[Senate Hearing 105-630]
[From the U.S. Government Publishing Office]


                                                        S. Hrg. 105-630

 
              PREPAREDNESS FOR EPIDEMICS AND BIOTERRORISM

=======================================================================

                                HEARING

                                before a

                          SUBCOMMITTEE OF THE

            COMMITTEE ON APPROPRIATIONS UNITED STATES SENATE

                       ONE HUNDRED FIFTH CONGRESS

                             SECOND SESSION

                               __________

                            SPECIAL HEARING

                               __________

         Printed for the use of the Committee on Appropriations


 Available via the World Wide Web: http://www.access.gpo.gov/congress/
                                 senate

                                 ______


50-023 cc           U.S. GOVERNMENT PRINTING OFFICE
                            WASHINGTON : 1998

_______________________________________________________________________
            For sale by the U.S. Government Printing Office
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                           ISBN 0-16-057529-X





                      COMMITTEE ON APPROPRIATIONS

                     TED STEVENS, Alaska, Chairman
THAD COCHRAN, Mississippi            ROBERT C. BYRD, West Virginia
ARLEN SPECTER, Pennsylvania          DANIEL K. INOUYE, Hawaii
PETE V. DOMENICI, New Mexico         ERNEST F. HOLLINGS, South Carolina
CHRISTOPHER S. BOND, Missouri        PATRICK J. LEAHY, Vermont
SLADE GORTON, Washington             DALE BUMPERS, Arkansas
MITCH McCONNELL, Kentucky            FRANK R. LAUTENBERG, New Jersey
CONRAD BURNS, Montana                TOM HARKIN, Iowa
RICHARD C. SHELBY, Alabama           BARBARA A. MIKULSKI, Maryland
JUDD GREGG, New Hampshire            HARRY REID, Nevada
ROBERT F. BENNETT, Utah              HERB KOHL, Wisconsin
BEN NIGHTHORSE CAMPBELL, Colorado    PATTY MURRAY, Washington
LARRY CRAIG, Idaho                   BYRON DORGAN, North Dakota
LAUCH FAIRCLOTH, North Carolina      BARBARA BOXER, California
KAY BAILEY HUTCHISON, Texas
                   Steven J. Cortese, Staff Director
                 Lisa Sutherland, Deputy Staff Director
               James H. English, Minority Staff Director
                                 ------                                

 Subcommittee on Departments of Labor, Health and Human Services, and 
                    Education, and Related Agencies

                 ARLEN SPECTER, Pennsylvania, Chairman
THAD COCHRAN, Mississippi            TOM HARKIN, Iowa
SLADE GORTON, Washington             ERNEST F. HOLLINGS, South Carolina
CHRISTOPHER S. BOND, Missouri        DANIEL K. INOUYE, Hawaii
JUDD GREGG, New Hampshire            DALE BUMPERS, Arkansas
LAUCH FAIRCLOTH, North Carolina      HARRY REID, Nevada
LARRY E. CRAIG, Idaho                HERB KOHL, Wisconsin
KAY BAILEY HUTCHISON, Texas          PATTY MURRAY, Washington
TED STEVENS, Alaska                  ROBERT C. BYRD, West Virginia
  (Ex officio)                         (Ex officio)
                      Majority Professional Staff
                            Bettilou Taylor

                      Minority Professional Staff
                              Marsha Simon

                         Administrative Support
                   Jim Sourwine and Jennifer Stiefel


                            C O N T E N T S

                              ----------                              
                                                                   Page
Opening remarks of Senator Lauch Faircloth.......................     1
Statement of Luther L. Fincher, Jr., fire chief, city of 
  Charlotte, NC..................................................     2
    Prepared statement...........................................     5
Statement of Robert Knouss, M.D., Director, Office of Emergency 
  Preparedness, U.S. Department of Health and Human Services.....     8
    Prepared statement...........................................    10
Statement of James M. Hughes, M.D., Director, National Center for 
  Infectious Diseases, Centers for Disease Control and 
  Prevention, U.S. Department of Health and Human Services.......    12
    Prepared statement...........................................    14
Statement of Richard Jackson, M.D., M.P.H., Director, National 
  Center for Environmental Health, Centers for Disease Control 
  and Prevention, U.S. Department of Health and Human Services...    18
    Prepared statement...........................................    19
Potential problems...............................................    22
Prepared statement of Dr. David L. Heymann on behalf of the World 
  Health Organization............................................    30
Statement of Michael Osterholm, Ph.D., chair, Committee on Public 
  Health, Public and Scientific Affairs Board, American Society 
  for Microbiology...............................................    32
    Prepared statement...........................................    35
Statement of Edgar Thompson, M.D., M.P.H., chair, government 
  relations, Association of State and Territorial Health 
  Officials......................................................    40
    Prepared statement...........................................    42
Statement of Ralph D. Morris, M.D., M.P.H., president, National 
  Association of County and City Health Officials................    48
    Prepared statement...........................................    51
  


              PREPAREDNESS FOR EPIDEMICS AND BIOTERRORISM

                              ----------                              


                         TUESDAY, JUNE 2, 1998

                           U.S. Senate,    
    Subcommittee on Labor, Health and Human
     Services, and Education, and Related Agencies,
                               Committee on Appropriations,
                                                    Washington, DC.
    The subcommittee met at 2:14 p.m., in room SD-138, Dirksen 
Senate Office Building, Hon. Lauch Faircloth, presiding.
    Present: Senator Faircloth.

                        NONDEPARTMENTAL WITNESS

STATEMENT OF LUTHER L. FINCHER, JR., FIRE CHIEF, CITY 
            OF CHARLOTTE, NC

                  OPENING REMARKS OF SENATOR FAIRCLOTH

    Senator  Faircloth. The subcommittee will come to order. 
Today the panel will discuss our Nation's preparedness for 
epidemics and bioterrorism.
    As some of you may know, Senator Specter, who had certainly 
planned to be with us, very successfully underwent heart bypass 
surgery and is going to be in the hospital for 5 or 6 days. The 
doctors tell us he is expected to make a full and complete 
recovery and will be back to his normal activities quickly. 
Knowing Arlen and the speed with which he does everything else, 
I would think he would handle this quickly too. But our 
thoughts and prayers are with him, and we wish him and his 
family a speedy recovery.
    I would like to welcome everyone here today to discuss the 
growing problems of epidemics and bioterrorism. I am not a 
scientist but I am a pretty good reader, and a book I read 
recently called the ``Hot Zone'' by Richard Preston got me to 
thinking about what we are going to be talking about today. It 
got me to thinking how long viruses have been around and how 
difficult it is to protect ourselves from them. I have also 
learned about bacteria and how quickly they have become 
resistant to antibiotics which has very important implications 
for both human and animal medicine.
    I am sure everyone here is aware that people are using 
germs and chemicals to try to hurt other people, not in a 
distant war, but right here in the United States. An incident 
recently occurred in my home State of North Carolina. And as I 
learn more about the growing problems of epidemics and 
bioterrorism, I'm concerned about our ability to protect people 
from these threats.
    When bioterrorism is discussed, most people think of a 
military or law enforcement response. Those answers are 
obviously important, but today we want to focus on the public 
health response because I don't think we have devoted the 
resources and attention needed to assure sufficient protection.
    Attorney General Janet Reno and FBI Director Louis Freeh 
share my concerns. During a recent congressional hearing, 
Attorney General Reno said she believes the Centers for Disease 
Control does not have adequate resources to deal with 
bioterrorism. Now this is coming from the U.S. Attorney 
General.
    FBI Director Freeh then added that the Centers for Disease 
Control almost shipped a dangerous biological agent to an 
individual who had created a false identity using a stolen 
letterhead. I mean, the very idea that this potentially very, 
very dangerous material which could have devastated hundreds 
and thousands of people almost was released simply because the 
Centers for Disease Control did not have the resources to 
perform an onsite inspection of the address they were shipping 
the substance to.
    Most of us believe our public health system has adequate 
resources to provide the network needed to protect us from the 
dangers of epidemics and terrorism. This simply is not true. 
Most people would be shocked to learn that less than 40 percent 
of our health departments can connect online to the command 
center at the Centers for Disease Control or to their own State 
health departments because they simply do not have computers. 
Some 20 percent of our health departments are still using 
rotary dial telephones.
    For those who feel we should just ignore the public health 
folks and let law enforcement or the military take charge, I 
suggest you think again.
    The first sign of a deadly new epidemic or serious 
terrorist attack is not going to be announced on the evening 
news. We're not going to see a battleship pull up to our shores 
and offload a microbe army. It will simply start with a large 
number of people falling ill and going to the doctor or 
emergency rooms in the area.
    We are going to hear today from folks who have experienced 
these situations firsthand and can show us all of its vital 
importance to provide more resources to the Centers for Disease 
Control, the Public Health Service, and our State and local 
public health departments.


                SUMMARY STATEMENT OF LUTHER FINCHER, JR.


    Our first witness today will be Luther Fincher who is chief 
of the Charlotte Fire Department, needless to say, Charlotte, 
NC. [Laughter.]
    Chief Fincher played a major role in responding to a recent 
incident that occurred in Charlotte.
    He also serves as vice president of the International 
Association of Fire Chiefs and will become their president in 
the year 2000. I wish all politics was as certain as becoming 
president of the fire chiefs, Luther. [Laughter.]
    Chief Fincher is a former Marine and attended the Kennedy 
School of Government at Harvard. His son Luther is also a 
member of the Charlotte Fire Department.
    Chief Fincher, you may begin.
    Mr. Fincher. Thank you, sir.
    Good afternoon, Mr. Chairman. I am Luther Fincher, chief of 
the Charlotte Fire Department in North Carolina. Thank you for 
this opportunity to speak and to provide input from an 
emergency services perspective to this committee.
    As the fire chief of the city of Charlotte and vice 
president of the International Association of Fire Chiefs, I 
will briefly talk about domestic terrorism in our country, the 
first responders' role, and the public health.
    On the morning of February 5, 1998, at approximately 10 
a.m., a subject entered the front doors of our county court 
located just five blocks from the center of Charlotte. Upon 
entering the security checkpoint, he informed sheriff's 
deputies that he had an explosive device containing a chemical 
that, if released, would hurt a lot of people.
    X rays at the checkpoint revealed that the device was real. 
It was detonated by bomb technicians 17 hours later when they 
determined that it did not contain chemical or biological 
agents. Fortunately for Charlotte, this incident had a positive 
outcome, but it was a wake-up call for us.
    Charlotte lacks sufficient resources and training to deal 
with urban terrorism. The emergency services community is 
neither prepared nor adequately trained to mitigate incidents 
which involve weapons of mass destruction and chemical or 
biological agents. The threat of contamination is an important 
complicating factor. We do not have the means to make sure that 
we can mitigate an incident effectively, treat the victims 
without preventing secondary contamination of emergency 
personnel.
    There are three areas where we must have clear 
understanding and Federal support.
    First is the role of the first responders and Federal 
responders. When an act of terrorism occurs, only local 
emergency responders will provide the first and immediate 
mitigation of the incident. The work accomplished by these 
first responders in the first 2 to 3 hours will likely 
determine the number of lives saved and the ultimate outcome of 
the operation. Without proper training and equipment, first 
responders can take what may be normally considered an everyday 
emergency incident and create a disaster.
    At this point public health is most vulnerable. The local 
health care system must treat patients while ensuring that 
first responders and its own workers do not become victims. 
Public health systems must be prepared to react immediately and 
with the correct information for first responders and our 
citizens. Decontamination procedures and facilities must be 
available, along with sufficient supplies of drugs and 
antidotes for whatever agent is present. The need and the 
challenge are enormous.
    In almost all cases, Federal resources will not arrive for 
6 to 8 hours. When they do arrive, the critical period is long 
past. As the terrorism response time line shows, the local 
first responders are unassisted for the most critical hours. 
Following notification of a terrorist act is an intense and 
vivid period when local first responders cope alone with the 
aftermath of these incidents.
    The National Guard has been designated to work with 
Federal, State, and local officials. The Federal Government 
must acknowledge the role of the National Guard and other 
Federal resources when assimilated into the existing incident 
command system.
    The Bureau of Justice Assistance training materials have 
been successful because they were developed with the National 
Fire Academy. The National Fire Academy's role in preparing 
fire and emergency service leaders for response to terrorism 
must be recognized and enhanced.
    There is also the need for training assistance beyond the 
120 most populous jurisdictions targeted by the Department of 
Justice [DOJ] and the Department of Defense [DOD]. Strategic 
and critical U.S. infrastructures are often located outside 
metropolitan areas. These areas are protected by volunteer 
departments. Congressional mandate must direct that Federal 
training reach fire and emergency services nationwide. The 
resident and nonresident programs of the National Fire Academy 
offer an excellent delivery system that should be utilized to 
the maximum extent possible.
    Second is the incident command system. When Federal 
resources arrive, the incident command system will already be 
in place. The incident commander will plug Federal resources 
into the system. There is an urgent need for all Federal 
agencies which respond to emergencies to understand and adopt 
the incident command system.
    Third is hospital capability. Any large scale incident 
involving weapons of mass destruction or chemical, biological, 
or nuclear agents will sorely test even the largest community's 
ability to deal with mass casualties. Congress needs to examine 
the ability of the hospitals to deal with victims at community 
hospitals or trauma centers under these conditions. Plans must 
be in place to protect local first responders as they mitigate 
incidents before the Federal resources arrive. The need for 
drug and antidote caches, decontamination facilities should be 
a focus of Congress. The Veterans Administration hospitals 
should be considered for an important role.
    In conclusion, I would like to leave you with several 
thoughts and recommendations. The fire and emergency services 
need assistance from the Federal Government in the areas of 
training, detection equipment, personnel protective clothing, 
and mass decontamination capabilities.
    No. 2, the Federal Government must organize its various 
missions and objectives with the clear understanding that once 
a terrorist incident occurs, the local first responder will be 
on the scene and operating within 6 minutes while Federal 
resources will not arrive for 6 hours. The Federal Government 
must understand its supportive and important role when plugged 
into the incident command system.
    No. 3, Federal departments and agencies must involve fire 
and emergency services in conception, design, and review of all 
Federal plans relating to response to terrorist incidents. We 
strongly encourage FEMA support for the National Fire Academy's 
involvement with the Department of Justice and the Department 
of Defense on training issues.


                           PREPARED STATEMENT


    I appreciate the opportunity to appear before you today and 
will be pleased to respond to any questions you may have.
    Senator  Faircloth. Thank you, Chief Fincher, and we will 
get to the questions later.
    [The statement follows:]

              Prepared Statement of Luther L. Fincher, Jr.

         STRENGTHENING THE LOCAL RESPONSE TO DOMESTIC TERRORISM

    Good morning, Mr. Chairman. I am Luther Fincher, Chief of the 
Charlotte Fire Department in North Carolina. I am appearing today as 
second vice president of the International Association of Fire Chiefs. 
We greatly appreciate the opportunity to be here.
    As we look forward to the twenty-first century, we see that the 
emergency services community faces new and difficult threats and 
challenges. These new hazards include many threats that have not been 
adequately dealt with in the past, including domestic terrorism.
    The emergency services community must face the fact that American 
security, intelligence, and law enforcement will not always 
successfully prevent terrorist attacks. Therefore, the emergency 
services must be available when terrorist incidents occur. We must 
understand the ramifications or responding to terrorist incidents, 
which are totally different from traditional large-scale emergencies. 
The safety of emergency service providers will be at stake and must be 
an early consideration. The media will also take an active interest in 
incidents, from start to finish. Our customers have very high 
expectations of government in terrorist situations, and they demand 
extraordinary effort.
    The federal government depends directly on local emergency service 
providers and their actions during the initial emergency phase of a 
terrorist incident. There are many eyes watching. Emergency managers, 
law enforcement personnel, firefighters, and emergency medical 
providers should be aware and prepared for this.

The role of first responders

    When an act of terrorism occurs, the local fire and emergency 
service organizations alone respond immediately to deal with the 
incident and begin mitigation. Their operations in the first two or 
three hours will largely determine the number of lives saved and the 
eventual outcome of the incident. Congress and the federal government 
must clearly understand the role of the local responder. In almost all 
cases, the federal assets responding to an incident will not arrive 
until six to eight hours have passed, well after the most critical 
period. For the record, the International Association of Fire Chief's 
terrorism response timeline shows the anticipated response of emergency 
forces. It clearly demonstrates that local first responders are 
unassisted for the most critical hours.
    This is the point at which public health is most vulnerable. The 
local healthcare system must respond to treat patients while ensuring 
that first responders and its own workers do not become victims as 
well. Time will be of the essence; public health systems must be 
prepared to react without outside assistance. Decontamination policies, 
procedures, and facilities must be available, along with sufficient 
supplies of drugs and antidotes for whatever nuclear, biological, or 
chemical agent is present. The need and challenge is enormous.
    Federal response plans regarding terrorism usually describe two 
roles--crisis management and consequence management. Crisis management 
deals with the enormous task of trying to prevent an incident from 
occurring. Consequence management concerns with planning for an 
incident before it occurs, then for recovery and rehabilitation after 
the event.
    Let me point out a third area--the area called ``local emergency 
response'' immediately after the event. ``Local emergency response'' 
fits between crisis and consequence management. It begins at the point 
immediately following notification of the terrorist act. ``Local 
emergency response'' is that intense and vivid period of several hours 
when local first responders cope with the aftermath of a major 
incident. It is that time when local first responders work alone.
The role of Federal responders
    In 1996, Congress passed two laws regarding acts of terrorism: The 
Antiterrorism and Effective Death Penalty Act and the Nunn-Lugar-
Domenici provisions of the Department of Defense Authorization. Both 
these important laws contain provision designed to help prepare local 
fire and emergency response organizations to deal with acts of 
terrorism. My testimony will focus on the policy issues which Congress 
must address to ensure that the administration delivers what is truly 
needed by American's fire and emergency services.
Department of Defense
    In November 1997, Secretary of Defense William Cohen announced he 
was significantly enhancing the role of the National Guard to work with 
other federal agencies and state and local officials. He recently 
announced establishment of the Consequence Management Program 
Integration Office to oversee the activities of the National Guard and 
reserve components. We welcome this news, as the National Guard, while 
military, is controlled by state government and accessible at the local 
level. In planning a role for the National Guard and the reserve 
component, the federal government must acknowledge that the military 
will be a supportive asset for the incident commander, who most likely 
will be the municipal or volunteer fire chief. We applaud the National 
Guard for its continuing effort to work closely in the IAFC and the 
fire service as it enhances its mission for maximum effectiveness at 
the local level. However, federal assets--military, law enforcement, 
emergency management--must understand that they will necessarily be in 
a support role.
    We request that the authority enhancing the current role of the 
National Guard to support local first responders be clearly defined. We 
need a ``wiring diagram'' of how federal assets are requested. What is 
the federal 911 number?'' How is it activated? Who determines what 
assets will be sent? What are the defined roles for each federal agency 
dispatched? Do they understand that they will report to the local 
incident commander for assignment? The answers to these questions must 
be understood and agreed upon by all parties. There can be no 
hesitation or confusion about any of this after an incident occurs.

Department of Justice

    The IAFC has a close relationship with the Bureau of Justice 
Assistance (BJA) and the FBI. Nancy Gist, Butch Straub, and Andy 
Mitchell of BJA have done an excellent job working with the fire 
service to produce excellent training materials. First was an awareness 
training package which has already trained 8,000 firefighters. 68,000 
are expected to be trained by June 1999. Additionally, more than 80,000 
videotapes warning first responders about the dangers of secondary 
bombs have been distributed to fire, police, and EMS organizations, The 
BJA program has been so successful because it was developed in close 
cooperation with the National Fire Academy (NFA) to ensure its 
acceptance by the fire service. The key role of the National Fire 
Academy in preparing fire and emergency service leaders to respond to 
terrorism must be recognized and enhanced to increase its capability.
    The IAFC has also found the FBI to be most helpful to the fire 
service as we prepare for terrorism. Specifically, we have excellent 
communication links with Bob Blitzer, Rinaldo Campana, and Barbara 
Martinez of the Domestic Terrorism and WMD Sections. We enjoy a high 
level of responsiveness and a willingness to work together in 
coordination of our efforts, and we plan to enhance this relationship 
in the future.

The incident command system

    To quote from the report prepared by the DOD Tiger Team dated 
January 1998, ``Local response to an emergency situation uses the 
Incident Command System (ICS) to ensure that all responders and their 
support assets are coordinated for an effective and efficient response. 
The Incident commander is normally the senior responder of the 
organization with the preponderance of responsibility for the event 
(e.g., fire chief, police chief, or emergency medical).'' That is an 
excellent explanation. When federal assets arrive, ICS will be in 
place. They will be plugged into that system by the Incident Commander. 
Therefore, there is an urgent need for all federal agencies which 
respond to emergencies to adopt the National Fire Academy's Incident 
Command System.

Training and equipment

    Both the Antiterrorism and Effective Death Penalty Act and Nunn-
Lugar-Domenici contain provisions for training and equipping first 
responders. Congress has identified these as the two key roles for the 
federal government in assisting first responders to deal with acts of 
terrorism. Indeed, they are the two crucial elements for which the fire 
and emergency services look to the federal government for assistance. 
Both programs are important, necessary, and beneficial, but both can be 
improved. There needs to be better coordination between the Department 
of Justice and the Department of Defense and the Federal Emergency 
Management Agency (FEMA). Congressional oversight is required.
    A national domestic preparedness consortium has been formed to 
provide operational training, exercises, tests, and evaluation for 
first responders and municipal leaders. This consortium consists of the 
National Exercise Test and Training Center--Nevada Test Site, the 
National Emergency Response and Rescue Training Center--Texas A&M 
University, the National Center for Domestic Preparedness--Ft. 
McCellan, AL, National Center for Bio-Med Research and Training--
Louisiana State University, and the National Energetic Materials 
Research and Testing Center--New Mexico Institute of Mining and 
Technology. These training and exercise areas and supporting 
organizations are important in preparing first responders to deal with 
acts of terrorism. The IAFC endorses the consortium and recommends 
continuing support from Congress as a matter of policy.
    Training must be expanded beyond the 120 most populous 
jurisdictions targeted by DOJ and DOD. Strategic and critical American 
infrastructure--such as water, electric power, and telecommunications 
sites--are often located outside major metropolitan areas. These areas 
are protected by combination career and volunteer departments and by 
all-volunteer departments. Congressional mandate must direct that 
federal training reach the fire and emergency services nationwide. The 
resident and non-resident programs of the National Fire Administration 
offer an excellent existing delivery system that can and should be 
utilized to the maximum extent possible.
    On the equipment issue, there is a clear and demonstrated need for 
sophisticated detection equipment. Firefighters need to know what they 
are facing--what chemical or biological agent. First, this information 
is necessary to protect ourselves and, second, to determine the correct 
strategy and tactics to deal with the incident. When such equipment is 
made available to first responders, provision must be made for training 
on its use, maintenance, spare parts, and future upgrades. This cannot 
be a one-shot deal but rather a continuing partnership between the 
federal government local fire and emergency responders.
    There is also a need to assist local response agencies acquire 
appropriate personal protective equipment. Local fire departments 
simply do not have the resources to purchase all the protective 
equipment necessary to deal with a large-scale chemical or biological 
attack. Federal assistance is vital.
    Another essential equipment need is the ability to engage in a 
large-scale decontamination effort. Some federal organizations, such as 
the Marine Corps' Chemical Biological Response Force, have some 
decontamination capabilities. However, they can only be effective when 
pre-positioned in anticipation of a specific event. The effectiveness 
of the capabilities are greatly diminished when geography dictates a 
response time of six to eight hours. Therefore, local first responders 
and public health providers must have policies, procedures, and 
facilities in place to deal with any nuclear, biological, or chemical 
agent that may be used.
Hospital capability
    In a terrorist incident, the fire and emergency services will be 
responsible for triage, emergency medical treatment, and transportation 
of the sick and wounded. A large-scale WMD incident will sorely test 
even the largest community's ability to deal with mass casualties. 
Congress needs to closely examine the ability of hospitals to deal with 
large numbers of victims. Drug and antidote caches, decontamination 
facilities, and hospital pre-plans must be a focus of congressional 
inquiry and policy. Veterans Administration Hospitals should be 
considered for an important role.

