--perhaps even my own. We are humbled by their courage and
their sacrifice! Ordinary Americans who in 45 minutes became heroes.
We remember the final recorded words of the men and women
hopelessly trapped above the fiery inferno of the World Trade Center--
messages of love to their families.
In Corinthians the Bible teaches; ``So we do not lose heart. Even
though our outer nature is wasting away, our inner nature is renewed .
. . for we know that if the earthly tent we live in is destroyed, we
have a building from God, a house not made with hands, eternal in the
heavens.''
Each of us will carry our own memories of 9/11. I will never forget
the sense of unity as 170 bipartisan members of Congress, not
Republicans or Democrats but Americans, stood on the front steps of the
Capitol in the lengthening evening shadows of that Tuesday to say a
prayer for our country and its victims . . . and then we sang America
the Beautiful. Our message then--and today--and tomorrow is that we are
one Republic, united we stand. Terrorists can challenge this nation's
spirit--but they cannot break it!
In righteousness, we are hunting down . . . to the ends of the
earth if necessary . . . the assassins of our brothers and sisters,
mothers and fathers, husbands and wives, and children. We will do what
is necessary to win this war that has been declared on us. The victims
deserve justice and our people deserve security. We are meting out
justice to these terrorists, and we do distinguish between terrorists
and those who harbor them and the rest of the Muslim world.
But Christians, Jews, and Muslims must all understand that the
Osama bin Ladens, are leading to the destruction of all religion and
society . . . if the Muslim fundamentalists don't realize that the war
will go on and on.
Take the radical Islamic-fundamentalist Taliban regime. This is a
government so oppressive that it executes little girls for the crime of
attending school. Girls, aged 8 and older, caught attending underground
schools are subject to being taken to the Kabul soccer stadium and made
to kneel in the penalty box while an executioner puts a machine gun to
the back of their heads and pulls the trigger. Spectators scattered
among the stands are then encouraged to cheer.
An Afghani woman was beaten to death recently by an angry mob after
accidentally exposing her arm. Osama Bin Laden's treatment of women is
so barbaric that he orders their fingernails and toenails pulled out if
they are painted. Women have almost no health care because male doctors
are forbidden to touch female patients and there are very few female
doctors. The beating, raping and kidnapping of women are commonplace.
A reporter for CNN recently told of meeting a family of three
little girls hidden under their scarves and garments while their father
stared into space. The girls had apparently not moved in weeks . . .
they had been made to watch as the Taliban militia shot their mother in
front of them and then stayed in their home for two days while the
mother's body lay in the courtyard. The reporter asked the girls what
the Taliban men did to them during those two days . . . they just wept
silently.
The Taliban is rounding up men from villages. Those that don't join
willingly are shot. There are news reports of mass graves--some
containing as many as 300 Afganis--scattered throughout the country.
The Taliban is taking more than a few pages from the Nazis. They
require all Hindus to carry a yellow sticker identifying them as
members of a religious minority. Hindus are required to put yellow
flags on their rooftops, as well. The Taliban also controls the heroin
trade and funds its domestic and international terrorism with drug
money.
So what do we do? Well, to quote from British Prime Minister Tony
Blair's magnificent speech: ``Don't overreact some say. We aren't.
Don't kill innocent people. We are not the ones who waged war on the
innocent. We seek the guilty. Look for the diplomatic solution. There
is no diplomacy with Bin Laden or the Taliban regime. State an
ultimatum and get their response. We stated the ultimatum; they haven't
responded. Understand the causes of terror. Yes, we should try, but let
there be no moral ambiguity about this: nothing could ever justify the
events of 11 September, and it is to turn justice on its head to
pretend it could. There is no compromise possible with such people, no
meeting of minds, no point of understanding with such terror. Just a
choice: defeat it or be defeated by it. And defeat it we must.'' These
are words worthy of Churchill.
I personally will never forget the smell of the smoldering crater
of the Pentagon or the smoke unfurling into the air of lower Manhattan
while at ``ground zero'' the firemen poured water onto the ruins of the
World Trade Center that is the grave of over 5,000 innocent people.
As I stood looking at the mass of twisted steel and concrete, my
thoughts turned to the words of a little girl's handwriting I had just
seen a victims' family center . . . the words, ``I miss you daddy!!
Love you, Jenny.'' It is indescribably sad.
So what do we do? Just what we are doing in Afghanistan now:
destroying the terrorists and their supporters. Our prayers are with
the brave men and women soldiers of our Armed Forces. It must be
galling to the Taliban that some of our bravest soldiers are women!
What else do we need to do? Well, if we didn't realize how
important airplane security and airport security was before September
11th, we sure do now. The safety and security of our aviation system is
critical to our citizens' security and our national defense.
The tragedy of September 11, 2001 requires that we fundamentally
improve airport and airline safety. That is why Congressman Rob Andrews
and I Introduced on September 25th the Aviation Security Act, H.R. 2951
which is the companion bill to that offered by Senators Hollings and
McCain. Our bills have bipartisan support in both the House and the
Senate. Our bill would make planes' cockpits secure; it would place
federal air marshals on more flights. It puts the FAA in charge of
airport security operations including increased training for airport
security personnel and anti-hijacking training for flight personnel.
The Aviation Security Act would improve the screening of flight
training so that a terrorist couldn't walk up to the counter, plunk
down $20,000 in cash and say, ``Teach me to fly a jet and, oh by the
way, I'm not interested in learning how to take off and land . . . just
teach me to steer the jet!''
Our bill would pay for this with a $1 charge on airline tickets.
When I talk to Iowans, none of them say this is too much to pay for
increased airline security. I don't want more families writing letters
like another one I saw at the victim's family center: ``Danny, I will
love you always--you will always be in my heart. Love Chris and your
son, Justin.''
So what do we do about other terrorist threats like the possible
bio-terrorist anthrax attack in Florida? First of all, we should not
panic. I am speaking as a Congressman but also as a physician.
Selecting and growing biologic agents, maintaining their virulence,
inducing the agents into forms that are hardy enough to be disseminated
and finding an efficient means of distribution is not easy for a nation
to do, much less terrorists.
However, the level of coordination and the profiles of the
terrorists associated with September 11, mean we must be prepared for
attempts at bio-terrorism. There are nations such as Iraq that might
help these terrorists in their evil plans. Clearly, we must try to root
out terrorist cells before they strike. Our intelligence services must
be bolstered and given the tools they need. Impoverished scientists
from countries like Russia that have worked on biological weapons must
be prevented from selling that knowledge to terrorists.
But it is important to understand that the first line of defense
against a biological attack will not be a fireman or a policeman. It
will be doctors and nurses; it will be the public health system because
the ultimate manifestation of the release of a biologic agent is an
epidemic. Smallpox and anthrax are most frequently mentioned as agents
of bio-terror.
Officially, only two stores of the smallpox virus exist, for
research purposes, in secure locations in Russia and the U.S. . . . but
there may be covert stashes in Iraq, North Korea and in other places in
Russia. People who were vaccinated before 1972 have probably lost their
immunity and routine inoculations were halted around the world in 1972.
Most people would therefore be at risk. Smallpox is very ``catchy'' and
about 30% fatal.
The first victims of smallpox would likely be the terrorists
themselves, but remember, these are people who commit suicide to spread
terror. Inhaled anthrax is fatal about 90% of the time, 20% of the time
if infection is from contact with animals. Its spores are resistant to
sunlight, but manufacturing sufficient quantities and then distributing
them widely by, say, crop-duster airplane, would be difficult.
Time Magazine even talks about a terrorist attack aimed at crops
and livestock that would be easier and less directly harmful to humans,
but economically very harmful. Foot-and-mouth disease can spread with
astonishing speed in sheep, cattle and swine. An outbreak in the U.S.
could be devastating to American agriculture.
So what can we do? First, we need better coordination between the
Defense Department, the State Department, the Agriculture Department,
the Centers for Disease Control, state public health programs and
directors, and the city-based Domestic Preparedness programs. This is a
job for the new Director of Homeland Security.
Second, we must make a systematic effort to incorporate hospitals
into the planning process. As of today I think it is accurate to say
that few U.S. hospitals are prepared to deal with community-wide
disasters for a whole host of financial, legal and staffing reasons.
There will be significant costs for expanded staff and staff
training to respond to abrupt surges in demand for care, for outfitting
decontamination facilities and rooms to isolate infectious patients.
There will be the costs of respirators and emergency drugs. The first
serious efforts to implement a civilian program to counter bio-
terrorism emerged in the spring of 1998 when Congress appropriated $175
million in support of activities to combat bio-terrorism through the
Department of Health.
