[House Hearing, 106 Congress]
[From the U.S. Government Publishing Office]



 
             TERRORISM PREPAREDNESS: MEDICAL FIRST RESPONSE

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

                                HEARING

                               before the

                   SUBCOMMITTEE ON NATIONAL SECURITY,
                  VETERANS AFFAIRS, AND INTERNATIONAL
                               RELATIONS

                                 of the

                              COMMITTEE ON
                           GOVERNMENT REFORM

                        HOUSE OF REPRESENTATIVES

                       ONE HUNDRED SIXTH CONGRESS

                             FIRST SESSION

                               __________

                           SEPTEMBER 22, 1999

                               __________

                           Serial No. 106-100

                               __________

       Printed for the use of the Committee on Government Reform




  Available via the World Wide Web: http://www.gpo.gov/congress/house
                      http://www.house.gov/reform

                                 ______

                    U.S. GOVERNMENT PRINTING OFFICE
63-355 CC                   WASHINGTON : 2000



                     COMMITTEE ON GOVERNMENT REFORM

                     DAN BURTON, Indiana, Chairman
BENJAMIN A. GILMAN, New York         HENRY A. WAXMAN, California
CONSTANCE A. MORELLA, Maryland       TOM LANTOS, California
CHRISTOPHER SHAYS, Connecticut       ROBERT E. WISE, Jr., West Virginia
ILEANA ROS-LEHTINEN, Florida         MAJOR R. OWENS, New York
JOHN M. McHUGH, New York             EDOLPHUS TOWNS, New York
STEPHEN HORN, California             PAUL E. KANJORSKI, Pennsylvania
JOHN L. MICA, Florida                PATSY T. MINK, Hawaii
THOMAS M. DAVIS, Virginia            CAROLYN B. MALONEY, New York
DAVID M. McINTOSH, Indiana           ELEANOR HOLMES NORTON, Washington, 
MARK E. SOUDER, Indiana                  DC
JOE SCARBOROUGH, Florida             CHAKA FATTAH, Pennsylvania
STEVEN C. LaTOURETTE, Ohio           ELIJAH E. CUMMINGS, Maryland
MARSHALL ``MARK'' SANFORD, South     DENNIS J. KUCINICH, Ohio
    Carolina                         ROD R. BLAGOJEVICH, Illinois
BOB BARR, Georgia                    DANNY K. DAVIS, Illinois
DAN MILLER, Florida                  JOHN F. TIERNEY, Massachusetts
ASA HUTCHINSON, Arkansas             JIM TURNER, Texas
LEE TERRY, Nebraska                  THOMAS H. ALLEN, Maine
JUDY BIGGERT, Illinois               HAROLD E. FORD, Jr., Tennessee
GREG WALDEN, Oregon                  JANICE D. SCHAKOWSKY, Illinois
DOUG OSE, California                             ------
PAUL RYAN, Wisconsin                 BERNARD SANDERS, Vermont 
HELEN CHENOWETH, Idaho                   (Independent)
DAVID VITTER, Louisiana


                      Kevin Binger, Staff Director
                 Daniel R. Moll, Deputy Staff Director
           David A. Kass, Deputy Counsel and Parliamentarian
                      Carla J. Martin, Chief Clerk
                 Phil Schiliro, Minority Staff Director
                                 ------                                

Subcommittee on National Security, Veterans Affairs, and International 
                               Relations

                CHRISTOPHER SHAYS, Connecticut, Chairman
MARK E. SOUDER, Indiana              ROD R. BLAGOJEVICH, Illinois
ILEANA ROS-LEHTINEN, Florida         TOM LANTOS, California
JOHN M. McHUGH, New York             ROBERT E. WISE, Jr., West Virginia
JOHN L. MICA, Florida                JOHN F. TIERNEY, Massachusetts
DAVID M. McINTOSH, Indiana           THOMAS H. ALLEN, Maine
MARSHALL ``MARK'' SANFORD, South     EDOLPHUS TOWNS, New York
    Carolina                         BERNARD SANDERS, Vermont 
LEE TERRY, Nebraska                      (Independent)
JUDY BIGGERT, Illinois               JANICE D. SCHAKOWSKY, Illinois
HELEN CHENOWETH, Idaho

