S. Hrg. 107-440
EFFECTIVE RESPONSES TO THE THREAT OF BIOTERRORISM
=======================================================================
HEARING
BEFORE THE
SUBCOMMITTEE ON PUBLIC HEALTH
OF THE
COMMITTEE ON HEALTH, EDUCATION,
LABOR, AND PENSIONS
UNITED STATES SENATE
ONE HUNDRED SEVENTH CONGRESS
FIRST SESSION
ON
EXAMINING EFFECTIVE RESPONSES TO THE THREAT OF BIOTERRORISM, FOCUSING
ON DETECTION, TREATMENT, AND CONTAINMENT MEASURES
__________
OCTOBER 9, 2001
__________
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COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS
EDWARD M. KENNEDY, Massachusetts, Chairman
CHRISTOPHER J. DODD, Connecticut JUDD GREGG, New Hampshire
TOM HARKIN, Iowa BILL FRIST, Tennessee
BARBARA A. MIKULSKI, Maryland MICHAEL B. ENZI, Wyoming
JAMES M. JEFFORDS (I), Vermont TIM HUTCHINSON, Arkansas
JEFF BINGAMAN, New Mexico JOHN W. WARNER, Virginia
PAUL D. WELLSTONE, Minnesota CHRISTOPHER S. BOND, Missouri
PATTY MURRAY, Washington PAT ROBERTS, Kansas
JACK REED, Rhode Island SUSAN M. COLLINS, Maine
JOHN EDWARDS, North Carolina JEFF SESSIONS, Alabama
HILLARY RODHAM CLINTON, New York MIKE DeWINE, Ohio
J. Michael Myers, Staff Director and Chief Counsel
Townsend Lange McNitt, Minority Staff Director
______
Subcommittee on Public Health
EDWARD M. KENNEDY, Chairman
TOM HARKIN, Iowa BILL FRIST, Tennessee
BARBARA A. MIKULSKI, Maryland JUDD GREGG, New Hampshire
JAMES M. JEFFORDS, Vermont MICHAEL B. ENZI, Wyoming
JEFF BINGAMAN, New Mexico TIM HUTCHINSON, Arkansas
PAUL D. WELLSTONE, Minnesota PAT ROBERTS, Kansas
JACK REED, Rhode Island SUSAN M. COLLINS, Maine
JOHN EDWARDS, North Carolina JEFF SESSIONS, Alabama
HILLARY RODHAM CLINTON, New York CHRISTOPHER S. BOND, Missouri
David Nexon, Staff Director
Dean A. Rosen, Minority Staff Director
(ii)
C O N T E N T S
__________
STATEMENTS
Tuesday, October 9, 2001
Page
Kennedy, Hon. Edward M., Chairman, Committee on Health,
Education, Labor and Pensions.................................. 1
Frist, Hon. Bill, a U.S. Senator from the State of Tennessee..... 5
Cleland, Hon. Max, a U.S. Senator from the State of Georgia; Hon.
Chuck Hagel, a U.S. Senator from the State of Nebraska; Hon.
Evan Bayh, a U.S. Senator from the State of Indiana; Hon. Jon
Corzine, a U.S. Senator from the State of New Jersey...........
Edwards, Hon. John, a U.S. Senator from the State of North
Carolina....................................................... 12
Henderson, M.D., Donald A., Director, Johns Hopkins Center for
Civilian Biodefense Studies, Baltimore, MD; Janet Heinrich,
Director, Health Care and Public Health Issues, U.S. General
Accounting Office, Washington, DC, Mohammad N. Akhter, M.D.,
Executive Director, American Public Health Association,
Washington, DC; and Michael T. Osterholm, Director, Center for
Infectious Disease Research and Policy, University of
Minnesota, Minneapolis, MN..................................... 17
Prepared statements of:......................................
Dr. Henderson............................................ 20
Ms. Heinrich............................................. 24
Dr. Akhter............................................... 38
Mr. Osterholm............................................ 44
ADDITIONAL MATERIAL
Articles, publications, letters, etc.:
The Center for Infectious Disease Research and Policy,
University of Minnesota, and the Workgroup on Bioterrorism
Preparedness............................................... 67
(iii)
EFFECTIVE RESPONSES TO THE THREAT OF BIOTERRORISM
----------
TUESDAY, OCTOBER 9, 2001
U.S. Senate,
Subcommittee on Public Health, of the Committee on Health,
Education, Labor, and Pensions,
Washington, DC.
The subcommittee met, pursuant to notice, at 10:02 a.m., in
room SD-430, Dirksen Senate Office Building, Hon. Edward M.
Kennedy (chairman of the subcommittee) presiding.
Present: Senators Kennedy, Mikulski, Wellstone, Reed,
Edwards, Clinton, Dodd, Murray, Frist, Hutchinson, Collins, and
Sessions.
Opening Statement of Senator Kennedy
The Chairman. We will start the hearing.
We have two very important panels today. First, we welcome
our colleagues to the committee. Then, we have a very important
vote at 10:30.
Three of my colleagues are here now. Senator Frist and I
will make a statement, and I know Senator Edwards is a
cosponsor of this bill with Senator Hagel. Under normal
circumstances, six times five is 30, and that is when the bell
is supposed to ring. It may ring a few moments before, but we
will try to conclude the Senators' statements prior to the
vote. Then we will commence with our second panel. We are
enormously grateful to them for being here and for their help
and assistance to this committee. They are old friends, and we
have benefited and the country has benefited immensely as a
result of their years of study and work on the matter of
bioterrorism and drug-resistant bacteria. We are immensely,
immensely appreciative of their willingness at this time to
give us the benefit of their judgment and also to give us an
idea about where we should be going and additional steps that
should be taken.
We will proceed in that order. I will make a brief opening
statement and recognize Senator Frist, and then we will turn to
our colleagues.
It is a privilege to hold today's hearing on improving the
Nation's preparedness for bioterrorism and to continue the work
that this committee began 3 years ago on this issue of special
importance. Yesterday, Tom Ridge was sworn in as director of
the new Office of Homeland Security. One of the immediate tasks
facing Governor Ridge is to close the gaps in our ability to
deal with the possibility of bioterrorism on American soil. All
of us in Congress stand ready to work with Governor Ridge and
Secretary Thompson on this vital assignment.
The response to the recent confirmed anthrax case in
Florida and the suspected case in Virginia shows that there are
many strengths in our public health and law enforcement
systems. But as our witnesses today will attest, there is still
much to be done. Every day we delay in expanding our
capabilities exposes innocent Americans to needless dangers. We
cannot afford to wait.
Senator Frist and I began addressing this challenge 3 years
ago. Last November, our initial legislation to strengthen the
Nation's capacity to respond to bioterrorism was enacted into
law. Last week, we proposed a fivefold increase in current
Federal funding to deal with the consequences of a possible
bioterrorist attack. Today's hearing will provide further
evidence that our $1.4 billion plan is fully justified.
Our first priority must be to prevent an attack. That means
enhancing our intelligence capability and our ability to
infiltrate terrorist cells. It also means using the renewed
partnership between the United States and Russia to make sure
that dangerous biological agents do not fall into the hands of
terrorists. We have worked with Russia to prevent the spread of
nuclear weapons, and we must work together now to prevent the
spread of biological weapons.
We must also improve America's preparedness for a
bioterrorist attack. The keys to responding effectively to a
bioterrorist attack lie in three key components--immediate
detection, immediate treatment, and immediate containment.
To improve detection, we should enhance the ability of
health professionals to recognize the symptoms of a
bioterrorist attack, identify biological weapons accurately,
and communicate essential medical information rapidly and
securely.
To improve the treatment of victims of a bioterrorist
attack, we must strengthen our hospitals and emergency medical
plans.
To improve containment, we must make certain that Federal
supplies of vaccines and antibiotics are available quickly to
assist local health officials in preventing the disease from
spreading. Developing new medical resources for the future is
also essential. We should use the remarkable skills of our
universities and biotechnology companies to give us new and
better treatments in the battle against bioterrorism.
Senator Frist and I look forward to working with our
colleagues on this committee and in Congress to achieve these
extremely important goals. Senator Edwards and Senator Hagel
have already put forward a number of significant proposals. We
welcome the contributions and leadership of our colleagues,
Senator Corzine, Senator Bayh, and Senator Cleland, a member of
our Armed Services Committee who has taken a particular
leadership position on this issue, as they testify before us
today.
September 11 was a turning point in American history. Our
challenge now is to do everything we can to learn from that
tragic day and prepare effectively for the future.
[The prepared statement of Senator Kennedy follows:]
Prepared Statement of Senator Edward M. Kennedy
It's a privilege to hold today's hearing on improving the
nation's preparedness for bioterrorism, and to continue the
work that this committee began three years ago on this issue of
special importance.
Yesterday, Governor Tom Ridge was sworn in as President
Bush's Director of the new Office of Homeland Security. As our
forces continue their actions over Afghanistan, we can expect
that our enemies will try to strike against our country again.
One of the most immediate tasks facing Governor Ridge as he
takes on this new extraordinary responsibility is to close the
gaps in our ability to deal with the possibility of
bioterrorism on American soil. All of us in Congress stand
ready to work with Governor Ridge and Secretary Thompson on
this vital assignment.
The response of the Centers for Disease Control, the FBI,
and local health authorities to the recent anthrax cases in
Florida shows that there are many strengths in our public
health and law enforcement system. But as our witnesses today
will attest, there is still much to be done.
Last week, Senator Frist and I proposed a five-fold
increase in current federal funding to deal with the
consequences of a possible bioterrorist attack. Today's hearing
will provide further evidence that our $1.4 billion plan is
fully justified, and that we should act now to provide this
emergency funding.
We want to reassure all Americans that much has already
been done to assure their safety from such an attack, and to
minimize the spread of biological agents if an attack does
occur. The kind of heroism we witnessed from average Americans
on September 11--with Americans caring for and protecting their
fellow citizens--would take place once again in responding to a
bioterrorist threat.
But every day we delay in expanding our capabilities
exposes innocent Americans to needless danger. We cannot afford
to wait.
That's why Senator Frist and I began addressing this
challenge three years ago. Last November, our initial
legislation to strengthen the nation's capacity to respond to
bioterrorism was enacted into law. Now we look forward to
working with the Administration and our colleagues in Congress
to assure that the essential work of strengthening these
defenses is accomplished as soon as possible.
Our first priority must be to prevent an attack from ever
occurring. That means moving quickly to enhance our
intelligence capacity and our ability to infiltrate terrorist
cells, wherever they may exist. It also means using the renewed
partnership between the United States and Russia to make sure
that dangerous biological agents do not fall into the hands of
terrorists.
Russia currently holds the largest supply of potential
biological weapons. We have an opportunity now to make needed
progress in securing these dangerous biological materials.
We've worked with Russia to prevent the spread of nuclear
weapons, and we must work together now to prevent the spread of
biological weapons.
We must also enhance America's preparedness for a
bioterrorist attack. Our citizens need not live their lives in
fear of a biological attack, but building strong defenses is
the right thing to do.
Unlike the assaults on New York and Washington, a
biological attack would not be accompanied by explosions and
police sirens. In the days that followed, victims of the attack
would visit their family doctor or the local emergency room,
complaining of fevers, aches in the joints or perhaps a sore
throat. The actions taken in those first few days will do much
to determine how severe the consequences of the attack will be.
The keys to responding effectively to a bioterrorist attack
lie in three key concepts: immediate detection, immediate
treatment and immediate containment.
To improve detection, we should improve the training of
doctors to recognize the symptoms of a bioterrorist attack, so
that precious hours will not be lost as doctors try to diagnose
their patients. As we've seen in recent days, patients with
anthrax and other rarely encountered diseases are often
initially diagnosed incorrectly. In addition, public health
laboratories need the training, the equipment and the personnel
to identify biological weapons as quickly as possible.
In Boston, a recently installed electronic communication
system will enable physicians to report unusual symptoms
rapidly to local health officials, so that an attack could be
identified quickly. Too often, however, as a CDC report has
stated: ``Global travel and commerce can move microbes around
the world at jet speed, yet our public health surveillance
systems still rely on a `Pony Express' system of paper-based
reporting and telephone calls.''