But we must do more to integrate federal, state and city agencies:
1. We must educate family doctors and public health staff about the
clinical findings of agents,
2. We need to further develop surveillance systems of early detection
of cases,
3. We need individual hospital and regional plans for caring for mass
casualties,
4. We need laboratory networks capable of rapid diagnosis,
5. And we need to accelerate the stockpiling and dispersal of large
quantities of vaccines and drugs.
The Public Health Threats and Emergencies Act of 2000 provides for
increased funding to combat threats to public health and we should
provide that increased funding this year.
I recently visited Broadlawns Hospital in Des Moines. Public
hospitals like Broadlawns and public health agencies have not been
adequately funded in recent years. They need to be bolstered in order
to cope with a biological attack. Even if a catastrophic biological
attack doesn't occur, and we pray it doesn't, the investment will pay
dividends in other ways.
Finally, let me return to the question of understanding the causes
of Muslim fundamentalists' hatred of the United States. President Bush
asked in his September 20 address to Congress, ``Why do they hate us?''
And those of us in the audience and those at home listening to the
President--still stunned by the magnitude of the attack--wondered what
degree of poverty or political resentment or religious convictions
could lead anyone to revel in the deaths of so many innocent people?
Shortly after the attack I was asked by the Des Moines Register
newspaper's editorial board why I thought there was so much hatred of
us in the Middle East. In April I had visited Israel, Jordan and Egypt.
Our Congressional delegation met with the leaders of these countries
and the Palestinians, but also met with people from these countries who
weren't in government.
I told the editorialists that there was much envy of our wealth and
dislike of our Western culture, particularly the role of women as
equals. I also said it was clear that our support of Israel was
significant.
But this is an incomplete answer and I do think we need to reflect
a moment on what we hear when, for example, we hear the translation of
Osama Bin Ladin's screed. In the end, coping with Islamic anti-
Americanism has to be a component of our ``war on terrorism.''
As someone who has traveled rather extensively to third world
countries on surgical trips, let me say that not everyone regards the
United States as a greedy giant. Even critics in other countries of
America's foreign policy still often praise U.S. values of freedom and
democracy.
But extremism thrives in poverty. Cairo is now a city of 18
million. In the center of the old city is a huge cemetery called the
City of the Dead. Years ago the authorities gave up evicting people
from living in the crypts--today it is home for a million people! And
population explosion in these countries is unbelievable. The breakdown
of services such as garbage collection is something few Americans can
comprehend.
Since the early 1970s, the populations of Egypt and Iraq have
nearly tripled. As a result, per capita income in Arab states has grown
at an annual rate of 0.3%. The labor force in these countries is
growing faster than that of any other region in the world. This leads
to large pools of restless, young men with no jobs.
Globalization has accelerated the pace of economic and social
change that creates insecurity. Most Islamic states don't have
democratic governments to mediate these conflicts. Generals, kings,
leaders for life, and parliaments with no power lead to frustrated
people.
When people feel powerless and extremely deprive--either
economically, politically or psychologically--the ground is fertile for
terrorism.
This sense of deprivation is part of the public backlash in those
countries against globalization, modernization, and secularism. And the
United States, regardless of its relationship with Israel, is the
country most benefiting from globalization, it is the most modem and
the most secular nation on earth. Two thirds of Egyptians and four-
fifths of Jordanians consider a ``cultural invasion'' by the West to be
very dangerous, according to a 1999 survey.
So what can we do? First, there is no compromise with people that
celebrate killing 5,000 people and would celebrate even more if they
killed 50,000. We will hunt down and destroy these assassins of our
brothers and sisters, mothers and fathers and our children.
We must also understand the region better. We do need to help those
countries tackle their underlying economic woes. We had to fight a
Second World War because of the failure of the Treaty of Versailles,
but the Marshall Plan helped us secure a safe Europe after W.W. II.
President Bush is already starting in this direction with Pakistan. The
Jordanian Free Trade Agreement is also an important step, especially
symbolically.
Education in the region is a problem. Secondary school education is
low, illiteracy is high, and fundamentalist Islamic sects have filled
the void. Those fundamentalist sects educate, feed and clothe the poor
and they win converts to their hatred of the West.
In Egypt and Jordan the state forbids the teaching of jihad in
those schools. As a condition of U.S. foreign aid, Pakistan should do
the same. Many of the Taliban are products of those schools that teach
hatred of us.
The United States should do more to promote democracy in the Middle
East. This means promoting free and fair elections, judicial and
legislative reform and rule of law. An investment in these countries
could be well worth the cost. Consider that the Wall Street Journal is
estimating the World Trade Center Attack to be costing the American
economy over $100 billion!
This war that we are in is a fight for freedom and justice. Whether
it is our military, our intelligence agencies, our resolve to make
airports more secure and our public health system better, I see around
this country the will and resolve to win this war. Our parents fought
World War II. Each generation is called on to sacrifice and I see the
valor of my fellow countrymen in its soldiers, and firefighters and
policemen and nurses and ordinary Americans, who in 45 minutes became
heroes.
This is our generation's challenge. It is our turn to fight for
freedom and justice. We will do our duty.
Mr. Greenwood. The Chair thanks the gentleman for the
abbreviated version of his opening statement and recognizes the
gentleman from Florida, Mr. Stearns.
Mr. Stearns. Good morning and thank you, Mr. Chairman. Like
my other colleagues, I wanted to commend you for holding this
hearing today. Looking at the two panels, of course, we have
folks from the private sector and folks from the government, so
we will be able to get a good cross-section of answers on some
of our questions.
How should our Federal Government shore up our defenses
against enemies who would harm us not with bullets but using
bacteria or viruses in our streets, subway cars, crops or water
supply? We have had several what-if scenarios recently. In
Florida, of course, one individual contracted the anthrax
bacterium and now a coworker has also been tested positive for
anthrax as well.
The FBI and CDC, of course, do not believe there is any
relationship to the September 11 attack, but I think all of
America has felt a collective shiver upon learning this news
last week, and this occurrence, this so-called ``random
illness'' so soon after the September 11, was quite a concern.
I think the fundamental questions we have for those
panelists is, do we have preparedness? Are we prepared to deal
with this crisis in America? And do we even have a definition
that the public health community is working off of, State,
Federal, and local, in dealing with these types of viruses and
bacteria?
Also, do we have the resources that are properly placed for
both the State and local governments in the health care
communities to sufficiently help solve this problem and clear
up and provide specific guidance about how we are going to deal
with bioterrorism situations?
And so I think, Mr. Chairman, just airing those two ideas
about what constitutes preparedness and whether we have the
resources available in this country and at the State, Federal,
and local level, and do the health care communities have the
specific instructions on what to do, is extremely important. So
I commend you for putting this hearing together.
And to--ultimately, not to overreact but put in perspective
what we can do to prepare, and to make sure that all of us are
safe.
And I yield back, Mr. Chairman.
Mr. Greenwood. The Chair thanks the gentleman from Florida
and would note, on our second panel, we will hear from Dr.
Scott Lillibridge from to the Office of the Secretary,
Department of Health and Human Services, who will give us an
update on the Florida situation.
That concludes the opening statements.
[Additional statements submitted for the record follow:]
Prepared Statement of Hon. Ted Strickland, a Representative in Congress
from the State of Ohio
I would like to thank Chairman Greenwood and Ranking Member Deutsch
for holding this hearing on an issue that has always been important but
has added urgency after the September 11 attacks. On that day, we saw
the almost unimaginable happen. I am glad the Subcommittee is today
addressing what the needs of our country will be should a bioterrorism
attack causing an epidemic occur. In addition, I would like to thank
the witnesses for sharing with us their expertise about local
communities' readiness and needs.
First, I want to echo the sentiments of my colleagues who warn that
confronting the threat of bioterrorism with anything short of calm and
thoughtfulness will lead to a response that is both ineffective and
wasteful of taxpayer money. Bioterrorism agents are difficult to turn
into weapons of mass destruction and easily degrade in the environment:
simply, science does not currently hold the mechanisms needed to easily
create the threat of a likely bioterrorist attack. However, as science
advances, the risk of such an attack will increase, and our country
must be prepared. It is essential that our approach to deal with such
an act enhances the ability of our local agencies by giving them the
resources they need to monitor and respond to all public health
threats, including bioterrorism, flu epidemics, and other challenges to
the health of our entire population. And by coordinating the many
Federal programs that have a role in mitigating the effects of any
bioterrorism attack, we will improve our nation's ability to respond
and potentially save many lives.
As a representative of a rural district, I am particularly aware of
the workforce shortage concerns expressed by the hospitals in my
district and the effects of these shortages on our preparedness in the
event of a bioterrorist attack. This concern is also elevated because
as reservists who also serve their communities as physicians, nurses,
or specialists are called to military duty, many rural and other
hospitals already struggling with a workforce shortage may be further
challenged to have the staff they need to provide routine patient care.