Wireless radio communications

    In 1996, the Public Safety Wireless Advisory Committee submitted 
its report to the Federal Communications Commission. One of its key 
recommendations was that the FCC set aside 2.5 MHZ of spectrum for 
interoperability. We need Congress to push for the policy to direct the 
FCC to establish several frequency ranges for interoperability 
purposes. In the World Trade Center and Oklahoma City incidents, the 
inability of the first responder agencies to communicate with each 
other and then with other levels of government severely hampered 
effective operations. This problem must be corrected.

                               CONCLUSION

    In conclusion, I would like to leave you with several 
recommendations.
  --The fire and emergency services need assistance from the federal 
        government in the areas of training, detection equipment, 
        personal protective equipment, and mass decontamination 
        capabilities.
  --Congress must recognize and direct federal agencies to organize 
        their various missions and objectives with the clear 
        understanding that, once a terrorist event occurs, the local 
        first responders will be on the scene and operating in six 
        minutes while federal assets will not arrive for six hours. The 
        federal government must understand completely its supplemental, 
        supportive role to the local incident commander.
  --Fire and emergency services must be involved in the conception, 
        design, and review of all federal plans relating to response to 
        terrorist incidents. We currently work with the Bureau of 
        Justice Assistance, Federal Bureau of Investigation, and the 
        National Guard. These relationships should continue and should 
        be a matter of congressional policy. We also strongly encourage 
        FEMA support for the National Fire Academy's involvement with 
        DOJ and DOD on fire service training issues.
    Thank you for the opportunity to appear before you today. I will be 
pleased to respond to any questions you may have.

STATEMENT OF ROBERT KNOUSS, M.D., DIRECTOR, OFFICE OF 
            EMERGENCY PREPAREDNESS, U.S. DEPARTMENT OF 
            HEALTH AND HUMAN SERVICES

    Senator  Faircloth. Our second witness will be Dr. Robert 
Knouss.
    Dr. Knouss, is the Director of the Office of Emergency 
Preparedness in the Department of Health and Human Services. 
Dr. Knouss is a graduate of the University of Pennsylvania 
School of Medicine and has served in the Public Health Service 
in positions at the National Institute of Health and the Office 
of Refugee Health.
    Dr. Knouss served as a Deputy Director of the Pan-American 
Health Organization for 10 years before returning to the 
Department of Health and Human Services.
    Dr. Knouss also served as staff for the Senate Labor and 
Human Resources Committee.
    Thank you, Dr. Knouss, and welcome.
    Dr. Knouss. Thank you very much, Senator.
    As you mentioned, my name is Dr. Robert Knouss. I am 
Director of the Office of Emergency Preparedness, and I am 
pleased to have this opportunity to comment and testify before 
you today.
    The Office of Emergency Preparedness is responsible for 
coordinating HHS' continuity of Government, continuity of 
operations, and the provision of public health and medical 
services following emergencies and disasters that sufficiently 
degrade local capacity as to require national assistance. In 
this role we also work with other Federal agencies and the 
private sector to develop capabilities and capacities for 
responding to the health and medical needs of affected 
populations.
    HHS is actively participating in the Department of Justice 
led effort to develop a 5-year interagency counterterrorism and 
technology plan, and that is a mouthful. This effort will 
address specific strategies and requirements for all agencies 
involved in the counterterrorism effort.
    I am also the Director of the National Disaster Medical 
System, which is a partnership between the Department of 
Defense, the Department of Veterans Affairs, Federal Emergency 
Management Agency, and our own Department, as well as the 
private sector. This system can provide medical response to an 
affected area, evacuate patients, and provide definitive care 
if local and State resources are overtaxed. Under the Federal 
response plan, the National Disaster Medical System [NDMS], 
assets are incorporated into Emergency Support Function No. 8, 
Health and Medical Services, and have been deployed to a wide 
variety of emergencies, such as natural disasters, plane 
crashes, and terrorist incidents.
    The Sarin gas attack on the Tokyo subway system and the 
Oklahoma City bombing of the Alfred P. Murrah Federal Building 
left the world shocked by these senseless and horrific acts of 
terrorism. One of our greatest challenges is addressing the 
complex preparedness issues posed by a terrorist use of a 
weapon of mass destruction on civilian populations. The human 
health impact of such a release or detonation is the primary 
consequence of such an attack.
    HHS is taking a systems approach to building response 
capability and capacity at the local, State, and Federal 
levels. Our counterterrorism strategy includes the following 
key elements: Enhancing local resources because disaster 
response in this country begins at the local level, as the 
chief has just indicated; developing partnerships to improve 
local and State health and medical system coordination and 
capability to respond effectively; and improving Federal health 
and medical capability to rapidly augment State and local 
responses. Our resources include those of the National Disaster 
Medical System.
    As part of this system, we have developed specialized 
national medical response teams located in Washington, DC, 
Winston-Salem, Denver, and Los Angeles that can augment local 
resources in the event of a WMD threat or event. Instances 
where these teams have been used include in response to the 
bombing in Centennial Olympic Park, prepositioned to respond if 
needed during the Summit of the Eight last year in Denver, 
during the inauguration in 1997 here in Washington, DC, and in 
the Capitol here in this area during the State of the Union 
Address this year. It was also one of these teams, the one in 
Winston-Salem, that responded under State auspices to the event 
that occurred earlier this year in Charlotte, NC.
    In creating these resources, we have not been alone. Some 
of the key HHS agencies with which we have been working very 
closely to address counterterrorism include the Centers for 
Disease Control and Prevention, the Agency for Toxic Substances 
and Disease Registry, FDA, and the NIH. External to HHS, we 
have been working with other Federal departments and agencies, 
the National Academy of Sciences, and local and State 
governments, as well as with nationally recognized individual 
experts.
    We have also supported 27 major metropolitan areas for the 
development of local metropolitan medical strike team systems. 
These enhancements to existing local response systems are 
designed to provide initial onsite response and provide for 
safe patient transportation to hospital emergency rooms for 
treatment in the event of a WMD terrorist attack. These systems 
are characterized by specially trained responders for on-site 
triage and initial medical treatment, specialized 
pharmaceuticals and decontamination equipment, enhanced 
emergency medical transportation, definitive hospital care, and 
the provision of assistance from the National Disaster Medical 
System, if needed. Our plans are to continue developing local 
MMST systems in conjunction with the Domestic Preparedness 
Program's 120-city initiative. Further system development is 
necessary to assure adequate surveillance, laboratory support, 
and pharmaceutical distribution systems in the event of a 
biological weapon release.
    The program of enhanced preparedness that the President 
called for in his Naval Academy commencement speech on May 22 
and his recent signing of Presidential Decision Directive No. 
62 will strengthen our Nation's defenses against the growing 
threat of unconventional attacks against the people of the 
United States. This directive designates HHS as the lead 
Federal agency in support of FEMA to plan and prepare a 
national response to medical emergencies arising from the 
terrorist use of weapons of mass destruction. We will be 
supported by other Federal agencies in this effort, and 
together we plan to continue to provide enhanced local response 
through the strengthening of local systems and the provision of 
Federal supporting teams, if necessary, for the prevention, 
detection, identification, and public health response to the 
release of a weapon of mass destruction.
    Of significant concern is how best to protect our civilian 
population from biological weapons. In response to the 
President's directive, our Department is exploring a range of 
approaches for upgrading our public health systems for 
detection and warning and for providing medical care for 
massive numbers of affected people. We are examining a broad 
spectrum of needs that includes research and development, 
pharmaceutical stockpiles, public health surveillance, and 
response capabilities.

                           PREPARED STATEMENT

    Secretary Shalala has recently requested that the Assistant 
Secretary for Planning and Evaluation convene a working group 
to develop an HHS strategic plan for strengthening and 
expanding our role in the Governmentwide bioterrorism effort. 
Implementation of the plan and oversight of the resulting 
activities will be the responsibility of the Assistant 
Secretary for Health and the Surgeon General.
    I want to thank you very much, Senator, for this 
opportunity to appear before you today on this very important 
issue, and I would be glad to eventually answer any questions 
you may have.
    Senator  Faircloth. Thank you, Dr. Knouss.
    [The statement follows:]

                  Prepared Statement of Robert Knouss

    Good afternoon. I am Dr. Robert Knouss, Director of the 
Office of Emergency Preparedness in the Department of Health 
and Human Services (HHS). I am pleased to have the opportunity 
to appear before the Senate Appropriations Subcommittee on 
Labor, Health and Human Services and Education on the very 
important topic of the Nation's Public Health Infrastructure 
Regarding Epidemics and Bioterrorism.
    The Office of Emergency Preparedness is responsible for 
coordinating HHS' continuity of government, continuity of 
operations, and the provision of public health and medical 
services following emergencies and disasters that sufficiently 
degrade local capacity as to require national assistance. In 
this role we also work with other federal agencies and the 
private sector to develop capabilities and capacities for 
responding to the health and medical needs of affected 
populations.
    HHS is actively participating in the Department of Justice 
led effort to develop a Five-Year Inter-Agency Counter-
terrorism and Technology Plan. This effort will address 
specific strategies and requirements for all agencies involved 
in the counter-terrorism effort.
    I am also the Director of the National Disaster Medical 
System (NDMS) which is a partnership between the Department of 
Defense, the Department of Veterans Affairs, the Federal 
Emergency Management Agency, HHS and the private sector. This 
system can provide medical response to an affected area, 
evacuate patients, and provide definitive care if local and 
state resources are overtaxed. Under the Federal Response Plan, 
NDMS assets are incorporated into Emergency Support Function 
No. 8, Health and Medical Services, and have been deployed to a 
wide variety of emergencies such as natural disasters, plane 
crashes, and terrorist incidents.
    The Sarin gas attack on the Tokyo subway system and the 
Oklahoma City bombing of the Alfred P. Murrah Federal Building 
left the world shocked by these senseless and horrific acts of 
terrorism. One of our greatest challenges is addressing the 
complex preparedness issues posed by a terrorist use of a WMD 
on civilian populations. The human health impact of such a 
release or detonation is the primary consequence of such an 
attack.
    HHS is taking a ``systems'' approach to building response 
capability and capacity at the local, state and federal levels. 
Our counter-terrorism strategy includes the following key 
elements: Enhancing local resources because disaster response 
in this country begins at the local level; developing 
partnerships to improve local and state health and medical 
system coordination and capability to respond effectively; and 
improving federal health and medical capability to rapidly 
augment state and local responses. Our resources include those 
of the National Disaster Medical System.
    As part of this system, we have developed specialized 
national medical response teams (located in Washington, D.C., 
Winston-Salem, Denver, and Los Angeles) that can augment local 
resources in the event of a WMD threat or event. Instances 
where these teams have been used include: (1) in response to 
the bombing in Centennial Olympic Park; (2) pre-positioned to 
respond if needed during the Summit of the Eight last year in 
Denver; (3) during the Inauguration in 1997; and (4) in the 
Capitol during the State of the Union Address this year. It was 
also one of these teams, the one in Winston-Salem, that 
responded under State auspices, to the event that occurred 
earlier this year in Charlotte, North Carolina.
    In creating these resources, we have not been alone. Some 
of the key HHS agencies with which we have been working very 
closely to address counter-terrorism issues include the Centers 
for Disease Control and Prevention, the Agency for Toxic 
Substances and Disease Registry, the Food and Drug 
Administration, and the National Institutes of Health. External 
to HHS we have been working with other federal departments and 
agencies, the National Academy of Science's Institute of 
Medicine, and local and state governments, as well as with 
nationally recognized individual experts.
    We have also supported 27 major metropolitan areas for the 
development of local Metropolitan Medical Strike Team Systems. 
These enhancements to existing local response systems are 
designed to provide initial on-site response and provide for 
safe patient transportation to hospital emergency rooms for 
treatment in the event of a WMD terrorist attack. These MMST 
Systems are characterized by specially trained responders for 
on-site triage and initial medical treatment; specialized 
pharmaceuticals and decontamination equipment; enhanced 
emergency medical transportation; definitive hospital care; and 
the provision of assistance from the National Disaster Medical 
System, if needed. Our plans are to continue developing local 
MMST Systems in conjunction with the Domestic Preparedness 
Program's 120-city initiative. Further system development is 
necessary to assure adequate surveillance, laboratory support 
and pharmaceutical distribution systems in the event of a 
biological weapon release.
    The program of enhanced preparedness that the President 
called for in his Naval Academy commencement speech on May 
22nd, and his recent signing of Presidential Decision Directive 
62, will strengthen our nation's defenses against the growing 
threat of unconventional attacks against the people of the 
United States. This directive designates HHS as the lead 
Federal agency, in support of FEMA, to plan and prepare a 
national response to medical emergencies arising from the 
terrorist use of weapons of mass destruction. We will be 
supported by other Federal agencies in this effort. Together we 
plan to continue to provide enhanced local response through the 
strengthening of local systems and the provision of Federal 
supporting teams, if necessary--for the prevention, detection, 
identification and public health response to the release of a 
weapon of mass destruction.
    Of significant concern is how best to protect our civilian 
population from biological weapons. In response to the 
President's directive, HHS is exploring a range of approaches 
for upgrading our public health systems for detection and 
warning and for providing medical care for massive numbers of 
affected people. We are examining a broad spectrum of needs 
that includes research and development, pharmaceutical 
stockpiles, public health surveillance, and response 
capabilities.
    Secretary Shalala recently requested that the Assistant 
Secretary for Planning and Evaluation convene a working group 
to develop a HHS strategic plan for strengthening and expanding 
our role in the Government-wide bioterrorism effort. 
Implementation of the plan and oversight of the resulting 
activities will be the responsibility of the Assistant 
Secretary for Health and Surgeon General.
    Thank you for this opportunity to discuss our counter-
terrorism initiatives with you. I would be glad to answer any 
questions.

STATEMENT OF JAMES M. HUGHES, M.D., DIRECTOR, NATIONAL 
            CENTER FOR INFECTIOUS DISEASES, CENTERS FOR 
            DISEASE CONTROL AND PREVENTION, U.S. 
            DEPARTMENT OF HEALTH AND HUMAN SERVICES

    Senator Faircloth. Our third witness will be Dr. James 
Hughes. Dr. Hughes is Assistant Surgeon General and Director of 
the National Center for Infectious Diseases at the Centers for 
Disease Control. Dr. Hughes is a physician and a graduate of 
Stanford University. He completed a fellowship in infectious 
diseases at the University of Virginia and is one of the 
world's foremost experts on infectious diseases. Dr. Hughes, we 
thank you for coming and welcome you here. You may begin your 
testimony.
    Dr. Hughes. Good afternoon. Thank you for that kind 
introduction, Senator.
    I am Dr. James Hughes, Director for the National Center for 
Infectious Diseases at the Centers for Disease Control and 
Prevention. Thank you for the opportunity to be here with Dr. 
Richard Jackson, who is Director of CDC's National Center for 
Environmental Health, to discuss the response to disease 
outbreaks caused by biological and chemical terrorism. I will 
focus on terrorist events involving biological agents, and Dr. 
Jackson will address chemical events.
    The bombings of the World Trade Center in New York and the 
Federal Building in Oklahoma City taught us how vulnerable we 
are to terrorist attacks. A biological or chemical attack used 
to be considered unlikely but now seems entirely possible, 
given the availability of information on how to prepare such 
weapons and activities by groups such as Aum Shinrykyo which 
released nerve gas in Tokyo's subway and experimented with 
biological weapons.
    An attack involving a biological agent may not be 
immediately detectable because of the delay between exposure 
and onset of illness which for infectious diseases can range 
from several hours to several weeks. For example, if the 
organism that causes anthrax were released in an airport, some 
victims might be in other cities or even other countries before 
they experience symptoms. An attack involving an organism such 
as those causing plague or smallpox that is spread from person 
to person could lead to a second and third wave of illness and 
involve health care workers and emergency responders.
    In his recent address at the U.S. Naval Academy, President 
Clinton announced his intention to upgrade our public health 
systems for disease detection and early warning. Many Federal 
agencies are collaborating to formulate policies and strategic 
plans to ensure prompt and effective responses to terrorist 
attacks, and CDC is working with Dr. Knouss in the Office of 
Emergency Preparedness and other Government entities, including 
FDA, DOD, FEMA, and the FBI.
    Protection against terrorism requires a strong public 
health system at the local, State, and national level. CDC's 
plan, Addressing Emerging Infections Disease Threats: A 
Prevention Strategy for the United States, launched an effort 
to rebuild the public health system's capacity to detect and 
respond to infectious diseases. Through fiscal year 1998, $59 
million have been appropriated to implement the plan 
incrementally.
    CDC will issue an updated version of this plan later this 
year which, like the 1994 plan, will emphasize that we must be 
prepared for the unexpected, whether it be an influenza 
pandemic, naturally occurring outbreaks of food-borne disease 
or drug-resistant infections or the deliberate release of 
anthrax by a terrorist.
    The cause of an outbreak is not always clear at first. For 
example, in 1993 a physician with the Indian Health Service in 
the Southwest reported that two previously healthy young people 
had died from acute respiratory failure, and additional cases 
were subsequently identified by other physicians. Investigation 
revealed that the outbreak was not caused intentionally, but 
rather by a previously unrecognized hantavirus spread by 
rodents.
    Senator  Faircloth. Spread by what, Doctor?
    Dr. Hughes. Rodents, deer mice actually. Critters, we say. 
[Laughter.]
    However, the techniques required to diagnose this outbreak 
were similar to those that would be needed to respond to a 
bioterrorist attack.
    Four components of the response to disease outbreaks are 
important to preparedness to address acts of terrorism in a 
coordinated fashion, starting with detection of unusual events. 
After a bioterrorist attack, initial disease detection is 
likely to take place at the local level, so it is essential to 
work with the medical community including emergency medical 
departments, poison control centers, and emergency responders. 
A recent Institute of Medicine report recommended expanding 
CDC's emerging infections initiative to improve State and local 
infrastructure.
    The second component is investigation and response which 
are also likely to take place at the local level initially, as 
we have heard.
    Third, rapid diagnosis will be critical so prevention and 
treatment measures can be implemented quickly. Because the 
agents most likely to be used as bioweapons are not currently 
major public health problems in the United States, we have 
limited biocontainment laboratory space and surge capacity to 
work with them. In addition, future events could involve 
organisms that have been genetically engineered to increase 
their virulence, manifest antibiotic resistance, or evade 
natural or vaccine-induced immunity.
    Finally, communications are crucial as delays will increase 
the probability that more people will be exposed.

                           PREPARED STATEMENT

    In conclusion, a strong and flexible public health 
infrastructure is the best defense against any disease 
outbreak, whether naturally occurring or intentionally caused. 
CDC's ongoing efforts to strengthen disease surveillance and 
response at the local, State, and Federal levels can complement 
efforts to detect and contain diseases caused by bioweapons.
    Thank you very much for your attention. I will be happy to 
answer any questions.
    Senator  Faircloth. Thank you, Dr. Hughes.
    [The statement follows:]

               Prepared Statement of Dr. James M. Hughes

    I am Dr. James M. Hughes, Director, National Center for 
Infectious Diseases, Centers for Disease Control and Prevention 
(CDC). With me today is Dr. Richard Jackson, Director of CDC's 
National Center for Environmental Health. We are here to 
discuss a very important topic: the public health response to 
disease outbreaks caused by biological and chemical terrorism. 
Our testimony summarizes the present system of public health 
surveillance and control at the state, local, and Federal 
levels. I will focus primarily on terrorist events that involve 
biological agents, and Dr. Jackson will address events that 
involve chemical agents.

                    U.S. VULNERABILITY TO TERRORISM

    The bombings of the World Trade Center in New York and the 
Federal building in Oklahoma City taught us how vulnerable we 
are to terrorist attacks within our own borders, even in times 
of peace. We know that in addition to bombs, today's terrorists 
can choose among many highly dangerous agents, including 
biological and chemical agents.
    An attack with a biological or chemical weapon used to be 
considered very unlikely, but now seems entirely possible. Many 
experts believe that it is no longer a matter of ``if'' but of 
``when'' such an attack will occur. They point to the 
accessibility of information on how to prepare biologic and 
chemical weapons (on the Internet and elsewhere) and to 
activities by groups such as Aum Shinrykyo, which, in addition 
to releasing nerve gas in Tokyo's subway, experimented with 
botulism and anthrax. Moreover, the Federal Bureau of 
Investigation (FBI) recently investigated a situation in Las 
Vegas where an individual was in possession of the organism 
causing anthrax. Although the individual had an attenuated 
strain of anthrax used in an animal vaccine rather than a 
virulent strain, the incident provided another reminder of how 
easily a terrorist might cause serious illness and panic in a 
U.S. city.
    The release of a biological agent or chemical toxin may not 
have an immediate impact because of the delay between exposure 
and onset of illness, or incubation period. For example, when 
people are exposed to a pathogen like anthrax or smallpox, they 
will not know that they have been exposed, and they may not 
feel sick for some time. The incubation period may range from 
several hours to a few weeks, depending on the microbe and the 
dosage. If a group of people in an airport were exposed to the 
organism that causes anthrax in an aerosolized form, some of 
them might be far away--perhaps even overseas--by the time they 
experienced the first symptoms.
    Moreover, if an attack involved an organism like those 
causing plague or smallpox that is spread from person to 
person, there could be a second or third wave of illness, and 
health care workers treating patients would be at risk of 
infection. Each wave of illness could be larger than the one 
before, as more and more people were exposed. In the best-case 
scenario, an observant health worker would recognize that 
something out of the ordinary has occurred and alert public 
health authorities. In the worst-case scenario, the first wave 
of cases may not appear to be connected--or may be mistaken for 
other diseases--and the outbreak would continue for some time 
before the diagnosis is made and action is taken to contain it. 
We may have only a short window of opportunity--between the 
time the first cases are identified and a second wave of people 
become ill--to determine that an attack has occurred, to 
identify the organism, and to prevent further spread.
    Most people agree that investing in defense is imperative, 
even at a time when the average American is not threatened by 
war, but defense is not solely through military means. As the 
anthrax example illustrates, the initial response to a 
bioterrorist act is likely to be made by the public health 
community rather than by the military. Protection against 
terrorism requires a strong public health system at the local, 
state, and national levels.

                       PLANNING AND PREPAREDNESS

    Many Federal agencies are working together to formulate 
policies and strategic plans to ensure prompt and effective 
responses to terrorist attacks that employ biological or 
chemical agents. In his commencement address at the U.S. Naval 
Academy on May 22, 1998, President Clinton announced his 
intention to upgrade our public health systems for disease 
detection and early warning, both to improve our preparedness 
against terrorism and to help us cope with naturally occurring 
infectious disease outbreaks. CDC and other agencies are 
assessing what is necessary to implement such an upgrade.
    CDC also is participating in a working group on domestic 
and international surveillance for bioterrorism, conducted 
under the auspices of the Emerging Infections Task Force of the 
Committee on International Science, Engineering, and Technology 
(CISET), National Science and Technology Council. The Task 
Force is based in the White House Office of Science and 
Technology Policy (OSTP). In addition, CDC works on 
bioterrorism issues with the Office of Emergency Preparedness 
(OEP), OSTP, and the National Security Council.
    Interagency planning will be especially important to ensure 
the availability of medical supplies needed to respond to 
terrorist acts. In addition, CDC, the National Institutes of 
Health (NIH), DOD, and other agencies need to collaborate on a 
research agenda to address scientific issues related to 
bioterrorism.

                               CDC'S ROLE

    To respond effectively to the threats of bioterrorism and 
epidemics, CDC and State and local health departments must act 
together as they do in other areas of public health. CDC and 
State and local health departments are the Nation's three-part 
shield of defense against public health threats of all kinds. 
Public health response to terrorism requires recognition of the 
unique, yet interdependent, roles that local, State, and 
Federal agencies play.
    As the Nation's prevention agency, CDC's mission is to 
monitor the health of the U.S. population and investigate and 
contain disease outbreaks, including those that are due to 
deliberate acts of terrorism. In 1994, CDC issued a strategic 
plan, Addressing Emerging Infectious Disease Threats: a 
Prevention Strategy for the United States, which launched a 
major effort to rebuild the component of the U.S. public health 
system that protects U.S. citizens against infectious diseases. 
The plan focuses on four goals, each of which has direct 
relevance to preparedness for bioterrorism: disease 
surveillance and outbreak response; applied research to develop 
diagnostic tests, drugs, vaccines, and surveillance tools; 
disease prevention and control; and infrastructure and 
training. Through fiscal year 1998, $59 million has been 
appropriated to implement the plan incrementally, with the help 
of many partners, beginning with the most critical areas and 
programs, and the President's fiscal year 1999 budget includes 
an additional $20 million to continue this effort.
    CDC intends to issue an updated version of the plan later 
this year. Like the 1994 plan, the new plan emphasizes that we 
must always be prepared for the unexpected--whether it be a 
naturally occurring influenza pandemic, multiply antibiotic 
resistant infections, or the deliberate release of anthrax by a 
terrorist.