To improve the treatment of victims of a bioterrorist
attack, we must strengthen our hospitals and emergency medical
plans. Boston, New York and a few other communities have plans
to convert National Guard armories and other public buildings
into temporary medical facilities, and other communities need
to be well prepared too. Even cities with extensive plans need
more resources to ensure that those plans will be effective
when they are needed.
To improve containment, we must make certain that federal
supplies of vaccines and antibiotics are available quickly to
assist local public health officials in preventing the disease
from spreading.
Developing new medical resources for the future is also
essential. Scientists recently reported that they had
determined the complete DNA sequence of the microbe that causes
plague. This breakthrough may allow new treatments and vaccines
to be developed against this ancient disease scourge. We should
use the remarkable skills of our universities and biotechnology
companies to give us new and better treatments in the battle
against bioterrorism.
Much has already been done to improve the nation's
readiness, but we need to be even more prepared. Senator Frist
and I look forward to working with our colleagues on this
committee and in Congress to achieve these extremely important
goals. Senator Edwards and Senator Hagel have already put
forward a number of significant proposals. And we welcome the
contributions and leadership of our colleagues, Senator
Corzine, Senator Bayh, and Senator Cleland, as they testify
before us today.
September 11th was a turning point in America's history.
Our challenge now is to do everything we can to learn from that
tragic day, and prepare effectively for the future.
Senator Frist?
Opening Statement of Senator Frist
Senator Frist. Thank you, Mr. Chairman.
As America begins to strike back against Osama bin Laden,
his terrorist cohorts, and the Taliban regime for the brutal
assaults of September 11, today we face the possibility that a
new front in the war on terrorism has opened at home--a second
potentially deadly case of anthrax discovered in Florida just
yesterday.
Just as many of us never imagined that America's commercial
airliners would be converted into weapons of mass destruction,
it is perhaps beyond the grasp of many that the weapons of
choice in the war of the 21st century may well be tularemia,
smallpox, and anthrax. But this should come as no surprise. As
we will hear today, the threats from biological and chemical
agents are real. Terrorist groups have the resources and the
motivation to use germ warfare.
Osama bin Laden has said publicly that it is his religious
duty to acquire weapons of mass destruction, including
biological and chemical weapons. We all know that rapid
advances in agent delivery technology have made the
weaponization of germs much, much easier.
Finally, with the fall of the Soviet Union, the expertise
of thousands and thousands of scientists knowledgeable, trained
professionally in germ warfare, may be available to the highest
bidder. It can be bought.
Unfortunately, as we will also hear today, America is not
yet fully prepared to meet the threat of biological warfare.
Great strides have been made in the past 3 years, but there is
much more to be done. There are gaps to be filled.
Today some of the Nation's leading experts on bioterrorism
will help provide us further guidance as we prepare to meet
this remote yet very real and growing threat. A biological or
chemical attack on our soil could be even more deadly and more
destructive than the recent attacks on the World Trade Center
and the Pentagon.
Without a substantial new Federal investment in our public
health infrastructure, increased intelligence and preventive
measures, expedited development and production of vaccines and
treatments, and constant vigilance on the part of our Nation's
health care workers, a terrorist attack using a deadly
infectious agent, whether delivered through air, through food,
or by any other means, could kill or sicken millions of
Americans.
Senator Kennedy has already mentioned the Public Health
Threats and Emergencies Act of 2000 which originated in this
committee and was ultimately passed. It provides a coherent and
I believe relatively comprehensive framework for responding to
health threats resulting from bioterrorism.
Last week, Senator Kennedy and I asked the administration
and the Senate Committee on Appropriations to provide an
additional $1.4 billion for these activities. The vast majority
of these funds would go toward a one-time investment in
strengthening the response capabilities of our hospitals, our
health care professionals, and local public health agencies
that would indeed form the front line response team in the
aftermath of a bioweapons attack.
I look forward to working with our colleagues in the U.S.
Senate and with the administration toward this goal.
I too would like to recognize those Senators before us for
their leadership on this particular issue. I believe their
presence here is a heartening signal of the growing focus and
commitment on the part of the United States Congress to take
those steps necessary this year to make sure that our Nation is
fully prepared to respond to any threat to the American people.
The Chairman. Thank you very much.
The Chairman. Senator Cleland, we welcome you to our
committee. We enjoy serving with you on the Armed Services
Committee where you have made this a particular area of your
expertise.
Welcome.
STATEMENTS OF HON. MAX CLELAND, A U.S. SENATOR FROM GEORGIA;
HON. CHUCK HAGEL, A U.S. SENATOR FROM NEBRASKA; HON. EVAN BAYH,
A U.S. SENATOR FROM INDIANA; AND HON. JON CORZINE, A U.S.
SENATOR FROM NEW JERSEY
Senator Cleland. Thank you very much, Mr. Chairman. I am
honored to be here with my distinguished colleagues and with
all of you.
Mr. Chairman, we have long known that the threat of
bioterrorism has existed. In the mid-1990's, intelligence
sources believed that Iraq had a sophisticated bioweapons
program, and during the cold war, the Soviet Union produced
unknown quantities of the smallpox virus.
In the wake of the September 11 attack on America, our
intelligence agencies now State that there is a 100 percent
chance of another domestic attack. What form of terror this
attack will take is unknown, but we have seen bin Laden and his
followers become more brutal and complex in their planning.
Are we fully prepared to deal with such bioterrorism
events? The answer at the moment is clearly no.
Look at the results of the Johns Hopkins-sponsored ``Dark
Winter'' smallpox bioterrorism exercise, which my former
colleague and friend Sam Nunn participated in. There was
another exercise, ``TOPOFF,'' regarding top officials regarding
a nuclear and bioterrorism drill conducted this year to test
the capabilities of the Centers for Disease Control and
Prevention, the Federal Emergency Management Agency, the FBI
and DOD. Both of these tests dramatically illustrate that our
response to date is woefully inadequate to deal with a domestic
bioterrorist event and that a reconsideration of both strategy
and organizational structure is needed.
I would like to call the committee's attention this morning
to restructuring and improving dramatically the CDC in Atlanta,
GA, which is an international resource for fighting
bioterrorism.
In 1999, I joined with Senators Kennedy, Mikulski, Murray,
and my late friend Paul Coverdell to address the critically
needed repairs and upgrade of the CDC's buildings and
facilities. This has been an ongoing effort. The CDC is
universally recognized as the lead Federal agency for
protecting the health and safety of people at home and abroad,
as well as the response and readiness for bioterrorist threats
against the United States.
However, Mr. Chairman, before last year, the CDC had been
insufficiently funded to maintain the security of its perimeter
and the safety of its laboratories. The CDC, which is based in
Atlanta, was still using World War II-era buildings from a
reclaimed army base. Scientists and laboratory staff were
patching holes in the ceilings to protect their research
studies. I have seen this kind of thing.
In fiscal year 2001, we started the first year of
compressing a 10-year CDC renovation plan into 5 years. That is
the massive upgrade that we are talking about. This faster
upgrade is more critical now than ever before.
I would like to acknowledge three of Georgia's outstanding
business leaders--Bernie Marcus, former head of Home Depot; Oz
Nelson, former head of UPS; and Phil Jacobs, head of Bell
South--known as friends of the CDC. They called these horrible
situations to my attention.
I would like to commend Senators Kennedy and Frist for your
insights in developing and getting the Public Health Threats
and Emergencies Act passed last year. This measure is critical
in helping us to develop the needed infrastructure.
I also commend key provisions in the measure which would
enable CDC to maximize its bioterrorism response capabilities
and to improve the preparedness of communities and hospitals.
The level of preparedness for homeland defense that we will
need to protect Americans will require money and resources and
will take time. We can and must take the additionally needed
steps and dramatically improve what we have in place,
especially the CDC. This is one reason, Mr. Chairman, why I am
seeking some $100 million extra beyond the $150 million that
the President has requested for this fiscal year 2002 budget,
and which will be going after three-quarters of a billion
dollars of your $1.4 billion bioterrorism budget.
I believe the President has taken an important step with
the creation of a Cabinet-level position for homeland defense,
but one of the key defenders in this homeland of ours is the
CDC, and I urge my colleagues to pay special attention to that
agency.
Thank you very much, Mr. Chairman.
The Chairman. I would just point out for the record,
Senator, that you were tireless in pursuing the importance of
upgrading the physical aspects of the CDC. None of us needs to
be told how important that is in terms of its contribution to
safety and public health. We were able to get that authorized
and funded last year because of your intervention, and that has
played an indispensable role both in New York and Florida.
Senator Cleland. And with the anthrax scare, Mr. Chairman,
the CDC has been able to be on top of that with 100 vials of
antibiotics there to deal with that situation. But what we are
talking about here is a bioterrorist attack where you have mass
casualties, and we are patently unprepared to deal with that.
The Chairman. Thank you very much.
Senator Cleland. I thank the chairman.
The Chairman. Senator Hagel.
Senator Hagel. Mr. Chairman, thank you.
I wish to extend my thanks to you and Senator Frist for
your leadership. It has been very much a part of this issue
over a rather sustained period of time; so to each of you, we
appreciate that leadership and the very fast action that you
are putting into place, especially with this hearing this
morning, and the actions and consequences that will result from
the hearing.
My colleague and your committee colleague, Senator Edwards,
and I collaborated last week on a bill that you mentioned,
Chairman Kennedy, that we have introduced. I would like to take
the time to address some of the general areas of what Senator
Edwards' and my bill will do to hopefully contribute to this
very real threat that our country and the world face, and to
also thank the professionals who will be coming behind this
panel of Senators. They are the real professionals who
understand the issue and who will be charged with some very
significant responsibilities as we set some perimeters for them
and provide them with the new resources that we must.
With that, the bill that Senator Edwards and I have
introduced is a bill that addresses some very general areas of
local, State, and Federal responders, and in particular the
State and local first responders who are the ones who need, it
is our belief, the resources because they are the ones who, as
we have seen in New York and at the Pentagon, must deal with
this on a real case basis and in real time.
So the $1.6 billion bill that Senator Edwards and I have
introduced focuses on some of the following key areas--
developing and stockpiling vaccines and antibiotics at the
Centers for Disease Control, Department of Energy, National
Institutes of Health, and Department of Agriculture; it
provides additional training and equipment to State and local
first responders; it enhances disease surveillance through
coordinated efforts between the CDC and State and local public
health services to provide sophisticated electronic nationwide
access to medical treatment, data, guidelines, and health
alerts.
This bill also strengthens the local public health
networks, including increased training, coordination, and
Federal assistance. It assists local hospital emergency rooms
with response training for personnel, biocontainment, and
decontamination capabilities. It protects food safety and the
agricultural economy from biological and chemical threats. This
is a very significant part, Mr. Chairman, of our bill to focus
on. It is one that I suspect, especially in light of the
conversation that you and I had last week when we testified
before the Senate Appropriations Committee, needs some
attention.
We provide in this bill assistance to States and local
governments and health facilities through a series of block
grants. We believe it is the best approach, the most
accountable and responsible approach, to let these State and
local first responders deal with these resources and frame them
as they believe they need them.
And our bill adds additional funding for Federal Government
programs, much of what we are already doing, but we go further
in some of these areas, and a number of agencies are connected
to our efforts.
Mr. Chairman, Senator Frist, we are all grateful again for
your leadership and for an opportunity for me to represent my
colleague, Senator Edwards, and myself here this morning to
address some of the specifics of our bill and would be pleased
to respond to any questions.
Thank you.
The Chairman. Thank you very much.
Senator Bayh?
Senator Bayh. Thank you very much, Mr. Chairman.
I would like to echo the words of my colleague, Senator
Hagel, in thanking you and Senator Frist for having this
hearing today and for your legislation. It is reassuring to the
country to have two individuals who have dedicated their lives
to the cause of public health leading us in this effort.
Senator Frist, I listened to your comments, and I whole-
heartedly concur. I believe that biological weapons have been
characterized as ``the poor man's nuclear weapon,'' and they
pose a much greater risk to our country today than ever before.