From both the perspective of a bioterrorism threat and the long-term
needs of our nation's health care delivery system, it is essential that
we strengthen programs to encourage more people to serve as physicians
and nurses. It would surely be a tragedy if certain regions of the
country could not respond to a bioterrorism attack because its
hospitals lack health professionals.
In conclusion, I want to commend the successes of all members of
the health care community for their response to the September 11
attacks. Physicians, nurses, medical supply distributors, and mental
health care professionals were all integral parts of the quick response
that was needed. I look forward to the witnesses' testimony.
______
Prepared Statement of Hon. Bobby L. Rush, a Representative in Congress
from the State of Illinois
Mr. Chairman, thank you for holding this timely hearing on the
federal government's preparedness to deal with bioterrorism. The two
Florida anthrax cases which occurred so soon after the September 11
terrorist attacks have thrust the issue of bioterrorism to the
forefront.
I would like to begin my remarks by pointing out that it is due to
the vigilance of Florida state public health officers who detected and
reported the first case of anthrax in Florida on October 3 that the
federal government was able to spring into action. I commend them for
their good work.
This incident, whether the act of terrorism or merely a natural
case of this disease, underscores the necessity of having a strong
network of local public health departments. The same local public
health officials that we rely on to respond to naturally occurring
disease outbreaks are the same officials that are responsible for
bioterrorism preparedness and response. Local public health officials
are the front line soldiers in the war against domestic bioterrorism.
They will be the first to come into contact with those infected and
they are responsible for alerting the federal government of any
possible bioterrorist attack.
However, there are serious questions of whether the federal
government is adequately preparing local health departments for a
bioterrorist attack. Too often, we have inadequately funded local
public health efforts. The key to preparing for a bioterrorist attack
is not just in funding bioterrorist programs, but in creating a strong
overall public health system. Unfortunately, some federal dollars are
tied to narrow programs and do not address public health as a whole.
While the topic of this hearing is the federal government's
readiness for a bioterrorist attack, it is clear that the swiftness of
the federal governments response to an attack is inextricably tied to
the strength of our local departments of public health.
Thank you.
______
Prepared Statement of Hon. John D. Dingell, a Representative in
Congress from the State of Michigan
Today's hearing on the level of preparedness of our public health
system for a bioterrorism attack or a pandemic caused by an unknown
organism is particularly important because it focuses on the very
serious deficiencies in our public health system at the local, state
and federal levels. Improvements in our public health system can save
lives lost every day to such diseases as new strains of infectious
tuberculosis that are resistant to antibiotics, undetected hanta virus,
and gastrointestinal illnesses. They also will better prepare us for
potential biological attacks.
To date, the Federal Government's approach has been highly
fragmented and focused on training police, firefighters, and emergency
medical personnel. This has worked well for chemical disasters; it does
not for biological disasters. The first responders to a biological
attack will most likely be hospital emergency room personnel and
medical staff in clinics and doctors' offices. These people have been
almost totally ignored in response planning and training. It also
appears that there may not be sufficient stockpiles of antibiotics,
antidotes and other medical supplies to respond to a bioterrorism
attack because of the ``just-in-time'' inventory that hospitals,
pharmacies, and other health care facilities have implemented.
The fragility of the response system has been demonstrated by the
anthrax incident in Florida. Because of one case of anthrax, 700 people
are being tested and treated with antibiotics. There were not enough
antibiotics available from local sources to treat even 300 people so
the National Pharmaceutical Stockpile was activated. What would happen
if there were 50 cases of anthrax and 35,000 people to be tested and
treated in a very short time frame? The answer is clear: the system
would break down.
But we know how to fix our public health infrastructure. We know
that increased funding is required, as well as improved federal
direction and coordination. Now it is a simple and direct question of
political will, given greater urgency because of the implications of
the tragic events of September 11. We need money for training, for
developing new vaccines and antibiotics, and for developing stockpiles
of pharmaceuticals and other medical supplies. We need money for public
hospitals and community health centers. And we need leadership from the
Federal Government.
We must be prepared to defend all our citizens from domestic or
foreign enemies and from a variety of threats that now include
biological agents. Undue haste and panic are unwarranted and, in fact,
are counterproductive. But we need to begin significant and serious
efforts to rebuild our public health system, and I look forward to
working with my colleagues on them.
Mr. Greenwood. The Chair would call forward the our first
panel of witnesses. They are Dr. Amy E. Smithson, Senior
Associate of the Henry L. Stimson Center here in Washington;
Dr. Joseph Waeckerle, who is the Chairman of the Task Force of
Health Care and Emergency Services Professionals on
Preparedness for Nuclear, Biological and Chemical Incidents
with the American College of Emergency Physicians; Dr. Kathryn
Brinsfield, Associate Medical Director and Director of
Research, Training and Quality Improvement, Boston Emergency
Medical Services.
We have Dr. Lew Stringer, Medical Director of the North
Carolina Division of Emergency Management; Mr. Ronald R.
Peterson, President of the Johns Hopkins Hospital, on behalf of
the American Hospitals Association; and Dr. Dennis O'Leary,
President of the Joint Commission on Accreditation of
Healthcare Organizations; and Dr. Frank E. Young, former head
of the Office of Emergency Preparedness, Department of Health
and Human Services.
We thank all of the witnesses for your testimony today, in
advance, and for your patience in waiting for us to begin. You
are hopefully all aware that this committee is holding an
investigative hearing, and when doing so, we have the practice
of taking testimony under oath.
Do any of you have objection to testifying under oath?
Seeing no such objection, I would advise you that under the
rules of the House and the rules of the committee you are
entitled to be advised by counsel. Do any of you desire to be
advised by counsel during your testimony?
Seeing no such interest, I ask you then to please rise and
raise your right hand, and I will give you the oath.
[Witnesses sworn.]
Mr. Greenwood. We will recognize Dr. Smithson first for
your testimony. Welcome. You are recognized for 5 minutes to
offer your statement.
TESTIMONY OF AMY E. SMITHSON, DIRECTOR, CHEMICAL AND
BIOLOGICAL WEAPONS NONPROLIFERATION PROJECT, HENRY L. STIMSON
CENTER; JOSEPH F. WAECKERLE, CHAIRMAN, TASK FORCE OF HEALTH
CARE AND EMERGENCY SERVICES PROFESSIONALS ON PREPAREDNESS FOR
NUCLEAR, BIOLOGICAL AND CHEMICAL INCIDENTS, ON BEHALF OF THE
AMERICAN COLLEGE OF EMERGENCY PHYSICIANS; KATHRYN BRINSFIELD,
DIRECTOR OF RESEARCH, TRAINING, AND QUALITY IMPROVEMENT, BOSTON
EMERGENCY MEDICAL SERVICES AND DEPUTY MEDICAL COMMANDER,
NATIONAL DISASTER MEDICAL SYSTEM'S INTERNATIONAL MEDICAL AND
SURGICAL RESPONSE TEAM-EAST; LLEWELLYN W. STRINGER, JR.,
MEDICAL DIRECTOR, NORTH CAROLINA DIVISION OF EMERGENCY
MANAGEMENT; RONALD R. PETERSON, PRESIDENT, JOHNS HOPKINS
HOSPITAL, ON BEHALF OF THE AMERICAN HOSPITAL ASSOCIATION;
DENNIS O'LEARY, PRESIDENT, JOINT COMMISSION ON ACCREDITATION OF
HEALTHCARE ORGANIZATIONS; AND FRANK E. YOUNG, FORMER HEAD,
OFFICE OF EMERGENCY PREPAREDNESS, U.S. DEPARTMENT OF HEALTH AND
HUMAN SERVICES
Ms. Smithson. Thank you, Mr. Chairman. And I thank the
other members of the committee for their appearance here today,
because I hope we all become more educated about what is
obviously a very confusing subject for the American public and
for some of our policymakers.
In a continuing effort to separate fact from fiction, what
I would like to do is start with a topic that has been in the
news quite a lot lately. Let's talk crop dusters.
There are many people in this country that are under the
impression that crop dusters are suited to disperse biological
warfare agents. Quite frankly, that is not the case. Crop
dusters disperse materials in 100-micron particle sizes and
larger.
The size of a biological warfare agent particle needed to
infect the human lung is 1 to 10 microns. So let's hopefully
cut down on some of the apprehension about crop dusters as an
instrument of biological terror.
As far as the case in Florida is concerned, let's also get
right to it. Rubbing some type of an anthrax substance on a
keyboard is not a mass casualty dispersal attempt. So I hope
that even though the timing of these two things, the September
11 conventional attacks and a very unusual and possibly
criminal case in Florida, has put us all on edge that we will
be able to calm down and begin to consider the nature of this
threat in a bit more, shall we say, calm atmosphere. Because
there are important things that Washington needs to do to
prepare this country better for a biological disaster, and
quite frankly, this needs to be done regardless of whether or
not terrorists overcome the significant technical hurdles
involved in dispersing these materials in a way that would
cause massive casualties.