                INVESTIGATING DISEASES OF UNKNOWN CAUSE

    CDC is often asked to assist State public health 
authorities or foreign health ministries when the cause of an 
outbreak is unknown. Early in an investigation, it may not be 
possible to know whether an outbreak is caused by an infectious 
agent or a chemical toxin. For example, a recent outbreak of 
acute kidney failure in children in Haiti was thought to be 
infectious, but investigation revealed that the illnesses were 
caused by chemical contamination of a medication used in 
children.
    In recent years, it has become more common for outbreak 
investigators to consider the possibility of a terrorist event 
when they investigate the cause of an outbreak. This 
possibility arose during the investigations of the 1993 
outbreak of hantavirus pulmonary syndrome in the United States, 
the 1994 outbreak of plague in India, and even the 1995 
outbreak of Ebola hemorrhagic fever in the Democratic Republic 
of the Congo (then Zaire).
    Whether an outbreak has a natural or man-made cause is not 
always clear in the first stages of an epidemiologic 
investigation. This point is well illustrated by what happened 
during the first days of the hantavirus outbreak in 1993. In 
May of that year, a physician at the Indian Health Service 
(IHS) in a southwestern State reported that two previously 
healthy young people had died from acute respiratory failure. 
Over the next few days, additional cases were identified by the 
State medical examiner's office and by other IHS physicians. 
The epidemiologists ruled out leakage of an air-borne toxic 
chemical from a nearby munitions depot. Microbiologists 
conducted laboratory tests for pneumonic plague, inhalational 
anthrax, and pulmonary tularemia, and were able to rule out 
these diseases. These three infections, though rare, occur 
sporadically in the southwestern United States, where they are 
endemic in the local animal populations. All three could have 
been biological weapons. Throughout the investigation, there 
were rumors that a biological agent had been released as an act 
of genocide against the Navajo people who lived in the affected 
area.
    As public health investigators proved, the outbreak was not 
caused by a chemical or biological weapon, but by a newly 
identified, highly lethal virus spread by rodents. Fortunately, 
CDC's application of sophisticated molecular biologic 
techniques led to the rapid identification of a previously 
unrecognized hantavirus as the cause of this illness five 
months before the virus was finally cultured using conventional 
techniques. The investigative skills, diagnostic techniques, 
and physical resources required to detect and diagnose this 
outbreak were similar to those that would be needed to identify 
and respond to a bioterrorist attack.
    Our experience with the hantavirus outbreak shows that a 
strong public health system for disease surveillance, outbreak 
investigation, and laboratory diagnosis is essential to protect 
the nation. With each outbreak investigation, public health 
personnel become better trained and more experienced in 
addressing cases of unexplained illness.

                  PUBLIC HEALTH RESPONSE TO TERRORISM

    Four components of the public health response to disease 
outbreaks are important to U.S. preparedness to address acts of 
terrorism in a coordinated fashion: detection of usual events, 
investigation and containment of potential threats, laboratory 
capacity, and coordination and communication.
    Detection of unusual events.--The public health effort to 
combat infectious diseases in the United States is based on the 
early detection of unexpected cases or clusters of illnesses, 
so that small outbreaks can be stopped before they become big 
ones. In its recent interim report, ``Improving Civilian 
Medical Response to Chemical or Biological Terrorist 
Incidents,'' the Institute of Medicine (IOM) cites public 
health departments' existing mission to promptly identify and 
control infectious disease outbreaks. The IOM report recommends 
expansion of CDC's emerging infections initiative as a means of 
improving State and local surveillance infrastructure.
    In the case of a bioterrorist attack, the initial detection 
of a disease is likely to take place at the local level. It is 
essential to work with members of the medical community who may 
be the first to recognize unusual diseases, and with State and 
local health departments, who are most likely to mount the 
initial response--especially if the intentional nature of the 
outbreak is not immediately apparent. Strong communication 
links between clinicians, emergency responders, and public 
health personnel are important.
    As mentioned, an astute physician--on the basis of only two 
unusual cases--alerted health authorities to what turned out to 
be an outbreak of hantavirus pulmonary syndrome. In contrast, 
during the 1995 Ebola outbreak in Zaire, there was no 
surveillance system in place, and the outbreak was not detected 
until at least two waves of infection had passed and many 
people, including a large number of health care workers, had 
died. Thus, early detection and response is critical.
    As part of the implementation of CDC's plan for emerging 
infections, CDC has established the Epidemiologic and 
Laboratory Capacity (ELC) program to help State and large local 
health departments develop the skills and resources to address 
whatever unforeseen infectious disease challenges may arise in 
the twenty-first century. One of the specific aims of the ELC 
program is the development of innovative systems for early 
detection and investigation of outbreaks. By July, thirty State 
and large local health departments will receive support from 
the ELC program. CDC has also entered into agreements with 
seven State health departments, in collaboration with local 
academic, government, and private sector organizations, to 
establish Emerging Infections Program (EIP) sites that conduct 
active, population-based surveillance for selected diseases, as 
well as for unexplained deaths and severe illnesses in 
previously healthy people.
    CDC has also helped establish sentinel surveillance systems 
that involve local networks of clinicians and other health care 
providers. One such network includes emergency departments at 
eleven hospitals in large U.S. cities. Another includes 
fourteen travel medicine clinics in the United States, plus 
seven overseas. A third network includes over 500 infectious 
disease specialists throughout the country. CDC is using these 
and other provider-based networks to alert and inform the 
medical community so that health workers can help recognize and 
assess unusual infectious disease threats.
    Investigation and response.--As is the case for any 
naturally-occurring infectious disease outbreak, the initial 
response to an outbreak caused by an act of bioterrorism is 
likely to take place at the local level. In the most likely 
scenario, CDC--as well as DOD and security agencies--will be 
alerted only after a State or local health department has 
recognized a cluster of cases that is highly unusual or of 
unknown cause. CDC is working with State and large local health 
departments through the ELC program and other efforts to 
provide tools, training, and financial resources for local 
outbreak investigations.
    CDC's Epidemic Intelligence Service (EIS) trains personnel 
to respond to outbreaks and other disaster situations to aid 
state and local officials in the identification of potential 
causes and implement appropriate solutions. It is interesting 
to remember that the EIS was established during the Cold War in 
response to the threat of biological warfare. In addition, CDC 
trains Public Health Prevention Service (PHPS) specialists who 
can provide on-site programmatic support to extend the manpower 
of state and local public health staff.
    Once the cause of a terrorist-sponsored outbreak has been 
determined, specific drugs, vaccines, and antitoxins may be 
needed to treat the victims and to prevent further spread. 
However, depending upon the pathogen that causes the outbreak, 
appropriate medical supplies may not be readily available since 
these organisms are uncommon causes of disease in the United 
States. This is an important issue that is being addressed 
collaboratively by a number of Federal agencies, including CDC, 
OEP, FDA, and other parts of the Department of Health and Human 
Services; DOD; FEMA and the Department of Veterans Affairs.
    In his May 22 speech, the President also announced that the 
United States would create stockpiles of medicines and vaccines 
to protect our civilian population against biological agents 
our adversaries are most likely to develop. A number of Federal 
agencies are working collaboratively to address this important 
issue as well.
    Laboratory support.--In the event of a bioterrorist attack, 
rapid diagnosis will be critical to the immediate 
implementation of prevention and treatment measures. However, 
because none of the biological agents considered most likely to 
be used as bio-weapons are currently major public health 
problems in the United States, we have limited capacity to 
diagnose them, either at the State and local or Federal level.
    We must also prepare for the possible use of other agents 
as bioterrorist threats. This was illustrated by a 1984 
foodborne outbreak of salmonellosis in Oregon caused by 
followers of Bhagwan Shree Rajneesh and a 1996 foodborne 
outbreak of shigellosis in Texas caused by a single 
perpetrator. Future events could involve organisms that have 
been genetically engineered to increase their virulence, 
manifest antibiotic resistance, or evade natural or vaccine-
induced immunity.
    In recent years, CDC has helped State health departments 
acquire the capacity to detect naturally occurring outbreaks of 
foodborne diseases. In 1997, the success of that effort was 
underscored when the Colorado State Health Department, using 
DNA fingerprinting techniques developed/standardized at CDC, 
detected a small cluster of cases of E. coli infection caused 
by consumption of a single brand of frozen hamburger patties. 
Twenty-five million pounds of ground beef were recalled, and a 
potential nationwide outbreak was averted. Providing state 
health departments with the capacity to detect outbreaks of 
diseases caused by terrorists may avert disasters with even 
greater potential to devastate our country.
    Coordination and communications.--One of the major 
objectives in CDC's emerging infections plan is to improve 
CDC's ability to communicate with State and local health 
departments, U.S. quarantine stations, health care 
professionals, other public health partners, and the public. In 
the event of an intentional release of a biological agent, 
rapid and secure communications will be especially crucial to 
ensure a prompt and coordinated response. Each hour's delay 
will increase the probability that another group of people will 
be exposed, and the outbreak will spread both in number and in 
geographical range.
    CDC may also need to communicate with WHO and with the 
ministries of health of other nations, especially if persons 
exposed in the United States have traveled to another country. 
Because of the ease and frequency of modern travel, an outbreak 
caused by a bioterrorist could quickly become an international 
problem.

                               CONCLUSION

    In conclusion, a strong and flexible public health 
infrastructure is the best defense against any disease 
outbreak--naturally or intentionally caused. CDC's on-going 
initiatives to strengthen disease surveillance and response at 
the local, State, and Federal levels can complement efforts to 
detect and contain diseases caused by the biological agents 
that might be used as weapons.
    Thank you very much for your attention. I will be happy to 
answer any questions you may have.

STATEMENT OF RICHARD JACKSON, M.D., M.P.H., DIRECTOR, 
            NATIONAL CENTER FOR ENVIRONMENTAL HEALTH, 
            CENTERS FOR DISEASE CONTROL AND PREVENTION, 
            U.S. DEPARTMENT OF HEALTH AND HUMAN 
            SERVICES

    Senator  Faircloth. And now we will hear from Dr. Richard 
Jackson. Dr. Jackson is the Director of the Centers for Disease 
Control's National Center for Environmental Health in Atlanta.
    Dr. Jackson received his medical training as a pediatrician 
at the University of California at San Francisco and further 
studied at the University of California at Berkeley. He 
currently serves on the Senior Health and Advisory Committee 
within the Department of Defense.
    I welcome you, Dr. Jackson, and we will hear your 
testimony.
    Dr. Jackson. Thank you, Senator.
    The Center for Environmental Health is a sister center to 
Dr. Hughes' Center for Infectious Disease. We do the non-
infectious issues, such as disasters, including heat waves, 
tornadoes. We look at radiation hazards to the population. We 
were involved in the investigation following Three Mile Island, 
following Chernobyl, following weapons tests, around sites 
where nuclear weapons were being produced, looking at health 
effects in civilian communities. We monitor birth defects in 
the population and we monitor disabilities in the population.
    But the primary activity that I would like to talk about 
today is monitoring chemical exposures in the population. We 
have at the National Center for Environmental Health the 
premier laboratory in the world for looking at chemicals in 
people. We do not look at chemicals in air, in water, in food, 
or in animals. We look at chemicals in people, and that is what 
we are good at.
    We have worked for 20 years now with the Department of 
Defense assisting them in analysis of chemicals, for example, 
in veterans and in GI's. We were involved in the evaluation of 
the health effects in Bhopal, India 14 years ago where 3,000 
people were killed, and one of my staff was in Tokyo following 
the Sarin gas episode looking at the health effects where 12 
people died there.
    My personal experience in this area was most dramatic with 
the spill in the Sacramento River where 35 miles of river--the 
fish and other animals were killed along the river and an 
entire community was sickened downwind from the Dunsmere spill 
episode. In such episodes, you do not know, initially when they 
start, whether you are dealing with a chemical or an infectious 
agent, and you do not know whether this is a random, accidental 
event or if it is a deliberate misdeed. There is one thing you 
always do know. You also know that you are going to have a lot 
of very worried people. You are going to have a lot of calls 
from the media. You are going to have a lot of calls from 
elected officials that want to know what is going on.
    We were involved in the episode of the methyl parathion 
spraying in seven States around the Nation, including 
Mississippi and Illinois. This was an illegal insecticide that 
was being sprayed in homes. At least 14,000 people were exposed 
to these chemicals because of this illegal use. A large number 
of people were made ill. It is reported that perhaps two people 
died from this episode. The question was whether a home was 
safe to go into, and just measuring a little bit of chemical 
off in one corner of the house was not going to tell you 
whether a child was safe in that house or not. What we needed 
was a special method to actually look at chemicals in people. 
In some cases we would decide the people had to get out of that 
house right away, be put in a motel for weeks at a time. That 
house needed to be sometimes ripped out completely and 
completely rebuilt. Other homes, no treatment was needed 
whatsoever. It was the monitoring of the people, measuring the 
chemical in the people in that home, that helped us decide what 
the follow-up should be for each of those homes for each of 
those 14,000 people.
    The ability to analyze this chemical in the people, the 
methyl parathion, in the people saved 50 million dollars' worth 
of rehab and remediation work.
    In the area of chemical terrorism, most people think that 
someone will drop like a stone when they are exposed to one of 
these chemicals. Cyanide, for example, people die almost 
immediately. But, in fact, for many of the chemicals that we 
would be worried about, there would be many people with much 
lower doses of exposure. There were 5,000 people that were 
concerned and injured in the Sarin episode in Tokyo who did not 
die. And there is every reason to believe--and a person 
testified, a doctor testified, before you about a month ago 
that said in Iraq people were exposed to complex mixtures of 
chemicals, not simply one chemical.
    So, the important issue for the laboratory is knowing who 
was exposed and how much were they exposed to. This is the 
information that the public and the doctors want: Who was 
exposed and how much did they get. The site managers need this 
information and the people that have to look at this weeks 
later are going to need this information about the exposures.
    The good news is the CDC lab can tell you about these 
individual chemicals. The bad news is we need a couple of tubes 
of blood oftentimes for each of these chemicals. It takes days 
and sometimes weeks, and each one of these is a special and 
expensive test.
    There is a need for our ability to have a rapid toxic 
screen to look at a large number of chemicals relatively 
rapidly, to be able to turn that round, to give that 
information back to site managers, to give it back to the 
doctors who are caring for these people, and to develop the 
capacity within State and local health departments to do this 
analysis themselves.

                           PREPARED STATEMENT

    We at the Center for Environmental Health are looking 
forward to working with our partners at this table and the rest 
of the people who will be testifying before you today on the 
importance of the laboratory in figuring out who was exposed 
and how much they were exposed to.
    Thank you.
    Senator  Faircloth. Thank you, Dr. Jackson.
    [The statement follows:]

               Prepared Statement of Dr. Richard Jackson

    I am Dr. Richard J. Jackson, Director of the National Center for 
Environmental Health of the Centers for Disease Control and Prevention 
(CDC). I appreciate the opportunity to summarize CDC's role in 
responding to chemical terrorism. As a former State public health 
official, I have experienced first hand the panic, fear and chaos 
associated with disease outbreaks and disastrous events.
    As Dr. Hughes summarized, CDC's mission is to monitor the health of 
the U.S. population and investigate and contain disease outbreaks, 
including those that are due to deliberate acts of terrorism. As with 
biological terrorist threats, CDC's response to chemical terrorism 
includes four components: surveillance and outbreak response; 
laboratory capacity to measure toxicants in the blood, serum or urine 
of people; disease prevention and control; and infrastructure and 
training. Whereas the Environmental Protection Agency has the lead for 
the effects of chemical toxicants on the environment, CDC's role 
pertains to the effects of chemicals on human health.
    CDC responds to chemical emergencies, whenever and wherever they 
occur, whether the emergency is caused by an act of terrorism or an 
accidental release. Television has given us all the opportunity to see 
a glimpse of the serious impact both of these types of emergencies can 
have on the population of a city or country. Two such examples in 
recent years are the chemical plant explosion in Bhopal, India and the 
terrorist attack in the subway in Tokyo, Japan. In December 1984, an 
explosion at a chemical plant in Bhopal, India caused an extremely 
toxic substance to be released into the air in an area surrounding the 
plant--a densely populated part of the city. In this incident, an 
estimated 30 to 40 tons of the substance were released into the 
atmosphere during a 2- to 3-hour period, resulting in over 3,000 dead 
and 60,000 seriously injured of the more than 200,000 people exposed. 
In the second example, in March 1995, a terrorist group in Japan 
released Sarin gas (a nerve agent) into the air of Tokyo's subway 
system. Within 24 hours of the attack over 5,000 people had sought 
medical attention. By the end of the crisis almost a thousand people 
were identified as experiencing some health effects and 12 people died. 
In the end, it was only the inefficiency of the mechanism used to 
disperse the chemical agent that prevented casualties from being far 
worse.
    The reason I have chosen to cite these two examples today is to 
point out the variability of the types of chemical emergencies that 
have occurred elsewhere and that could occur in the United States. 
There are three points I would like to make about the emergency 
response responsibilities and capabilities at the various levels of 
government: (1) the nation's public health system, health officials at 
the local, State, and federal levels, is a critical resource aimed at 
protecting the health of U.S. residents whenever a health emergency 
occurs; (2) CDC has the expertise and capacity to respond to many types 
of chemical emergencies; and (3) the Federal agencies tasked with 
responding to chemical emergencies are discussing ways to improve our 
response capabilities to better triage exposed populations and 
communicate with our partners, the media, and most importantly, the 
public.

        PUBLIC HEALTH ROLE IN RESPONDING TO CHEMICAL EMERGENCIES

    Terrorism is a community problem. Health decisions for the 
community in response to a terrorist event require the involvement of 
public health professionals from the local, state, and Federal levels. 
State and local public health officials will be among the first to 
respond to any chemical weapon attack, long before any Federal units 
are on the scene. It is these local public health professionals with 
whom CDC has had a long term relationship. It is CDC that State and 
local officials call upon for help and advice in any kind of public 
health emergency. And, it is the State and local public health 
professionals who work along side the local police, firefighters, and 
emergency medical personnel and who have the greatest impact on the 
health and safety of people in affected areas.
    We, in public health, also have the responsibility to protect the 
community of emergency responders--so that they do not become victims 
as well. We have the responsibility to protect the community of exposed 
people--to carry out surveillance, to determine who has been exposed to 
toxic chemicals and at what level they have been exposed, to ensure 
that they receive appropriate care and treatment, and to create 
registries during the early stages of the event to allow for 
appropriate long term follow up. Lastly, we have the responsibility to 
protect the larger community impacted by a terrorist act--to calm the 
panicked and worried well with good scientifically based but 
understandable information and to help communities recover from the 
trauma of a terrorist act or chemical emergency. Experienced public 
health doctors, laboratorians, and epidemiologists are essential in 
helping communities to respond quickly and to sort out questions of 
exposure, treatment, and recovery.

                 CDC'S EMERGENCY RESPONSE CAPABILITIES

    CDC has considerable experience working on all types of chemical 
emergencies. When a disaster or emergency occurs, CDC responds to 
requests for assistance from state or local agencies by helping to:
  --Make a preliminary assessment of the situation either by telephone 
        or by sending an emergency response coordinator or team to the 
        site;
  --Coordinate our activities with those of the local, state, and other 
        federal personnel, including assistance to help protect the 
        health and safety of emergency response teams;
  --Provide assistance to help protect the health and safety of 
        emergency response teams;
  --Develop a strategy for dealing with the public health aspects of an 
        emergency;
  --Provide technical assistance in areas such as epidemiology, 
        toxicology, and laboratory science;
  --Perform any necessary laboratory tests, most of which are currently 
        beyond the capacity of local, state, or university laboratory;
  --Determine when protection, treatment, and prevention objectives are 
        achieved; and
  --Set up a program to deal with the recovery process.
    Throughout the response process, CDC makes resources 
available to use in aiding both the short term response and the 
long term recovery of the community involved. We have state of 
the art communications equipment that allows us to provide a 
link between on-site and off-site responders. CDC has a staff 
of health communicators and educators, who are invaluable to 
our communications with the media and the affected and worried 
public. CDC has the experienced professionals, including 
doctors and epidemiologists, needed to triage victims, ensure 
medical treatment for those who are ill, and provide follow up 
for those who are at risk of disease. And, CDC's laboratory 
capacity is unique in the world in that it has the technology 
and highly trained professionals necessary to make measurements 
of chemical exposures in people.
    One common thread in the laboratory component of the public 
health response to these tragedies is to determine what 
chemical agents were used, who has been exposed to the agents 
and to how much. This information is critical for appropriate 
medical treatment for those who have been exposed, and to allay 
the fears of those who have not been exposed.

                       CDC'S LABORATORY CAPACITY

    CDC's environmental laboratory is unique in that it is the 
only laboratory that can accurately measure more than 200 
toxicants (chemicals) in people, not simply in the environment. 
Such measurement is known as biomonitoring. Let me provide an 
example of the value of this information and how CDC's 
scientific capacity helped to address a recent chemical 
emergency involving the pesticide methyl parathion.
    Methyl parathion is illegal for indoor pesticide use 
because it acts as a nerve agent. Though not as strong as the 
nerve agent used by terrorists to kill people on a Japanese 
subway in 1995, it affects people the same way.
    Starting in the fall of 1996, seven states--Mississippi, 
Louisiana, Texas, Arkansas, Tennessee, Alabama, and Illinois--
became aware that methyl parathion was being used indoors to 
control indoor pests. Two children died. Thousands of homes 
were affected. In order to take appropriate action, public 
health officials had to determine who had been exposed and to 
what extent. They also had to respond to a flood of calls from 
people who feared that methyl parathion had been sprayed in 
their homes.
    State and local health officials asked CDC, the Agency for 
Toxic Substances and Disease Registry, and the Environmental 
Protection Agency to help with this emergency. To quantify 
human exposure to this deadly pesticide, CDC's Environmental 
Health Laboratory developed a mass spectrometry assay to 
measure a metabolite of methyl parathion in urine. Through this 
unique test, it was possible to determine the amount of 
exposure a person had to this nerve agent. State and other 
federal officials used CDC's test to determine who had been 
exposed, how much, who was at greatest health risk, and whether 
homes needed to be evacuated and remediated. To date, more than 
14,000 persons in these seven states have been tested--4,000 of 
whom were assured they had no significant exposure. In the 
absence of CDC's unique laboratory capacity and diagnostic 
test, there would have been be no way to obtain this personal 
exposure and health risk information. In addition to the public 
health benefit, CDC's test provided precise exposure 
information which averted more than $50 million in unnecessary 
home remediation costs. The methyl parathion emergency just 
described illustrates the importance of precise measurements of 
chemicals in people, not simply in the environment. Similar 
laboratory and epidemiologic capability and response would be 
needed to respond to an act of terrorism.
    Having such measurements means that in any chemical 
emergency persons truly exposed can be identified, and persons 
not exposed could be reassured they were not at risk. Emergency 
response and medical personnel can then focus their limited 
resources in the most efficient and effective ways possible.

                 ADDITIONAL STRATEGIES BEING CONSIDERED

    In addition to the current capabilities that I have just 
described, CDC is working with other Federal agencies to define 
improved systems and technologies for responding to these types 
of emergencies. Some of the strategies being considered 
include:
  --The development of the laboratory capacity to more rapidly provide 
        critical measurements chemical agents in people.
  --The provision of additional training for local health professionals 
        in order to assure that there are an adequate number of highly-
        trained professionals at state and local levels who know how to 
        address and manage these chemical emergencies, including 
        physicians who know the proper medical treatment for victims.
  --The provision of training, laboratory capacity, quality assurance 
        and quality control, along with the development of technology 
        that can be transferred to Regional or State laboratories to 
        aid in the response to chemical emergencies.
  --The enhancement of current information and communication systems at 
        the local, state, and Federal levels.
    In closing, I would like to reiterate that public health at 
all levels--local, State, and Federal--is the integrating 
factor in our response system to all types of health 
emergencies. One of the most critical components of the public 
health response to a chemical weapon terrorist attack is the 
capability of state and local public health agencies. Personnel 
working at state and local public health institutions will be 
among the first to respond to any act of terrorism. Whether 
natural or intentional, health emergencies require an immediate 
response, capacity to triage victims, medical treatment for 
those who are ill, follow-up for those who are at risk of 
disease, and assistance to help communities recover from the 
crisis.
    Thank you for the opportunity to testify today. I will be 
happy to respond to any questions you may have.