So to both you and Chairman Kennedy, I give my thanks for
focusing on this very timely threat to our national security.
I want to acknowledge the good work of our colleague,
Senator Hagel and my friend and colleague Senator Edwards. My
proposal, Mr. Chairman, builds upon your work and Senator
Frist's work and their work and seeks to refine and perhaps
improve upon the area of State preparedness, which is vitally
important to a successful response to an attack of this kind.
To Senator Cleland, my good friend, I would say, Max, that
my proposal will be squarely within the context of the CDC,
under its umbrella and its good leadership, so I thank you for
your work in this regard as well.
Finally, Mr. Chairman, I am here today not only testifying
in behalf of my own proposal but on behalf of seven of our
colleagues, six of whom also served as former Governors and are
well aware of the important role that State and local
communities play in responding to any attack of this kind.
Mr. Chairman, I would like to build upon your
recommendations, your legislation, and Senator Frist's and also
Senator Hagel's and Senator Edwards', particularly in the area
of State preparedness, because one of the things that we have
learned, as you mentioned in your very eloquent opening
remarks, is that State and local communities are on the front
lines of responding to any threat to our country of this
nature.
Yet, Mr. Chairman, it should be deeply concerning to all of
us that a recent report indicated that too many States are not
as prepared as they need to be to respond to a biological or
chemical attack. As a matter of fact, the GAO just a few months
ago determined that many States lacked the planning, the basic
public health infrastructure, and the ability to respond to
mass casualties or a surge of casualties that would be
occasioned by a biological or chemical attack. And this, Mr.
Chairman, in spite of the $124 million that has been spent over
the last 2 years assisting States and local communities to beef
up their capacity. Clearly, more work needs to be done.
This is vitally important, as both of you have mentioned,
because particularly in the area of a biological attack, it is
quite possible that for the first several days while the
diseases are communicable, cases could go undiagnosed or
misdiagnosed because many of the symptoms, as I am sure Senator
Frist would concur, replicate those of influenza or other
diseases. So it is vitally important, Mr. Chairman, that we
have trained health responders on the scene at the State and
local level to make sure that we respond as comprehensively and
quickly as possible.
Specifically, Mr. Chairman, I propose the following--that
we allocate $5 million per year to each individual State and an
additional $200 million to be allocated on the basis of
population. I believe that this is an improvement, Mr.
Chairman, over the competitive grant approach. Competitive
grants work very well in many circumstances, but here, Mr.
Chairman, I think we simply do not want to leave any State
behind in its preparedness to respond to a biological or
chemical attack.
It would be ironic, Mr. Chairman, if we left some States
out. That would have the unintended consequence perhaps of
identifying them as softer targets for anyone who would wish to
do our country ill. So I would respectfully request that we
allow every State to improve its planning to prepare for this
eventuality.
Our proposal is somewhat more flexible than some others
that have been suggested because it is impossible for those of
us sitting in Washington here today to identify each State's
needs and the myriad possibilities that need to be addressed.
Therefore, we require a plan to be submitted to the Secretary
of Health and Human Services detailing the State's proposal and
describing in depth its training and other initiatives but
giving greater latitude to Governors and local officials to
allocate the resources as needed and as dictated by the
requirements of each individual State.
Finally, Mr. Chairman, we would fund a simulation for each
State so that each State could literally do a run-through of
its plan to see where its strengths and weaknesses are and
obviously improve those areas in need of additional attention.
We require that they be part of the CDC's national
communication network that has been underway for 2 years. We
clearly need to have improved communication.
And finally, Mr. Chairman, we would provide some additional
funding as necessary for the best practices program currently
funded through the CDC so that States and local communities can
learn from one another about what works and what does not work.
Again, Mr. Chairman, I would like to thank you, Senator
Frist, and your colleagues on the committee for your courtesy
today. State Governors and local officials are clearly on the
front lines, and Mr. Chairman, I would like to work with you to
ensure that those who will respond first to a disaster of this
kind are prepared to do so in the most timely and effective
manner.
I thank you for holding the hearing.
The Chairman. Thank you very much. We look forward to
working with all of our panelists.
We are glad to welcome Senator Corzine. His State and its
people have suffered immensely. We can understand why, having
gone through the horrific experience on September 11, Senator
Corzine wants to make sure that we as a country are prepared to
deal with other potential challenges of bioterrorism.
We welcome you.
Senator Corzine. Mr. Chairman, Senator Frist, and members
of the committee, I am truly appreciative of the opportunity to
talk to you about the preparedness issue with regard to
biological and chemical weapons. It is a real issue.
Just this last Friday, I sat with 34 hospital
administrators in New Jersey and discussed this issue, and
quite frankly, I came away chilled and sobered by the lack of
coordinated planning with regard particularly to biological
attacks. It is of very serious concern; I agree with many of
the comments of my colleagues and do believe very much that it
needs to be a very coordinated approach that works with the
States and local governments.
I think there is a growing consensus not only in New Jersey
but across the country that we are unprepared for a serious
biological and chemical attack, and I compliment you and
Senator Frist for your efforts and leadership in this area. I
think it is terrific what you have proposed.
I would like to take it a step further, particularly with
regard to the planning and coordination, and to that end, I
introduced legislation, the Biological and Chemical Attack
Preparedness Act, which happens to be S. 1508, really designed
to build on your efforts, but it deals with improving
coordination and planning of hospitals, State, local, and
Federal governments in responding to these kinds of attacks.
This bill is in concert with Senators Torricelli and Jack
Reed, and the fundamental goal is to ensure that every American
has access to public health resources in the event of such an
attack through pre-prescribed comprehensive and coordinated
planning.
Our Nation's response, Mr. Chairman, to chemical and
biological attacks will depend on a system that, frankly, is
patchwork at best, and the disparities in planning and capacity
of the various States and individual hospitals is really quite
serious. It is in my own State and I suspect across the Nation.
Improving our preparedness will require, first, resources.
My legislation, as the others have suggested, provides for a
grant program that would help hospitals, States, and
municipalities purchase the items, services, and training that
would be needed in the event we need to meet this kind of
disaster.
But simply distributing money is not sufficient in my view.
We also need to ensure that every part of the country is
covered and that they fully take up their responsibility in
this area. We need a systematic, complete, comprehensive
approach to the problem, with more coordination among the many
parties involved.
In an effort to promote such coordination, I would require
each State to promptly develop and implement a public health
disaster plan that addresses biological and chemical weapon
attacks. Each disaster plan would be created in consultation
with the many stakeholders in the State health care
infrastructure, but it would be complete.
The fact is they need to be developed for each individual
State. The needs of New Jersey are more than a little bit
different than those of Wyoming.
The legislation I propose has an accountability feature in
it. It requires certification of the Department of Health and
Human Services that we are meeting that comprehensive coverage
element, and it has a condition that if those plans are not in
place and do not meet the compliance requirements of Health and
Human Services, then Medicaid funding would be held in
abeyance.
As part of the disaster plan, each State would designate
specific hospitals to assume responsibility for meeting related
medical needs. One of the things that is very clear is that
while this patchwork exists, everybody seems to be trying to
meet the same problem, and there is a real need for a
coordinated approach so that we do not overspend in this
effort. We want to have a coordinated and comprehensive
approach.
Mr. Chairman, I thank you for all the efforts that you and
Senator Frist are making. I think we need to have an
accountable system, one that takes into account the ideas of
all those at the local level; but I think we need to move very
quickly. This is a danger, and it is probably not whether, but
when we will have to deal with these issues, as we are seeing
in Florida now.
I appreciate this chance to comment, and I would like to
work with my colleagues to make sure that we have that
comprehensive approach for every American.
Thank you.
The Chairman. Thank you.
Senator Edwards is a cosponsor and is also a member of the
committee. As a matter of courtesy, if you want to make a brief
comment, Senator, in addition to what Senator Hagel has said
about your bill, we would welcome it at this time. Then it
would be our intention to recess and vote and return with the
second panel.
Senator Edwards?
Opening Statement of Senator Edwards
Senator Edwards. Thank you, Mr. Chairman. I will be very
brief because I know we need to get to the second panel.
Senator Hagel covered very well the legislation that he and
I have introduced. I also want to thank the chairman and
Senator Frist for all the work you have done, the leadership
you have shown, and all the members of the panel. We need the
contributions of everyone on this very important issue to our
country.
The focus of Senator Hagel's and my legislation is on the
people who will have to identify that a biological attack has
occurred--your local emergency room, your local public health
department, your family physician. These are the people who
have to be trained and equipped to recognize and identify what
is happening; and once they identify it, they have got to know
what to do with that information.
In effect, what we need to do is provide education and
training for local first responders, and put a disease
surveillance system in place so they can transfer the
information to the place it needs to go.
The second thing we need to do is make to sure that we have
adequate antibiotics and vaccine available to treat whatever
the biological agent is.
And the third priority is to deal with the issue of agri-
terrorism, which I know all of us have had a great concern
about. Senator Frist, Senator Kennedy, and I have discussed
this. We need to protect our food supply, including our crops
and farms.
And I might add that I think a very important component of
our bill is that, in the past, a lot of the funding that has
been appropriated bioterrorism has stayed in Washington, DC. I
think that misallocation is an enormous mistake which our bill
seeks to remedy. We can equip all the expert response teams in
the world here in Washington, but the people who need help are
the people out there on the front lines--the doctors, the
emergency rooms, the nurses, and the public health officials.
Our bill gets the money out of Washington to the place where I
believe that it is most needed--the people on the front lines.
Mr. Chairman, I thank you for allowing me to make a
statement.
Senator Hagel, I thank you for your cosponsorship, and I
thank all my colleagues for their very important contribution
to this issue of national security.
The Chairman. I want to thank all of you very much.
A number of points caught my attention. One was Senator
Bayh's mention of the difference in the grants approach. We
have a competitive grant program because we have limited
resources. Senator Frist can speak to this as well, but we
would support the broader amounts for block grants with
additional resources; we would be glad to work with you. It may
be worthwhile to start that way in order to get this program
started, but we do want to make sure that every State gets
resources--but that moves the total amount up. I certainly feel
that it would be justified, but it is basically a question of
resources. We would be glad to work with you to take that into
account.
Senator Bayh. Thank you, Mr. Chairman.
The Chairman. We thank all of the members. There are a lot
of good ideas and a lot of areas covered that were not included
in our proposal, so we value all of these suggestions. There
will be others of our colleagues who have thought about this
issue and have been meeting with experts back in their own
communities. I think what is important for the American people
to understand is that we have a way to go. But we have members
of the administration and of Congress who are serious about
trying to work through a process to do everything that we
possibly can. We are committed to getting the resources out
there, and we are going to go about our business in getting
this job done.
We look forward to the next panel. They are the real
experts. I think they can give the American people some very
important insights about where we are in addition to what we
should be doing.
We will recess now for 10 minutes.
[Recess.]
The Chairman. The committee will come to order.
We have a very distinguished panel of experts in
bioterrorism. Janet Heinrich led the team that prepared the
recent GAO report on bioterrorism. As we developed legislation
last year, Senator Frist and I were struck by how difficult it
was to get a clear accounting of Federal activities in
bioterrorism. We are grateful to her for the comprehensive and
insightful report on this issue.
We welcome any comments that Senator Mikulski would like to
make by way of introduction of Dr. Donald Henderson.
Senator Mikulski. Thank you very much, Mr. Chairman. Again,
I want to thank you and Senator Frist for organizing this
hearing. What I am so proud of is that both of you have taken
the leadership well before this gruesome attack on the United
States of America. Your leadership in other hearings on
bioterrorism as well as your leadership in improving the public
health infrastructure I think has laid the groundwork for us to
be able to be ready, prepared, and able to respond. So I wish
to thank you.
Mr. Chairman, many of us have been working on this issue
for some time, and I am proud to introduce to you one of the
outstanding people in the United States of America in the field
of epidemiology, eradicating disease, and helping America be
prepared now.
Dr. Donald Henderson comes to the table having recently
been appointed by Secretary Thompson to head his Bioterrorism
Advisory Panel. You could not have picked a better witness, and
Secretary Thompson could not have picked a better person. Dr.