                               Ex Officio

DAN BURTON, Indiana                  HENRY A. WAXMAN, California
            Lawrence J. Halloran, Staff Director and Counsel
                Marcia Sayer, Professional Staff Member
                  Tom Costa, Professional Staff Member
                           Jason Chung, Clerk
           David Rapallo, Minority Professional Staff Member



                            C O N T E N T S

                              ----------                              
                                                                   Page
Hearing held on September 22, 1999...............................     1
Statement of:
    Gordon, Ellen, director, Iowa Division of Emergency 
      Management and immediate past president, National Emergency 
      Management Association.....................................     6
    Johnson, David R., M.D., deputy director for public health 
      and chief medical executive, Michigan Department of 
      Community Health, on behalf of the Infectious Disease 
      Policy Committee, Association of State and Territorial 
      Health Officials [ASTHO]...................................    15
    Knouss, Robert F., M.D., Director, Office of Emergency 
      Preparedness, Department of Health and Human Services......    76
    Lillibridge, Scott R., M.D., National Center for Infectious 
      Diseases, Centers for Disease Control and Prevention, 
      Department of Health and Human Services....................   103
    O'Toole, Tara, M.D., senior fellow, Center for Civilian 
      Biodefense Studies, the Johns Hopkins University, Schools 
      of Public Health and Medicine..............................    48
    Plaugher, Edward P., fire chief, Arlington County, VA, and 
      director, Metropolitan Medical Response System, Washington, 
      DC.........................................................    29
    Waeckerle, Joseph F., M.D., editor in chief, ``Annals of 
      Emergency Medicine,'' fellow, American College of Emergency 
      Physicians, and chairman, Department of Emergency Medicine, 
      Baptist Medical Center, Menorah Medical Center.............    36
Letters, statements, et cetera, submitted for the record by:
    Gordon, Ellen, director, Iowa Division of Emergency 
      Management and immediate past president, National Emergency 
      Management Association, prepared statement of..............     9
    Johnson, David R., M.D., deputy director for public health 
      and chief medical executive, Michigan Department of 
      Community Health, on behalf of the Infectious Disease 
      Policy Committee, Association of State and Territorial 
      Health Officials [ASTHO], prepared statement of............    18
    Knouss, Robert F., M.D., Director, Office of Emergency 
      Preparedness, Department of Health and Human Services, 
      prepared statement of......................................    82
    Lillibridge, Scott R., M.D., National Center for Infectious 
      Diseases, Centers for Disease Control and Prevention, 
      Department of Health and Human Services, prepared statement 
      of.........................................................   105
    O'Toole, Tara, M.D., senior fellow, Center for Civilian 
      Biodefense Studies, the Johns Hopkins University, Schools 
      of Public Health and Medicine, prepared statement of.......    51
    Plaugher, Edward P., fire chief, Arlington County, VA, and 
      director, Metropolitan Medical Response System, Washington, 
      DC, prepared statement of..................................    31
    Shays, Hon. Christopher, a Representative in Congress from 
      the State of Connecticut, prepared statement of............     3
    Waeckerle, Joseph F., M.D., editor in chief, ``Annals of 
      Emergency Medicine,'' fellow, American College of Emergency 
      Physicians, and chairman, Department of Emergency Medicine, 
      Baptist Medical Center, Menorah Medical Center, prepared 
      statement of...............................................    38