                           POTENTIAL PROBLEMS

    Senator  Faircloth. I do not have a lot of questions, but I 
have a few.
    I want to thank the panel for an informative and somewhat 
frightening presentation as to what we could be facing and how 
little we are aware of the potential problem that exists.
    Chief Fincher, the two men that were arrested in Las Vegas 
recently, when they boasted to an informant that they had 
anthrax--it took 3 days to determine what the substance really 
was, which seems to me like a long time. Now, I have never 
examined anything to find out whether it was anthrax or not, 
but if it really was, 3 days would have given it time to do 
most anything it was going to do. How long did it take you in 
the Charlotte incident to determine what the material was?
    Mr. Fincher. After doing the x rays and the questioning of 
the subject who had the instrument with him, it was determined 
there were no other agents attached to it other than 
explosives. So, it was quickly determined.
    But listening to his discussion about having anthrax with 
him--that is the word he used--we got with the South Carolina 
law enforcement in South Carolina to check his home, and he had 
petri dishes in there, connections to the Internet system, and 
actually growing some type of fungus or molds inside of an 
aquarium. We never did determine what he had at home, but we 
know that it was not anthrax. We knew the instrument he had 
with him was just an explosive device.
    Senator  Faircloth. How long did it take to do all this?
    Mr. Fincher. I would have to yield to the experts in that 
area, sir.
    Senator  Faircloth. How long did it take you in Charlotte 
before you found out?
    Mr. Fincher. 16 hours.
    Senator  Faircloth. 16 hours.
    Mr. Fincher. Yes, sir.
    Senator  Faircloth. I have been told that Charlotte was 1 
of the 12 cities that will be trained through the 120-cities 
project that the Justice Department is sponsoring. This project 
apparently provides training for local responders to help 
prepare for a terrorist attack.
    Once you have been trained, where does the money come from 
for the equipment and manpower to do the job?
    Mr. Fincher. That is a question that we all have, sir. We 
know that the training is a good first step. It is more of an 
awareness level training, and the Department of Defense will 
leave approximately 300,000 dollars' worth of equipment in our 
community just kind of on permanent loan. But we are going to 
need specific training on the instrumentation, the protective 
devices to protect our actual first responders who are exposed.
    Senator  Faircloth. So, there is no plan for funding right 
now to train you, but to provide the money for personnel or 
equipment beyond what the Department of Defense would leave 
with you, there is no planning for funding beyond that?
    Mr. Fincher. No, sir; not that I am aware of.
    Senator  Faircloth. Dr. Knouss, do you consider epidemics 
an emergency we need to prepare for?
    Dr. Knouss. I take it by that question that you are talking 
about naturally occurring epidemics.
    Senator  Faircloth. That is right, yes.
    Dr. Knouss. OK, because we are also very concerned about 
trying to plan for an influenza pandemic as well at the same 
time and many of our colleagues at the Centers for Disease 
Control are also trying to deal with some of the issues that 
are common to how to deal with naturally occurring epidemics as 
well.
    But, sir, we are at the present time, and as the President 
announced 1\1/2\ weeks ago at Annapolis, we are going to be 
making a concerted effort at the present time to begin to be 
able to strengthen our capability, particularly in the public 
health infrastructure dealing with some of the research and 
development activities and trying to enhance some of our 
response capabilities to deal with the potential for an 
epidemic that might result from a terrorist attack.
    One of the things that I just might point out is that there 
are some potential biological weapons that do not present the 
threat of an epidemic in terms of secondary and tertiary 
spread. What they do present is a very massive initial exposure 
to an illness. So, for example, with a disease like anthrax, 
the risk is to those people that are initially exposed, but 
anthrax is not a disease that will be passed on from person to 
person.
    On the other hand, a disease like bubonic plague, which we 
were very concerned about when we had the scare from the 
incident in Ohio and some other threats that have arisen, that 
disease is highly infectious and can be passed on from person 
to person.
    I think that Dr. Hughes might at some point address this 
issue of the dual challenges of one where you have an attack 
that might expose a large number of people in an initial 
incident as opposed to one in which you really run the risk of 
secondary and tertiary spread of the disease from person to 
person as a result of the initial infection of the population.
    But, yes, sir, we are concerned about preparing for the 
possibility of epidemics. They are different in nature. Each 
one has its own unique characteristics and presents its own 
unique challenges. We are now, I would say it is safe to say, 
really in our initial planning stages of how to be able to best 
prepare the country to be able to deal with that kind of 
attack.
    Senator  Faircloth. You mentioned--I have just enough 
knowledge to be aware of my ignorance. On the bubonic plague, 
it was a bacterial disease, was it? Does that still exist? Is 
there potential to break out somewhere again in the country?
    Dr. Knouss. With your permission, Senator, one of the 
preeminent infectious disease experts is sitting to my left and 
I would really like to be able to defer to him to answer those 
kinds of questions.
    Senator  Faircloth. Dr. Knouss, if you are not in politics, 
you should get into politics. [Laughter.]
    You understand how to handle a problem. This whole Senate 
was designed by Tom Sawyer, you know the story of painting the 
fence? Pass it on. [Laughter.]
    Dr. Hughes, I was just reading on the bubonic plague. I 
think it wiped out one-third of the people in Europe and many 
cities. I notice Toulon, Marseilles lost as much as 60 percent 
and it took 100 years to rebuild the population to what it was 
when it first struck.
    Now, my question is, does bubonic plaque still exist today?
    Dr. Hughes. That disease most certainly still exists and 
the organism exists. In fact, it is present in the United 
States, and every year in this country we have between 5 and 15 
cases.
    Senator  Faircloth. Of bubonic plague?
    Dr. Hughes. Of bubonic plague, and they occur in Western 
States. I might say that over the past 10 years, the geographic 
extent over which they have occurred has actually increased. 
So, it is an example of a disease that is emerging in new areas 
in this country.
    Now, globally it is a much bigger problem, and you may 
recall the epidemics of plague in India in 1994 that caused 
major----
    Senator  Faircloth. I do not recall. Was bubonic plague in 
India in 1994?
    Dr. Hughes. Yes; there was an outbreak of bubonic plague. 
Well, just briefly to comment on that because it is important 
in several ways. There was an outbreak of bubonic plague in a 
rural area about 150 miles east of Bombay, and then an outbreak 
of bubonic plague, the type of plague that can be transmitted 
from person to person, in a city named Surat. It resulted in 
total economic collapse in the city of Surat, fleeing of the 
population, including many health care workers, and had major 
implications for the United States. It provided another 
reminder that we live on a global village and there was 
legitimate concern about the potential for patients with 
bubonic plague coming from India into the United States because 
of the volume of travel from India to the United States. So, it 
highlights how problems in other parts of the world are 
directly germane to us in this global village in which we live.
    It also emphasizes very clearly how absolutely critical 
surveillance is, epidemiologic response capacity, and 
laboratory diagnosis capacity. When that outbreak occurred, 
there was one functional WHO collaborating center in the world 
that could be called upon to deal with this problem, and that 
happened to be at our facility in Fort Collins, CO.
    Senator  Faircloth. Do we have a global monitoring program? 
And the changes in Russia--how would that have affected it? And 
how many people does the Centers for Disease Control have to 
monitor for plague outbreaks? How many people are looking at 
potential plague epidemics around the world?
    I read something rather interesting. I am sure it is 
redundant for you. It came out of the chicken flu in Hong Kong 
that in World War I--I believe they called it spanish flu 
then--took literally months to move from Kansas where it 
probably began to Verdun in the front lines of Europe. It was 
literally months, but today the way the world moves so rapidly, 
most any disease could be around the world within literally 
hours.
    How many people do we have to monitor such a possibility?
    Dr. Hughes. Well, I guess all CDC employees, sir. These 
diseases can break out anywhere in the world.
    Now, we have our hands full----
    Senator  Faircloth. Now, what now? Six?
    Dr. Hughes. The global population.
    Senator  Faircloth. No, no, no. How many people does the 
Centers for Disease Control have to monitor these possible 
plague epidemics?
    Dr. Hughes. Well, the total number who work at CDC is about 
6,500 people. There are about 1,100 in the National Center for 
Infectious Diseases.
    Now, fortunately, of course, we are not in this alone. We 
work globally to support the efforts of the World Health 
Organization to strengthen global surveillance around the 
world, and the influenza situation is a good example of why 
that is so critical.
    That episode in Hong Kong involving the avian influenza 
strain that had never before infected humans was a very loud 
wake-up call about the long overdue state that we are in, in 
terms of the next influenza pandemic.
    Senator  Faircloth. Dr. Jackson, some States would like to 
close their State laboratories and have private laboratories 
take over. In your judgment would this compromise our 
protection or improve it? Is keeping a State agency open 
necessarily good or bad? What would be your opinion as to 
States closing labs and contracting with private laboratories?
    Dr. Jackson. Senator, you cannot do epidemic investigations 
without a strong laboratory. Bad data is worse than no data at 
all. You are better off not knowing than being given bad 
information. You have got to have strong labs working with you.
    The State labs perform an extremely important function. A 
lot of the tests they do are not terribly cost effective. If 
you are only looking at 10 rabies tests a month or you are only 
looking at a certain chemical like dioxin or solvents in the 
blood or something like that, they tend not to be cost 
effective for a commercial laboratory. They tend to be too high 
tech for a hospital laboratory, and yet this is a public 
service that State and local laboratories need to provide to 
the public health protectors in that community.
    I think it is very dangerous to back away from the support 
for public health laboratories either at a State or a local 
level. We are going to have to be smart about it because not 
every lab ought to offer every test, but we have got to figure 
out the best way to deploy limited resources to make sure that 
we have got the services close to the people that really need 
it.
    Thank you.
    Senator  Faircloth. I was interested in the rapid toxic 
screen project that you have underway. I understand the 
military is involved in the project as well. Can you tell me 
why this would be a valuable tool in the event of an epidemic 
or attack?
    Dr. Jackson. When one of these events occurs, literally 
thousands of people arrive at the hospital door, and you have 
got to very quickly figure out who are the people that are 
going to need immediate care. You will take care of those 
people right away and you can figure out by looking at them 
pretty much what kind of treatment they are going to need. 
There is going to be a whole group of people that you are going 
to have to figure out what do they really have on board. Are 
they going to be exposed to a carcinogen? Do they have 
reproductive or birth defect hazards that they are going to be 
concerned about, a string of other exposures?
    These are not routine tests that any laboratory can run, 
and you need an ability to take a human specimen, a blood 
specimen, a urine specimen, and look at that chemical in that 
person to say how much they have. It is going to be important 
to the person making a decision at the scene. It is also going 
to be important to people who are trying to reconstruct this 
event a bit later on to tell people and communicate here is 
what you need to worry about.
    That episode I was talking about in Sacramento on the 
Sacramento River, one of the things we had to decide very 
quickly was to tell women whether to go get a certain kind of 
blood test for neural tube defects, a birth defect, because 
this chemical was associated with reproductive hazards. So, 
knowing who had how much chemical was very, very helpful to the 
people on scene.
    Senator  Faircloth. How many containment labs do we need?
    Dr. Jackson. Containment labs are the biological labs, and 
I am going to defer to Dr. Hughes on that.
    Dr. Hughes. We need more than we have, sir.
    Senator  Faircloth. How many do we have?
    Dr. Hughes. Well, it depends on how one defines a 
biological lab. Let me give you a specific example to answer 
that question. When people talk about containment labs or 
maximum containment labs that came into play in the ``Hot 
Zone'' book that you mentioned, those are labs that conduct 
work at biosafety level 4 where people have to wear space 
suits, among other protective equipment. There are two of those 
in the United States, one at CDC and one at U.S. Army Medical 
Research Institute of Infectious Disease [USAMRIID] at Fort 
Detrick in Frederick, MD.
    Senator  Faircloth. The one at Fort Sam Houston?
    Dr. Hughes. No, no. Fort Detrick in Frederick, MD.
    Senator  Faircloth. OK, I am sorry.
    Dr. Hughes. We refer to it as USAMRIID facility there. But 
there are two in the United States.
    There is one in South Africa. There is one in Russia, at 
least one. There is one being built in Canada. There is one 
being built in France. But the global capacity to work with 
those types of agents is very limited.
    Beyond those agents, though, there are many other organisms 
that need to be worked at at relatively high levels of 
biocontainment, and we and others are constrained for that 
space as well.
    Senator  Faircloth. Dr. Knouss, I am going to ask this 
question and we will wind it up. When can we expect vaccines 
and antibiotics to be in the hands of the people in the field 
like Chief Fincher?
    Dr. Knouss. We are trying now to decide what are the most 
important things to have in a stockpile, particularly for 
dealing with biological terrorist attack, how large that 
stockpile should be, how it should be positioned. When we began 
working with the cities to create metropolitan medical strike 
teams, we developed----
    Senator  Faircloth. What are you doing now?
    Dr. Knouss. It is the systems that are the local response 
capability that we have been training in the 27 largest cities, 
and hopefully in the not too distant future, we will be getting 
to Charlotte as well.
    We created a list of pharmaceutical supplies that most of 
the cities have purchased using some of the funds that we have 
provided to them.
    What that does not cover is the potential for biological 
attack. Now we are at the point where we are trying to 
determine how large a stockpile ought to be, how it ought to be 
able to be distributed, how much needs to be prepositioned at 
the local level as opposed to at a national level because for 
any one of these events, the difficulty in planning for them 
and the difficulty in the cost associated with it is that these 
are relatively low probability but very high impact events. In 
other words, there is a low probability that any single 
community might be affected by one of these events, but if it 
is, it will have a very serious impact if we are not able to 
prevent it.
    So, the question then for us becomes how best to be able to 
invest in what kinds of antibiotics and vaccines, how to 
preposition them, how to be able to distribute them rapidly 
after a determination has been made that there is a significant 
exposed population.
    For two issues we still have a lot of work to do in terms 
of being able to develop good vaccines.
    The current vaccine supplies for smallpox are becoming less 
potent because they are held over from our smallpox eradication 
days and the decision has to be made as to how we are going to 
adequately vaccinate a population if it still should be exposed 
to the use of smallpox or release of smallpox, if that should 
ever occur again in the population.
    And the second is on the anthrax vaccine, all the total 
production is being used by the military. Therefore, we are 
really at a position now where we have to start thinking about 
whether or not a second generation of anthrax vaccine that 
would require fewer doses than the current vaccine should be 
developed, how much supply we are going to need and where it 
ought to be prepositioned.
    So, all of those are very serious questions that we still 
have in our minds. A lot of discussions are taking place at the 
present time. I think probably in the not too distant future, 
the administration will be in a position to be able to come 
forth with some proposals in that regard.
    Senator  Faircloth. Dr. Knouss, the Government has 
absolutely the best planners and thinkers. If something 
happened today, we have nothing, do we? Is that what you are 
saying?
    Dr. Knouss. No; I am saying it a little bit differently 
than that, Senator.
    Senator  Faircloth. Do we have anything this afternoon?
    Dr. Knouss. There are some things that we are ready for, 
but there is a lot of----
    Senator  Faircloth. Anthrax.
    Dr. Knouss. Well, there is some anthrax vaccine that is 
available and we have a lot of anthrax antibiotics. But we do 
not have an adequate system in order at the present time, if we 
had a very large exposed population, to be able to deal with 
that problem, and that is what is of concern to us. It is going 
to be some time----
    Senator  Faircloth. Why not? How long have we been planning 
on this? How long have we known that potential terrorist 
attacks were out there? We do not have a system. We must have 
known it for a long time. If we do not know now, when will we 
find out?
    Dr. Knouss. There are two aspects of that, Senator. One is 
that I think everyone's sensitivity has been heightened.
    Senator  Faircloth. Has what?
    Dr. Knouss. Has been heightened. Our sensitivity to the 
potential problem has been heightened.
    Senator  Faircloth. How long has it been heightened? It has 
been how long since the Oklahoma bombing, how long since we 
have been reading about the terrorist potential for 
antiterrorist viruses and whatever from the Persian Gulf 
conflict?
    I sit here as a citizen and it sounded like we are no 
farther along than we were, say, 5 years ago. We are still 
studying. We are still planning. We are giving it thought. We 
are thinking about it, but if something happened today on a 
situation that has been developing in this country for years, 
5, 6 years, it would sound to me from what you are saying that 
we would be pitifully prepared. Is that not true or are we 
ready to go this afternoon?
    Dr. Knouss. We are at neither of those extremes.
    Senator  Faircloth. We are what?
    Dr. Knouss. We are at neither of those extremes. We are 
making progress but we have a long way to go. That really sums 
up the position that we are in at the present time. We have 
taken a lot of steps over the last several years. Let me just 
say from the time that we were at Oklahoma City and experienced 
what happened at Oklahoma City, we made an enormous progress in 
prepositioning assets for the Olympics that took place in 
Atlanta, Georgia and were able to respond in Centennial Olympic 
Park when that bombing took place.
    We have now been training teams in some cities around the 
country. We have some additional capability of being able to 
respond to a chemical attack.
    Senator  Faircloth. To what?
    Dr. Knouss. To a chemical attack.
    Senator  Faircloth. Well, I don't understand we're speaking 
of the American people. The millions and hundreds of millions 
and billions of dollars that have been poured into these kind 
of programs, and I would like to hear that it was further 
developed than it is, but if it is not.
    Dr. Hughes, I am having trouble understanding. Did you tell 
me we had thousands of people monitoring on the plague 
epidemics around the world? Will you tell me exactly how many 
we have working on worldwide plagues?
    Dr. Hughes. Oh, on plague, OK. Let me be very specific 
about that. We most certainly do not have thousands.
    Senator  Faircloth. How many people?
    Dr. Hughes. In 1994 when----
    Senator  Faircloth. I mean in 1998--now.
    Dr. Hughes. May I have 30 seconds to tell it? Because I 
think you will see that plague is an area where we have made a 
little progress because of the wake-up call in India. I 
mentioned there was one WHO collaborating center, laboratory in 
the world in 1994. It was staffed by one person. One person.
    Senator  Faircloth. We had one laboratory with one person.
    Dr. Hughes. Right.
    Senator  Faircloth. Did they feel like it was overstaffed? 
[Laughter.]
    Dr. Hughes. We are not sure who that person talked to. 
[Laughter.]
    Clearly not overstaffed; clearly understaffed. But yet we 
were the last line of defense for the world really in helping 
the Indian Government----
    Senator  Faircloth. Even that one person----
    Dr. Hughes. We obviously mobilized a few other people who 
knew something about plague and we sent four people to India to 
work. Now, today----
    Senator  Faircloth. We are not really taking it seriously 
if we have one lab with one person.
    Dr. Hughes. The only reason we had one was because of those 
few cases that occur in the United States each year that I 
mentioned to you.
    Today we have probably five or six. I would have to check 
for the record to be precise, but we have approximately six 
people working on plague. But that plague laboratory has been 
rejuvenated as part of this incremental implementation of the 
CDC plan. So, we are in better shape with plague than we would 
be with anthrax, say, where we have nobody basically working on 
anthrax.
    Senator  Faircloth. Gentlemen, thank you so much. To each 
of you, I thank you. It is something that the American people 
are more concerned about than you might expect. It is something 
we hear about. I realize you are under constraints to be able 
to expand and hire. Thank you.
    Gentlemen, thank you and we will continue to discuss the 
country's preparedness or lack thereof for epidemics and 
bioterrorism.

  PREPARED STATEMENT OF DR. DAVID L. HEYMANN, ON BEHALF OF THE WORLD 
                          HEALTH ORGANIZATION

    We have received a prepared statement from Dr. David L. 
Heymann, on behalf of the World Health Organization, his 
statement will be inserted into the record at this point.
    [The statement follows:]

               Prepared Statement of Dr. David L. Heymann


THE NEED FOR GLOBAL SURVEILLANCE AND MONITORING FOR INFECTIOUS DISEASES

The challenge
    Infectious diseases remain a global problem in the late twentieth 
century. Global surveillance is an urgent necessity to protect the 
health of people throughout the world. There is reason to believe that 
the emergence of previously unknown diseases and the re-emergence of 
old ones is increasing. One-third of the 52 million deaths in the world 
in 1995 were due to infectious diseases, and this ratio remained the 
same in 1996 and 1997. Infectious diseases spread when adequate 
financial and human resources are not devoted to infectious disease 
control and when microbes in animals find suitable conditions to jump 
the species barrier and infect humans. Factors responsible for the 
increase in infectious diseases include social changes such as mass 
population movements, rural-to-urban migrations and accelerated 
urbanization, population growth, rapid transport, global trade, new 
food technologies, and new life styles as well as environmental changes 
such as altered land use patterns and irrigation that increase the risk 
of human exposure to animal reservoirs and vector-borne infections. A 
new outbreak may first appear in a circumscribed area, but with 
expanding global travel and trade, the disease can span entire 
continents within days or weeks as influenza periodically demonstrates. 
The diseases that have crossed, or threaten to cross, international 
borders menace international public health security. Today these 
infectious disease outbreaks and epidemics are not only costly to the 
economies of the countries in which they occur, but are also a concern 
for all countries because no country is safe from infectious disease.
    For example, during 1997:
  --Major cholera epidemics spread throughout eastern Africa, affecting 
        hundreds of thousands of people in more than ten countries over 
        several months; trade sanctions were unnecessarily placed on 
        fish exports from these countries resulting in severe economic 
        impact on their fragile economies;
  --Yellow fever fatalities were reported in seven countries in Africa 
        and South America;
  --Meningitis caused major epidemics in Africa, with over 70,000 
        deaths reported in the 1996-1997 season;
  --More than 15,000 cases of typhoid fever with resistance to first 
        line antibiotics occurred in Tadjikistan;
  --Epidemic typhus resurged in Burundi with over 30,000 cases and 
        untold deaths;
  --An avian influenza virus emerged in humans in Hong Kong, killing 
        six out of eighteen people, and was carefully monitored for its 
        potential to be the next pandemic influenza threat;
  --Rift Valley Fever afflicted thousands of people, killing hundreds 
        and many of their livestock in Kenya and Somalia;
  --The prevalence of hepatitis C continues to increase in countries 
        where blood is not screened prior to use and where 
        sterilization of medical equipment is faulty;
  --Lassa fever, with high mortality, re-emerged in Sierra Leone;
  --An outbreak of dengue fever occurred in Cuba for the first time 
        since the 1981 epidemic;
  --The investigation of an unexpectedly large human monkeypox outbreak 
        in Africa raised new issues about this important disease and 
        the safety of smallpox vaccination in the era of AIDS;
  --The number of cases of new variant Creutzfeldt-Jakob Disease 
        reached twenty-four in the United Kingdom and France combined 
        with the continuing threat of bovine spongiform Encephalopathy 
        (BSE or mad cow disease), and the United Kingdom's economic 
        loss from BSE was estimated to have reached 5.7 billion U.S. 
        dollars;
  --Eschericia coli 0157 continued to surface in industrialized 
        countries including Japan and the United States; and
  --Vancomycin-resistant Staphylococcus aureus was identified in Japan 
        for the first time, and later in the United States.

The solution
    The concern of industrialized countries such as the United States, 
where prevention and control efforts have dramatically decreased 
infectious disease mortality, is international public health security: 
ensuring that infectious diseases which are occurring elsewhere do not 
spread internationally across their borders.
    The concern of developing countries is to detect and stop 
infectious diseases early, thus avoiding high mortality and negative 
impacts on tourism and trade. Yet, developing countries are constrained 
by the lack of appropriate technologies and the difficulty of financing 
the necessary interventions on a sustainable basis.
    The solution, which addresses the interests of both the 
industrialized and developing countries, is to combine their efforts to 
strengthen detection and control of infectious disease. The major 
requirements for the prevention and control of infectious diseases 
globally and nationally are:
  --Strong global and national epidemiological surveillance and public 
        health laboratories to detect infectious diseases, to provide 
        data for analyzing and prioritizing health services, and to 
        monitor and evaluate the impact of control efforts plus global 
        monitoring and alert systems to bring together laboratories and 
        disease surveillance systems from all countries to share 
        information internationally through electronic and printed 
        media.
  --Sustainable and well-managed infectious disease control programs 
        which effectively diagnose infectious diseases and administer 
        vaccines, curative drugs, and other interventions where and 
        when they are needed.
  --Continuing research and development of simple-to-use and robust 
        vaccines, antimicrobial drugs, and laboratory tests for 
        effective surveillance, prevention, and control of infectious 
        diseases.