Mother Nature is out there and occasionally she wreaks
havoc with the human population. Not only are we talking about
emerging infectious diseases, but the increasing antibiotic-
resistant diseases that our public health officials on this
panel can speak to much better than I.
So this country needs to be prepared to deal with a
biological disaster regardless of whether or not terrorists
ever figure this out.
I would focus the remainder of my remarks on what I
consider to be the division of labor that needs to be achieved
between Washington and the rest of the country, the Federal
Government and the rest of the country.
There are several important missions for the Federal
Government. At the top of that list would be the need to
enhance our programs involved in the research and development
of vaccines and antibiotics. You will find a few remarks in
that regard in my written testimony. In addition, the other
thing that the Federal Government will need to provide is
emergency medical manpower in the event that there is some type
of significant disease outbreak in this country.
At present, in the survey that I did for Ataxia, which
encompassed officials from 33 cities across this country, it is
very clear that our hospital systems and health care systems
cannot handle the patient load of a regular influenza outbreak
season. So they are going to probably need in very quick order
outside medical assistance in order to cope with the incredible
burdens on the health care system that would result from a
major disease outbreak.
Now, there have been statements that 7,000 medical
personnel could be put on the spot in fairly short order. If
you are to examine the outcome of the mid-May 2000 Top Off
drill, you will see that the conclusion from the slated release
of plague in Denver is that 2,000 outside medical personnel
needed to be put on the ground within 24 hours or the local
health care system would collapse.
Well, I couldn't find anybody in any survey that felt like
the Federal Government could meet just the 2,000 goal, much
less the 7,000. I would recommend that Congress sponsor annual
medical mobilization exercises to see whether or not the
Federal Government can deliver what is on paper.
There are other roles that I would recommend for the
Federal Government, but most important the resources that are
spent on enhancing public preparedness have to get outside of
Washington, DC's Beltway. Right now, in this area, $8.7 billion
are being spent on readiness, but only $311 million is making
it outside of the Beltway. That is simply an unsuitable balance
of where the resources are being spent.
There are a few important things I would like to highlight
in terms of local readiness. If our health care systems are
going to be able to withstand the patient burden of a disease
outbreak, they need to have in place an agreement among
entities that are now competitors in most of our communities.
Hospitals are private entities. They need to have regional
hospital planning where there is a pre-agreed burden-sharing
arrangement so that some hospitals convert over to infectious
disease hospitals, others will take trauma patients, ladies
having babies and heart attack victims, because these things
will continue to occur, so those types of plans need to be
established.
And there were only a couple of cities that I surveyed for
Ataxia where this type of planning was even beginning. So I
would encourage you to support regional hospital planning
grants.
In addition to continuing to strengthen traditional public
health capabilities such as the improvements being made to our
laboratories, I would also encourage you to look at what may
give our physicians and our laboratories that heads-up early
warning that something is going wrong in the community, in the
health of their metropolitan community.
There are a few cities across the country that are engaged
in what is called syndrome surveillance, disease syndrome
surveillance. They are taking data that is available and
putting it to the purpose of giving us that heads-up. This is
another wise investment for Congress to make in the days ahead.
I thank you for your time, and would be glad to answer your
questions.
Mr. Greenwood. I am sure that we will have very many
questions. The surveillance aspect which you referred to last
will be the subject of a hearing on this subcommittee on
October 25.
[The prepared statement of Amy E. Smithson follows:]
Prepared Statement of Amy E. Smithson, Director, Chemical and
Biological Weapons Nonproliferation Project, Henry L. Stimson Center
When a major, complex problem comes to light, even the most learned
and experienced can find it tough to think calmly and rationally about
the reasonable, constructive steps that government should take to
address it. When the problem identified is as frightening and
potentially devastating as a bioterrorist attack, rationality can take
a backseat. In the last few years, indeed in the weeks since September
11th, countless government officials have extolled their terrorism
response capabilities, only to ask Congress in the next breath for just
a few million more dollars so they can better address the problem. A
few million here and a few million there soon adds up to serious money.
Already, the General Accounting Office and some nongovernmental
researchers like myself, have issued warnings about overlapping and
short-sighted terrorism preparedness programs.
The convening of this hearing is a positive sign that Congress may
soon begin to exercise more rigorously its oversight functions
regarding terrorism prevention and response programs. The appointment
of Governor Tom Ridge as Director of the new Office of Homeland
Security would seem to be a constructive step that could put improved
coordination and streamlining of the federal response bureaucracy on a
fast track, but that may not be the case if he is not given strong
budgetary authority. An initial review of section 3(k) of the Executive
Order establishing the Office of Homeland Security and the Homeland
Security Council does not appear to vest sufficiently strong budgetary
authority in this new office. As a matter of priority, the Office of
Homeland Security and Congress must work together to tame the unwieldy
federal bureaucracy and to get preparedness resources flowing to the
nation's cities and long-neglected public health system. To aid
Governor Ridge in his efforts, Congress should grant him czar-like
budgetary authority. Unless this occurs in tandem with a consolidation
of the number of congressional oversight committees, a few years from
now a great deal of money will have been spent with marginal impact on
reducing the threat of terrorism and mitigating the aftereffects of an
unconventional terrorist attack.
grasping for perspective in the aftermath of september 11th
Despite what you might have heard in recent weeks, there are
meaningful technical hurdles that stand between this nation's citizens
and the ability of terrorist groups to engage in mass casualty attacks
with chemical and biological agents. Between the misleading statements
that have been made about the ability of crop dusters to disperse
biological agents and the recent death of a 63-year old man in Florida
from inhalational anthrax, the public is understandably spooked about
the whole subject of bioterrorism. Facts often get overlooked in such
an atmosphere, but I will resort to them nonetheless. Crop dusters
disperse materials in a 100 micron or greater particle size, which is
significantly larger than what would be required for the effective
dispersal of a biowarfare agent. Another fact that has been glossed
over is that the sheer mechanical stresses involved in putting a wet
slurry of biowarfare agent through a sprayer can kill 95 percent or
more of the microorganisms, to say nothing of the sensitivity that some
agents have to environmental stresses once released. In order for an
aerosol spray of biological agent to infect a person, the agent must
arrive in the human lung alive, in a 1 to 10 micron particle size.
As for the developing situation in Florida, the investigation is
ongoing and conclusions cannot be drawn at this point. In the end, this
sad situation may fit into a pattern typical of past terrorist activity
with chemical and biological substances. Data compiled by the Center
for Nonproliferation Studies at the Monterey Institute of International
Studies show that over the past 25 years instances where subnational
actors actually used a chemical or biological substance relate mostly
to disgruntled workers, domestic disputes, or others with some type of
vendetta against political figures or rivals. The substances of choice
tended to be household, industrial chemicals and the scope of intended
harm included one or a few individuals, not dispersal at public
locations or in a manner where mass casualties could result. In 96
percent of these cases where terrorists used chemical or biological
substances, three or fewer people were injured or killed. Difficult
though it may be, one should not jump to the conclusion that what has
occurred in Florida is related to the horrific events of September
11th. In the headquarters building of American Media Inc., anthrax was
reportedly found on an individual's computer keyboard, a dispersal
approach that does not enable mass casualties. Should the investigation
reveal that the perpetrator(s) who introduced Bacillus anthracis into
this building employed a dry, microencapsulated form in the requisite
microscopic particle size, then concern would be warranted. That would
indicate that a subnational actor had indeed scaled technical obstacles
that other terrorists had previously been unable to overcome. Greater
detail about terrorist activities with chemical and biological
substances can be found in Chapter 2 of Ataxia: The Chemical and
Biological Terrorist Threat and the US Response, which is available on
the internet at: www.stimson.org/cwc/ataxia.htm.
When one retreats from the hyperbole and examines the intricacies
involved in executing a mass casualty attack with biowarfare agents,
one is confronted with technical obstacles so high that even terrorists
that have had a wealth of time, money, and technical skill, as well as
a determination to acquire and use these weapons, have fallen short of
their mark. Chapter 3 of Ataxia addresses this point at some length,
examining the lessons that should be learned from the very terrorist
group that got the hyperbole started, Aum Shinrikyo. To summarize,
although the results of the cult's 20 March 1995 sarin gas attack were
tragic enough--12 dead, 54 critically and seriously injured, and
several thousand more so frightened that they fled to hospitals--Aum's
large corps of scientists hit the technical hurdle likely to stymie
other groups that attempt to follow in its wayward path toward a
chemical weapons capability. They were unable to figure out how to make
their $10 million, state-of-the-art sarin production facility work and
therefore were unable to churn out the large quantities of sarin that
would be needed to kill thousands. As for Aum's germ weapons program,
it was a flop from start to finish because the technical obstacles were
so significant.
the compelling need for disease outbreak readiness
No matter where one comes out in the debate about whether
terrorists can pull off a biological attack that causes massive
casualties, the fact of the matter is that the debate itself is moot.