Henderson is known globally for his leadership in eliminating
smallpox around the world and also was dean of the Johns
Hopkins School of Public Health.
After leaving that post, he assembled the Center for
Civilian Biodefense Studies, a small group operating out of
Johns Hopkins that, quite frankly, I have going through
earmarks--those little congressional mandates--because nobody
else thought it was an important issue. Those little earmarks
enabled Dr. Henderson to assemble the staff to do a good job.
I really encourage us to listen to him because yes, we do
need to do prevention and work through our law enforcement and
national security, and yes, we need to be prepared, and we are
going to have questions of Dr. Henderson and the panel, and we
need to be able to respond. I am concerned that, after all the
early surveillance and after all the detection, we will not be
ready to respond because our first responders themselves will
be wounded warriors.
So we look forward to listening to our experts, and Mr.
Chairman, I really think we need to move with a great sense of
urgency both here, with our authorizing, as well as with the
appropriations, because we need to be able to manage the
attacks, and we also need to manage the panic around those
attacks.
So I am very honored to introduce Dr. Henderson to you.
[The prepared statement of Senator Mikulski follows:]
Prepared Statement of Senator Mikulski
Mr. Chairman, thank you for holding this important hearing
today on bioterrorism. I want to applaud you and Senator Frist
for your leadership on this issue. I extend a special welcome
to Dr. D. A. Henderson, Director of the Center for Civilian
Biodefense Studies at Johns Hopkins, a real hero and an expert
in his field.
What happened on September 11th was not only an attack
against America. It was a crime against democracy, and decency.
It was a crime against humanity. American citizens, American
aircraft, American buildings were brought down by these
barbaric terrorist attacks. Yet the American people--and our
free and open society--stand unbowed and united.
Now Americans are more determined than ever to protect the
safety and security of this great nation. Bioterrorism is one
of the gravest threats and greatest challenges we face.
Preparing our federal, state, and local governments to detect
and respond to a bioterrorist attack will require an enormous
commitment of resources and the coordination of nearly every
federal agency. It's a daunting task, but the United States
Congress--and the American people--are up to the challenge.
Efforts are underway. I was proud to be an early cosponsor
of Senator Frist and Senator Kennedy's Public Health Threats
and Emergencies Act that became law last year. Strengthening
our nation's public health infrastructure is essential to our
preparedness for and response to a bioterrorist attack. I have
been working with my colleagues on the Subcommittee and on the
Appropriations Committee over the last couple of years to make
sure we have the infrastructure and resources to prepare
ourselves for this threat. Now it's time to step up these
efforts.
Many federal agencies and departments have been involved--
from the Centers for Disease Control and Prevention to Ft.
Detrick in Maryland that is on the frontline of bioweapons
research to develop our best defense against these weapons. As
Chairman of the Appropriations Subcommittee that funds the
Federal Emergency Management Agency (FEMA), I am working with
Ranking Member Bond and Director Allbaugh to ensure that FEMA
is ready to handle its role of consequence management in the
event of a bioterrorist attack.
An explosion of doctors' visits--not the explosion of a
building--may be the first sign of a bioterrorist attack.
That's why we need a strong public health infrastructure--to
detect a bioterrorist attack; to make sure federal, state, and
local agencies have the resources, tools, and technology to
combat bioterrorism; and to ensure that health professionals
are trained to recognize the symptoms of potential biologic
agents. We must encourage research into new drugs and vaccines
to prevent against the effects of a bioterrorist attack. And we
must give FDA the tools and resources it needs to protect the
safety of our food supply. Investments in the fight against
bioterrorism will pay off in other public health arenas such as
antimicrobial resistance and infectious disease detection.
Public health departments are on the front lines of this new
kind of war. Let's make sure they are combat ready and fit-for-
duty.
Lines of communication and accountability among our federal
agencies, as well as at all levels, must be clear. Cowardly
terrorists don't respect borders or boundaries. I want to make
sure that our government agencies aren't letting jurisdictional
boundaries or smokestack mentalities prevent the type of
critical planning and training our country needs.
I look forward to the testimony of all our witnesses today.
We have much to learn and much to do. This is a national
problem that requires a national solution and national
leadership from the federal government. It requires the best
and the brightest at all levels of government and industry. We
must not wait for another disaster to occur. We must be ready
with a plan of defense and a plan of offense. I look forward to
working with my colleagues to make sure that we are combat
ready for a bioterrorist attack. Thank you.
The Chairman. Thank you so much.
Dr. Henderson, Senator Frist and I both want to thank you
so much for your help in drafting our own legislation. You were
good enough to give up part of your vacation to come back. You
have a longstanding commitment in this area, and we look
forward to your testimony.
I see my colleague Senator Wellstone here, who would like
to introduce a very special witness, and we are glad to hear
from him.
Senator Wellstone. Thank you, Mr. Chairman. I will be very
brief.
Mr. Chairman, it is interesting that Michael Osterholm, of
whom we are very proud in Minnesota, dedicated his book,
``Living Terrors: What America Needs to Know to Survive the
Coming Bioterrorist Catastrophe''--which is unfortunately
prophetic--to ``Donald Henderson who, more than 20 years ago,
led mankind's greatest public health and medical
accomplishment, the eradication of smallpox, and who has
courageously entered the fight again to prevent its horrible
return.''
I also want to honor you, Dr. Henderson. If Dr. Osterholm
does, then I certainly as a Senator from Minnesota will do so
as well.
Michael Osterholm was the former Minnesota State
Epidemiologist, and he has been internationally recognized. I
think Senator Frist and Senator Kennedy have both met with
Michael, and I thank both of you for your very fine work. He
has been an internationally recognized leader in the area of
infectious disease for the past two decades. He is a recipient
of numerous honors and awards, and he served as personal
advisor on bioterrorism to the late King Hussein of Jordan. He
has led numerous successful investigations into infectious
disease outbreaks of global importance. He has lectured around
the world, and he is now director of the Center for Infectious
Disease Research and Policy and professor at the School of
Public Health at the University of Minnesota.
He is a very strong, steady, intelligent, experienced
voice, and we thank him for being with us.
The Chairman. Thank you very much.
We are also fortunate to have Dr. Mohammad Akhter, who has
been a leader in public health, director of the American Public
Health Association. He has been a dedicated and skilled
advocate for better health for all, and through his clinical
practice around the world, he has encountered some of the
infectious diseases that might be used in a biological attack.
So our committee looks forward to hearing from him.
And finally, Janet Heinrich led the team that prepared the
recent GAO report on bioterrorism. I mentioned earlier, Dr.
Heinrich, how helpful it was to get your report and how much we
appreciate your assistance in finding out where the gaps are
and the areas we should be addressing. We are looking forward
to continuing to work with you to try to address those
observations. So, in the great tradition of the GAO, it is very
constructive and helpful work, and we are looking forward to
your testimony.
Dr. Henderson, please.
STATEMENTS OF DR. DONALD A. HENDERSON, DIRECTOR, JOHNS HOPKINS
CENTER FOR CIVILIAN BIODEFENSE STUDIES, BALTIMORE, MD; JANET
HEINRICH, DIRECTOR, HEALTH CARE AND PUBLIC HEALTH ISSUES, U.S.
GENERAL ACCOUNTING OFFICE, WASHINGTON, DC; DR. MOHAMMAD N.
AKHTER, EXECUTIVE DIRECTOR, AMERICAN PUBLIC HEALTH ASSOCIATION,
WASHINGTON, DC; AND MICHAEL T. OSTERHOLM, DIRECTOR, CENTER FOR
INFECTIOUS DISEASE RESEARCH AND POLICY, UNIVERSITY OF
MINNESOTA, MINNEAPOLIS, MN
Dr. Henderson. Thank you, Mr. Chairman and distinguished
members of the committee, for this hearing and for your
leadership in this field, and my appreciation to Senator
Mikulski for her very generous introduction.
Tragically, we find ourselves contemplating the possibility
of a bioterrorist attack on U.S. civilians. As we consider
these grave matters, it is important that we recognize that
that attack is by no means a foregone conclusion; but the risk
of this is not zero.
Some of the distinguished experts in this field have
pointed out that it is difficult to identify a pathogenic
organism, to grow it properly, to put it in the proper form,
and then to disperse it. I think we need to remind some of our
distinguished experts in the field that those who flew the
airplanes into the trade towers did not know how to make
airplanes. They have money, they have access, and they can
coopt that which they do not have.
There is much that can be done if we take some prudent
action beforehand. It has been emphasized by several that the
first responders are health care workers and public health
officials. There are many who still do not appreciate this and
who still seem to think that we would be dealing with fire,
police, and emergency rescue people. They will be needed for
explosive and chemical events, but a bioterrorist attack on the
United States would be completely different from the events of
September 11. It would in all likelihood be a covert attack.
There would be no discrete event, no explosion, no immediately
obvious disaster to which the firefighters and the police and
the ambulances would rush. We would know we had been attacked
only when people began appearing in emergency rooms and
doctors' offices.
Our ability to effectively deal with such an event depends
directly on the capacity of our medical care institutions and
our public health system to quickly recognize that an attack
has occurred, to promptly identify those who might be at risk,
and to deliver effective medical care, possibly on a massive
scale.
A number of steps have been taken to prepare the Nation to
respond, and clearly, I would say from my position that we are
better positioned to do this now than we were several months
ago, indeed, several weeks ago. But there is an awfully great
deal that needs to be done yet.
On October 4, Secretary of Health and Human Services Tommy
Thompson named me to chair an advisory council which is to work
with him in furthering efforts to prepare the Nation to
respond. I am honored to accept this post. The council is
intended to draw on expertise and persons from across the
country with varied experience at local, State, and Federal
levels. The membership of the council and its precise functions
will be established within the next few days.
There is particular concern on the part of your committee
and certainly at this time in the executive office as to needs
in the immediate and near term--really, within the next 30 to
90 days--to better prepare the Nation to respond to possible
acts of bioterrorism, and that is what I will tend to focus on.
In doing so, however, it is important that we bear in mind
that there are no simple actions that we can take or one-time
infusions of funding that will rebuild a deteriorated public
health system quickly and provide the needed surge capacity in
our hospitals to be able to cope on an emergency basis with
large numbers of casualties. We do need a longer-term strategy.
The Department of Health and Human Services over the past
several years, and especially in recent months, has taken a
number of important steps to improve our readiness to respond
to bioterrorism. There are many capable people working on a
number of different projects. The efforts, however, still lack
coherence. The diverse and disconnected efforts have to be
brought together into a single unified program, and that is, I
know, high on the Secretary's agenda. We need a single,
centralized medical and public health strategy for preparing
the Nation to respond.
State and local public health departments across the
country are the real backbone for detection and response to
biological weapons attack, and that has been noted earlier this
morning. They need resources, and they need them urgently if
they are to effectively carry out even the rudimentary actions
which are absolutely essential for dealing with a major
infectious disease outbreak.
It is difficult for me to exaggerate the deficiencies of
our present public health capabilities. Assuming that Federal
funds could expeditiously be made available, there will be need
for an expedited process to get those funds to State and local
levels. Reference has been made to block grants as perhaps
being an approach to do that.
Such funds cannot be overly constrained, because certainly,
priorities and needs do differ from Newark to Phoenix to
Montgomery County, AL.
There are specific public health functions in need of
immediate improvement. If we are to detect and rapidly identify
a new health problem, health officials must be available 24
hours a day, 7 days a week, to take calls from clinicians
reporting cases which may be suggestive of a bioweapons-related
disease. In many areas of the country today, this is not done,
and indeed it is not possible because of lack of personnel to
take those calls.
Support in terms of training and equipment is being
provided to a national network of 80 laboratories capable of
diagnosing the principal threat agents. One of these
laboratories in Florida is the one responsible for the early
diagnosis of the anthrax case. That process needs to be
substantially speeded up--that is, their capacity to
differentiate a number of different organisms which ordinarily
laboratories would not see--so that the full range of potential
agents could be rapidly and accurately identified.
The Department of Health and Human Service began some years
ago to require a national stockpile of drugs and equipment that
could be called upon in case of need for a mass casualty
situation. Because of recent events, the nature and quantity of
materials available will need to be reviewed, and I have been
asked to meet with an expert advisory group later this month to
do exactly that.