WHO's global strategy and collaboration with CDC
    To combat the spread of infectious disease a global framework is 
needed to build up the necessary networks for surveillance and control 
of infectious diseases. The World Health Organization works to build 
such a global framework and effective networks through its Division of 
Emerging and other Communicable Disease Surveillance and Control (EMC).
    WHO has responded to the threats of infectious disease by 
developing a four-part strategy for international surveillance. First, 
WHO has instituted a global monitoring and alert system for 
communicable diseases that brings together laboratories and disease 
surveillance systems from all countries to share information 
internationally through electronic and printed media. Revision of the 
International Health Regulations (IHR) is underway and will be proposed 
for adoption by the World health Assembly in 1999. The new 
International Health Regulations will require Member States to report a 
spectrum of communicable disease syndromes of international public 
health importance in addition to the three specific diseases covered at 
present. These proposed new regulations are now being field-tested. 
Second, WHO rapidly and widely disseminates global information 
collected from national Ministries of Health, WHO Collaborating 
Centers, and governments via electronic means and the WHO World Wide 
Web site. EMC also has an electronic alert system designed to help 
facilitate expert verification of unconfirmed outbreak information on a 
confidential basis. Third, WHO helps in establishing national and 
regional preparedness for communicable disease prevention and control. 
EMC provides manuals, standards, and guidance to national centers. The 
weak link in current global monitoring capacity is the collection of 
clinical/epidemiological data. At present, few countries have an 
adequate national infectious disease monitoring system, and most are 
extremely weak. Some of the most important geographical regions in 
terms of disease emergence, are the weakest, and this situation needs 
to change. Finally, WHO encourages international preparedness for 
communicable disease prevention and control, which supports and 
augments national and regional preparedness while national systems 
improve their capabilities.
    The key to global surveillance and control of infectious diseases 
has been a collaborative effort between WHO and its partners, including 
national-level agencies like the Centers for Disease Control and 
Prevention (CDC), which play a critical role in continuing domestic 
surveillance and control which minimizes the risk of international 
transmission of infectious diseases.
    WHO's goal is to strengthen national preparedness in all countries, 
which will require a substantial long-term commitment of human and 
material resources by many partners to strengthen the infrastructure 
and processes for disease control and surveillance in poorer countries. 
WHO's role has been to reinforce global laboratory-based surveillance 
by providing training and support to existing WHO Collaborating Centers 
and laboratories. WHO gives seed funding for development and 
distribution of diagnostic reagents and designates new centers and 
laboratories to fill geographic gaps. CDC already provides valuable 
assistance in quality assurance to WHO supported laboratories 
monitoring bacterial, viral, parasitic and zoonotic diseases throughout 
the world. CDC also provides expert training in epidemiology and other 
areas of public health, working with WHO and other international 
partners.
    WHO has improved global epidemiological surveillance and 
facilitated rapid reporting of and response to infectious disease of 
international public health importance. Surveillance has specifically 
focused on developing a system to detect and investigate unusual 
infectious disease outbreaks, whether naturally occurring or 
intentionally caused. WHO has been working with the monitoring group of 
the Biological Weapons Convention (BWC) to make sure that all diseases 
of concern to BWC are included in these surveillance guidelines. WHO 
Member States and WHO's network of regional offices, country 
representatives, and technical partners such as CDC are now being 
linked electronically for verification and response. The response 
mechanism permits rapid and coordinated international investigation and 
containment of infectious disease outbreaks of international 
importance. WHO-coordinated international response broadens 
international cooperation so that no country is required to shoulder 
the entire burden of responding to an infectious disease outbreak of 
international importance. Without such a coordinated international 
response, many disease outbreaks could have resulted in extensive 
international spread.
    EMC is strengthening global surveillance through adding new 
collaborating partners to the network of WHO Collaborating Centers in 
infectious disease and/or the anti-microbial resistance (ARM) 
monitoring network. WHO is working to incorporate military laboratories 
which often have good capabilities even in poorer countries, together 
with WHO Collaborating Centers into the global monitoring system for 
diseases and antimicrobial resistance.
    Increased support to CDC for international collaboration with WHO 
would permit more rapid strengthening of surveillance and control 
capabilities worldwide, especially in poor countries. By permitting 
rapid detection and containment of infectious diseases when and 
wherever they occur, the risk of their entering the United States of 
America is minimized. Together, WHO and CDC will be working to advance 
all of the elements of current efforts to strengthen the global 
monitoring system to ensure international public health security.

STATEMENT OF MICHAEL OSTERHOLM, Ph.D., CHAIR, COMMITTEE 
            ON PUBLIC HEALTH, PUBLIC AND SCIENTIFIC 
            AFFAIRS BOARD, AMERICAN SOCIETY FOR 
            MICROBIOLOGY

    Senator Faircloth. I would like to welcome the second panel 
of experts and I would like to take a moment, if you would, to 
limit your opening statement to 5 minutes, but do not feel you 
should rush. We asked you to come and if you are not through, 
why, we will cut the light off and you can finish.
    The three panelists are Dr. Michael Osterholm. Is that 
right, Doctor?
    Dr. Osterholm. That is right.
    Senator  Faircloth. He will be representing the American 
Society for Microbiology. He is chair of the Committee on 
Public Health and serves on the public and scientific affairs 
board, the task force on biological weapons, and the task force 
on antibiotic resistance. He is a professor at the School of 
Public Health at the University of Minnesota and serves on the 
editorial board of a number of prestigious medical journals, 
including the New England Journal of Medicine and Science 
magazine. Thank you for being here.
    The second witness on this panel will be Dr. Edward 
Thompson. Dr. Thompson is a physician and has a masters of 
public health degree from Johns Hopkins University. He has 
served as Mississippi health officer since 1993 and will 
represent the views of the State public health professionals 
today. Thank you, Dr. Thompson.
    Our third witness will be Dr. Ralph D. Morris, president of 
the National Association of County and City Health Officials. 
This group represents nearly 3,000 local public health 
departments. He is a medical doctor and director of the 
Galveston County Health Department in Texas. I assume Galveston 
is in Galveston County.
    Dr. Morris. That is correct, sir.
    Senator  Faircloth. Does it go beyond the island?
    Dr. Morris. Well, we consider anybody north of the causeway 
a Yankee, sir. [Laughter.]
    Senator  Faircloth. Dr. Osterholm, we will begin with your 
testimony please.
    Dr. Osterholm. Thank you. Senator Faircloth, we would like 
to thank you on behalf of the American Society for Microbiology 
to be able to be here with you today to testify on issues 
related to public health needs and the threat of bioterrorism. 
The ASM has submitted a written statement for the hearing 
record, which I will briefly summarize.
    The high consequence implications for bioterrorism puts it 
into a special category that requires immediate and 
comprehensive response. However, the ASM believes that 
enhancing the public health infrastructure response to 
bioterrorism will also increase our ability to respond to 
naturally occurring and reemerging infectious diseases that now 
seriously threaten the health and security of the United 
States.
    Biologic weapons for the use against civilian populations 
differ in important respects from other weapons of mass 
destruction and require a very different approach for the 
deterrence, detection, and response. Understanding these 
differences is critical.
    A key difference is that most biological weapons cause 
diseases that exist in nature. This is even true for the 
fictional examples of genetically engineered biological weapons 
since the symptoms they cause may not differ significantly from 
the infectious diseases that are found in nature. The 
investigative steps for detecting and identifying a biologic 
agent released into a civilian population will be the same as 
that for a naturally occurring agent. Therefore, the first and 
most fundamental defense strategy for dealing with bioterrorism 
is to develop effective means for combating infectious diseases 
and improving our public health infrastructure and biomedical 
research capacity.
    However, experts have concluded that the ability of the 
U.S. public health system and allied health professionals to 
deal with emerging diseases is in serious jeopardy today. Even 
with the recent infusion of Federal support for the emerging 
infections program, the overall infrastructure for infectious 
disease surveillance at the Federal, State, and local levels 
has seriously suffered. Gaps in surveillance have a direct 
impact on our overall ability to respond to threats or acts of 
bioterrorism.
    Such deficiencies are a very critical, weak link in our 
Nation's defense against biological weapons. Unlike nuclear 
convention bombs or even chemical weapons, a biological weapon 
is unlikely to cause instant harm. Because symptoms take days 
to develop, an act of bioterrorism may go undetected for days 
or even weeks after it occurs. For some of the diseases, many 
secondary cases could occur among contacts of ill persons and 
would also be randomly distributed. Delay in detecting these 
cases by hours could mean the difference between an order of 
magnitude in the increased number of serious illnesses and 
deaths.
    Successful detection of a secret bioterrorist attack 
depends on many members of the health care and public health 
system promptly recognizing an unusual infectious disease 
pattern. This will require a concerted effort of clinicians, 
specialized personnel to confirm the diagnosis of the suspected 
disease agent, public health experts to determine multiple 
causes have occurred simultaneously but unexpectedly, and 
finally additional experts to conclude that the cases of 
disease in question were not acquired naturally but through a 
deliberate act of bioterrorism.
    All of the recent efforts surrounding the use of the 
National Guard, Department of Defense, and local hazmat teams 
will do nothing--I repeat, will do nothing--to assist us in the 
recognition and even in many cases our response to biological 
terrorism.
    State health departments and CDC resources and expertise 
are vital for detecting bioterrorist actions in the same way 
that its expertise has helped in identifying the biological 
agents responsible for unusual, naturally occurring disease 
outbreaks. However, currently neither the CDC nor the State 
health departments have the capacity to respond to threatened 
bioterrorism actions involving potential weapons such as 
anthrax, plague, tularemia, or smallpox.
    One major concern is that the CDC does not have adequate 
and safe space for working with these relatively rare but 
dangerous etiologic agents. State health departments also do 
not have the expertise or facilities for working with exotic 
agents. Additional funding, not reallocated funding, but new 
funding for laboratory facilities, equipment, and research is 
urgently needed.
    Ensuring the adequacy of vaccines and the antimicrobial 
drugs will be critical for minimizing casualties with an attack 
with biologic weapons. Federal agencies should investigate the 
needs and accessibility for vaccines and antibiotics that may 
be necessary in the event of a bioterrorism attack and they 
should work with pharmaceutical industries to ensure that 
emergency supplies can be produced and made available on short 
notice.
    The ASM, therefore, makes the following specific 
recommendations to increase U.S. preparedness.
    First, an investment of approximately $200 million could 
provide an essential first step toward enhancing efforts to 
address bioweapons threats.
    Second, the CDC plan to combat new and reemerging 
infectious diseases should be funded at a proposed level of 
$125 million in fiscal year 1999.
    An additional $50 million is needed to complete phase II of 
the new laboratory facility at CDC that will be used for 
working with particularly dangerous microbiological pathogens, 
including those that might be used for bioterrorism purposes.
    The ASM believes it is imperative that CDC be given 
specific resources at a minimum of $1 million to implement the 
congressionally mandated program to monitor the transfer of 
select infectious agents.
    Congress mandated CDC to implement and enforce regulations 
for monitoring the transfer and exchange of biologic agents 
within the United States under the authority of the Anti-
terrorism and Effective Death Penalty Act of 1996. However, 
section 511 of that act, regulatory control of biologic agents, 
was intended to protect public safety while allowing free and 
open scientific research. Regulations implemented by the 
Department of Health and Human Services are not currently 
fulfilling that mandate. The registration program for 
laboratories transferring and receiving specified infectious 
agents must be funded by Congress to prevent interference with 
very valuable and critical scientific research.

                           PREPARED STATEMENT

    In closing, the ASM believes that improving the U.S. 
bioterrorism response capabilities will provide broader 
benefits to public health overall. Efforts to improve disease 
surveillance, biomedical research, and development of improved 
diagnostics, therapeutic agents, and vaccines serve the dual 
purpose of protecting the public health and defending against 
biologic weapons. None of the additional capacity implemented 
to counter the threat of bioterrorism will be inactive or 
wasted.
    Thank you for the opportunity to testify. I would be 
pleased to respond to your questions at the appropriate time.
    Senator  Faircloth. Thank you, Doctor.
    [The statement follows:]

                Prepared Statement of Michael Osterholm

    Mr. Chairman, Senator Faircloth, members of the Subcommittee, thank 
you for inviting the American Society for Microbiology (ASM) here today 
to discuss issues related to the public health infrastructure, 
epidemics, and bioterrorism. I am chair of the Public Health Committee 
of the American Society for Microbiology's Public and Scientific 
Affairs Board and my testimony today is presented on behalf of the ASM. 
For the record, I am the State Epidemiologist and Chief of the Acute 
Disease Epidemiology Section of the Minnesota Department of Health.
    The ASM is pleased to have this opportunity to serve as a resource 
to the Subcommittee and offers to make its full professional 
capabilities available, particularly as you consider some of the 
special public health needs that stem from threats of bioterrorism. We 
would like to thank Chairman Specter, Senator Faircloth, and other 
Senators on the Subcommittee for convening this hearing and also for 
their past and continued strong support for the infectious disease 
programs of the Centers for Disease Control and Prevention (CDC) and 
the National Institutes of Health (NIH), both of which are critical 
components of an overall national defense against infectious diseases 
and bioterrorism. We particularly thank Senator Faircloth for 
initiating this hearing.
    The ASM is the largest single life science society in the world, 
with over 42,000 members, representing a broad spectrum of 
subdisciplines in the microbiological sciences, including medical, 
environmental, and public health microbiology as well as infectious 
diseases. The Society's mission is to promote a better understanding of 
basic life processes and the application of this knowledge for improved 
health and environmental well being. For nearly a century, ASM has 
brought its scientific, educational, and technical expertise to bear on 
issues surrounding the safe and appropriate study, handling, and 
exchange of pathogenic microorganisms. On numerous occasions, members 
of the Society have provided advice to government agencies and to 
Congress concerning both technical and policy issues related to the 
control of biological weapons. The ASM has established a Task Force on 
Biological Weapons Defense to assist in formulating policy on 
scientific issues.

             INFECTIOUS DISEASES AS A PUBLIC HEALTH THREAT

    The threat of bioterrorism needs to be considered in the broader 
context of the public health threat posed by infectious diseases. 
Although biological weapons pose a new and credible potential threat, 
naturally occurring infectious diseases caused by emerging and 
reemerging pathogens seriously threaten the health and security of the 
United States on an existing and continuing basis. The high consequence 
implications for bioterrorism put it into a special category that 
requires immediate and comprehensive response. However, the ASM 
believes that building the public health infrastructure to respond to 
bioterrorism will also increase our ability to respond to the naturally 
occurring and reemerging infectious diseases which seriously threaten 
the health and security of the United States. In 1996, for example, 
infectious diseases ranked as the third leading cause of death in the 
United States. Moreover, since 1980, the death rate in this country 
from infectious diseases has increased almost 60 percent. During this 
same period, more than 30 infectious agents have been discovered--most 
of them dangerous, and some of them deadly.
    Infectious agents, old and new, pose challenges of immense 
complexity to the researchers studying them as well as to the 
physicians and other healthcare providers who are helping patients 
combat them. Many factors help to account for why the traditional 
patterns of infectious disease have been changing, including shifts in 
human demographics, improper uses of antibiotics, changes in climate 
patterns, changes in host-parasite interactions and microbial 
evolution. Meanwhile, enormously expanded world travel and 
unprecedented international trade provide an efficient means for 
transporting agents that cause infectious diseases from one part of the 
world to another, making it possible for a dangerous pathogen to move 
from a remote village virtually anywhere in the world to an 
industrialized U.S. urban center very quickly, typically in less than 
24 hours.
    Infectious diseases may be introduced into an unsuspecting U.S. 
population not only from natural human, animal, or plant sources but 
also deliberately as part of a ``bioterrorism'' scheme--that is, as 
part of a release of pathogens intended to harm humans directly or to 
damage the animals or plants on which we depend. Although casualties 
may be limited if unsophisticated groups deploy biological weapons, the 
threat of mass deaths from a biological weapons attack is of grave 
concern.
    The ASM recognizes that there is serious public concern about 
pathogenic microorganisms being used as weapons by nations or 
individuals. As these concerns are addressed, we recommend a thorough 
review of general strategies and specific measures needed to protect 
the public. With this in mind, the ASM offers the following 
observations and recommendations.

                  UNIQUE ASPECTS OF BIOLOGICAL WEAPONS

    Biological weapons differ in several important respects from other 
weapons of mass destruction and thus require a different approach for 
deterrence, detection, and response. Understanding these differences is 
critical to formulating public policy.
    A key difference is that most biological weapons cause diseases 
that exist in nature and may occur spontaneously in human populations. 
This is even true for fictional examples of genetically engineered 
biological weapons, since the symptoms they cause may not differ 
significantly from the infectious diseases that are found in nature. 
The investigative steps for detection and identification of the agent 
would be the same as that for a naturally occurring agent. Therefore, 
the first and most fundamental defense strategy for dealing with 
bioterrorism is to develop effective means for combating all infectious 
diseases. Fears about state sponsored or individual terrorists 
intentionally spreading agents of infectious disease should not 
distract us from the underlying war against naturally occurring 
diseases, including emerging infections that threaten to spread as new 
epidemic waves causing illness and death.
    Improving the public health infrastructure and biomedical research 
capacity is the most effective approach for addressing both familiar 
and new or emerging infectious diseases. However, several expert 
committees, including one convened by the Institute of Medicine, have 
concluded that the ability of the U.S. public health system and allied 
health professionals to deal with emerging diseases is in serious 
jeopardy. For example, a 1992 survey by the Council of State and 
Territorial Epidemiologists indicates that the number of professional 
positions dedicated to infectious disease surveillance in most states 
has fallen below a vital threshold, making infectious disease 
surveillance efforts inadequate throughout much of the United States. 
Even with the recent infusion of federal support for the emerging 
infections program, the overall infrastructure for infectious disease 
surveillance at the state and local level has suffered. In part this 
has been due to the substantial reductions in support for surveillance 
of vaccine-preventable diseases, HIV infection and tuberculosis. 
Frequently, state and local health departments will share 
infrastructure support with other disease programs. In many states no 
one is tracking foodborne and waterborne diseases any longer. Such gaps 
in surveillance have a direct impact on our overall ability to respond 
to threats or acts of bioterrorism.
    Such deficiencies count for a great deal because, unlike nuclear or 
conventional bombs or even chemical weapons, a biological weapon is 
unlikely to cause instant harm. Thus, because symptoms take time to 
develop, an act of bioterrorism may go undetected for days or even 
weeks after it occurs. For example, if a biological agent were secretly 
released in a busy metropolitan travel center, such as Washington's 
Ronald Reagan National Airport, cases affecting travelers might not 
begin to appear until 2 to 14 days later and, by then, among 
individuals in scattered locations throughout the United States and 
other parts of the world. If the disease were even moderately 
contagious, secondary cases would occur among contacts of ill persons 
and would also be randomly distributed. Delay in detecting these cases 
by hours could mean the difference between an order of magnitude in the 
increased number of serious illnesses and deaths. In particular, for 
such agents as anthrax, plague and even smallpox, a delay of hours in 
responding to these potential disease problems will result in many more 
cases and deaths.
    Thus, initial detection of a bioterrorist attack could be difficult 
and the response to it would certainly entail a much more complex 
strategy than is typically required following an incident involving 
explosives or chemical weapons. Current systems for counteracting 
bioterrorist attacks are erroneously being built on models for 
incidents involving chemical agents, such as the release in 1995 by 
members of the Aum Shinrikyo of sarin gas in Tokyo. In this and other 
cases like it, the impact of the attack is immediate, localized, and 
the affected area and victims are readily identified. Hence, medical 
management and decontamination efforts can be directed quickly to 
specific sites. Moreover, first responders and military strike teams 
can be trained to anticipate such events in a useful fashion, thereby 
giving some assurance that damages may be minimized, if not altogether 
avoided.
    In the case of a clandestine biological attack, however, sick 
individuals will not likely be met first by specially trained first 
response teams. Instead, these infected individuals will seek medical 
attention in a variety of civilian settings, including emergency rooms, 
doctors offices, or clinics at scattered locations. Successful 
detection of a secret bioterrorist attack thus depends on many members 
of the health care and public health system promptly recognizing an 
unusual infectious disease pattern. This will require the concerted 
efforts of clinicians, specialized laboratory personnel to confirm the 
diagnoses of the suspected disease agent, public health experts to 
determine that multiple cases have occurred simultaneously but 
unexpectedly, and, finally, additional experts to conclude that the 
cases of disease in question were not acquired naturally but through a 
deliberate act of bioterrorism.
     unique role of the centers for disease control and prevention
    To respond to such threats, a multiagency partnership involving 
federal, state, and local authorities is essential. The ASM believes 
that the Centers for Disease Control and Prevention is an indispensable 
civilian component of this partnership. In particular, its resources 
and expertise are vital for detecting bioterrorist actions aimed at the 
general population, much in the same way that its expertise has helped 
in identifying the biological agents responsible for unusual, naturally 
occurring disease outbreaks. Therefore, it is important to enhance 
existing public health systems for detecting unusual disease events, 
the capacity to investigate and control potential threats, and the 
laboratory capabilities to identify and diagnose suspected agents.
    In combating bioterrorism or in responding to natural infectious 
disease outbreaks, the public is best protected when health care 
professionals and diagnostic laboratories work together with state and 
local health departments as well as with the CDC to ensure that unusual 
outbreaks of diseases are detected and identified early and that 
appropriate epidemiological and treatment responses are rapidly 
initiated. For example, during the outbreaks of Legionnaires' disease 
in 1976 and of hantavirus pulmonary syndrome in 1993, alert physicians 
notified their respective state health departments and the CDC of 
unusual cases of illness. In these separate incidents, similarities 
among the many case reports were noted by state officials and CDC 
experts working in partnership. They conducted follow-up investigations 
to identify the cause of the diseases, the sources of infections, and 
appropriate prevention strategies to implement. Despite these 
outstanding examples of public health response, the existing 
surveillance systems in place still required that days occur between 
the initial recognition of sporadic cases and the recognition of an 
outbreak by state and federal authorities.
    Although the partnership between CDC and state health departments 
has been established for decades, the system for communication and 
cooperation is far from perfect and badly needs modernizing and other 
improvements that will help to automate the system and make best use of 
new electronic means for assembling and analyzing data. Rapid channels 
of communication and information systems must be linked to allow for 
examination of multiple data sources to detect unusual patterns or 
early warnings of disease.
          tracking of potentially dangerous biological agents
    Among specific responsibilities, Congress mandated CDC to implement 
and enforce regulations for monitoring the transfer and exchange of 
biological agents within the United States, under authority of the 
Antiterrorism and Effective Death Penalty (AEDP) Act of 1996. However, 
although section 511 of that Act, ``Regulatory Control of Biological 
Agents,'' was intended to protect public safety while allowing free and 
open scientific research, regulations implemented by the Department of 
Health and Human Services (HHS) are not fulfilling that mandate. In 
particular, a registration program and fee schedule for institutions 
and laboratories transferring and receiving specified infectious agents 
are interfering with valuable scientific research without providing the 
public a safety benefit.
    The ASM has recommended that CDC be given specific resources of at 
a minimum $1 million to implement the congressional mandate under 
section 511 of the AEDP Act of 1996 without imposing undue restrictions 
on scientific research. Additional funding would also enable CDC to 
provide specific new educational and training programs to ensure 
research institutions are in full compliance with that Act, which is 
intended to restrict the availability of potential biological warfare 
agents without hindering legitimate research. U.S. officials, including 
experts at CDC, should also be involved in monitoring exchanges at the 
international level of infective agents that could pose a threat to the 
United States. The ASM recognizes that the major mission of the CDC is 
not regulating, but to detect, diagnose, prevent and control infectious 
diseases.