One need only consult public health journals to understand that it is
only a matter of time before a strain of influenza as virulent as the
one that swept this country in 1918 naturally resurfaces. Further
confirmation of a looming public health crisis can be secured through a
steady stream of reports from the World Health Organization and the
National Institutes of Medicine, which describe how an increasing list
of common diseases (e.g., pneumonia, tuberculosis) are becoming
resistant to antibiotics. These public health watchdogs are also
justifiably worried about the array of new diseases emerging as mankind
ventures more frequently into previously uninhabited areas. Microbes
have an astonishing capability to humble the human race: scourges such
as plague, polio, and smallpox have devastated generations past. Even
with everything that is in the modern medical arsenal, public health
authorities will find it difficult to grapple with disease outbreaks in
the future. Rapid global travel capabilities will facilitate the
mushrooming of communicable diseases through population concentrations
and will in turn hinder use of the traditional means of containing a
contagious disease outbreak, namely quarantine.
An even grimmer picture materializes when one consults those on the
forefront of health care in America. The best medical care in the world
can be found in this country, but US hospitals are at present poorly
prepared to handle an epidemic. To illustrate the point, US hospitals
already have difficulty handling the patient loads that accompany a
regular influenza season. Ambulances wait for hours in emergency
department bays, unable to unload patients until bed space is
available. The press of genuinely ill and worried citizens clamoring
for medical attention in the midst of a plague or smallpox epidemic
would so far outstrip a normal flu season that local health care
systems would quickly collapse.
Ataxia, the afore-mentioned report that I released last October
with my co-author, Leslie-Anne Levy, presents a series of
recommendations on how to improve federal terrorism preparedness
programs. Ataxia is based largely on interviews with first responders
from 33 cities in 25 states conducted over a period of 1\1/2\ years, so
this report is steeped in candor and the common-sense wisdom borne of
experience. Drawing from this research and the feedback that continues
to come my way in the aftermath of Ataxia's publication, I would like
to address a few issues critical to an effective response to a major
disease outbreak, whether caused intentionally or naturally. Those
issues could be listed as the ability to detect an eruption of disease
promptly, the need to establish response plans among regional health
care facilities that could be quickly activated, and the ability of the
federal government to provide timely delivery of emergency supplies of
medicine and medical manpower. Any response, however, would be thrown
off track if there is not a clear agreement on lines of authority, so I
will start there.
leadership in confronting disease outbreaks
How many FBI special agents or Federal Emergency Management Agency
(FEMA) officials know off the top of their heads the appropriate adult
and child dosages of ciprofloxacin for prophylaxis in the event of a
terrorist release of anthrax? Darned few, if any. No, the FBI excels at
catching criminals and FEMA at providing mid- and long-term recovery
support to communities stricken with all manner of disasters. An
outbreak of disease is first and foremost a public health problem, so
let's not be confused about who should be calling the shots in an
epidemic--public health officials. Yet, this simple fact is certainly
not reflected in what is taking place with regard to bioterrorism
preparedness, inside or outside the beltway.
Inside of Washington's beltway, concepts of crisis and consequence
management not only linger, they predominate. With an apparent lack of
budgetary authority and proposals circulating anew to have the Justice
Department retain a leadership and coordination role despite the Bush
administration's earlier appointment of FEMA in this capacity, it is
fair to say that Governor Ridge's office will have difficulty presiding
over the tug of war about which federal agency should lead the federal
component of unconventional terrorism response. In America's cities,
counties, and states there is also a fair amount of jostling as to who
exactly would have the authority to make certain decisions during an
epidemic. Only a handful of states, unfortunately, have untangled the
cross-cutting jurisdictions left over from more than a century of
contradictory laws passed as authorities scrambled to deal with the
different diseases that were sweeping the country. Prompt, decisive
action could make a lifesaving difference in the midst of an outbreak,
but the experience of various terrorism exercises and drills gives
ample reason to believe that precious time would be squandered as
local, state, and federal officials squabbled over who has the
authority to do what. These circumstances beg for a clear vision and a
firm hand to untangle this mess and put the people who know the most
about disease control and eradication--public health officials--
unquestionably in charge of any biological disaster, whether natural or
manmade. FEMA, the FBI, the Pentagon, and other federal and local
agencies should be playing support roles, not reshaping and second-
guessing the directions of public health professionals as they manage
the crisis and consequences of a major eruption of disease.
addressing problems of disease outbreak detection and overall medical
readiness
Perhaps the first challenge facing the health care community would
be figuring out that something is amiss. Many diseases present with
flu-like symptoms, and the physicians and nurses who could readily
recognize the finer distinctions between influenza and more exotic
diseases are few in number indeed. Thus, in a spot test conducted in
mid-February 2000 in Pittsburgh, Pennsylvania, only one out of 17
doctors correctly identified smallpox after hearing a case history and
being shown photographs of the disease's progression. Smallpox, it
should be recalled, presents in a most visible manner, with pustules
covering the body. That sixteen doctors would not correctly diagnose
smallpox can be attributed to the success of public health authorities
in eliminating scores of diseases in America. Subsequently, medical and
nursing schools concentrated training on ailments that health care
givers are more likely to see.
In another illustration of the problem, there have been far too
many reports in recent weeks of physicians prescribing antibiotics for
patients worried about a possible bioterrorist attack. Of all people,
physicians should understand how such prescriptions could backfire, not
just in adverse reactions to the antibiotics if citizens begin self-
medicating their children and themselves when they come down with the
sniffles, but in the lessened ability of those very drugs to help their
patients in a time of true medical need.
The exotic disease recognition problems are not limited to the
medical community. In the nation's laboratories, microbiologists and
other technicians who analyze the samples (e.g., blood, throat
cultures) that physicians order to help them figure out what ails their
patients are much more likely to have encountered exotic diseases in
textbook photographs rather than under their microscopes. Thanks to the
laboratory enhancement program initiated by the Centers for Disease
Control and Prevention, the ability to identify out-of-the-ordinary
diseases more rapidly is on the rise in several dozen laboratories
across the country. However, such is not the case in the 158,000
laboratories that serve hospitals, private physicians, and health
maintenance organizations are the backbone of disease detection in this
nation. In conjunction with the Centers for Disease Control and
Prevention and the Association of Public Health Laboratories, the
American Society of Microbiology is developing protocols to assist
clinical microbiology laboratories in identifying bioterrorist agents.
Although the protocols have yet to be published, volume number 33 in
the Cumulative Techniques and Procedures in Clinical Microbiology
series addresses bioterrorism issues and is available from the American
Society of Microbiology. As of yet, there is no national guideline
requiring private laboratories to enhance their ability to identify
such diseases, a component of the preparedness framework that should be
weighed carefully by public health authorities.
To date, the domestic preparedness training program, now
administered by the Justice Department, has managed to draw some
medical and laboratory personnel, mostly emergency department
physicians and nurses, into the classroom in the cities where training
is being provided. To enhance the disease detection and treatment
skills of the medical community nationwide, however, a different
strategy is required. If a long-term, systemic difference is to be made
in the skills of medical and laboratory personnel, then more
comprehensive instruction in medical, nursing, microbiology, and other
pertinent schools is required. Knowledge of exotic diseases should be
required to obtain diplomas, and the topic should become a mainstay of
the refresher courses offered to maintain professional credentials.
Those involved in setting the curricula for pertinent schools should
waste no time in heeding the long-standing warnings of the Institute of
Medicine and the World Health Organization and adjusting their course
offerings, requirements, and other professional activities accordingly.
With modern data collection and analysis capabilities, however, one
need not rely solely on the ability of laboratories and medical
personnel to pick up the telltale early signs of a disease outbreak. In
a few areas in the United States, public health and emergency
management officials are teaming to test concepts to get a head start
on detection. The concept focuses on early signs of syndromes (e.g.,
flu-like illness, fever and skin rash) that might indicate the presence
of diseases of concern. They are compiling historical databases to
supply a baseline of normal health patterns at various times of the
year, against which contemporary developments can be measured. Since
people feeling ill tend to take over-the-counter medications, consult
their physicians, or request emergency medical care, some areas are
beginning to track the status of health in their communities via select
Emergency Medical Services call types (e.g., respiratory distress,
adult asthma); sales of certain medications (e.g., over-the-counter flu
remedies); reports from physicians, sentinel hospitals, and coroners
about select disease symptoms or unexplained deaths; or some
combination of these markers. Once a metropolitan area has compiled
data to understand normal patterns activity patterns at various times
of the year, abnormal activity levels can be detected. For instance,
when EMS calls rise above the expected rate in the fall season, public
health officials and emergency managers would get the earliest possible
indication that something was amiss, which would enable them to cue
medical personnel and laboratories to search more diligently for what
might be causing a possible disease outbreak. This concept of syndrome
surveillance will be key to allowing public health officials to get the
jump on prophylaxis or whatever other control measures might be in
order.