Secretary Thompson has initiated a number of steps to
ensure that the supplies of smallpox vaccine are immediately
ready for distribution if needed and has taken steps to expand
the amount of smallpox vaccine available at an early time.
But perhaps the most uncertain part of the equation that
has not really been addressed is how to get those drugs and
vaccines to the population involved in a very short period of
time. Distribution is not easy. Health departments have had
very little experience in the large-scale, rapid distribution
of either drugs or vaccines. Here again is where resources are
needed for the State and local health departments to undertaken
contingency planning for distribution and to prepare
themselves.
However much we try to provide from the Federal level, we
will be highly dependent on the knowledgeable people at the
local level who know the area, as they say, know the territory,
and know the buttons to push to get something done.
For our public health officials, emergency room health
personnel, and infectious disease physicians, educational
materials are urgently in need. At this time, many of these
diseases are totally unknown to those who would be likely to
see cases. To date, few good materials have yet to be provided.
Obviously, it does little good to have a public health
system that can detect disease outbreaks and manage epidemics
if we cannot take care of the sick people. Over the past
decade, our hospitals and the medical care system have labored
under intense financial pressures. One reaction to these
pressures has been the elimination of excess capacity from the
health care system. Today, few hospitals could respond
effectively to a sudden, significant surge in patient demand.
Indeed, based on our contacts with hospitals and hospital
associations, we believe that 500 patients would overwhelm the
health care systems of most cities.
The first step is to recognize that the problem exists and
to encourage hospitals to join forces in the search for
solutions. We would advocate an effort to establish regional
consortia of hospitals, groups of institutions collocated in
cities or counties around the Nation, to begin planning. Here,
they need to plan with the State and local health departments.
But even simple steps will require money, and financial
relief or incentives to enable hospitals to carry out these
initial steps should be considered.
Finally, just a word on research and development. A well-
conceived and integrated plan for research and development is
clearly needed. We have a number of challenges. In the near
term, we could use an improved anthrax vaccine, and a great
deal has been done. With an intensive effort, that vaccine
should be able to be available within a matter of a couple of
years. There are new therapies to treat anthrax. We need drugs
to deal with the complications of smallpox vaccine.
Beyond this, one could envisage an array of solutions that
might prevent the use of biological weapons or at least
mitigate the likelihood of their use and so make bioterrorism
and its consequences less likely or less severe. The science
section of The New York Times today provides an interesting
array to display some of the initiatives that might be taken.
But years and not months will be required for the
development. Regrettably, I am afraid that biological weapons
and biological terrorism will be with us for the foreseeable
future.
Thank you, Mr. Chairman.
The Chairman. Thank you, Dr. Henderson.
[The prepared statement of Dr. Henderson follows:]
Prepared Statement of Donald A. Henderson, M.D., MPH, Director, Johns
Hopkins Center for Civilian Biodefense Studies
Mr. Chairman, distinguished members of the Committee, tragically,
we find ourselves contemplating the possibility of a bioterrorist
attack on US civilians. As we consider these grave matters, it is
important that we recognize that such an attack is by no means a
foregone conclusion although the risk is not zero. However, there is
much that can be done--if we take prudent actions beforehand--to
mitigate the consequences of an epidemic deliberately initiated by
terrorists.
A bioterrorist attack on the US would be completely different from
the events of 11 September. It would in all likelihood be a covert
attack. There would be no discrete ``event''; no explosion, no
immediately obvious disaster to which firefighters and police and
ambulances would rush. We would know we had been attacked only when
people began appearing in emergency rooms and doctors' offices with
inexplicable illnesses or with seemingly common illnesses of unusual
severity.
The ``first responders'' to bioterrorism would be health care
workers and public health officials. Our ability to effectively deal
with such an event depends directly on the capacity of our medical care
institutions and our public health system to quickly recognize that an
attack has occurred; to promptly identify those who might be a risk; to
deliver effective medical care--possibly on a massive scale; and,
should the bioweapon prove to be transmitted from person to person, to
rapidly track and contain the spread of disease. A number of steps have
been taken to fully prepare the nation to respond and, clearly, we are
better positioned than we were several months ago, indeed several weeks
ago, but much remains to be done.
On October 4, Secretary of Health and Human Services Tommy Thompson
named me Chair of an Advisory body which is to work with the Secretary
in furthering efforts to prepare the nation to respond to acts of
bioterrorism or other attacks which could place large numbers of US
civilian victims needing medical attention. I am honored to accept this
post, but as I am sure you will understand, it is premature to discuss
either the functions or composition of the Advisory Council other than
to say that it will operate in accordance with the Federal Advisory
Committee Act (FACA). It will draw on expertise and persons from across
the country and with varied experience at local, state and federal
level. The membership of the Council and its precise functions will be
established within the next few weeks.
There is concern on the part of your Committee as to needs in the
immediate and near-term--that is, the next 30-60 days--to better
prepare the nation to respond to possible acts of bioterrorism and that
I am happy to address. In doing so, however, it is important that we
bear in mind that there are no simple actions or one-time infusions of
funding that will rebuild a deteriorated public health system and
provide the needed surge capacity in our hospitals to be able to cope,
on an emergency basis, with large numbers of casualties. A longer-term
strategy is critical. We must also, at the same time, embark on a
search for better ways to prevent and treat infectious disease,
especially those diseases likely to be used as biological weapons. We
must find ways to use our significant assets in biomedical research to
make bioweapons effectively obsolete as weapons of mass destruction.
HHS, over the past several years but especially in recent months,
has taken a number of important steps to improve our readiness to
respond to bioterrorism. There have been many laudable new initiatives,
and existing programs that have relevance to bioterrorism response that
have been promoted. Many capable people are working hard on a number of
projects. The efforts, however, lack needed coherence. The task now is
to combine these diverse and disconnected efforts into a unified
program of action. We need a single, centralized medical and public
health strategy for preparing the nation to detect and respond to
bioterrorist attacks. It is an effort that appropriately should be
managed by HHS, integrated across the Department, coordinated with
state and local authorities, and able to interface efficiently with
other federal agencies.
The difficulty of understanding and managing the complex
interactions among the different agencies, levels of government and
private sector organizations that have roles to play in bioterrorism
response is profound. New partnerships must be forged. Policy makers
must be educated to understand the operational realities faced by
hospitals and public health agencies. They must recognize that
protecting national security will demand investments in sectors not
typically considered integral to defense strategy.
State and local public health departments across the country are
the backbone for detection and response to a biological weapons attack.
They need resources and they need them urgently if they are to
effectively carry out even the rudimentary actions that are absolutely
essential for dealing with a major infectious disease outbreak. It is
difficult to exaggerate the deficiencies of our present public health
capacities. Indeed, it is inaccurate to even call the varied public
health structures at state, city and county level a public health
``system'', since many of these units are not connected or coordinated
in any meaningful way. In the near term, it is important that we
identify and support the essential steps needed to make this motley
arrangement functional.
Assuming that federal funds can expeditiously be made available,
there will be a need for an expedited process to get these funds to
state and local level. The leisurely and tortuous administrative
channels will need to be foreshortened so that funds become available
in weeks, not months. Moreover, such funds should not be overly
constrained by restrictive definitions of how they are to be spent. The
variety of needs in the 50 state and 3000 local public health
departments around the country are such that, for a program of this
urgency and complexity, it would not be sensible for the federal
government to dictate what the most urgent spending priorities should
be in Newark or Phoenix or Montgomery County, Maryland.
Public Health Functions in Need of Immediate Improvement
Systems Linking the Medical Community to Public Health
If we are to detect and rapidly identify a new health problem,
public health officials must be available 24 hours a day seven days a
week to take calls from clinicians reporting cases which may be
suggestive of such as a bioweapons-related disease. This is not
possible in most areas of the country. Creating this vital link between
the medical system--which is likely to be where the first evidence of a
bioterrorist attack arises--and public health will in some cases
require hiring more health department staff. In some locales, it may
require purchasing beepers or an answering service. It need not--
indeed, should not be--a high-tech operation, but it is vital to the
early discovery of an intentional epidemic. And early discovery is
vital to saving lives.
Improved Communications and ``Connectivity'' among Public Health
Agencies
There is a need to augment communications at local, state and
federal level to assure the possibility for rapid communications 24
hours per day, 7 days per week between agencies.
Improved Laboratory Diagnostic Capacity
Support in terms of training and equipment is being provided to a
national network of more than 60 laboratories capable of diagnosing the
principal threat agents. This process needs to be substantially speeded
up so that the full range of potential agents can be rapidly and
accurately identified.
Ensuring the Adequacy, Availability of the National Pharmaceutical
Stockpile (NPS)
HHS began some years ago to acquire a national stockpile of drugs
and equipment that could be called upon in time of need for mass
casualty situations. Today, the NPS consists of caches of such
supplies, located in strategic locations around the country. CDC has
reported that these supplies can be delivered within 12 hours to any
point in the nation. Because of recent events, the nature and
quantities of materials available will be reviewed by an expert
advisory group later this month.
In addition, Secretary Thompson has initiated a number of steps to
ensure that the supplies of smallpox vaccine held by the federal
Centers for Disease Control and Prevention (CDC) are immediately ready
for distribution if needed. The Secretary has recently directed that
the amount of smallpox vaccine produced under the HHS contract with
Acambis be significantly increased, and has taken steps to move up the
date of delivery.
Perhaps the most uncertain part of the equation in getting drugs
and vaccine to the population relates to the question of distribution.
Health departments have had little experience in the large scale, rapid
distribution of either drugs or vaccines. Should such be needed, there
predictably would be staggering logistical problems. Here again is
where resources are needed for state and local health departments to
undertake contingency planning for distribution.
Improved Training of Public Health Officials, Emergency Room Health
Personnel and Infectious Disease Physicians
These three groups of professionals along with the laboratory
personnel represent the foundation for early detection, diagnosis,
definition of the epidemic and application of preventive and
therapeutic measures. Educational materials are urgently in need.
Resources are required for training programs, drills, tabletop
exercises, etc. In the longer term there is a need for rigorous
curricula and training programs to prepare public health professionals
to manage deliberate epidemics, and to incorporate public health
practice-related curricula into academic training programs.
Medical Care Functions In Need of Improvement
Obviously, it does little good to have a public health system that
can detect disease outbreaks and manage epidemics if we cannot
effectively take care of sick people. Over the past decade, hospitals
and the medical care system generally, have labored under intense
financial pressures. One reaction to these pressures has been the
elimination of excess capacity from the health care system.
Today, few hospitals could respond effectively to a sudden,
significant surge in patient demand. Research done by the Hopkins
Biodefense Center indicates that no hospital, or geographically
contiguous group of hospitals, could effectively manage even 500
patients demanding sophisticated medical care such as would be required
in an outbreak of anthrax, for example. In the event of a contagious
disease outbreak--such as smallpox--far fewer patients could be
handled. There isn't enough staff, enough supplies, enough drugs on
hand to cope with such an emergency. This problem of lack of surge
capacity has no simple solutions.
The first step is to recognize that the problem exists and to
encourage hospitals to join forces in the search for solutions. We
advocate an immediate effort to establish regional consortia of
hospitals--groups of institutions co-located in cities or counties
around the nation--to begin planning how best to use available
resources most efficiently. Hospitals should immediately review their
existing disaster plans, paying particular attention to management of
mass casualties and to how they would handle large numbers of patients
with potentially contagious disease. Even these simple steps will
require money. Congress should immediately investigate how they might
provide financial relief or incentives to enable hospitals to carry out
these initial steps. Secondly, medical professionals must be made aware
of the possibility of bioterrorist attacks and learn to recognize the
symptoms of the six or so pathogens thought most likely to be used as
bioweapons. It is imperative that clinicians not only be able to
recognize the symptoms of anthrax, smallpox, etc., but that they be
aware of the responsibility to report suspicions of such diseases to
the public health authorities--and that they know exactly who to call
and how to reach them.