              ENHANCING THE CAPACITY TO RESPOND TO THREATS

    When bioterrorism activities are suspected, state and federal 
response teams largely made up of public health and medical delivery 
infrastructure, must respond quickly to minimize the impact and 
exposure to whatever infectious agents that have been deployed. 
Recently described efforts by teams from the Department of Defense and 
local or national guardians will likely play a minor meaningful role in 
this response. The incubation period before symptoms appear varies for 
different infectious diseases and also depends on other factors, 
including dose and means of exposure. In most instances, response teams 
can expect at least a small window of opportunity during which exposed 
individuals may be treated to prevent illness from developing.
    However, to take advantage of such opportunities, public health 
officials and other members of such response teams must be able to 
identify and then quickly diagnose those individuals who were likely 
exposed to the infectious agent, so that they can be appropriately 
treated and quarantined as necessary. The ability to respond quickly 
and effectively to such incidents depends absolutely on having well-
balanced, appropriately trained teams at the ready. Such teams require 
highly skilled individuals from several disciplines, including those 
with clinical, laboratory, microbiological and epidemiological 
expertise.
    Currently, neither the CDC nor state health departments have the 
capacity to respond fully to threatened bioterrorist actions involving 
potential biowarfare agents, including those that cause anthrax, 
plague, tularemia, and brucellosis. One major concern is that the CDC 
has little capacity for working with these diseases and does not have 
adequate and safe laboratory space for working with these relatively 
rare but dangerous etiologic agents. State health departments also do 
not have the expertise or facilities for working with exotic biological 
agents. Moreover, few laboratories are prepared to conduct the 
analytical tests needed to identify such agents.

                       RECOMMENDATIONS FOR ACTION

    Hence, additional funding for laboratory facilities and equipment 
is urgently needed. Research is also needed to develop diagnostic tests 
that are simple, rapid, inexpensive, and capable of being conducted 
locally. Most laboratory tests for targeted biological agents take 
special expertise and considerable time to confirm. Improved diagnostic 
methods with faster turn-around times need to be developed and made 
widely available. For instance, to improve nationwide surveillance 
efforts, state health departments will need access to diagnostic 
methods that enable them to compare the molecular ``fingerprints'' of 
locally isolated infectious agents to those that appear in a national 
electronic database. CDC does not have established agreements with the 
Department of Defense to access rapid testing technology. In addition, 
appropriately trained epidemiologists are needed at the federal and 
state level to investigate disease outbreaks and to serve as part of 
surveillance system teams.
    Another major concern is that many of the microorganisms that might 
be used as biowarfare agents are not causing major public health or 
veterinary health challenges in the United States. Hence, there is 
little if any capacity nationwide to deal with large outbreaks of these 
diseases. Moreover, few physicians or veterinarians have had to deal 
with actual cases of these diseases, making it unlikely for them to 
suspect isolated cases caused by such relatively rare and unfamiliar 
illnesses. To close such gaps, specific training is urgently needed for 
physicians, other health care personnel, and veterinarians. 
Professional societies with expertise in these areas will play an 
important role in providing such training.
    The ASM would like to draw attention to the Institute of Medicine's 
interim report, ``Improving Civilian Response to Chemical or Biological 
Terrorist Incidents.'' This report contains many useful recommendations 
for Congress and the Administration to examine. Importantly, the first 
recommendation in the IOM report is ``to provide federal financial 
support for improvements to state and local surveillance 
infrastructure,'' including expansion of the CDC Emerging Infections 
Initiatives. The IOM report also recommends that professional societies 
be enlisted in the effort to educate first responders, emergency 
departments, and poison control centers by incorporating useful 
information on biological and chemical warfare agents into texts, 
manuals, and reference libraries. Professional societies, including 
ASM, could assist in such efforts.
    In closing, ASM recognizes that preparedness to protect U.S. 
citizens against the threat of bioterrorism will require additional 
federal resources. The ASM, therefore, makes the following specific 
recommendations:
  --The ASM estimates that an investment of approximately $200 million 
        could provide an essential first step toward enhancing efforts 
        to address bioweapons threats.
  --The ASM further recommends that Congress fully fund the CDC plan to 
        combat new and reemerging diseases at a proposed level of $125 
        million in fiscal year 1999.
  --An additional $50 million is needed to complete phase II of the new 
        laboratory facility at CDC that will be used for working with 
        particularly dangerous microbiological pathogens, including 
        those that might be used for bioterrorist purposes.
  --The ASM recommends that CDC be given specific resources at a 
        minimum of $1 million to implement the congressionally mandated 
        program to monitor the transfer of select infectious agents.
    As we mobilize these resources, we must ensure that we also 
maintain or strengthen our essential public health efforts. Diverting 
resources needed for vaccines that protect the public against deadly 
natural diseases such as polio and diphtheria would be wrong. Thus, 
even as we prudently build our capacity for countering the genuine 
threat of bioterrorism, we must not overreact to that threat by 
ignoring our vulnerability to naturally occurring infectious diseases.
    The ASM believes that improving U.S. bioterrorism response 
capabilities will provide broader benefits to public health. Efforts to 
improve disease surveillance and research and development of improved 
diagnostics, therapeutic agents and vaccines serve the dual purpose of 
protecting the public health and defending against biological weapons. 
For example, enhanced surveillance and response systems will allow 
faster detection and intervention for other infectious diseases that 
affect the U.S. population. Clinical, diagnostic, and epidemiological 
expertise are not currently available for detecting and combating 
certain key biological agents; moreover, improved computer hardware and 
software are needed to improve infectious disease surveillance and 
communication capabilities.
    Very importantly, biomedical research must also be expanded to find 
new ways of preventing and treating infectious diseases. Basic research 
is the underpinning for the long term ability to address infectious 
disease threats.
    None of the additional capacity implemented to counter the threat 
of bioterrorism will be inactive or wasted.
    Thank you for the opportunity to testify. I would be pleased to 
respond to any questions.

STATEMENT OF EDGAR THOMPSON, M.D., M.P.H., CHAIR, 
            GOVERNMENT RELATIONS, ASSOCIATION OF STATE 
            AND TERRITORIAL HEALTH OFFICIALS

    Senator  Faircloth. Dr. Edward Thompson.
    Dr. Thompson. Thank you, Senator.
    Senator  Faircloth. You are--what is your title?
    Dr. Thompson. I am the State health officer for the 
Mississippi State Department of Health. I am what in most 
States is called the commissioner of health.
    Senator  Faircloth. OK, yes. Thank you.
    Dr. Thompson. We spoke earlier of plague, Senator. There is 
a human plague of which most of us are ignorant, but those of 
us named Ed are very familiar with it. The disease causes 
everyone to assume that if your name is Ed, it is short for 
Edward. In my case it is not. It is Edgar. But thank you for 
the attempt.
    I am here representing the Association of State and 
Territorial Health Officials, and for the record I am Dr. Ed 
Thompson.
    I would like to talk to you for a minute about why we as 
public health officials from the State level are here. I mean, 
after all, we need a Federal response to bioterrorism. The 
Federal agencies and the Department of Defense will take care 
of all this and everything will be well. Well, to quote Three 
Dog Night, ``that ain't the way that it works.'' This is going 
to have to be addressed at the State level as well.
    I would like to talk just a minute about why, in addition 
to our other expertise, we and some of the other public health 
doctors are here today. It is because we have seen a glimpse of 
the enemy. We have seen directly the effects of an outbreak of 
disease or an incident of chemical contamination in a 
population. Just 3 weeks ago we had a fatal case of----
    Senator  Faircloth. Where was this 3 weeks ago?
    Dr. Thompson. Just 3 weeks ago in Mississippi, in Jackson. 
We had a fatal case of meningococcal meningitis in a school, 
and when you deal with the frightened parents and the frantic 
educators and the frothing media, you see in microcosm what a 
biological attack could do. Trying to provide reassurance in a 
packed community center in a north Mississippi town where three 
cases of Rocky Mountain spotted fever have occurred, two of 
them fatal, you see what terror is.
    As shocking and deadly as the bombings of the World Trade 
Center and the Oklahoma City Federal Building were, the lethal 
and disruptive potential of biological agents is even greater 
with an ability to create sustained fear and disruption 
unmatched by explosives and chemical poisons. Any public health 
official who has dealt with the effect of even a small outbreak 
of infectious disease in a community can tell you that 
infectious agents are an ideal terrorist weapon.
    Readiness for the possibility of biological terrorism not 
only means making sure our national security systems are 
adequate, but that our public health system has the ability and 
the resources to respond. An effective public health response 
can mean significant reduction of damage and death.
    Now, a critical role of State health departments in 
responding to biological terrorist attack will be detection. 
The appearance of an unusual disease or increased cases of an 
ordinary disease will likely be first recognized through public 
health surveillance at the State and local level. We saw this 
in 1984 in Oregon when a terrorist attack using salmonella 
bacteria was detected and averted when local public health 
authorities through basic public health surveillance identified 
the threat.
    Another of our most important goals will be to provide 
manpower. Much of the case finding, immunizing, medication 
delivery, and other hands-on control will be done by State and 
local health department nurses, environmentalists, and disease 
investigators. Our experience with the chemical contamination 
of thousands of Mississippi homes with methyl parathion 
illustrates this. Despite the deployment of dozens of Federal 
personnel from several agencies, the majority of the manpower, 
or much of it nurse power, came from the State and local health 
departments.
    Senator, you asked earlier if the Nation is prepared to 
respond to bioterrorism. Well, if the States are prepared, the 
Nation is prepared, and if the States are not, the Nation is 
not.
    Are the States prepared? Well, States are not prepared now, 
but State and local health departments are uniquely qualified 
to become prepared and to fill critical roles. We have skill 
and experience in rapidly mounting mass immunization campaigns, 
large scale administration of medications, emergency public 
communications, and disaster response. We do all these things, 
not just practice them. We are the experts in basic 
surveillance and disease reporting because we are the ones who 
do it for most diseases. We have the foundation on which to 
build a solid system to deal with outbreaks and epidemics, 
whether natural or manmade, but much remains to be done.
    The most immediate need is for a comprehensive national 
strategy to address the threat of bioterrorism. On May 22, the 
President announced his intent to create one and ASTHO commends 
him for that leadership. In holding this hearing, Senator, you 
too are providing leadership on this issue. But the focus so 
far has been on planning by Federal agencies. Dealing with 
bioterrorism will depend on civilian Federal agencies, the 
military, and State and local public health and other 
officials. No one of the three can do the job alone.
    Congress and the administration need to convene a national 
planning process involving State and local governments, as well 
as the affected Federal agencies, including especially the 
Centers for Disease Control. We need a national plan 
coordinated at the Federal, State, and local levels among 
public health agencies, emergency management, law enforcement, 
and the military. This planning process must involve State and 
local public health officials at every stage.
    The other major need is for resources. Some of these 
resources involve new technology or making existing technology 
available to States, especially the public health laboratories. 
But even more important is support, funding, for essential 
public health activities and infrastructure. Not all the 
infrastructure needed by the States is at the State level. CDC 
and its infectious disease and environmental laboratories are 
national resources on which all States draw in public health 
emergencies. Funding to improve and assure their capacity to 
meet these needs is critical to the States.
    Only the coordinated national planning process we are 
calling for will answer the question of what defending against 
bioterrorism will cost. We estimate as much as $200 million for 
public health infrastructure alone, but it will be a unique 
bargain. Some emergency preparedness measures are limited to 
emergency use. Public health preparedness for bioterrorism is a 
broader investment.

                           PREPARED STATEMENT

    Improved surveillance, laboratory capability, and 
communication systems will be immediately applicable to 
naturally occurring diseases, including emerging infectious 
diseases and epidemic diseases, such as influenza. The same 
technology and infrastructure that is needed to detect and 
control disease of deliberate origin can be used against 
naturally occurring health threats day in and day out in every 
State.
    I thank you and I look forward to answering the questions 
at the appropriate time.
    Senator  Faircloth. Thank you, Dr. Thompson.
    [The statement follows:]

               Prepared Statement of Dr. Edward Thompson

    Mr. Chairman, Senator Faircloth, Senator Cochran and other Members 
of the Subcommittee, I am Dr. Ed Thompson, Health Commissioner for the 
State of Mississippi. I am here today representing the Association of 
State and Territorial Health Officials (ASTHO). ASTHO is an alliance of 
the chief health officer in each of the 57 states and territories in 
the United States. My testimony also reflects the perspectives of the 
Council of State and Territorial Epidemiologists and the Association of 
State and Territorial Public Health Laboratory Directors. It is not 
intended to represent a formal position on the part of any of the three 
organizations, as none of them have adopted specific positions on this 
issue.
    ASTHO greatly appreciates the leadership that you have shown, Mr. 
Chairman, in holding this hearing on the role of public health in 
responding to bioterrorist threats, a subject of immense importance for 
our nation's security and well-being, and currently overlooked. ASTHO 
also greatly appreciates the leadership you have shown, Senator 
Faircloth, in sponsoring S. 1786, a bill requesting the Centers for 
Disease Control and Prevention to report within 60 days information 
regarding its ability to respond to the growing threats of viral 
epidemics and biologic and chemical terrorism and the resources it 
needs to adequately respond. This bill, and your interest in bringing 
this issue to the attention of the Congress, is federal leadership at 
its best. ASTHO applauds you and thanks you. I also want to extend 
special appreciation to Senator Cochran who has always been 
particularly responsive to state health officials' program priorities 
and to the public health needs of the citizens of Mississippi and the 
nation.
    I don't need to remind this Subcommittee why this hearing is 
needed. The terrorist bombing of the World Trade Center in 1993 and the 
Alfred P. Murrah Federal Building in Oklahoma City in 1995, and the 
nerve gas attack on the Tokyo subway in 1995 are seared into Americans' 
consciousness. As shocking and deadly as these bomb and chemical 
attacks were, the lethal and disruptive potential of biological agents 
is even greater, with an ability to create sustained fear and 
disruption unmatched by explosives and chemical poisons.
    Recent conflict with Iraq over weapons inspections remind us that 
biological and chemical weapons are probably in the possession of a 
number of hostile governments. Even more frightening, weapons of mass 
destruction, including deadly biological agents, are very likely within 
the capability of a number of non-governmental extremist groups both 
domestic and foreign.
    This means we must also be aware of and prepared for the 
possibility of a major biological terrorist event here, at home, in the 
United States. Readiness for such an attack not only means making sure 
our national security systems are adequate and vigilant, but that our 
public health system at the federal, state and local level has the 
ability and the resources to rapidly identify, investigate and control 
the consequences of a terrorist event that could affect thousands of 
Americans. An efficient, effective public health response can mean the 
difference between chaos, widespread panic and increased casualties and 
significant reduction of disease, disability and death related to the 
event.
    The importance of the public health role cannot be overemphasized. 
For example, in the case of a biologic terrorist attack involving the 
release of smallpox at a major sports event in an outdoor stadium in a 
major U.S. city, such as Los Angeles, the disease, which has a 30 
percent fatality rate among healthy adults, would rapidly become 
epidemic. The longer the release event goes unrecognized, the more 
widespread the infection and the number of eventual victims could 
quickly become millions.
    My testimony will address the specific role of state health 
departments in responding to a serious biological terrorist event, the 
current readiness of states to respond, and what states need to 
appropriately respond. I will confine my comments to a biologic 
terrorist event because a chemical or radiological attack, for many 
states, falls largely to other agencies such as emergency management, 
for major response. An attack involving a biologic agent, on the other 
hand, uniquely requires the capabilities of the state health 
department.
    My testimony will also point out that appropriately preparing for a 
bioterrorist attack will have positive outcomes--on a daily basis--by 
improving our ability to address naturally occurring infectious disease 
outbreaks, food safety concerns and environmental hazards.