             TERRORISM PREPAREDNESS: MEDICAL FIRST RESPONSE

                              ----------                              


                     WEDNESDAY, SEPTEMBER 22, 1999

                  House of Representatives,
       Subcommittee on National Security, Veterans 
              Affairs, and International Relations,
                            Committee on Government Reform,
                                                    Washington, DC.
    The subcommittee met, pursuant to notice, at 10:06 a.m., in 
room 2247, Rayburn House Office Building, Hon. Christopher 
Shays (chairman of the subcommittee) presiding.
    Present: Representatives Shays, Allen, and Tierney.
    Staff present: Lawrence J. Halloran, staff director and 
counsel; Marcia Sayer and Tom Costa, professional staff 
members; and Jason Chung, clerk.
    Mr. Shays. I'd like to call this hearing to order and 
welcome our witnesses and our guests.
    How does a nation prepare for the unthinkable?
    The specter of mass casualties caused by a terrorist's 
release of radiological, chemical, or biological weapons grows 
larger on our domestic horizon. In a world made more dangerous 
by the proliferation of the technologies of mass destruction 
and by the willingness of some to use them against us, the once 
improbable has become the inevitable.
    Are we prepared?
    By most accounts, the answer is no. Despite significant 
efforts to combat terrorism and improve national readiness, 
medical response capabilities are not yet well-developed or 
well-integrated into consequence management plans.
    Providers are not trained to diagnose or treat the uncommon 
symptoms and diseases of unconventional warfare. Public health 
surveillance systems are not sensitive enough to detect the 
early signs of a terrorist-induced outbreak. Hospitals and 
clinics lack the space, equipment, and medicine to treat the 
victims of weapons of mass destruction.
    Combatting terrorism challenges Federal, State, and local 
governments to coordinate response plans, train and equip 
critical personnel, and integrate military support.
    In previous oversight hearings, we examined Federal 
spending priorities and the role of the national government in 
the early response to terrorism. Today, we assess what is being 
done to help States and localities build a public health 
infrastructure capable of deterring, detecting, and, if 
necessary, treating those affected by terrorist events.
    For more than symbolic reasons, we asked first responders 
to testify first, preparing for low incidence, high-consequence 
events is the daily business of public safety, public health, 
and emergency management professionals. We have much to learn 
from them as we design and implement a Federal program to 
augment their work.
    Witnesses from the Department of Health and Human Services' 
Office of Emergency Preparedness and the Centers for Disease 
Control and Prevention will then discuss the national program 
to support local first response, improve public health 
monitoring, and stock the medical arsenal in the fight against 
terrorism.
    We appreciate their testimony and their willingness to 
listen to their State and local partners first.
    [The prepared statement of Hon. Christopher Shays follows:]
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    Mr. Shays. Again, I'd like to welcome our witnesses and 
introduce them.
    We have Ellen Gordon, administrator, Iowa Emergency 
Management Division, and past president, National Emergency 
Management Association.
    I understand, Ms. Gordon, that you will be leaving a little 
early because of another appointment.
    Dr. David R. Johnson, Infectious Disease Policy Committee, 
Association of State and Territorial Health Officials and 
deputy director for public health and chief medical executive, 
Michigan; Ed Plaugher, chief, Arlington County Fire Department, 
Virginia, director of Metropolitan Medical Response System, 