Research and Development
A well-conceived and integrated plan for research and development
is needed to deal with a number of challenges--in the near term: an
improved anthrax vaccine, new therapies to treat anthrax, and drugs to
deal with the complications of smallpox vaccine. But beyond this, one
could envisage an array of solutions that might prevent the use of
biological weapons or at least mitigate the likelihood of their use and
so make bioterrorism and its consequences less likely or less severe--
new vaccines and treatments for currently untreatable viral and toxin
diseases; rapid diagnostic tests; sensor systems; and immune
enhancement mechanisms. Years, not months, will be required for their
development but, regrettably, biological weapons and biological
terrorism will be with us for the foreseeable future.
The Chairman. Dr. Heinrich?
Ms. Heinrich. Mr. Chairman and members of the subcommittee,
I appreciate the opportunity to be here today to discuss our
ongoing work on public health preparedness for a domestic
bioterrorist attack.
We recently released a report which you referred to on
Federal research and preparedness activities related to public
health and medical consequences of a bioterrorist attack on the
civilian population. I would like to begin by giving a brief
overview of the findings in our report and then address
weaknesses in the public health infrastructure that we believe
warrant special attention.
We identified more than 20 Federal departments and agencies
as having a role in preparing for or responding to the public
health or medical consequences of a bioterrorist attack. These
agencies are participating in a variety of activities, from
improving the detection of a biological agent and developing
new vaccines to managing a national stockpile of
pharmaceuticals.
Coordination of these activities across departments and
agencies is fragmented. The chart that we have prepared gives
examples of efforts to coordinate these activities at the
Federal level as they existed before the creation of the Office
of Homeland Security. I will not walk you through the whole
chart, but as you can see, a multitude of agencies have
overlapping responsibilities for various aspects of
bioterrorism preparedness. Bringing order to this picture will
be challenging, and as Dr. Henderson said, we are in great need
of coherence.
Federal spending on domestic preparedness for bioterrorist
attacks involving all types of weapons of mass destruction has
risen 310 percent since fiscal year 1998 to approximately $1.7
billion in fiscal year 2001.
Funding information and research in preparedness of a
bioterrorist attack as reported to us by the Federal agencies
involved shows increases year by year from generally low or
zero levels in 1998. For example, within HHS, CDC's
Bioterrorism Preparedness and Response Program first received
funding in fiscal year 1999. Its funding has increased from
approximately $121 million at that time to approximately $194
million in fiscal year 2001.
While many of the Federal activities are designed to
provide support for local responders, inadequacies in the
public health infrastructure at the State and local levels may
reduce the effectiveness of the overall response effort. Our
work has pointed to weaknesses in three key areas--training of
health care providers, communication among responsible parties,
and capacity of hospitals and laboratories.
As we have heard, physicians and nurses in emergency rooms
and private offices will most likely be the first health care
workers to see patients following a bioterrorist attack. They
need training to ensure their ability to make astute
observations of unusual symptoms and patterns and report them
appropriately. Most physicians and nurses have never seen
diseases such as smallpox or plague, and some biological agents
initially produce symptoms that can be easily confused with
influenza or other common illnesses, leading to a delay in
diagnosis.
In addition, physicians and other providers are currently
underreporting identified cases of diseases to the infectious
disease surveillance system.
Because the pathogen used in a biological attack could take
days or weeks to identify, good channels of communication among
the parties involved in the response are essential to ensure as
timely a response as possible. Once the disease outbreak has
been recognized, local health departments will need to
collaborate closely with personnel across a variety of agencies
to bring in the needed expertise and resources.
Past experiences with infectious disease outbreaks have
revealed a lack of sufficient secure channels in sharing such
information.
Adequate laboratory and hospital capacity is also in
question. Even though the West Nile virus outbreak was
relatively small, it strained laboratory resources for several
months. Further, Federal and local officials told us that there
is little or no excess capacity in the health care system in
most communities for accepting and treating mass casualty
patients.
In conclusion, although numerous bioterrorist-related
research and preparedness activities are underway in Federal
agencies, we remain concerned about weaknesses in public health
and medical preparedness at the State and local levels.
Mr. Chairman, this concludes my prepared remarks. I would
be happy to answer questions.
The Chairman. Thank you very much.
[The prepared statement of Ms. Heinrich follows:]
Prepared Statement of Janet Heinrich, Director, Health Care--Public
Health Issues
Mr. Chairman and Members of the Subcommittee: I appreciate the
opportunity to be here today to discuss our work on the activities of
federal agencies to prepare the nation to respond to the public health
and medical consequences of a bioterrorist attack.\1\ Preparing to
respond to the public health and medical consequences of a bioterrorist
attack poses some challenges that are different from those in other
types of terrorist attacks, such as bombings. On September 28, 2001, we
released a report \2\ that describes (1) the research and preparedness
activities being undertaken by federal departments and agencies to
manage the consequences of a bioterrorist attack,\3\ (2) the
coordination of these activities, and (3) the findings of reports on
the preparedness of state and local jurisdictions to respond to a
bioterrorist attack. My testimony will summarize the detailed findings
included in our report, highlighting weaknesses in the public health
infrastructure that we have identified in our ongoing work and which we
believe warrant special attention.
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\1\ Bioterrorism is the threat or intentional release of biological
agents (viruses, bacteria, or their toxins) for the purposes of
influencing the conduct of government or intimidating or coercing a
civilian population.
\2\ See Bioterrorism: Federal Research and Preparedness Activities
(GAO-01-915, Sept. 28, 2001). This report was mandated by the Public
Health Improvement Act of 2000 (P.L. 106505, sec. 102). Also, see the
list of related GAO products at the end of this statement.
\3\ We conducted interviews with and obtained information from the
Departments of Agriculture, Commerce, Defense, Energy, Health and Human
Services, Justice, Transportation, the Treasury, and Veterans Affairs-,
the Environmental Protection Agency-, and the Federal Emergency
Management Agency.
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In summary, we identified more than 20 federal departments and
agencies as having a role in preparing for or responding to the public
health and medical consequences of a bioterrorist attack. These
agencies are participating in a variety of activities, from improving
the detection of biological agents to developing a national stockpile
of pharmaceuticals to treat victims of disasters. Federal departments
and agencies have engaged in a number of efforts to coordinate these
activities on a formal and informal basis, such as interagency work
groups. Despite these efforts, we found evidence that coordination
between departments and agencies is fragmented. We did, however, find
recent actions to improve coordination across federal departments and
agencies. In addition, we found emerging concerns about the
preparedness of state and local jurisdictions, including insufficient
state and local planning for response to terrorist events, a lack of
hospital participation in training on terrorism and emergency response
planning, the timely availability of medical teams and resources in an
emergency, and inadequacies in the public health infrastructure. The
last includes weaknesses in the training of health care providers,
communication among responsible parties, and capacity of laboratories
and hospitals, including the ability to treat mass casualties.
Background
A domestic bioterrorist attack is considered to be a low-
probability event, in part because of the various difficulties involved
in successfully delivering biological agents to achieve large-scale
casualties.\4\ However, a number of cases involving biological agents,
including at least one completed bioterrorist act and numerous threats
and hoaxes, \5\ have occurred domestically. In 1984, a group
intentionally contaminated salad bars in restaurants in Oregon with
salmonella bacteria. Although no one died, 751 people were diagnosed
with foodborne illness. Some experts predict that more domestic
bioterrorist attacks are likely to occur.
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\4\ See Combating Terrorism: Need for Comprehensive Threat and Risk
Assessments of Chemical and Biological Attacks (GAO/NSIAD-99-163, Sept.
14, 1999), pp. 10-15, for a discussion of the ease or difficulty for a
terrorist to create mass casualties by making or using chemical or
biological agents without the assistance of a state-sponsored program.
\5\ For example, in January 2000, threatening letters were sent to
a variety of recipients, including the Planned Parenthood office in
Naples, Florida, warning of the release of anthrax. Federal authorities
found no signs of anthrax or any other traces of harmful substances and
determined these incidences to be hoaxes.
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The burden of responding to such an attack would fall initially on
personnel in state and local emergency response agencies. These ``first
responders'' include firefighters, emergency medical service personnel,
law enforcement officers, public health officials, health care workers
(including doctors, nurses, and other medical professionals), and
public works personnel. If the emergency were to require federal
disaster assistance, federal departments and agencies would respond
according to responsibilities outlined in the Federal Response Plan.
\6\ Several groups, including the Advisory Panel to Assess Domestic
Response Capabilities for Terrorism Involving Weapons of Mass
Destruction (known as the Gilmore Panel), have assessed the
capabilities at the federal, state, and local levels to respond to a
domestic terrorist incident involving a weapon of mass destruction
(WMD), that is, a chemical, biological, radiological, or nuclear agent
or weapon.\7\
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\6\ The Federal Response Plan, originally drafted in 1992 and
updated in 1999, is authorized under the Robert T. Stafford Disaster
Relief and Emergency Assistance Act (Stafford Act; P.L. 93-288, as
amended). The plan outlines the planning assumptions, policies, concept
of operations, organizational structures, and specific assignment of
responsibilities to lead departments and agencies in providing federal
assistance once the President has declared an emergency requiring
federal assistance.
\7\ Some agencies define WMDs to include large conventional
explosives as well.
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While many aspects of an effective response to bioterrorism are the
same as those for any disaster, there are some unique features. For
example, if a biological agent is released covertly, it may not be
recognized for a week or more because symptoms may not appear for
several days after the initial exposure and may be misdiagnosed at
first. In addition, some biological agents, such as smallpox, are
communicable and can spread to others who were not initially exposed.
These differences require a type of response that is unique to
bioterrorism, including infectious disease surveillance, \8\
epidemiologic investigation, \9\ laboratory identification of
biological agents, and distribution of antibiotics to large segments of
the population to prevent the spread of an infectious disease. However,
some aspects of an effective response to bioterrorism are also
important in responding to any type of large-scale disaster, such as
providing emergency medical services, continuing health care services
delivery, and managing mass fatalities.
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\8\ Disease surveillance systems provide for the ongoing
collection, analysis, and dissemination of data to prevent and control
disease.
\9\ Epidemiological investigation is the study of patterns of
health or disease and the factors that influence these patterns.
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Federal Departments and Agencies Reported a Variety of Research and
Preparedness Activities
Federal spending on domestic preparedness for terrorist attacks
involving WMD's has risen 310 percent since fiscal year 1998, to
approximately $1.7 billion in fiscal year 2001, and may increase
significantly after the events of September 11, 2001. However, only a
portion of these funds were used to conduct a variety of activities
related to research on and preparedness for the public health and
medical consequences of a bioterrorist attack. We cannot measure the
total investment in such activities because departments and agencies
provided funding information in various forms--as appropriations,
obligations, or expenditures. Because the funding information provided
is not equivalent,\10\ we summarized funding by department or agency,
but not across the federal government (see apps. I and II).\11\
Reported funding generally shows increases from fiscal year 1998 to
fiscal year 2001. Several agencies received little or no funding in
fiscal year 1998. For example, within the Department of Health and
Human Services (HHS), the Centers for Disease Control and Prevention's
(CDC) Bioterrorism Preparedness and Response Program was established
and first received funding in fiscal year 1999 (see app. I and app.
II). Its funding has increased from approximately $121 million at that
time to approximately $194 million in fiscal year 2001.
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\10\ For example, an agency providing appropriations is not
necessarily indicating the level of its commitments (that is,
obligations) or expenditures for that year--only the amount of budget
authority made available to it by the Congress, some of which may be
unspent. Similarly, an agency that provided expenditure information for
fiscal year 2000 may have obligated the funds in fiscal year 1999 based
on an appropriation for fiscal year 1998. To simplify presentation, we
generally refer to all the budget data we received from agencies as
``reported funding.''
\11\ Although there are generally no specific appropriations for
activities on bioterrorism, some departments and agencies did provide
estimates of the funds they were devoting to activities on
bioterrorism. Other departments and agencies provided estimates for
overall terrorism activities, but were unable to provide funding
amounts for activities on bioterrorism specifically. Still others
stated that their activities were relevant for bioterrorism, but they
were unable to specify the funding amounts. Funding levels for
activities on terrorism, including bioterrorism, were reported for
activities prior to the 2001 Emergency Supplemental Appropriations Act
for Recovery From and Response to Terrorist Attacks on the United
States (P.L. 107-38).