   THE STATE HEALTH DEPARTMENT'S ROLE IN RESPONDING TO BIOTERRORIST 
                                THREATS

    The role of state health departments in responding to a biological 
terrorist attack will be first and foremost detection. The appearance 
of an unusual disease, or increased cases of an ``ordinary'' disease, 
will likely be first recognized through basic public health 
surveillance at the state and local level. Identification of the 
causative agent of any unusual disease cluster or outbreak may well 
fall first to state or local public health laboratories. We have seen 
this already in the 1984 salmonella poisoning in Oregon where a 
terrorist attack was detected and averted when local public health 
authorities, carrying out their basic public health surveillance, 
identified the threat.\1\
---------------------------------------------------------------------------
    \1\ Torok, Thomas, J., et al. A Large Community Outbreak of 
Salmonellosis Caused by Intentional Contamination of Restaurant Salad 
Bars. JAMA, Vol 278:5, pp. 389-395.
---------------------------------------------------------------------------
    Another primary role for state health departments in the event of a 
biological terrorist attack is coordinating assistance to local health 
departments that may become quickly overwhelmed and reporting 
epidemiologic findings to appropriate federal agencies, primarily the 
Centers for Disease Control and Prevention. Each state's health 
department is likely to be substantially engaged in any serious 
biological terrorist attack within its borders even if only a few 
individuals become seriously ill.
    Another key state activity is the development of a bioterrorist 
plan that actively involves the participation of the state's health 
department. Regular training, including periodic table top and field 
practice drills, implementing the bioterrorist plan will be required. 
Regular updating of the plan will be needed as intelligence about 
likely bioterrorist agents becomes available. It is essential that 
state health departments have the resources to respond to a major 
bioterrorist event within their state borders because proximity reduces 
the time involved to detect the agent which in turn is essential to 
institute control and treatment measures that will reduce related 
disease and death. The reality is that minutes count when responding to 
a bioterrorist attack.
    One of our most important roles will be to provide most of the 
actual response force. At the most basic level, whatever combination of 
case-finding, interviewing, immunizing, medication delivery, or other 
hands-on control techniques are needed for the particular biological 
agent and situation will be largely carried out by state and/or local 
health department staff. It is our nurses, our environmentalists, our 
disease investigators who will actually do the work, if it gets done. 
Mississippi's recent experience with the chemical contamination of 
thousands of homes with methyl parathion illustrates this. Despite the 
deployment of dozens of federal personnel from several agencies, the 
majority of the manpower (much of it nursepower) came from the state 
and local health departments.
    The likely scenario that a few major cities have either already 
tested, or are planning to test, in a table top exercise unfolds as 
follows: A bioterrorist event occurs involving the unannounced release 
of anthrax spores in an open air location during a major public event. 
The first responsibility immediately falls to the local health 
department to detect that an unusual number and type of case reporting 
is occurring. Responsibility for diagnosis of the agent falls next to 
the local or state public health laboratory. Investigation, by 
interviewing victims, again is the responsibility of the local health 
department, with assistance from the state health department, in order 
to identify the source of the agent, when the release took place, and 
who might have been exposed. Other critical phases of the exercise 
where major responsibility falls to the local health department, with 
assistance from the state health department, involves the distribution 
of vaccine and other essential treatment resources and distribution of 
diseased victims around the state and region as thousands become 
symptomatic.
    Essential state health department functions in preparing for and 
responding to a bioterrorist incident would involve the following 
specific activities:
  --Epidemiologic surveillance.--Active surveillance for the occurrence 
        of unusual diseases or conditions. This is an essential current 
        function that needs significant enhancement to ensure timely 
        detection of a bioterrorist event. Timeliness is critical. 
        Victims of a biologic attack will not exhibit symptoms for 
        days, or even weeks. The delay between exposure and onset of 
        illness, in the case of an infectious agent such as smallpox, 
        can mean spread of the disease to hundreds, even thousands. If 
        it occurs in a major metropolitan area the disease could become 
        pandemic in a matter of hours. Detecting the agent as soon as 
        possible can save lives.
  --Active surveillance involves active monitoring of a comprehensive 
        reporting system and both routine and periodic education of 
        mandated reporters: physicians, hospitals, medical examiners, 
        and clinical laboratories about the signs and symptoms 
        indicative of exposure to the most likely bioterrorist agents. 
        These include the infectious microorganisms that cause anthrax, 
        brucellosis, plague, Q-fever, tularemia, smallpox, viral 
        encephalitis, and hemorraghic fever; and the bacteria-produced 
        poisons botulinum toxin and staphylococcal enterotoxin B; the 
        plant-derived toxin ricin, and fungal metabolite T-2 mycotoxin. 
        These are the core military biological weapons. In addition, 
        surveillance of the state's vital records department for 
        premature deaths in otherwise healthy individuals will signal 
        unusual disease exposure. To conduct active surveillance, state 
        health departments will need adequate numbers of 
        epidemiologists trained in recognizing and instituting 
        appropriate control measures for both natural, unintentional 
        events such as pandemic influenza as well as bioterrorist 
        agents.
  --Laboratory analysis.--Active surveillance is dependent upon 
        laboratory capability to rapidly analyze samples for exposure 
        to bioterrorist agents. This requires, ideally, at least one 
        laboratory per state that is appropriately equipped to detect 
        the most hazardous etiologic agents such as smallpox, and 
        Bacillis Anthracis, the causative agent of anthrax. This 
        requires at a minimum Biosafety Level 3 containment facilities. 
        Biosafety Level 4 containment facilities, may be needed in 
        certain high risk states, or regionally, but the Centers for 
        Disease Control could handle this function if provided 
        additional capacity. If established in states or regions, 
        Biosafety Level 4 facilities also require personnel trained in 
        handling, testing and reporting biohazardous agents and the 
        availability of laboratory assays indicating exposure to nerve 
        agents and cyanide and serological, immunological, and nuclear 
        assays for identification of all the expected biological 
        terrorist agents.
  --Public health laboratories are ideally suited for the critical role 
        of identifying bioterrorist agents, but most will need 
        considerable upgrading to carry out their essential detection 
        function, and should have access to rapid detection kits for 
        the most likely bioterrorist agents currently only available to 
        the military. These ``smart kits,'' or other instrumentation 
        like them, that have been developed by the National Naval 
        Research Institute should be required equipment in every state 
        and local public health laboratory. State public health 
        laboratories also need protocols and procedures for rapid 
        submission of samples both from the field (hospitals, 
        commercial laboratories and local health departments) and to 
        CDC which serves as a national and world-wide reference 
        laboratory. Additional laboratory staff trained in detecting 
        bioterrorism agents will need to be located in close proximity 
        to high risk metropolitan areas.
  --Verification of the bioterrorist agent through laboratory analysis 
        is essential to institute effective delivery of definitive 
        treatment measures. Rapid, seamless electronic communications 
        among federal, state, and local levels is also an important 
        public health laboratory capability. Again, minutes count when 
        responding to a bioterrorist attack.
  --Epidemiolgic investigation.--Rapid, efficient epidemiological 
        investigation will be needed to identify likely sources of 
        contamination or infection, e.g., common food, water, or air 
        sources. This involves basic ``shoe leather'' epidemiologic 
        interviews with those who have been exposed as well as others 
        logically connected to the event. This function is essential to 
        establish where the exposure to the bioterrorist agent occurred 
        and when it occurred so that appropriate control and treatment 
        measures, such as rapidly distributing ameliorating vaccine, 
        can be instituted. This involves having adequate numbers of 
        infectious and environmental epidemiologists additionally 
        trained in bioterrorist detection that can be made available to 
        local health departments. It also means ``shoe leather'' 
        interviewers should be considered for advance vaccination 
        protection as essential health care workers.
  --The importance of this basic public health activity cannot be 
        overemphasized. It is essential to effective control of an 
        infectious agent that can rapidly affect thousands and even 
        threaten millions of lives world wide if it becomes pandemic.
  --Information and communications systems.--Reporting will need to be 
        electronic and permit receipt, compilation and analysis of 
        information from multiple reporting sources such local health 
        departments, hospitals, clinics, etc. This is also critical 
        with regard to laboratories which must have communication links 
        to federal, state, and local public health agencies. The 
        communication system must be electronically compatible and, 
        ideally provide 100 percent coverage of the state's population. 
        Communications also need to be seamless with federal agencies, 
        particularly CDC as it will have an important role as well in 
        any bioterrorist event.
  --Coordination of essential equipment and treatment.--State's will 
        need to be able to coordinate essential equipment and treatment 
        facilities needed at the local level. Some of the 
        considerations will include:
  --Health care facilities and personnel.--In the case of an infectious 
        biologic terrorist agent such as smallpox, the impact will be 
        felt first in emergency rooms, physician's offices, and medical 
        clinics. To protect essential health care workers against 
        biologic agents, a national program of voluntary vaccination 
        against likely, known military agents such as anthrax and 
        smallpox, should be considered. Essential health care workers 
        include physicians, nurses, laboratory workers and other allied 
        health care workers such as radiology technicians and as 
        already discussed, essential state and local health department 
        officials and workers. A biological terrorist incident probably 
        will not be effectively controlled without instituting, in 
        advance, protections for these essential individuals. On the 
        other hand, current limited supplies of smallpox and anthrax 
        vaccine probably should not be used for first responders since 
        they are unlikely to come in contact with victims of biologic 
        terrorism.
  --Isolation beds.--In the case of an infectious disease agent, such 
        as smallpox, an adequate number of isolation beds to treat 
        several thousand victims must be developed, designated and 
        coordinated. This must be an essential component of the state's 
        bioterrorist plan. Implementation of rapid isolation measures, 
        and other controls, will be imperative in halting the spread of 
        the disease. Because of the likely number of victims involved, 
        state health departments will need to coordinate distribution 
        of victims around the state in medical treatment facilities 
        and, in many cases, across state lines to nearby cities.
  --Availability and distribution of vaccines and other necessary 
        treatment resources.--The President has made this a national 
        priority and state health officials applaud him for his 
        leadership in addressing this critical need. A national 
        stockpile of vaccines against the most likely biologic 
        terrorist agents is absolutely essential in any effort to 
        respond to a biologic terrorist event. Rapidly identifying and 
        vaccinating individuals not yet sick, but who have been exposed 
        to a terrorist agent, can prevent development of the disease, 
        or ameliorate its consequences. Organizing the distribution of 
        vaccine is a basic, public health role, and must be part of a 
        state's bioterrorist plan.
  --Much must be done, and done immediately, before it is too late. The 
        Institute of Medicine, at the request of the Department of 
        Health and Human Resources, is currently developing a report on 
        the research and development needs for biologic and chemical 
        terrorist agents. The Congress and the Administration should 
        move to implement its recommendations immediately and begin 
        production of a civilian stockpile of vaccine against the most 
        likely biologic terrorist agents as a national priority.
  --Other treatment needs can be stockpiled in designated major 
        hospitals, Red Cross facilities, or other sites in high risk 
        areas. These would include a range of antibiotics, blood 
        supplies, various intravenous fluids for hydration, nutrition 
        and other needs. These also must be addressed in the state's 
        bioterrorist plan.
        are states prepared to respond to a bioterrorist event?
    The ``short answer'' is no, but the answer is not short. States are 
not prepared now, but state and local health departments are uniquely 
qualified to become prepared and fill critical roles. We have skill and 
experience in rapidly mounting mass immunization campaigns, large-scale 
administration of medications, emergency public communications, and 
disaster response. We do all these things--not just practice them--on 
an all-too frequent basis. We are the ``experts'' in basic surveillance 
and disease reporting, because we are the ones who do it for most 
diseases. We have the foundation on which to build a solid system to 
deal with biological cataclysm, whether man-made or natural.
    But in many ways we are not yet prepared. The potential is there, 
but much remains to be done.
    Critically, resources, both human and technical, are not adequate. 
Some need to be developed, and some that once were adequate have 
eroded. A fundamental need is to ``shore up'' and improve our 
dangerously neglected basic public health capabilities.
    A second major unmet need is planning. Most states do not have a 
bioterrorist plan. Some states are currently working on a bioterrorist 
addendum to their medical disaster plan--New York and Texas are two 
examples. Minnesota is ready to conduct a table top test of its 
bioterrorist plan. There are several others moving in this direction. 
But every state needs to make this a priority.
    A case example of how ill-prepared state health departments feel 
they are to respond to a bioterrorist event is the quote below from a 
draft document on catastrophic disaster and terrorism by the Illinois 
Department of Health. The document reflects a statewide effort.
    ``The Department is mandated to protect the public health and 
safety of the citizens of Illinois. However, limited opportunities have 
been made available to adequately prepare staff for a response to a 
terrorist incident involving radiological, biological, or chemical 
materials. Therefore, the Department's response capabilities are 
currently limited. Several factors have prevented the Department from 
attaining a higher level of preparedness. These factors include: 
absence of a consistent funding source for training and education 
programs; limited personnel in infectious diseases, environmental 
health and laboratory services programs; and a lack of Federal guidance 
and information on source standards and detection methods.'' \2\
---------------------------------------------------------------------------
    \2\ Illinois Department of Public Health. Catastrophic Disaster/
Terrorism Report. Draft report.
---------------------------------------------------------------------------
    A key issue in successful planning is for state health departments 
to be active participants in emergency management plans for responding 
to bioterrorism. This is not happening to the extent it should in many 
states. State health departments must be regarded as essential partners 
in bioterrorist planning.
    To assist state and local governments in the development of 
bioterrorist preparedness, ASTHO calls upon the Congress and the 
Administration to convene a national planning process that will involve 
all affected federal agencies, including especially the Department of 
Health and Human Services which has too often been overlooked in its 
important role in the case of a civilian bioterrorist event, and state 
and local governments. A primary goal of the planning process, in 
addition to delineating activities and coordination among federal 
agencies, should be to provide guidelines, or a model bioterrorist 
plan, to state and local governments that they can adapt to their 
particular needs and resources. States could significantly inform and 
assist the national planning process--now--by surveying their public 
health resources, including epidemiologic and laboratory resources; 
medical care resources; and other key resources such as appropriate 
stockpiling centers. California is currently undergoing a survey of its 
resources to develop its bioterrorism plan.
    what resources do states need now to be prepared for a civilian 
                          bioterrorist event?
    The first thing states need to be prepared is a plan. As already 
discussed, this should be a national priority and will involve 
coordination at the federal, state and local levels among public health 
agencies, but also with emergency management agencies, law enforcement 
agencies, the military, and potentially many more.
    The other major need is for material resources. Some of these 
resources involve new technology, or making existing technology 
appropriately available to states, especially their public health 
laboratories. But even more important is support--funding--for old 
fashioned, but essential public health activities and infrastructure.
    Congress has recently been engaged in a massive debate over the 
state of the nation's public works infrastructure. The widely supported 
conclusion is that we must upgrade our nation's highways which are 
becoming clogged with traffic, and rebuild dangerously crumbling 
bridges and tunnels. Congress has made the commitment to spend the 
nation's resources to upgrade and update this fundamental underpinning 
of our way of life: transportation.
    State health officials are extremely concerned about another 
essential, threatened underpinning of the American way of life: public 
health. Public health infrastructure is not visible like highways and 
bridges, but it is no less important. It has been steadily eroding over 
the past two decades and is in desperate need of upgrading. The extant 
challenges of food safety, pandemic influenza, and unintentional 
environmental hazards are daunting enough without adequate, updated 
resources, but the prospect of a civilian bioterrorist event involving 
thousands of causalities is overwhelming.
    The importance of the role of public health in a bioterrorist event 
cannot be over emphasized. The greatest need--now--at the state level 
is for planning and supporting and upgrading existing infrastructure as 
follows:
  --States need adequate epidemiologic resources--surveillance and 
        investigation.--An important obstacle to developing 
        bioterrorist preparedness is the categorical nature of current 
        surveillance funding. At least 80 percent of a given state's 
        federally supported surveillance must be committed to HIV/AIDS, 
        TB, and STDs (Sexually Transmitted Diseases). Many states have 
        no funds available to them for generic, active surveillance of 
        the occurrence of unusual disease or conditions. This is a 
        major public health infrastructure weakness that a bioterrorist 
        event would exploit immediately with terrible consequences in 
        unnecessary disease, disability and death. States need a source 
        of unfettered funding for active, generic surveillance systems 
        which also benefit preparedness for non-terrorist events such 
        as influenza, unintentional food poisoning or environmental 
        hazards. This should be a priority for Congress and the 
        Administration, but must not come at the expense of funding for 
        current programs which are vital and needed. States also need 
        an adequate number of epidemiologists trained in detection, 
        control and treatment of bioterrorist agents.
  --States need upgraded public health laboratory facilities and 
        trained personnel.--State public health laboratories are not 
        currently equipped to detect the most likely bioterrorist 
        agents such as anthrax and smallpox. ASTHO recommends that most 
        states have a Biosafety Level 3 facility. The national planning 
        process should address the question of whether particularly 
        high risk states, or regions should have a Biosafety Level 4 
        facility, or whether all highly hazardous agents should be 
        forwarded to CDC for comprehensive analysis. If the latter, CDC 
        will clearly need resources to develop additional capacity. 
        Again, the primary issue is rapidity of diagnosis, but other 
        concerns are the numbers of specimens that may be involved in a 
        bioterrorist event and maintenance of skills in handling 
        hazardous materials. It is clear, however, that all state 
        public health laboratories require updated technologies to 
        quickly identify unusual microbiol agents, determine their 
        antibiotic susceptibility, and point of origin. ``Smart kits'' 
        should be made available for quick screening of the most likely 
        bioterrorist agents; newer technologies such as polymerase 
        chain reaction (PCR) are needed, but many state public health 
        laboratories lack the equipment, staff and training to provide 
        these services. Once again, enhancement of state and CDC 
        laboratory capacity should not come at the expense of existing 
        program funding.
    States need enhanced, electronic information and communications 
systems to permit rapid assessment, analysis, and reporting.

OTHER IMPORTANT BENEFITS THAT RESULT FROM BEING PREPARED FOR A CIVILIAN 
                           BIOTERRORIST EVENT

    Enhancing public health infrastructure at the federal, state and 
local levels to prepare for a civilian bioterrorist event has many 
important benefits for the public's health. Improved surveillance, 
investigation, laboratory capability, and communications systems will 
be immediately applicable to food safety, unintentional environmental 
hazards, and influenza, both the pandemic (approximately every ten 
years) and interpandemic time periods. State health department 
officials are faced, nearly every day, with the need to evaluate the 
risk or occurrence of disease outbreak or environmental health hazards. 
An adequate, updated public health infrastructure will yield a real 
return on every dollar invested in prevented disease and avoided health 
care costs.
    Some emergency preparedness measures, though necessary, are largely 
limited to emergency use. The second largest fire department in 
Minneapolis is at the airport just outside the city. Every day the 
airport fire department stands ready to respond to major disaster. 
Equipment is in excellent maintenance condition, it's upgraded 
regularly and personnel conduct regular practice runs to keep their 
skills honed. Minneapolis has never had an airline disaster, but its 
airport couldn't operate without its fire department.
    Public health preparedness for civilian bioterrorism is an even 
better investment bet. Much of the enhancement in infrastructure would 
be used daily and have positive consequences--every day--for the 
public's health. The same technology and infrastructure that is needed 
to detect and control disease of deliberate origin in emergencies can 
be used against naturally occurring health threats day in and day out 
in every state. The high tech troop carrier we need to fight the war 
can be an efficient school bus if the war never comes.

                   SUMMARY OF ASTHO'S RECOMMENDATIONS

    A national planning process involving federal, state, and local 
governments to respond to civilian bioterrorism should be convened. The 
planning process should emphasize the role of public health at all 
levels of government as the first line of defense after a bioterrorist 
attack has occurred and a critical component in all phases of the 
crisis.
    In conjunction with the national planning process, each state 
should develop a bioterrorism plan and survey their current resources 
as a basis for strategic action.
    There should be increased national resources committed to enhancing 
the nation's public health infrastructure at the federal, state and 
local level to address bioterrorism. Infrastructure enhancements should 
address identified laboratory needs within the CDC, surveillance and 
epidemiologic investigation at the state and local level, state and 
local public health laboratory capability, and enhanced information and 
communication systems. State and local public health infrastructure 
funding should be flexible to permit each entity to address its own 
specific infrastructure needs.
    ASTHO estimates that $200 million will be needed to fund state and 
local public health infrastructure needs to respond to bioterrorism, 
but cautions that precise funding requirements will only become evident 
through a national planning process.

STATEMENT OF RALPH D. MORRIS, M.D., M.P.H., PRESIDENT, 
            NATIONAL ASSOCIATION OF COUNTY AND CITY 
            HEALTH OFFICIALS

    Senator  Faircloth. Senator Cochran had planned to be here 
with you this afternoon, but because a number--and I understand 
a large number--of Senators are going to be out of town at 
Senator Goldwater's funeral tomorrow, he had to reschedule the 
hearing on Governmental Affairs which he chairs. So, he sends 
his apologies for not being able to be with you.
    Dr. Thompson. We will forgive him.
    Senator  Faircloth. Our next witness, Dr. Ralph Morris, is 
president of the National Association of County and City Health 
Officials. This group represents nearly 3,000 local public 
health departments. He is a doctor and director of the 
Galveston County Health Department.
    Dr. Morris, we are delighted to have you. Are you not glad 
you did not have that job in 1908 or 1903 or whenever the 
hurricane destroyed the city?
    Dr. Morris. We are actually getting ready to commemorate 
the 100th year anniversary of that 1900 hurricane in another 2 
years.
    Senator  Faircloth. What year did it happen?
    Dr. Morris. 1900, and it was the largest natural disaster 
this country has ever experienced with approximately 6,000 
deaths. I can assure you, sir, as the local health officer, 
that is one of the things that weighs very heavy on my mind in 
terms of planning for disasters and we take it very seriously 
in Galveston County in terms of hurricane preparedness.
    Senator  Faircloth. I do a lot of reading. I just read a 
book on raising the island 18 feet after the hurricane by 
building a seawall.
    Dr. Morris. That is correct.
    Senator  Faircloth. Dr. Morris, we will hear your 
testimony.
    Dr. Morris. OK. Thank you, sir.
    Good afternoon, Mr. Chairman. My name is Ralph Morris. I am 
director of the Galveston County Health District and I am 
pleased to serve as president of the National Association of 
City and County Health Officials [NACCHO]. NACCHO is the 
organization representing almost 3,000 local health departments 
across this country.
    Senator Faircloth, on behalf of the Nation's public health 
officials, I want to thank you for your invaluable leadership 
in addressing these important issues under discussion today.
    I am here today to explain how local health departments 
serve on the front lines in battling public health crises of 
all sorts and why we need a national network of electronic 
communication among local, State, and Federal public health 
agencies.
    When an outbreak occurs, regardless of the cause, local 
health departments and State health departments are responsible 
for gathering information and determining the cause. This 
process is called disease surveillance and it is a fundamental 
function of public health at the local, State, and Federal 
level. Surveillance is our early warning system for protecting 
the public.
    In order to conduct disease surveillance effectively, local 
health departments must be able to exchange information with 
local doctors, hospitals, other local health departments, State 
health departments, and CDC. A local health department does the 
groundwork such as tracking down who has been exposed, 
gathering information about the exposure, obtaining laboratory 
specimens, and preventing further spread of the disease. The 
local health department is responsible for giving accurate and 
timely information to the media, to the community, hospitals, 
doctors, and local elected officials.
    Let me give you some real-life examples.
    In Galveston last February, a case of meningococcal 
septicemia was reported to our department on Monday morning. It 
happens that the weekend before was Mardi Gras and that the 
patient was an escort to one of the duchesses. Mardi Gras 
attracts approximately 100,000 to 200,000 people to the island. 
This individual attended two balls during Mardi Gras and was 
also on a float on the main parade of Mardi Gras. It was a very 
lonely feeling to get that report of this contagious, 
potentially fatal disease.
    We had to find out and start treatment of individuals who 
were scattered all over the State who had been exposed to the 
disease. We used phones to work with other local health 
departments and the State health department. We played phone 
tag and relied on voice mail and spent an undue amount of time 
arriving at a common understanding of the problem and what we 
needed to do to solve it. If we had been electronically 
connected with the State health department and other local 
health departments, the process would have been much faster. 
Fortunately, we had no secondary cases and the patient did 
survive.
    Last winter in Texas, we faced another outbreak of invasive 
group A Streptococcus, also known as flesh-eating bacteria. If 
we had had state-of-the-art communications, we would have been 
able to quickly exchange information about where the cases were 
found and to accurately inform the community and local 
officials about this frightening organism.
    Recently we have dealt with an influx of smoke and haze 
from Mexico which presented an immediate health threat to the 
general public, as well as susceptible individuals. Here again, 
an electronic network would have allowed us to do our work more 
thoroughly, timely, and in an accurate manner. In addition, 
many of us were not familiar with the specific health hazards 
of this smoke and haze from Mexico.
    The knowledge gap is particularly alarming with respect to 
biological and chemical terrorism. Few of us in public health 
are familiar with the prevention, diagnosis, and treatment of 
the health effects of these agents of biological warfare. We 
need quick access to guidelines for implementing emergency 
measures, as well as an ability to communicate instantly and 
securely with other government agencies that would respond to 
terrorism. Diseases of biological terrorism are similar to 
other infectious diseases. They may be insidious in the onset 
and difficult to recognize. We will not recognize them promptly 
enough to save lives if we do not have good infrastructure for 
communication and access to information.
    In the military and law enforcement, good communication are 
taken for granted. In public health, we are way behind. Most 
local health departments still rely on the phone, the fax 
machine, and paper and pencil to do their job, and many of the 
phones are still rotary. About one-half of all local health 
departments do not have the use of electronic mail. At least 
1,000 local health departments have no access to any online or 
Internet service. Among those that do, one-third are not even 
linked to their State health department, and fewer than one-
quarter can reach other local health departments 
electronically. Building an electronic network requires 
thoughtful planning, updated hardware and software, connections 
to the Internet, and training personnel how to use it.
    NACCHO strongly supports the proposal under development at 
CDC for establishing a national health alert network. This 
network will equip the front lines of public health local 
health departments and, with essential electronic information 
tools, and train public health workers in the skills they need 
to protect the public.
    Mr. Chairman, dramatic gains have been made in health in 
this country in the past century. Life expectancy has increased 
by 30 years; 25 of those years have been due to basic public 
health measures. Taking these gains for granted and letting the 
public health infrastructure deteriorate is asking for 
disaster. When public health in one location suffers, the 
health of the Nation as a whole is threatened because new 
health threats do not respect geographic or political 
boundaries.

                           PREPARED STATEMENT

    CDC's health alert network will save critical time which 
will translate into saving lives. The health of all Americans 
depends on taking national proactive measures to preserve, 
coordinate, and strengthen our public health system.
    Thank you very much.
    Senator  Faircloth. Thank you, Dr. Morris.
    [The statement follows:]

               Prepared Statement of Dr. Ralph D. Morris

    Good morning, Mr. Chairman and members of the Subcommittee. 
I am Ralph D. Morris, MD, MPH. I am Director of the Galveston 
County Health Department in Texas and am pleased also to serve 
as President of the National Association of County and City 
Health Officials (NACCHO). NACCHO is the organization 
representing the almost 3,000 local public health departments 
in the country. I am here today to explain how local health 
departments serve on the front lines in battling public health 
crises of all sorts, and why we need a national network of 
electronic communications among public health agencies to help 
protect our communities from the public health consequences of 
acts of terrorism. The same high-speed access to information 
that is essential for this purpose is equally important in 
helping local health departments deal with a myriad of other 
alarming public health threats, such as new and virulent 
infectious diseases and diseases that are spread through our 
food supply.
    Outbreaks of disease can occur for many reasons--because 
one child infected with infectious bacterial meningitis spends 
a day going to classes in a school before his illness is 
diagnosed--because one shipment of frozen strawberries from 
Mexico arrives in grocery stores infected with the Hepatitis A 
virus--because a hurricane or a flood disrupts water and sewer 
lines and causes a public water supply to become dangerously 
contaminated--or because a criminal introduces a lethal 
biological agent, such as anthrax, into the air. Whatever the 
reason for an unusual outbreak of illness, the local health 
department has the local responsibility for detecting that 
outbreak, tracing it to its source, and stopping its spread.
    The potential public health threats we all face are growing 
in number and complexity. Rapid air travel means grave 
infectious diseases can be spread from one country to another 
simply when an infected person takes a plane flight. Our food 
supply has become globalized, and we are more vulnerable to 
food-borne diseases from imported food than ever before. 
Insidious bacteria that have mutated so that they are no longer 
easily treatable with existing antibiotics are multiplying in 
number. Virulent new viruses, such as hantavirus and Ebola, are 
emerging. And reports of instances where persons have access to 
biological weapons are increasing. While we rely on law 
enforcement to prevent and deal with criminal acts, when those 
acts pose a threat to health, we rely on the public health 
system. Just as our military needs to keep up a defense against 
new weapons development, so our public health system must 
maintain a defense against new diseases and new ways that 
diseases can be spread.
    When people get sick, they seek care from their doctor or a 
hospital. No single physician or hospital will necessarily 
notice that anything unusual is occurring--but if they all 
report any one case of unusual infectious disease that they 
observe, the local health department can put that information 
together to discern a pattern. This process is called disease 
surveillance, and it is a fundamental function of public health 
at the local, state and federal levels. Surveillance is our 
early warning system that something is wrong.
    In order to conduct disease surveillance effectively, local 
health departments must be able to send and receive information 
quickly to and from local doctors and hospitals, to and from 
health departments in neighboring jurisdictions, to and from 
the state health department, and to and from the Centers for 
Disease Control and Prevention in Atlanta. The local health 
department does the work on the ground, such as tracking down 
who has been exposed to a disease, sometimes obtaining 
laboratory specimens for accurate diagnosis, and taking 
whatever measures are necessary to prevent its further spread. 
The local health department also is responsible for giving 
accurate and timely information to the media and the community. 
In order to do its job, the health department needs not only 
local expertise, but also immediate access to higher levels of 
expertise that are available at the state health department and 
at CDC.
    In Galveston last February, we discovered a case of 
meningococcal septicemia in a participant in the Mardi Gras 
parade. We had to find and notify persons who had subsequently 
scattered all over the state that they'd been exposed to this 
potentially fatal disease. We used phones to work with other 
local health departments. We played phone tag, relied on 
messages, and spent an undue amount of time arriving at a 
common understanding of the problem and what we had to do to 
solve it. If all the local health departments had been 
connected electronically, the process would have taken place 
much faster.
    Just a few months ago in Texas, several of our local health 
departments and the state were faced with an outbreak of 
invasive group A streptococcus, also known as ``flesh-eating 
bacteria.'' Here again, if we'd had state-of-the-art 
communications, we'd have been able more quickly to exchange 
information about where cases were found and get accurate 
information about this frightening organism out to the 
community. Now we are dealing with an influx of smoky, hazy air 
from Mexico, which has presented some immediate health hazards 
to susceptible people, as well as some longer-term hazards that 
we need to monitor. We could do this, and all our public health 
emergency response work, in a more thorough, timely and 
accurate manner with instant, uniform access to authoritative 
information.
    Every day, my colleagues in other jurisdictions face 
outbreaks of illness caused by salmonella, E. Coli bacteria, 
the hepatitis A virus, meningococcal bacteria, and a 
frightening array of new antibiotic-resistant bacteria. None of 
these diseases respects city or county or state boundaries--we 
all must be well-prepared to share information about suspicious 
incidents of disease, deal with outbreaks and communicate about 
them to our neighbors. Agents of biological terrorism are 
highly similar to other agents of disease in that they may be 
insidious in onset and difficult to recognize. We won't 
recognize them promptly enough to save lives if we can't trade 
information with each other instantaneously.
    Currently, electronic communications are the best way to 
send and receive data quickly, and the Internet is the best way 
to share data and get access to current information about a 
disease. In the military and in law enforcement, these methods 
of emergency communication are taken for granted. But in public 
health, we are way behind. Most health departments still rely 
on the phone, the fax machine, and paper and pencil to track 
down the information they need to evaluate reports of disease, 
identify who may have been exposed, analyze this data to 
determine whether they've got a potential epidemic on their 
hands, and call in expert advice. If they need to send or 
receive information quickly, they just cross their fingers that 
they can reach the right people by phone or that the fax goes 
through. If there is an epidemic in the making and preventive 
measures such as immunization of the population that has been 
exposed to a disease are possible, saving time means saving 
lives.
    We have data that show just how far behind public health is 
in its access to the information superhighway. About one-half 
of all local health departments don't have the use of 
electronic mail. At least one thousand local health departments 
have no access to any on-line or Internet service. Among those 
that do, one-third are not even linked to their state health 
department, and fewer than one-quarter can reach other health 
departments electronically. In some health departments, up to 
five employees must share one computer.
    Even where some type of electronic communications capacity 
exists, a huge problem remains. The capacity is useless unless 
people are trained to work with it effectively. Among those 
health departments that do have it, 70 percent of the health 
directors assessed that their staff had little or no expertise 
in using on-line data and services. Building an electronic 
communications network requires, therefore, not only acquiring 
appropriate, updated hardware and software and modem or cable 
connections to the Internet, but also training essential 
personnel how to use it.
    The knowledge gap is particularly alarming with respect to 
biological and chemical terrorism. Few of us in public health 
are familiar with the prevention, diagnosis or treatment of the 
health effects from agents of biological warfare. We need quick 
access to authoritative guidelines for implementing emergency 
measures, as well as an ability to communicate instantaneously 
and securely with other government agencies that would respond 
to an instance of terrorism.
    NACCHO strongly supports a proposal under development at 
CDC for establishing a national Health Alert Network that will 
fill the huge gap in communications capacity that now handicaps 
us in our ability to recognize and deal quickly with public 
health emergencies. Such a network must equip the front lines 
in public health, local health departments, with essential 
electronic information tools and train public health workers in 
the skills they need to use it well. There must be a seamless 
defensive shield, that enables the local, state and federal 
partners in public health to work together to meet every 
preventable health threat as it occurs. The same network that 
will equip us to cope with an act of terrorism, such as an 
intentional release of anthrax, will also equip us to deal with 
the threats that occur even more frequently, when contagious 
diseases or contaminated food or water threaten our 
communities.
    I and my colleagues who work in local public health are 
accustomed to using scarce resources efficiently and 
creatively, but most of us just don't have enough to update our 
information systems and our staff to the level needed to meet 
the threats posed by our nation's growing vulnerability to new 
global health threats. I urge the Subcommittee to provide in 
fiscal year 1999 and subsequent years sufficient funding to 
develop a public health alert network in a planned, phased-in 
fashion. We just can't afford to get any farther behind. 
Whether the cause of a public health emergency is an innocent 
cook at a church supper or an international terrorist, our need 
to respond quickly remains the same. Saving time means saving 
lives.