Washington, DC; and Dr. Joseph F. Waeckerle, fellow, American 
College of Emergency Physicians, chairman, Department of 
Emergency Medicine, Baptist Medical Center of Kansas City, MO; 
and, finally, Dr. Tara O'Toole, fellow, Center for Civilian 
Biodefense Studies, Johns Hopkins University.
    At this time, we are going to recognize a very fine member 
of our committee, Mr. Allen from Maine.
    Mr. Allen. Thank you, Mr. Chairman, and thank you for 
holding this hearing, which I expect to be very interesting.
    Let me welcome our witnesses from all of the interested 
groups here today, as well as our distinguished witnesses from 
the Department of Health and Human Services. We're really glad 
that you could all be with us today.
    When I first heard about this hearing and conjured up an 
image of what the medical response would be to a terrorist 
incident involving a chemical or biological weapon, I imagined 
what most people would probably do--paramedics rushing to a 
building, putting on the yellow decontamination suits, 
quarantining an area, and hosing down victims, furniture, and 
everything else in sight.
    But from what I've learned in preparing for this hearing, 
this may not be the most likely scenario. In fact--and I'm sure 
our witnesses will elaborate on this--a more likely and 
potentially deadly case would involve a terrorist incident that 
goes unnoticed, affecting thousands and thousands of people who 
do not even know it.
    In this scenario, it will be doctors, nurses, and the 
health care infrastructure that really is the first responders. 
They will treat increasing numbers of patients with symptoms 
that may mirror influenza, for example. It will be up to them 
to determine the existence of the terrorist incident, to work 
with victims's families and friends to track the source of the 
agent, and to rapidly implement a plan to protect the health of 
our society.
    But how are we going to prepare the health community for 
such an incident? This is the question for today's hearing.
    I look forward to hearing from all of our witnesses about 
challenges to the current system, as well as recommendations 
for improving detection, surveillance, and treatment.
    How can we maximize communication and coordination among 
all levels of government and leverage the assistance of private 
entities? And how are the exciting new initiatives underway at 
the Department of Health and Human Services moving us toward 
these goals?
    I know this is a lot to ask of you in a single hearing, so 
I thank you for your participation. It is a pleasure to meet 
you and I look forward to working with all of you beyond 
today's hearing.
    Mr. Chairman, thank you again.
    Mr. Shays. Thank you, Mr. Allen.
    Just some housekeeping. I ask unanimous consent that all 
members of this subcommittee be permitted to place an opening 
statement in the record, and that the record will remain open 
for 3 days for that purpose.
    Without objection, so ordered.
    I ask further unanimous consent that all witnesses be 
permitted to include their witness statements in the record.
    Without objection, so ordered.
    At this time, I will invite our witnesses to stand so we 
can swear them in.
    [Witnesses sworn.]
    Mr. Shays. Thank you. Note for the record that all five of 
our witnesses have responded in the affirmative, and to say 
that, though we don't have the traditional red and green light, 
we have this ridiculous little clock that will only tell me how 
well you are doing, but we are going to ask that you keep it 
around the 5-minute range. We do let our witnesses in certain 
cases go an additional 5 minutes. I know that you've come from 
different places around the country, so we welcome your 
participation, but we'd like to have you keep as close to the 5 
minutes as you can, but you have 10 if you need it.
    We're going to start with you, Ms. Gordon.