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Research Activities Focus on Detection, Treatment, Vaccination, and
Equipment
Research is currently being done to enable the rapid identification
of biological agents in a variety of settings; develop new or improved
vaccines, antibiotics, and antivirals to improve treatment and
vaccination for infectious diseases caused by biological agents; and
develop and test emergency response equipment such as respiratory and
other personal protective equipment. Appendix I provides information on
the total reported funding for all the departments and agencies
carrying out research, along with examples of this research.
The Department of Agriculture (USDA), Department of Defense (DOD),
Department of Energy, HHS, Department of Justice (DOJ), Department of
the Treasury, and the Environmental Protection Agency (EPA) have all
sponsored or conducted projects to improve the detection and
characterization of biological agents in a variety of different
settings, from water to clinical samples (such as blood). For example,
EPA is sponsoring research to improve its ability to detect biological
agents in the water supply. Some of these projects, such as those
conducted or sponsored by DOD and DOJ, are not primarily for the public
health and medical consequences of a bioterrorist attack against the
civilian population, but could eventually benefit research for those
purposes.
Departments and agencies are also conducting or sponsoring studies
to improve treatment and vaccination for diseases caused by biological
agents. For example, HHS' projects include basic research sponsored by
the National Institutes of Health to develop drugs and diagnostics and
applied research sponsored by the Agency for Healthcare Research and
Quality to improve health care delivery systems by studying the use of
information systems and decision support systems to enhance
preparedness for the delivery of medical care in an emergency.
In addition, several agencies, including the Department of
Commerce's National Institute of Standards and Technology and DOJ's
National Institute of Justice are conducting research that focuses on
developing performance standards and methods for testing the
performance of emergency response equipment, such as respirators and
personal protective equipment.
Preparedness Efforts Include Multiple Actions
Federal departments' and agencies' preparedness efforts have
included efforts to increase federal, state, and local response
capabilities, develop response teams of medical professionals, increase
availability of medical treatments, participate in and sponsor
terrorism response exercises, plan to aid victims, and provide support
during special events such as presidential inaugurations, major
political party conventions, and the Superbowl.\12\ Appendix H contains
information on total reported funding for all the departments and
agencies with bioterrorism preparedness activities, along with examples
of these activities.
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\12\ Presidential Decision Directive 62, issued May 22, 1998,
created a category of special events called National Security Special
Events, which are events of such significance that they warrant greater
federal planning and protection than other special events.
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Several federal departments and agencies, such as the Federal
Emergency Management Agency (FEMA) and CDC, have programs to increase
the ability of state and local authorities to successfully respond to
an emergency, including a bioterrorist attack. These departments and
agencies contribute to state and local jurisdictions by helping them
pay for equipment and develop emergency response plans, providing
technical assistance, increasing communications capabilities, and
conducting training courses.
Federal departments and agencies have also been increasing their
own capacity to identify and deal with a bioterrorist incident. For
example, CDC, USDA, and the Food and Drug Administration (FDA) are
improving surveillance methods for detecting disease outbreaks in
humans and animals. They have also established laboratory response
networks to maintain state-of-the-art capabilities for biological agent
identification and the characterization of human clinical samples.
Some federal departments and agencies have developed teams to
directly respond to terrorist events and other emergencies. For
example, HHS' Office of Emergency Preparedness (OEP) created Disaster
Medical Assistance Teams to provide medical treatment and assistance in
the event of an emergency. Four of these teams, known as National
Medical Response Team, are specially trained and equipped to provide
medical care to victims of WMD events, such as bioterrorist attacks.
Several agencies are involved in increasing the availability of
medical supplies that could be used in an emergency, including a
bioterrorist attack. CDC's National Pharmaceutical Stockpile contains
pharmaceuticals, antidotes, and medical supplies that can be delivered
anywhere in the United States within 12 hours of the decision to
deploy. The stockpile was deployed for the first time on September 11,
2001, in response to the terrorist attacks on New York City.
Federally initiated bioterrorism response exercises have been
conducted across the country. For example, in May 2000, many
departments and agencies took part in the Top Officials 2000 exercise
(TOPOFF 2000) in Denver, Colorado, which featured the simulated release
of a biological agent. \13\ Participants included local fire
departments, police, hospitals, the Colorado Department of Public
Health and the Environment, the Colorado Office of Emergency
Management, the Colorado National Guard, the American Red Cross, the
Salvation Army, HHS, DOD, FEMA, the Federal Bureau of Investigation
(FBI), and EPA.
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\13\ 1n addition to simulating a bioterrorism attack in Denver, the
exercise also simulated a chemical weapons incident in Portsmouth, New
Hampshire. A concurrent exercise, referred to as National Capital
Region 2000, simulated a radiological event in the greater Washington,
D.C. area.
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Several agencies also provide assistance to victims of terrorism.
FEMA can provide supplemental funds to state and local mental health
agencies for crisis counseling to eligible survivors of presidentially
declared emergencies. In the aftermath of the recent terrorist attacks,
HHS released $1 million in funding to New York State to support mental
health services and strategic planning for comprehensive and long-term
support to address the mental health needs of the community. DOJ's
Office of Justice Programs (OJP) also manages a program that provides
funds for victims of terrorist attacks that can be used to provide a
variety of services, including mental health treatment and financial
assistance to attend related criminal proceedings.
Federal departments and agencies also provide support at special
events to improve response in case of an emergency. For example, CDC
has deployed a system to provide increased surveillance and
epidemiological capacity before, during, and after special events.
Besides improving emergency response at the events, participation by
departments and agencies gives them valuable experience working
together to develop and practice plans to combat terrorism.
Fragmentation Remains Despite Efforts to Coordinate Federal Programs
Federal departments and agencies are using a variety of interagency
plans, work groups, and agreements to coordinate their activities to
combat terrorism. However, we found evidence that coordination remains
fragmented. For example, several different agencies are responsible for
various coordination functions, which limits accountability and hinders
unity of effort; several key agencies have not been included in
bioterrorism-related policy and response planning; and the programs
that agencies have developed to provide assistance to state and local
governments are similar and potentially duplicative. The President
recently took steps to improve oversight and coordination, including
the creation of the Office of Homeland Security.
Departments and Agencies Use a Variety of Methods to Coordinate
Activities
Over 40 federal departments and agencies have some role in
combating terrorism, and coordinating their activities is a significant
challenge. We identified over 20 departments and agencies as having a
role in preparing for or responding to the public health and medical
consequences of a bioterrorist attack. Appendix III, which is based on
the framework given in the Terrorism Incident Annex of the Federal
Response Plan, shows a sample of the coordination efforts by federal
departments and agencies with responsibilities for the public health
and medical consequences of a bioterrorist attack, as they existed
prior to the recent creation of the Office of Homeland Security. This
figure illustrates the complex relationships among the many federal
departments and agencies involved.
Departments and agencies use several approaches to coordinate their
activities on terrorism, including interagency response plans, work
groups, and formal agreements. Interagency plans for responding to a
terrorist incident help outline agency responsibilities and identify
resources that could be used during a response. For example, the
Federal Response Plan provides a broad framework for coordinating the
delivery of federal disaster assistance to state and local governments
when an emergency overwhelms their ability to respond effectively. The
Federal Response Plan also designates primary and supporting federal
agencies for a variety of emergency support operations. For example,
HHS is the primary agency for coordinating federal assistance in
response to public health and medical care needs in an emergency. HHS
could receive support from other agencies and organizations, such as
DOD, USDA, and FEMA, to assist state and local jurisdictions.
Interagency work groups are being used to minimize duplication of
funding and effort in federal activities to combat terrorism. For
example, the Technical Support Working Group is chartered to coordinate
interagency research and development requirements across the federal
government in order to prevent duplication of effort between agencies.
The Technical Support Working Group, among other projects, helped to
identify research needs and fund a project to detect biological agents
in food that can be used by both DOD and USDA.
Formal agreements between departments and agencies are being used
to share resources and knowledge. For example, CDC contracts with the
Department of Veterans Affairs (VA) to purchase drugs and medical
supplies for the National Pharmaceutical Stockpile because of VA's
purchasing power and ability to negotiate large discounts.
Coordination Remains Fragmented Within the Federal Government
Overall coordination of federal programs to combat terrorism is
fragmented.\14\ For example, several agencies have coordination
functions, including DOJ, the FBI, FEMA, and the Office of Management
and Budget. Officials from a number of the agencies that combat
terrorism told us that the coordination roles of these various agencies
are not always clear and sometimes overlap, leading to a fragmented
approach. We have found that the overall coordination of federal
research and development efforts to combat terrorism is still limited
by several factors, including the compartmentalization or security
classification of some research efforts.\15\ The Gilmore Panel also
concluded that the current coordination structure does not provide for
the requisite authority or accountability to impose the discipline
necessary among the federal agencies involved.\16\
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\14\ See also Combating Terrorism: Comments on Counterterrorism
Leadership and National Strategy (GAO-01-556T, Mar. 27,2001), p. 1.
\15\ See Combating Terrorism: Selected Challenges and Related
Recommendations (GAO-01-822, Sept. 20, 2001), pp. 79, 84.
\16\ Advisory Panel to Assess Domestic Response Capabilities for
Terrorism Involving Weapons of Mass Destruction (Gilmore Panel), Toward
a National Strategy for Combating Terrorism, Second Annual Report
(Arlington, Va.: RAND, Dec. 15, 2000), p. 7.
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The multiplicity of federal assistance programs requires focus and
attention to minimize redundancy of effort.\17\ Table 1 shows some of
the federal programs providing assistance to state and local
governments for emergency planning that would be relevant to responding
to a bioterrorist attack. While the programs vary somewhat in their
target audiences, the potential redundancy of these federal efforts
highlights the need for scrutiny. In our report on combating terrorism,
issued on September 20, 2001, we recommended that the President,
working closely with the Congress, consolidate some of the activities
of DOJ's OJP under FEMA. \18\
---------------------------------------------------------------------------
\17\ See also Combating Terrorism: Issues in Managing
Counterterrorist Programs (GAO/T-NSIAD-00-145, Apr. 6, 2000), p. 8.
\18\ See GAO-01-822, Sept. 20, 2001, pp. 104-106.
Table 1: Selected Federal Activities Providing Assistance to State and
Local Governments for Emergency Planning Relevant to a Bioterrorist
Attack
------------------------------------------------------------------------
Department
or agency Activities Target audience
------------------------------------------------------------------------
HHS-CDC Provides grants, technical support, State and local
and performance standards to health agencies.
support bioterrorism preparedness
and response planning.
------------------------------------------------------------------------
HHS-OEP Enters into contracts to enhance Local jurisdictions
medical response capability. The (for fire, police,
program includes a focus on and emergency
response to bioterrorism, medical services;
including early recognition, mass hospitals; public
postexposure treatment, mass health agencies; and
casualty care, and mass fatality other services).
management.
------------------------------------------------------------------------
DOJ-OJP Assists states in developing States (for fire, law
strategic plans. Includes funding enforcement,
for training, equipment emergency medical,
acquisition, technical assistance, and hazardous
and exercise planning and materials response
execution to enhance state and services; hospitals;
local capabilities to respond to public health
terrorist incidents. departments; and
other services).
------------------------------------------------------------------------
FEMA Provides grant assistance to State emergency
support state and local management agencies.
consequence management planning,
training, and exercises for all
types of terrorism, including
bioterrorism.
------------------------------------------------------------------------
Source: Information obtained from departments and agencies.
We have also recommended that the federal government conduct
multidisciplinary and analytically sound threat and risk assessments to
define and prioritize requirements and properly focus programs and
investments in combating terrorism.\19\ Such assessments would be
useful in addressing the fragmentation that is evident in the different
threat lists of biological agents developed by federal departments and
agencies.
---------------------------------------------------------------------------
\19\ See Combating Terrorism: Threat and Risk Assessments Can Help
Prioritize and Target Program Investments (GAO/NSIAD-98-74, Apr. 9,
1998) and GAO/NSIAD-99-163, Sept. 14, 1999.