                          LACK OF PREPAREDNESS

    Senator  Faircloth. I think the general public is not aware 
of the overall lack of preparedness that exists in the country, 
and I think the Congress is not aware either.
    Dr. Osterholm, you mentioned the Institute of Medicine 
report in your testimony. I wanted to restate their first 
recommendation which was to provide Federal funding to improve 
the State and local infrastructure. In your view why do we seem 
to keep having such a difficult time getting people to discuss 
or to focus on this need?
    Dr. Osterholm. Senator, I think the easy answer is, first 
of all, disease surveillance and infrastructure is not sexy. It 
is day-to-day work. It is like keeping our bridges in place. 
Very few times do you take your car and stop before you get to 
a bridge and decide do I go over it or not because I am not 
sure it is safe. You just assume it is safe. You take it for 
granted. We take for granted in this country that there is a 
system in place to detect infectious diseases to respond to 
infectious diseases and to plan for the future.
    What we have really is a piecemeal surveillance system. We 
do not have a blueprint in this country for figuring out when 
and where and how we are going to detect infectious diseases. 
It would be like if every little phone company around the 
country could still set their own standards of how they are 
going to share information, it would be a disaster.
    The way that that is most frequently manifested is how we 
come to Congress to get our money. As a State epidemiologist in 
a State health department and also a member of ASM, the way I 
do my disease surveillance is what can I get from immunization, 
what can I get from the STD program, what can I get from the 
HIV program, what can I get from emerging infectious diseases, 
what can I get from the Lyme disease program, and it is one big 
pot, and Peter robs Paul all the time to make sure that we have 
a basic infrastructure.
    While I commend the CDC for the efforts demonstrated over 
here to the left of me with the emerging infectious diseases, 
at the same time we have seen major cuts in our funding support 
for immunization, HIV surveillance, for the area of STD and 
tuberculosis, so that we never have really established what 
does it take to do infectious disease surveillance in this 
country and what is it we need as a basic infrastructure.
    So, the bottom line is I think the reason we do not have a 
good system is we have never really had a system, No. 1, and 
No. 2 is that as long as we continue to fund it by robbing 
Peter to pay Paul, you are always going to have a response like 
this and that is the whole basis upon which this Nation's 
protection is now sitting for the issue of bioterrorism.
    Senator  Faircloth. You mentioned the Institute of Medicine 
recommendation that physician groups be enlisted to protect the 
public and that is certainly reasonable. But we keep hearing 
that doctors are often part of the problem, not the solution, 
in addressing and reporting symptoms that might indicate 
serious problems, that they simply do not do it. Is that true 
or not true?
    Dr. Osterholm. Well, Senator, I was born and raised in an 
area of Iowa that is well known for having a lot of sinkholes, 
these big holes in the ground that basically just keep getting 
bigger and bigger year after year. A long time ago, farmers 
recognized that if they keep pouring stuff down those holes, 
but they kept getting bigger anyway, after a while they stopped 
pouring things down the holes, meaning that after a while you 
learn that if what you do does not make any difference, then 
why continue to do it.
    What has happened in many areas of this country is that 
physicians and other areas of the medical care delivery system 
do not work with their public health departments anymore 
because the public health departments have nobody to respond, 
so even if they did provide all the cases or they provided the 
information, it is kind of like the big sinkhole.
    Public health clearly does not want that to be the case. We 
believe that that is not the way to run things. So, we have to 
have that system in place.
    In our State of Minnesota, we have really put a real 
emphasis on this area and we have tried to be creative in our 
support of funding. In fact, about 95 percent of my budget 
there is what we call soft money, just like any other academic 
center. We are going out constantly trying to bring in money to 
support our infrastructure. In that case where we have been 
able to show a clinician that if you provide a service to us, 
meaning giving us the information, you will get something back 
and you will have a response system. That does not occur around 
much of the country.
    So, I think that part of the problem clearly with 
physicians and the medical care system is in part education to 
make sure that they understand why and what they need to do, 
but part of it is, if you tell them to do something and there 
is no response, after a while they just will not do it anymore. 
I think that we have unfortunately far too often conditioned 
our medical community that public health will not be there in a 
way that will be sufficient to merit their effort.
    Senator  Faircloth. I want to come back to the question 
again in a minute.
    But, Dr. Thompson, the National Governors Association has 
scheduled their first meeting on the subject of bioterrorism 
here in Washington on June 18. Do you know what we might expect 
to come out of that? You are going to be here I assume.
    Dr. Thompson. I do not know that I will but I would 
certainly hope that the State health officials will be an 
integral part of that as we would be of anything addressing 
this issue.
    I think what we will get out of it, I hope, is a 
recognition among the Governors that there are several classes 
of terrorism. Two or three of them are very similar in their 
effects and their response. The sort of terrorism that is done 
with explosives, the sort of terrorism done with chemicals is 
responded to fairly traditionally by emergency medical service 
first responders through our State disaster plans and similar 
plans that address a natural disaster or a manmade disaster 
where you have an impact and an aftermath of that impact.
    Bioterrorism, attacks with biological agents, are a very 
different terrorist weapon, and I think as the Governors 
Association comes to recognize that, they will help us make the 
Congress and the administration recognize as well that 
bioterrorist attacks, of all the terrorist weapons that 
possibly could be used, are unique in several ways, the most 
important one of which is not just its effect. I believe that 
biological agents are potentially the most effective, the most 
devastating, and the most terrorizing of all the potential 
weapons, short of nuclear weapons, that terrorists could use.
    But not even that, the most important distinction that I 
hope the Governors will come to understand and the rest of the 
Nation as well is that the response to biological attack, to 
biological agents will be different than it is to any other 
terrorist weapon because it will necessarily integrally and as 
the first focus involve State and local public health. It is 
where it will be detected because you will not see an 
explosion. You will see not even people flooding a hospital. 
You will see people coming into their doctor's office sick. 
After a while they may flood the hospital, but initially it is 
our surveillance systems that will pick up the first fluttering 
and catch it early or we will fail and we will wait until they 
flood the hospitals and it is too late. It is a different 
response pattern than you will use for any other terrorist 
attack.
    And the third major distinction is although we have got to 
be prepared for all sorts of terrorism, bioterrorism 
preparedness has the almost unique quality of spilling over 
into everyday public health improvement activities because 
almost everything we need to do--almost, not quite, but almost 
everything we need to do--to prepare for a bioterrorist attack 
anywhere in the country will have daily applications. Those 
same laboratories, those same surveillance experts, those same 
epidemiologists, those same tools will be used every day with 
ordinary epidemics, with ordinary small outbreaks. Like a 
battle tank we have got to have to win the war that somehow has 
the ability to be a very efficient schoolbus, it is the best 
bargain of all the types of preparedness we have got to deal 
with.
    That is what I hope we will accomplish in this meeting.
    Senator  Faircloth. As you described a bioterrorism 
attack--I must say I had imagined it entirely different from 
what you just said. I would have thought it would have been 
some sweeping panic that would strike us. You are saying it 
would be more of a creeping, devastating type of effect on our 
bodies that would take days and maybe weeks to begin to show?
    Dr. Thompson. Yes; I almost hesitate to say what I am about 
to say, but I will. If we are very fortunate and we are some 
day attacked by very naive, very inastute terrorists, if we are 
lucky enough to get dumb terrorists, they will detonate a 
capsule of anthrax over a major sports stadium or they will 
announce that they have just set off a bomb containing 
botulinum toxin in a busy airport, that is if we are lucky.
    If I were going to do it and if we get a smart terrorist, 
this is what they will do. They will quietly simultaneously or 
in quick succession release smallpox virus or some other 
communicable virus or bacteria in dozens of different 
locations, probably not----
    Senator  Faircloth. That virus you mentioned, how would 
that affect you?
    Dr. Thompson. Smallpox? Smallpox would not begin to show--
--
    Senator  Faircloth. Oh, smallpox.
    Dr. Thompson. Yes; old-fashioned smallpox which is not that 
difficult to obtain. Although it has been eradicated from human 
populations, lab samples are around.
    Senator  Faircloth. Would the immunity that we all got as 
children not----
    Dr. Thompson. It is gone. So, we would begin to see after 
smallpox virus had been quietly and in an undetected manner 
released in dozens of locations, probably places like Jackson, 
MS, and Omaha, NE, probably not Los Angeles and New York--we 
would begin after several days to see symptoms, ill-defined 
symptoms, presented. As we began to recognize more and more 
cases of a disease we could not quite pin down, we would 
eventually diagnose smallpox through public health surveillance 
techniques, and by that time, second generation cases would be 
appearing in New York and San Francisco and places like that as 
the people who had been in Omaha, Jackson, and Tallahassee had 
now traveled to these large cities. It would have spread into 
our population in a very insidious fashion before we ever 
recognized that it occurred.
    When a bomb blows up, you know where it hit. You know who 
it blew up and you know what has to be done for them. 
Bioterrorism with infectious agents has the ability to kill 
people, to make people sick, and to terrorize those who are not 
sick wondering if they may become sick. That is why it is such 
a terrifying weapon.
    Senator  Faircloth. That is frightening, and this is 
something that is frightening to not only me, but to a lot of 
the Congress also, more so than a bomb planted somewhere. As 
horrible as that is and as deadly as it is, it is likely to be 
confined to a building or is a contained type of terrorism, 
whereas the type of thing you are talking about, as rapidly as 
we move as a nation, the terrorist would not even have to do 
the spreading. They plant it in the proper airport, so they 
could pretty well cover the country by sundown if they got it 
out by breakfast.
    Dr. Thompson. And we would not know they had been there 
until 2 days later or 3.
    Senator  Faircloth. Literally if you planted some sort of a 
virus at four, five, six major airports around the country in 
the morning, you would have it pretty well over the country by 
the end of that day.
    Dr. Thompson. With some agents, that is true.
    Senator  Faircloth. If it moves that way. Certainly people 
would be all over the country by the end of the day.
    It is frightening to think about. In talking to Dr. Knouss, 
I was somewhat frightened by his--I mean in testifying 
honestly--the lack of preparedness we might have was--Dr. 
Osterholm, do you want to comment on that or, Dr. Morris, or 
any of you? Were you--or did I misunderstand the testimony? 
Certainly it appears we need to do a lot in light of our 
current unpreparedness.
    Dr. Morris. I think a lot of these new threats are just 
coming into our awareness and the public awareness.
    Senator  Faircloth. How recently, Dr. Morris?
    Dr. Morris. I am sorry?
    Senator  Faircloth. How recently?
    Dr. Morris. I would say in the past 2 or 3 years, 
particularly with the incidents that have been described 
earlier. I know for a local health department in terms of day-
to-day activities, we have our hands full in terms of just 
keeping up with the regular activities that we have, and to 
talk about planning for something so catastrophic, as Dr. 
Thompson was just talking about, is almost unimaginable.
    But I think we are at the point now where we have gotten a 
couple of wake-up calls that if we do not pay attention and 
start putting some resources or rededicating some resources, at 
some point in the future, we really could be in trouble in 
trying to respond to either a natural occurring epidemic or 
something that is manmade.
    Dr. Osterholm. Senator, I think that to answer that 
question as you posed it, having spent almost 25 years in 
public health, having been in the middle of a number of 
outbreaks of Legionnaire's disease, toxic shock syndrome, HIV, 
meningitis--I can go down the list--a number of food-borne 
outbreaks, there have been outbreaks that have clearly 
challenged us. There have been outbreaks when I had to be at 
the bedside and watch a 17-year-old boy die of meningococcemia 
realizing he shared a birthday with my daughter. There were 
times that it was very hard to be in my job.
    But there is simply nothing that scares the hell out of me 
like this issue because the implications for this are so far-
reaching. It is so easy today to imagine how a terrorist could 
take a plane and fly a line from Arlington, VA, up to Silver 
Spring, MD, and put 2 million people in Washington, DC, at high 
risk of anthrax over the next 2, 3, or 4 weeks. It is very 
simple. Secretary Cohen showed that when he was on TV not long 
ago with his bag of flour that he demonstrated what it would be 
like if those were anthrax spores. Today if you hit a major 
building in this country with an aerosolizing device to put 
smallpox in would mean that in 2 weeks we could have tens to 
thousands of cases that then would spread out.
    So, I think the implications are very, very high stake 
here. You heard earlier from Dr. Knouss the concept of very low 
probability but very, very high consequence.
    I would just share with you I think as a local person out 
there representing a national organization that Washington has 
responded to the issues of terrorism. The problem is it 
continues to be oriented toward the area of chemical terrorism.
    Senator  Faircloth. The area of chemical?
    Dr. Osterholm. Chemical terrorism, the kind of situation 
that Dr. Thompson just shared with you. Nunn-Lugar legislation 
has helped us a great deal at the local level to begin dealing 
with chemical terrorism. It has done nothing for biologic 
terrorism. Giving the National Guard $300 million and 
stationing 12 units around the country does little to nothing 
to help us with the planning of biological terrorism.
    Frankly, it is the issue of the State and local health 
departments that have not been brought in on any of this in 
terms of planning and infrastructure support which is the 
critical first step. So, I think what we have to be careful 
here is not to confuse action as opposed to what is going to 
make a difference, and there has been action but I have not 
seen a lot yet that is going to make a difference.
    Senator  Faircloth. Dr. Osterholm, one time I was deeply in 
debt to a bank when I was about 22 years old and far more than 
a 22-year-old should have been. I went in one day and he told 
me I had a problem. He told me that on a regular basis. And I 
asked him which one was he discussing. And he said, your 
problem is you are mistaking motion for action. And that is 
something we do often in government and in governmental policy.
    One question I want to ask--and our time is running out. I 
understand there is a serious problem developing with microbes 
that are developing a resistance to the antibiotics that we 
have traditionally used. Of course, I grew up thinking that 
penicillin was the miracle cure for all of our problems. Why 
are these resistant microbes developing?
    I mean, I understand they are developing resistance because 
of the overuse of antibiotics. So, that is the why. What do we 
do about it? Where is it developing? Where do we start? Is it 
animals, people, or is it a problem at all?
    Dr. Osterholm. Well, Senator, to give you the necessary 
short answer, I will abbreviate it, but we would all be happy, 
I think, to come back to a second hearing that could take up an 
entire day on this very issue, a very important issue, by the 
way, a very important issue.
    I think the short answer is that whether it is in animals 
or in humans, whether it is domestic or international, we 
unfortunately have abused and used antibiotics in ways that 
were never intended. Frankly, Darwinian evolution is taking 
over. The bugs are winning, and while we have made great 
inroads in understanding that we have a problem today, we have 
only had limited action in terms of doing something about it.
    Actually what we have here before you today in the issue of 
bioterrorism is very consistent with responding to 
antimicrobial resistance. One of the ways that we are going to 
do something about it is if we know about it, and today in many 
of our systems around the country, we do not have the ability 
to detect it until some clinician realizes that the antibiotics 
they were going to use for that patient are not working and 
only find out that that particular infectious agent is 
resistant to those bugs. We need a population based 
surveillance system that is routinely picking this up. If you 
have that in place and it is just, oh, by the way, so happens, 
unfortunately, a biological terrorism event occurs, you will 
pick that up too.
    So, I think to address your question here, is if we had a 
better system in place, we could have the information to bring 
back the policymakers to other scientists to be able to say 
this is how bad the problem is right now. This is what is 
happening. What is it that we should and can do about it?
    Senator  Faircloth. How could you put such a system in 
place, Dr. Thompson or Dr. Morris, in Galveston or Jackson?
    Dr. Thompson. I think the first key here is--and I tend to 
use the term ``State and local health departments 
interchangeably because in Mississippi they are one and the 
same. In places like Texas----
    Dr. Morris. They are not.
    Dr. Thompson [continuing]. There are large city health 
departments that are independent of the State. The picture is 
quite different. So, you are talking about a State health 
department lab in Mississippi is comparable to a city health 
department lab, say, in Galveston or San Antonio.
    But around the country there are State and large city 
health department laboratories that could form a big part of 
the basis for such a surveillance system. A lot of the 
technology is very complex, but some of it is not and can be 
accomplished on a regular basis by laboratories that are 
already there and need only a little bit of additional funding 
to become capable of watching for the development of antibiotic 
resistance. Some of the surveillance would require special 
laboratories and even that of the CDC, but the basic sort of 
watching to see when we see it coming could be done with a 
network of State and large local health department laboratories 
that already exist.
    Dr. Morris. It has been mentioned earlier that the public 
health surveillance system in this country is really a 
haphazard system. I think the first step would be to establish 
some type of plan or coordinated effort between the Federal, 
State, and local levels of government in terms of surveillance.
    Another essential component would be the training of public 
health workers at the three levels of government to be sure 
that they understand the plan and understand the basic concepts 
of surveillance and epidemiology, and then finally, giving 
those people and departments the necessary tools in terms of 
hardware and software so that they can carry out that type of 
surveillance.
    I can tell you for a fact that is what we need in Texas in 
terms of developing some type of comprehensive, coordinated 
surveillance in our State.
    Senator  Faircloth. I understand this is coming about from 
the resistance to antibiotics because we are giving too many 
antibiotics. Is that a fair assumption of one of the problems? 
The resistance comes from overuse of the antibiotics?
    Dr. Morris. Overuse and then incomplete treatment regimens. 
Certainly in dealing with tuberculosis, one of the major 
reasons has been people taking incomplete courses of 
antibiotics. Of course, that is a very long regimen.
    Senator  Faircloth. I remember some time ago, 40 years ago, 
penicillin had just become the all-time favorite drug and 
literally a lot of doctors were giving it for everything and in 
massive doses, I mean, bad colds, runny noses. You went to the 
doctor, you were almost sure to come out with a shot of 
penicillin regardless of what you went in with. I would assume 
that has changed, but that at one time was the thing.
    I want to thank you all for being here today. I realize the 
inconvenience of coming from Minnesota, Mississippi, and Texas. 
But I want you to know that you play such a vital role in the 
preparedness that should exist nationwide.
    The money problems we are simply going to have to address, 
but of all the things that we spend money on in this country--
and we spend massive amounts of it--I do not know of anything 
more important to the population of this country as a whole 
than those things we have been talking about here today. If we 
cannot put it in those channels, where are we going to put it? 
The public health service saves the lives and protects the 
public health and the overall welfare of the people.
    So, we are all going to have to become advocates and we are 
going to have to speak up for these needs. In the Congress we 
can get penny wise and pound foolish and spend a lot of money 
in things that are not as potentially devastating to us as a 
Nation like the things we have been talking about today, and 
not only devastating as a Nation but for communities or 
individuals.

               PREPARED STATEMENT OF SENATOR THAD COCHRAN

    We have received a prepared statement from Senator Cochran, 
it will be inserted into the record at this point.
    [The statement follows:]

               Prepared Statement of Senator Thad Cochran

    Mr. Chairman, I believe as you do that there must be a 
stronger federal commitment to preparing our nation for the 
consequences of infectious disease outbreaks and lethal 
chemical exposure, terrorist or otherwise. In terrorist 
situations, our armed services and police forces will be 
required to act quickly to command and coordinate the 
investigation of the incident and culprits, ensure the 
prevention of possible civil unrest, and provide for the 
defense of United States citizens from ongoing attacks. 
However, the biological and chemical risks posed to our country 
present a much broader problem, one that must be addressed by 
the public health community--the Centers for Disease Control 
and Prevention (CDC) and State and Local Health Departments.
    Whether the infectious disease event or chemical exposure 
results by way of nature, accident, or intent, the United 
States must have a public health mechanism adequately prepared 
to respond quickly and effectively to save lives. One of our 
witnesses, Mississippi State Department of Health Officer, Dr. 
F.E. ``Ed'' Thompson, Jr., last year successfully coordinated 
the efforts of both local and national public health 
organizations to quickly respond to widespread residential 
chemical exposure on the Mississippi Gulf Coast. Local bug 
sprayers had used cotton pesticides indoors and subjected 
residents to dangerous, if not deadly, levels of chemicals. 
Utilizing CDC environmental laboratories, Dr. Thompson was able 
to determine very quickly the levels of contaminants in 
individuals, so as to decide who would need to abandon their 
homes and seek alternative housing, while allowing those with 
safe levels to stay in their homes, thereby saving lives as 
well as government resources.
    Mr. Chairman, I am hopeful that through today's hearing we 
can learn of additional ways we can prepare for the biological 
and chemical threats to our nation and can assist our local, 
State and national health organizations in meeting any 
challenges that may befall us.

                     ADDITIONAL COMMITTEE QUESTIONS

    Senator Faircloth. There will be some additional questions 
which will be submitted for your response in the record.
    [The following questions were not asked at the hearing, but 
were submitted to Dr. Thompson for response subsequent to the 
hearing.]

    Questions Submitted by Senator Thad Cochran for Response of Dr. 
                                Thompson

    Question. Dr. Thompson, many in Washington have suggested 
that the biological and chemical threat to the civilian 
population is best handled by the military, since it has great 
expertise in chemical and biological warfare defense and 
possesses facilities such as Fort Dietrich. The military will 
not doubt be a vital part of any response to biological or 
chemical terrorism event, but do you think the military alone 
can adequately address the public health issues associated with 
such a catastrophe?
    Answer. Clearly the military cannot handle a civilian 
bioterrorist event alone. While the military has capabilities, 
expertise, and resources that will be vital in responding to 
such events, effective response to bioterrorist attack cannot 
be mounted by the military alone, especially if the weapon is 
an infectious agent, such as smallpox. The public health 
skills, in-place systems, local knowledge, and public trust 
that state and local public health departments have will also 
be vital to adequate response. The third indispensable 
component will be Federal civilian public health agencies, 
primarily the CDC. All three, military, civilian Federal, and 
State/Local public health departments, will be essential; no 
one or two of them can handle it alone.
    Question. Dr. Thompson, you described the need to fund a 
public health infrastructure. What is your estimate of the cost 
of such an infrastructure, on both the local, State, and 
National level?
    Answer. An initial estimate of the cost of shoring up the 
public health infrastructure would be $200 million for state 
and local needs, and at least $108 million for CDC and its 
laboratories. A more accurate determination of additional needs 
would come as a part of the national planning process, with 
state and local involvement, recommended by ASTHO.

                         CONCLUSION OF HEARING

    Senator Faircloth. So, I thank you for your awareness and 
alerting us to the problem, and I intend to follow it and to 
pursue it. I thank you for coming, that concludes our hearing. 
The subcommittee will stand in recess subject to the call of 
the Chair.
    [Whereupon, at 4:07 p.m., Tuesday, June 2, the hearing was 
concluded, and the subcommittee was recessed, to reconvene 
subject to the call of the Chair.]

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