Nationwide, syndrome surveillance is being done in several
locations, drawing in no small part upon the path breaking work done by
New York City's Department of Public Health and Office of Emergency
Management. Their efforts are summarized in box 6.7 of Ataxia, which
again is available online so that policy makers and public safety and
public health officials around the United States and elsewhere can have
the benefit of the composite knowledge of the individuals who shared
their expertise and experiences with me.
What is now called for is a more systematic approach to
institutionalizing syndrome surveillance across the nation. A model for
syndrome surveillance should be refined and then made available
nationally, along with funds to allow metropolitan areas to conduct the
necessary historical analysis and establish the computer database,
communications, and other components needed to put syndrome
surveillance in place. Again, the data and the computing capabilities
are available, it is just a matter of harnessing them for the purposes
of early disease outbreak recognition. In their own ways, the Kennedy-
Frist and the Edwards-Hagel bills address these matters. Coordination
of congressional action is called for so that the most readiness can be
gained for taxpayers' dollars.
the need for regional hospital planning
The next challenge facing a metropolitan area in the midst of a
major disease outbreak would be contending with the flood of humanity
that would seek health care services. As already noted, hospitals would
be quickly overwhelmed, so it will be critical for regional health care
facilities to have a pre-agreed plan that divides responsibilities and
locks in arrangements to bring emergency supplies in the interim until
federal assistance can arrive. In the era of managed health care,
hospitals compete with each other for business and rely on just-in-time
delivery of supplies, keeping an average of two or three days supplies
in inventory. Since community-wide hospital planning has fallen by the
wayside, precious time could be wasted if hospitals lack prior
agreement as to which facilities would convert to care of infectious
disease cases--particularly important if a communicable disease is
involved--and which ones would attend to the other medical emergencies
that would persist throughout an epidemic. Business competitors, in
other words, must convert within hours to work as a team.
This regional hospital plan must also contend with how to handle
the overflow of patients and provide prophylaxis to thousands upon
thousands of people. Whether the approach involves auxiliary facilities
near major hospitals, the conversion of civic or sporting arenas to
impromptu hospitals, or the use of fire stations or other neighborhood
facilities to conduct patient screening and prophylaxis, such a plan
needs to be put in place. Other factors that regional hospital planning
must address are how to tap into local reserves of medical personnel
(e.g., nursing students, retired physicians), how to break down and
distribute securely the national pharmaceutical stockpile, and how to
enable timely delivery of emergency supplies of everything from
intravenous fluids to sheets, tongue depressors, and food.
federal roles in biodisaster preparedness
Washington's willingness to fund regional hospital planning as well
as programs that institute disease syndrome surveillance nationally
will be critical to biodisaster readiness. In addition, the federal
government has important roles to play in the development and
production of essential medicines, in the provision of medical manpower
during an emergency, and in general mid- to long-term recovery disaster
recovery assistance. With regard to the latter role, FEMA's
capabilities have risen steadily over the last decade and little, if
anything, would need to be added to its existing capabilities and
regular Stafford Act assistance activities.
Long before the current concerns about bioterrorism, I was at a
loss to explain how the federal government could have known about the
extent of the Soviet Union's biowarfare program--including the
production of tons of agents such as smallpox and antibiotic resistant
plague and anthrax--as early as 1992 and not kicked this nation's
vaccine research, development, and production programs into a higher
gear until 1997. The extent of the problem is illustrated by the fact
that only one company is under contract to produce the anthrax vaccine,
no company currently produces the plague vaccine, and it was not until
recently that steps were taken to meaningfully jumpstart smallpox
vaccine production. Such matters should have been promptly addressed if
only to enable protection of US combat troops, not to mention producing
enough vaccine to cover the responders on the domestic front lines,
namely the medical personnel, firefighters, police, paramedics, public
health officials, and emergency managers who would be called upon to
aid US citizens in the event of a biological disaster.
As for the effort that was mounted, many nongovernmental experts
have been taken aback at the structuring and relatively meager funding
of the Joint Vaccine Acquisition Program. With a $322 million budget
over ten years, this program aims to bring seven candidate biowarfare
vaccines through the clinical trials process. Giving credit where it is
due, one must acknowledge that this program as well as Defense Advanced
Research Projects Agency-sponsored research into innovative medical
treatments are making headway. However, the federal government must
find ways to shrink the nine to fifteen year timeline that it takes to
bring a new drug through clinical trials to the marketplace. Food and
Drug Administration officials are already wrestling with how to adjust
the clinical trials process for testing of new vaccines and additional
bumps are to be expected on the road ahead.
Next, the National Institutes of Health and the pharmaceutical
industry, not the Defense Department, are this country's experts at
clinical testing and production of medications. My point is not that
the Defense Department should not have a role--perhaps even a lead role
since the candidate vaccines originated with the US Army Medical
Research Institute for Infectious Diseases--but these other important
players need to be at the table if an accelerated program is to be
achieved. As I noted, Governor Ridge will have his hands full, no
matter which direction he turns. Moreover, close congressional
oversight of this particular aspect of the nation's biological disaster
readiness is warranted.
On the chemical side of the house, by the way, the picture is
similarly discouraging. The Pentagon now turns to one company for
supply of the nerve agent antidote kits, known as Mark 1 kits, that the
Health and Human Services Office of Emergency Preparedness has
encouraged cities participating in the Metropolitan Medical Response
System program to purchase. Many a city is still waiting to receive the
Mark 1 kits ordered long ago, and when they do, these kits will have a
considerably shorter shelf life than the kits made available to the
military.
emergency medical manpower needs during a major disease outbreak
Secretary of Health and Human Services Tommy Thompson stated on
September 30th in an interview with ``60 Minutes'' that his department
has ``7,000 medical personnel that are ready to go'' in the event of a
bioterrorist attack. While that statement may be true in theory, in
practice it may not hold. Somewhat lost in the late 1990s rush to soup
up federal teams for hot zone rescues was the one major non-FEMA
federal support capability that would clearly be needed after an
infectious disease outbreak and perhaps after a chemical incident as
well--medical assistance. The National Disaster Medical System was one
of several improvements made to federal disaster recovery capabilities
over the last decade, a time during which the federal government
demonstrated that it could bring appreciable humanitarian and
logistical assets to bear after natural catastrophes and conventional
terrorist bombings. While these events flexed the muscles of the FEMA-
led recovery system, including the deployment of Disaster Medical
Assistance Teams, they did not even approach the type of monumental
challenge that a full-fledged infectious disease outbreak would
present. Prior to Secretary Thompson's recent statement, officials from
the Health and Human Services Department and the Pentagon have also
stated that they could mobilize significant medical assets quickly.
Yet considerable skepticism exists that these two departments
combined could have met the medical aid requests made from Denver after
the release of plague was simulated during the mid-May 2000 TOPOFF
drill, much less a call for even more help. During that hypothetical
event, health care officials quickly found their medical facilities
sinking under the patient load and concluded that 2,000 more medical
personnel were needed on the ground within a day to prevent the flight
of citizens that would have further spread the disease. Getting that
number of physicians and nurses to a city and into hospitals and field
treatment posts would be a tremendous logistic achievement. No one that
interviewed for Ataxia, including members of the Disaster Medical
Assistance Teams and other medical and public health professionals,
felt that the federal government could deliver 2,000 civilian medical
professionals within the required timeframe. For its part, the Pentagon
has yet to articulate clearly or commit to civilians at the federal or
local level just how much medical manpower it could deliver and in what
timeframe.
Quite frankly, the time has come for the Pentagon to stop being coy
about what medical assets it could bring bear in a domestic emergency.
Articulation of this capability, even if it needs to be done in
classified forums, is necessary for sound planning on the civilian
side. Furthermore, there have been no large-scale dress rehearsals to
confirm whether civilian or military medical assets could muster that
many medical professionals that quickly, or even over a few days. Even
so, the 2,000 figure from the Denver segment of TOPOFF seems almost
quaint when compared to one US city's rough estimate that 45,000 health
care providers--many of whom would have to be imported--would be
required to screen and treat its denizens.