---------------------------------------------------------------------------
Understanding which biological agents are considered most likely to
be used in an act of domestic terrorism is necessary to focus the
investment in new technologies, equipment, training, and planning.
Several different agencies have or are in the process of developing
biological agent threat lists, which differ based on the agencies'
focus. For example, CDC collaborated with law enforcement,
intelligence, and defense agencies to develop a critical agent list
that focuses on the biological agents that would have the greatest
impact on public health. The FBI, the National Institute of Justice,
and the Technical Support Working Group are completing a report that
lists biological agents that may be more likely to be used by a
terrorist group working in the United States that is not sponsored by a
foreign government. In addition, an official at USDA's Animal and Plant
Health Inspection Service told us that it uses two lists of agents of
concern for a potential bioterrorist attack. These lists of agents,
only some of which are capable of making both animals and humans sick,
were developed through an international process. According to agency
officials, separate threat lists are appropriate because of the
different focuses of these agencies. In our view, the existence of
competing lists makes the assignment of priorities difficult for state
and local officials.
Fragmentation is also apparent in the composition of groups of
federal agencies involved in bioterrorism-related planning and policy.
Officials at the Department of Transportation (DOT) told us that even
though the nation's transportation centers account for a significant
percentage of the nation's potential terrorist targets, the department
was not part of the founding group of agencies that worked on
bioterrorism issues and has not been included in bioterrorism response
plans. DOT officials also told us that the department is supposed to
deliver supplies for FEMA under the Federal Response Plan, but it was
not brought into the planning early enough to understand the extent of
its responsibilities in the transportation process. The department
learned what its responsibilities would be during the TOPOFF 2000
exercise, which simulated a release of a biological agent.
Recent Actions Seek to Improve Coordination Across Federal Departments
and Agencies
In May 2001, the President asked the Vice President to oversee the
development of a coordinated national effort dealing with WMDs.\20\ At
the same time, the President asked the Director of FEMA to establish an
Office of National Preparedness to implement the results of the Vice
President's effort that relate to programs within federal agencies that
address consequence management resulting from the use of WMDs. The
purpose of this effort is to better focus policies and ensure that
programs and activities are fully coordinated in support of building
the needed preparedness and response capabilities. In addition, on
September 20, 2001, the President announced the creation of the Office
of Homeland Security to lead, oversee, and coordinate a comprehensive
national strategy to protect the country from terrorism and respond to
any attacks that may occur. These actions represent potentially
significant steps toward improved coordination of federal activities.
Our recent report highlighted a number of important characteristics and
responsibilities necessary for a single focal point, such as the
proposed Office of Homeland Security, to improve coordination and
accountability. \21\
---------------------------------------------------------------------------
\20\ According to the Office of the Vice President, as of June
2001, details on the Vice President's efforts had not yet been
determined.
\21\ See GAO-01-822, Sept. 20, 2001, pp. 41-42.
---------------------------------------------------------------------------
Despite Federal Efforts, Concerns Exist Regarding Preparedness at State
and Local Levels
Nonprofit research organizations, congressionally chartered
advisory panels, government documents, and articles in peer-reviewed
literature have identified concerns about the preparedness of states
and local areas to respond to a bioterrorist attack. These concerns
include insufficient state and local planning for response to terrorist
events, a lack of hospital participation in training on terrorism and
emergency response planning, questions regarding the timely
availability of medical teams and resources in an emergency, and
inadequacies in the public health infrastructure. In our view, there
are weaknesses in three key areas of the public health infrastructure:
training of health care providers, communication among responsible
parties, and capacity of laboratories and hospitals, including the
ability to treat mass casualties.
Questions exist regarding how effectively federal programs have
prepared state and local governments to respond to terrorism. All 50
states and approximately 255 local jurisdictions have received or are
scheduled to receive at least some federal assistance, including
training and equipment grants, to help them prepare for a terrorist WMD
incident. In 1997, FEMA identified planning and equipment for response
to nuclear, biological, and chemical incidents as areas in need of
significant improvement at the state level. However, an October 2000
research report concluded that even those cities receiving federal aid
are still not adequately prepared to respond to a bioterrorist attack.
\22\
---------------------------------------------------------------------------
\22\ A.E. Smithson and L.-A. Levy, Ataxia: The Chemical and
Biological Terrorism Threat and the U.S. Response (Washington, D.C.:
The Henry L. Stimson Center, Oct. 2000), p. 271.
---------------------------------------------------------------------------
Inadequate training and planning for bioterrorism response by
hospitals is a major problem. The Gilmore Panel concluded that the
level of expertise in recognizing and dealing with a terrorist attack
involving a biological or chemical agent is problematic in many
hospitals. \23\ A recent research report concluded that hospitals need
to improve their preparedness for mass casualty incidents. \24\ Local
officials told us that it has been difficult to get hospitals and
medical personnel to participate in local training, planning, and
exercises to improve their preparedness.
---------------------------------------------------------------------------
\23\ Advisory Panel to Assess Domestic Response Capabilities for
Terrorism Involving Weapons of Mass Destruction, p. 32.
\24\ D.C. Wetter, W.E. Daniell, and C.D. Treser, ``Hospital
Preparedness for Victims of Chemical or Biological Terrorism,''
American Journal of Public Health, Vol. 91, No. 5 (May 2001), pp. 710-
16.
---------------------------------------------------------------------------
Local officials are also concerned about whether the federal
government could quickly deliver enough medical teams and resources to
help after a biological attack. \25\ Agency officials say that federal
response teams, such as Disaster Medical Assistance Teams, could be on
site within 12 to 24 hours. However, local officials who have deployed
with such teams say that the federal assistance probably would not
arrive for 24 to 72 hours. Local officials also told us that they were
concerned about the time and resources required to prepare and
distribute drugs from the National Pharmaceutical Stockpile during an
emergency. Partially in response to these concerns, CDC has developed
training for state and local officials in using the stockpile and will
deploy a small staff with the supplies to assist the local jurisdiction
with distribution.
---------------------------------------------------------------------------
\25\ Smithson and Levy, p. 227.
---------------------------------------------------------------------------
Components of the nation's public health system are also not well
prepared to detect or respond to a bioterrorist attack. In particular,
weaknesses exist in the key areas of training, communication, and
hospital and laboratory capacity. It has been reported that physicians
and nurses in emergency rooms and private offices, who will most likely
be the first health care workers to see patients following a
bioterrorist attack, lack the needed training to ensure their ability
to make observations of unusual symptoms and patterns. \26\ Most
physicians and nurses have never seen cases of certain diseases, such
as smallpox or plague, and some biological agents initially produce
symptoms that can be easily confused with influenza or other, less
virulent illnesses, leading to a delay in diagnosis or identification.
Medical laboratory personnel require training because they also lack
experience in identifying biological agents such as anthrax.
---------------------------------------------------------------------------
\26\ Smithson and Levy, p. 248.
---------------------------------------------------------------------------
Because it could take days to weeks to identify the pathogen used
in a biological attack, good channels of communication among the
parties involved in the response are essential to ensure that the
response proceeds as rapidly as possible. Physicians will need to
report their observations to the infectious disease surveillance
system. Once the disease outbreak has been recognized, local health
departments will need to collaborate closely with personnel across a
variety of agencies to bring in the needed expertise and resources.
They will need to obtain the information necessary to conduct
epidemiological investigations to establish the likely site and time of
exposure, the size and location of the exposed population, and the
prospects for secondary transmission. However, past experiences with
infectious disease response have revealed a lack of sufficient and
secure channels for sharing information. Our report last year on the
initial West Nile virus outbreak in New York City found that as the
public health investigation grew, lines of communication were often
unclear, and efforts to keep everyone informed were awkward, such as
conference calls that lasted for hours and involved dozens of people.
\27\
---------------------------------------------------------------------------
\27\ See West Nile Virus Outbreak: Lessons for Public Health
Preparedness (GAO/HEHS-00-180, Sept. 11, 2000), pp. 21-22.
---------------------------------------------------------------------------
Adequate laboratory and hospital capacity is also a concern.
Reductions in public health laboratory staffing and training have
affected the ability of state and local authorities to identify
biological agents. Even the initial West Nile virus outbreak in 1999,
which was relatively small and occurred in an area with one of the
nation's largest local public health agencies, taxed the federal,
state, and local laboratory resources. Both the New York State and the
CDC laboratories were inundated with requests for tests, and the CDC
laboratory handled the bulk of the testing because of the limited
capacity at the New York laboratories. Officials indicated that the CDC
laboratory would have been unable to respond to another outbreak, had
one occurred at the same time. In fiscal year 2000, CDC awarded
approximately $11 million to 48 states and four major urban health
departments to improve and upgrade their surveillance and
epidemiological capabilities. With regard to hospitals, several federal
and local officials reported that there is little excess capacity in
the health care system in most communities for accepting and treating
mass casualty patients. Research reports have concluded that the
patient load of a regular influenza season in the late 1990s overtaxed
primary care facilities and that emergency rooms in major metropolitan
areas are routinely filled and unable to accept patients in need of
urgent care. \28\
---------------------------------------------------------------------------
\28\ J.R. Richards, M.L. Navarro, and R.W. Derlet, ``Survey of
Directors of Emergency Departments in California on Overcrowding,''
Western Journal of Medicine, Vol. 172 (June 2000), pp. 385-88. R.
Derlet, J. Richards, and R. Kravitz, ``Frequent Overcrowding in U.S.
Emergency Departments,'' Academic Emergency Medicine, Vol. 8, No. 2
(2001), pp. 151-55. Smithson and Levy, p. 262.
---------------------------------------------------------------------------
Concluding Observations
We found that federal departments and agencies are participating in
a variety of research and preparedness activities that are important
steps in improving our readiness. Although federal departments and
agencies have engaged in a number of efforts to coordinate these
activities on a formal and informal basis, we found that coordination
between departments and agencies is fragmented. In addition, we remain
concerned about weaknesses in public health preparedness at the state
and local levels, a lack of hospital participation in training on
terrorism and emergency response planning, the timely availability of
medical teams and resources in an emergency, and, in particular,
inadequacies in the public health infrastructure. The latter include
weaknesses in the training of health care providers, communication
among responsible parties, and capacity of laboratories and hospitals,
including the ability to treat mass casualties.
Mr. Chairman, this completes my prepared statement. I would be
happy to respond to any questions you or other Members of the
Subcommittee may have at this time.
Contact and Acknowledgments
For further information about this testimony, please contact me at
(202) 512-7118. Barbara Chapman, Robert Copeland, Marcia Crosse, Greg
Ferrante, Deborah Miller, and Roseanne Price also made key
contributions to this statement.
Appendix 1: Funding for Research
Total Reported Funding for Research on Bioterrorism and Terrorism by Federal Departments and Agencies, Fiscal
Year 2000 and Fiscal Year 2001
----------------------------------------------------------------------------------------------------------------
Dollars in millions
-----------------------------------------------------------------------------------------------------------------
Fiscal year Fiscal year
Department or agency 2000 2001 Sample activities
funding funding
----------------------------------------------------------------------------------------------------------------
U.S. Department of Agriculture (USDA)-- 0 $0.5 Improving detection of biological
Agricultural Research Service agents.
----------------------------------------------------------------------------------------------------------------
Department of Energy $35.5 $39.6 Developing technologies for detecting
and responding to a bioterrorist
attack.
Developing models of the spread of
and exposure to a biological agent
after release.
----------------------------------------------------------------------------------------------------------------
Department of Health and Human Services (HHS)-- $5.0 0 Examining clinical training and
Agency for Healthcare Research and Quality ability of frontline medical staff
to detect and respond to a
bioterrorist threat.
Studying use of information systems
and decision support systems to
enhance preparedness for medical
care in the event of a bioterrorist
event.
----------------------------------------------------------------------------------------------------------------
HHS--Centers for Disease Control and Prevention $48.2 $46.6 Developing equipment performance
(CDC) standards.
Conducting research on smallpox and
anthrax viruses and therapeutics.
----------------------------------------------------------------------------------------------------------------
HHS--Food and Drug Administration (FDA) $8.8 $9.1 Licensing of vaccines for anthrax and
smallpox.