The only way to find out whether the federal government is truly up
to the most important role it may have to perform after a bioterrorist
attack or a natural disease outbreak is to hold a large-scale medical
mobilization exercise. Despite the expense, Congress should mandate a
realistic test of how much civilian and military medical assistance can
be delivered, how fast. Unlike TOPOFF, where federal assets were pre-
picked and pre-staged, the terms of the exercise should specify that
teams deploy as notified. While the general nature and identity of the
exercise location(s) would certainly be known beforehand and the
timeframe of the drill agreed within a window of several months, local
officials should trigger the onset of the exercise. In short, dispense
with the tabletop games that allow everyone the comfort of claims of
what they could do and see what a real exercise brings. A genuine and
probably sobering measure of federal capabilities could be taken, and
the lessons of the exercise could inform the structure of federal and
local plans and programs.
conclusions
One need not resort to hyperbole when it comes to how difficult it
would be for major US cities to handle a pandemic; the truth is
sobering enough. Even though the basic components of the ability to
handle a disease outbreak--hospitals, public health capabilities at the
federal, state, and local levels, and a wealth of medical
professionals--are already in place, there is ample room for
improvement. The pragmatic steps that the federal government should
take are clear. Mr. Chairman, Members of the Committee, Washington can
take the smart route to enhance biodisaster preparedness nationwide or
it can continue to go about this in an expensive and inefficient way.
The keys to biodisaster readiness are as follows:
<bullet> The sufficiency of existing federal programs, response teams,
and bureaucracies needs to be assessed and redundant and
spurious ones need to be eliminated. In the interim until an
assessment of the sufficiency of existing assets is made, a
government-wide moratorium on any new rescue teams and
bureaucracies should be declared, with the exception of the
enhanced intelligence, law enforcement, and airport security
measures that are being contemplated.
<bullet> Defense Department programs related to the development and
production of new vaccines and antibiotics need to be put on a
faster track and incorporate expertise in such matters from
outside the Pentagon.
<bullet> The federal government should continue to revive the nation's
public health system, an endeavor that involves sending funds
to the local and state levels, not keeping them inside the
beltway. In addition, the federal government should fund
regional hospital planning grants and additional tests of
disease syndrome surveillance system, followed by plans and
funds to establish such capabilities nationwide.
<bullet> Appropriate steps should be taken to see that physicians,
nurses, laboratory workers, and public officials benefit from
training that is institutionalized in the nation's universities
and schools.
<bullet> Last, but certainly not least, Washington needs to develop a
plan to sustain preparedness over the long term. Drills at the
local and federal levels are necessary because plans that sit
on the shelf for extended periods of time are often plans that
do not work well when emergencies occur.
I will wrap up with one more essential task to which each
individual member of Congress must attend. Since September 11th, I have
received numerous calls from offices on both sides of the Hill and both
sides of the aisle, asking me to brief them on these issues and to help
fashion legislation that would put Representative ``X's'' or Senator
``Z's'' stamp on the legislation that is taking shape. While I have
responded as quickly as possible to such requests, they are in some way
indicative of the problem that Washington faces if it is to craft
meaningful, cost-effective preparedness programs.
With all due respect, I would point out that while the attacks of
September 11th occurred in New York City and Northern Virginia, they
were attacks on this nation as a whole. Those who risked their lives
that day to save the lives of others were not thinking about themselves
or their future, they were selflessly acting in the interests of
others. Put another way: this is no time for pet projects, whether they
be to benefit one's home district constituents or a particular branch
of government. This is not about job employment, it is about saving
American lives. The future well-being of each American, I would
contend, is equally important.
On behalf of the local public health and safety officials who have
shared their experience and common sense views with me, I urge Congress
to waste no time in passing legislation that brings the burgeoning
federal terrorism preparedness programs and bureaucracies into line and
points them in a more constructive, cost-effective direction. The key
to biodisaster preparedness lies not in bigger budgets and more federal
bureaucracy, but in smarter spending that enhances readiness at the
local level. Even if terrorists never strike again in this country,
such investments would be well worthwhile because they would improve
the ability of hometown rescuers to respond to everyday emergencies.
Mr. Greenwood. Dr. Waeckerle.
TESTIMONY OF JOSEPH F. WAECKERLE
Mr. Waeckerle. Good morning.
Mr. Greenwood. You are recognized.
Mr. Waeckerle. Good morning to all of the members and my
fellow panelists. I am Joe Waeckerle; I am a Board certified
emergency physician in Kansas City, practicing. I have been
involved in this area for the last 8 or 9 years as a consultant
to the FBI, the Defense Science Board and CDC and Office of
Emergency Preparedness.
I also serve as the task force chair, as you spoke to
earlier. I am passionate about domestic preparedness and have
spent too much time in the area, as we all must now.
America has been targeted. America has been attacked and
America has suffered, and we all mourn as we should. But we
need to do more than mourn to better protect our country and
honor those who have suffered and died. We need to be prepared
and, especially, prepared against biologic weapons.
We are extremely vulnerable. Numerous analyses of the
escalating risks to America and the considerable deficiencies
have been presented before you and other Members of Congress,
both internal, external and from distinguished people, like Dr.
Smithson to my right. They have demonstrated considerable
deficiencies which the government has appropriately addressed,
but there are many that still linger.
Careful consideration of the lingering major deficiencies
are obvious points of interdiction requiring urgent reform that
we can address, and I hope to do so for some today.
The failure to recognize biowarfare is a national threat
that has resulted in a lack of a comprehensive national
strategy. I therefore ask Congress to demand a specific
comprehensive and sophisticated strategy of deterrence and
defense against bioweapons. This currently does not exist and
has not trickled down to the local community.
The failure to mandate and implement a centralized Federal
authority has resulted in a void in leadership which, as you-
all alluded to, is remarkable and causes fragmented,
uncoordinated, redundant and inefficient planning and
preparation.
Please authorize and fund a central Federal management and
oversight group, whether it be in Governor Ridge's office or
another, so that we can develop and implement a comprehensive
deterrent and defense strategy, and we can have better
communication and cooperation and integration between the
Federal family and the local first responders who will be the
first people to protect our country.
I will not discuss planning or detection deficits, you will
discuss those, but I will tell you that I served on the Defense
Science Board's recent task force, and that report was given to
you, I believe, 2 weeks ago. It is remarkably well done. I
apologize for saying so. And I urge you to look at it.
I would like to talk about three other issues.
The failure to maintain our public health system: Not
having a public health infrastructure in this country has
severely retarded our ability to detect, identify and
investigate epidemiologic--appropriate epidemiologic studies.
The Congress, therefore, must ensure that the public health
system be retooled with appropriate capabilities and capacities
for biowarfare, and be linked to emergency and other health
care professionals so we have better detection and better
notification.
This is an added value to the natural epidemics and
infections occurring today that it will benefit such retooling.
The failure to engage hospitals in this endeavor is a severe
problem.
Hospitals are certainly financially frail. There is
overcrowding. There are too few beds, too light staff, and too
little supplies and resources due to financial frailty. There
is no surge capacity. Congress must recognize that emergency
departments and their hospitals are the critical component of
the infrastructure of biodefense, along with public health, and
must take steps to necessarily fortify their abilities.
Finally, the failure to engage emergency health care
professionals has resulted in the lack of awareness of national
strategy, a lack of clinical acumen of the bioagents and a lack
of understanding of their vital roles.
Patients will come to the emergency departments, as you
correctly pointed out. The ER is where we always go. That will
be the incident scene in contrast to the tragedies in New York
City. The first responders will now be emergency physicians,
emergency nurses and emergency medical technicians. So they
must be able to detect and diagnose and notify our system and
implement treatment quickly. Unfortunately, we are not prepared
to do such, as our task force pointed out.
Also, because of that, we may be not only the first
responders, but the second victims, further destroying the
infrastructure of our health care in this country. Congress
must therefore authorize and implement an overall plan for
providing, sustaining and monitoring appropriate educational
experiences for these essential emergency care professionals.
An overarching strategy that our task force recommends you
consider is to no longer fund private contractors through DOD
or DOJ, but to allow HHS or the new office to directly partner
with the professional organizations of all health care
professionals, who communicate, educate, monitor and regulate
their own members on a day-to-day basis.
Don't reinvent the wheel. The wheel is there.
In conclusion, to deter or mitigate any terrorist action
against our country or our people, Congress must provide the
leadership, financial support and organizational and logistical
support requisite to developing a comprehensive national
strategy, preparation and response.
Certainly such preparation is costly, both financially and
personally to all of us. However, America must remain resolute.
For what is the price of our freedom, of our country's well-
being and our citizens' lives?
Thank you for the opportunity.
[The prepared statement of Joseph F. Waeckerle follows:]
Prepared Statement of Joseph F. Waeckerle, Chairman, Task Force of
Health Care and Emergency Services Professionals on Preparedness for
Nuclear, Biological, and Chemical Incidents, The American College of
Emergency Physicians
introduction
Chairman Greenwood and members of the Subcommittee, good morning. I
am Dr. Joseph F. Waeckerle, Editor in Chief of the Annals of Emergency
Medicine, the Journal of the American College of Emergency Physicians.
I am a Board of Emergency Medicine certified physician, and the
Chairman of the American College of Emergency Physicians' Nuclear,
Biological, and Chemical Task Force. I am here today testifying on
behalf of the American College of Emergency Physicians (ACEP), which
represents more than 22,000 emergency physicians and their more than
one hundred million patients.
I want to thank you for the opportunity to appear before you today
to discuss the readiness and capacity of the federal programs to
provide needed health related services in the event of a biological
terrorist attack.
The focus of the nation since September 11 has been on the tragic
and senseless loss of lives caused by terrorists willing to fly air
planes into buildings. I want to talk to you today about the new
weapons of war that have emerged in our modern world which perhaps
represent the greatest long-term threats to our national security.
Preeminent among them are biological warfare agents. To date, our
nation has had very little experience with threatened bioweapon use.
What experience we have had has involved small, isolated events not
indicative of the true potential devastation of bioagents.
The use of biologic agents as weapons of war could approximate the
lethality of a nuclear explosion, can decimate a large population, and
thereby destabilize a nation. It can inflict psychological and economic
hardship and political unrest by attacking small populations in
multiple sites over a protracted period. America's citizens, national
security and international stature are at risk should a bioweapon be
used.
america's state of readiness
There have been numerous analyses of the escalating risks to
America and the considerable deficiencies in our responses to the
threat of any weapon of mass destruction much less biologic warfare.
Internal reports from the Federal government (Defense Science Board,
Defense Threat Reduction Agency, General Accounting Office), external
assessments by august panels such as Hart-Rudman and the Gilmore
commission, and private testimonies including the Smithson report and
individuals before Congress repeatedly warn of the serious deficiencies
in our planning and preparation. Authorities have acted on these
deficiencies, but we must decisively improve much more. Careful
consideration of the existing strategies and response protocols reveals
major deficits that are obvious points of interdiction.
national strategy deficit
A comprehensive national strategy must be predicated on an in-depth
analysis of threats and risks. By identifying credible threats,
available assets, and resultant vulnerabilities, a cogent national
strategy can be generated. To date, the approach has centered on an
``all-hazards'' approach. Most of our nation's hospitals have policies
to respond to hazardous materials (HAZMAT) incident, which are
inadequate for responding to some chemical agents and nearly all
biologic agents. Certainly, conventional weapons are and should be our
main focus. Current planning has also focused on chemical weapons with
many federal agencies and departments specifically addressing these
threats. This is appropriate to a degree because there are currently
about 850,000 facilities in the US using hazardous or extremely
hazardous materials. Better preparation for possible hazardous
materials incidents whether they are the result of industrial accidents
or perpetrated by terrorists is beneficial to our country.
Many governments and civilian authorities rightly believe that
biologic agents suitable for warfare are readily available. The
dissolution of the USSR has led to the cessation of funding for their
once formidable bioweapons facilities and financial hardship for the
employees. As such, security is minimal and personal motivation to
survive, much less profit, is utmost, so bioagents may be ``on the
market.'' Compared with conventional weapons, research and development
of bioagents are economically feasible today for many other nations as
well. Research and development is now where once only a few had the
capability and resources to pursue these avenues. As a result, many
nations/states have aggressively and successfully pursued their own
biowarfare research and development.
There is also legitimate scientific application of microbiology,
which could be used to develop biologic agents. The pharmaceutical
industry, beverage industry, and others pursue research in biology to
benefit mankind. Because of the overlapping assets used for producing
legitimate products and bioweapons, it is extremely difficult to
estimate and regulate research and development activities to prevent
legitimate research from falling into the wrong hands. Today, any
bidder may easily procure samples of bioagents from a variety of
sources both legitimate and illicit.
Even if only small samples of a bioagent are available, technologic
advancements make it possible for nations or organizations to culture
and harvest adequate quantities of an agent relatively inexpensively
and virtually anywhere. Bioagents can also can be easily stored and
transported. Dissemination, which may be most problematic in using
these agents, is now more easily accomplished as well.
For those individuals seeking to gain competency in this area,
knowledge is readily available. Educational opportunities are offered
in the formal education process including high school, college, and
graduate level courses and informally through widespread availability
of knowledge via the Internet. In addition, motivated researchers using
advanced techniques can now build engineered pathogens that are even
more suitable for biowarfare.
The list of agents that could be used in a biological attack is
formidable and growing. Legitimate and nefarious researchers have
scrutinized the naturally occurring agents as to what clinical and
biologic effects are most requisite. Also, newly engineered bioagents
are now more than ever viable threats against which the US is
vulnerable because they are custom built as weapons.
The capability is there, and today's world fosters malcontents,
extremists and malicious opportunists that view the United States with
hostility. These groups include nation/states, groups, and
individuals--both domestic and international--that are motivated by
political, social, economic, religious, or criminal intent. Nations who
could not challenge the United States because of the high cost of
conventional warfare now have the capability through the use of
biologic weapons to challenge our dominance as the sole remaining
superpower. Individuals and groups of zealots, extremists and criminals
also view the recent availability of bioagents as an opportunity to
wage asymmetric warfare in order to exert influence and manipulate the
system for their own gain.
Some authorities have argued that moral constraints will limit the
use of such particularly lethal weapons (weapons of mass destruction)
especially if civilians are exposed. However, the September 11 assaults
on America have shown the contrary.
The inevitable conclusion is that the availability of biowarfare
agents and supporting technologic infrastructure, coupled with the fact
that there are many who are motivated to do harm to the US means that
America must be prepared to defend her homeland against biological
agents. Denial of this threat or the excuse that this threat is too
difficult to plan for is no longer tenable.
Although the probability of a bioattack is difficult to measure,
the consequences are high. Biowarfare is a multidimensional problem due
to the diversity of bioagents each with particular threat
characteristics, plethora of vulnerable targets and varied routes of
dissemination. As such, there is no typical presentation, no easily
recognizable signature to allow easy detection or identification,
limited treatment options and a disturbing array of sequelae. A
biological attack on America will impose unparalleled demands on all
aspects of our government and our societal infrastructure that must be
met.
The consequences of poor preparation are not tenable.
Considerations for the use of potential biological weapons are the sine
qua non of future defense readiness. Biological weapons are such
formidable weapons of uniqueness and complexity that a specific defense
strategy is essential. The triumvirate of research, preparedness and
response issues pertinent to biowarfare are central to the formulation
of a robust strategic blueprint. Congress must demand a specific,
comprehensive and sophisticated strategy of deterrence and defense.
command, control and communication deficits
The United States must designate and give adequate authority to a
central office to coordinate the various agencies involved in emergency
response. A single line of authority is traditional in the Defense
Department and law enforcement for good reason. Yet the United States
has a multitude of federal agencies and departments with vested
interests in WMD preparation, and there is no authority structure. The
result is efforts in formulate and implement a national strategy are
fragmented, uncoordinated, redundant and inefficient. Unfortunately,
the absence of unity not only decays the Federal effort it undermines
the critical partnership between Federal authority and State and local
authorities.
Communication is also a major problem in domestic preparation
today. Due to the lack of an overreaching authority, there is little
communication among active Federal participants in domestic
preparedness. Equally disturbing, the lack of communication among the
Federal families trickles down to the state and local communities. As a
result, preparation for the possible use of WMD especially biological
weapons without Federal assistance is not achievable for most
communities in America. Our communities desperately need guidance and
support but little communication results in little progress. This is an
unacceptable outcome given the risks.
Until authority is mandated, centralized and implemented, turf
battles, egos, pettiness and power and money struggles will preclude
effective use of our dollars and prevent a collaborative and integrated
preparedness process on a national level or local level. Congress
should authorize and fund a centralized Federal management and
oversight office.
planning deficits
Any response to a weapon of mass destruction on American soil will
first be local and community-based perhaps for an extended period of
time. This means that communities must have plans that are well
conceived and effectively coordinated. Although a general plan in most
communities today, the local response is currently not well informed,
not well financed, not well trained or drilled, and not properly
integrated into the overriding federal response. Federal authorities
must ensure coordinated ventures with the local communities but they
must first cooperate among themselves to do so.
Furthermore, current disaster preparedness programs in US
communities are often insufficient in their design in that they are
generally inappropriate for specific preparation and response against
biowarfare. A biological agent incident requires a vastly different
response with regard to management and personnel and resources needed.
The multi-agency, multi-jurisdictional character of the many
uncoordinated strategies being delivered by the Federal family to the
local community makes success against biowarfare a remote possibility.
Congress must direct the centralized the federal management and
oversight office to provide preparedness and response, education,
guidance, and financial support directly to State and local
communities.
response deficits
The cornerstone of the Nation's response will lie in the medical
and public health communities. It is critical they be actively involved
in the threat-assets-risk analy