STATEMENT OF ELLEN GORDON, DIRECTOR, IOWA DIVISION OF EMERGENCY 
  MANAGEMENT AND IMMEDIATE PAST PRESIDENT, NATIONAL EMERGENCY 
                     MANAGEMENT ASSOCIATION

    Ms. Gordon. Thank you, Mr. Chairman and Mr. Allen, for the 
opportunity to appear before you today.
    As introduced, I am Ellen Gordon, director of the Iowa 
Division of Emergency Management, and also representing the 
National Emergency Management Association this morning and the 
core membership of the State directors across the country.
    Also, I serve on the congressionally established advisory 
panel led by the Virginia Governor, Jim Gilmore, charged with 
assessing domestic response capabilities for terrorism 
involving weapons of mass destruction, so I think the 
information from this hearing should be very helpful to this 
panel. However, today it is the State emergency management 
perspective in which I speak.
    We are very concerned, as everyone else is, about the issue 
of domestic preparedness, and have been working in close 
partnership with the National Governors Association to provide 
policy and program recommendations to the Federal Government to 
enhance our coordination efforts between agencies with domestic 
preparedness roles and responsibilities.
    NEMA and NGA cosponsored a national policy summit this last 
February that brought together for the very first time policy 
executives from Governors' offices, State emergency management, 
and law enforcement.
    We are also working with the Department of Justice and FEMA 
and others to clearly define the role of the States and the 
Governors in this critically important issue, and to provide 
information, resources, and tools to States and local 
governments to enhance our preparedness and response 
capabilities.
    Today I think it is with great pleasure to be in the same 
room with some of the agencies. I think it is for the very 
first time that we are here together, and I hope this talks 
about the future that we, too, can start spending more time in 
coordinating our efforts together.
    This fall and winter we hope to sponsor some regional 
terrorism workshops, once again in conjunction with the 
National Governors Association, and out of those workshops we 
expect to provide additional policy and funding recommendations 
to Congress and the Federal Government following the completion 
of those.
    The public health systems' preparedness and readiness to 
respond to weapons of mass destruction incidents is well behind 
the other efforts undertaken by most fire and emergency service 
organizations, at least at the awareness level.
    One of the reasons that we believe this to be true appears 
to be a lack of national program direction that provides for 
coordination with the National Domestic Preparedness Office, 
the Department of Justice, and FEMA; inadequate funding for 
local and State preparedness activities; and a concentration of 
resources funded toward metropolitan areas.
    As a whole, the State directors of emergency management 
believe that most public health systems are unprepared to 
respond to WMD incidents for the following reasons.
    Capabilities at the local level are disparate in terms of 
competency and capabilities.
    Most, if not all, funding for equipment, personnel, and 
training has been focused into the major urban and metropolitan 
areas. Terrorism knows no geographic boundaries.
    There is little capacity to detect a biological and 
chemical event early, and by the time the detection and 
implication are confirmed by CDC or another lab in another 
State, the threat will have escalated many times over. This is 
especially true in small rural areas.
    There is a lack of strong coordination of information 
between the medical, emergency management, and law enforcement 
community.
    Not all public health services nor private hospitals are 
properly equipped to handle WMD issues related to 
decontamination, mass casualties, and mental health care for 
victims, first responders, and the community, at large.
    In Iowa, as in most States, we are reaching out to our 
partners in law enforcement, fire, emergency medical services, 
the State Department of Public Health, and our universities to 
integrate them all into a State-wide terrorism consequence 
management strategy. Public health is a critical component of 
the comprehensive plan, yet collectively we are far from where 
we need to be to have a strong integrated response capability 
not only in Iowa, but other States, as well.
    States need immediate help of Congress and the Federal 
Government to bring the public health systems up to appropriate 
level of readiness and capability, and our ideas are as 
follows.
    One, conduct a national assessment of the public health 
community's true capability to respond to WMD incident.
    Two, integrate public health into response plans, including 
urban and rural areas, alike.
    Three, provide the same level of funding and emphasis that 
is presently being directed at the first responders by 
Department of Defense and Department of Justice.
    Four, aiding and strengthening capacities to respond, 
especially at the local level. We recommend that a public 
health infrastructure be built that would provide labs for 
sampling and the conducting of disease surveillance, and 
provide computer linkages between local health agencies, 
hospitals, and labs, and the State health agencies to monitor 
and communicate and identify trends. We believe this system 
would facilitate early protection and early treatment of 
victims.
    Five, provide training and education awareness programs 
outside of metropolitan areas to public health officials and 
emergency room personnel and physicians, to name a few.
    Last, develop guidance and standardized training to ensure 
the safety of medical first responders.
    It is up to all of us to work harder and more effectively 
at coordinating all the various players in response and 
recovery to this very complex issue. Plans must be developed in 
every State to provide for close coordination and communication 
between public health, law enforcement, emergency medical 
services, emergency management, and the education community.
    Funding and resources must be enhanced and used more 
effectively to prepare the Nation's public systems for WMD 
incidents.
    Readying the Nation to respond to domestic terrorism is not 
a simple task, as we all know, but it must be done for the 
safety and well-being of citizens throughout this country 
living in communities large and small depending upon their 
government to be there when they need it most.
    Again, thank you for the opportunity to be here and the 
opportunity to leave early so I can get to my next appointment.
    We stand ready to provide any further assistance to this 
committee as you deem necessary, and I would be happy to answer 
any questions.
    Mr. Shays. Thank you, Ms. Gordon.
    [The prepared statement of Ms. Gordon follows:]
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    Mr. Shays. Dr. Johnson.

STATEMENT OF DAVID R. JOHNSON, M.D., DEPUTY DIRECTOR FOR PUBLIC 
  HEALTH AND CHIEF MEDICAL EXECUTIVE, MICHIGAN DEPARTMENT OF 
 COMMUNITY HEALTH, ON BEHALF OF THE INFECTIOUS DISEASE POLICY 
    COMMITTEE, ASSOCIATION OF STATE AND TERRITORIAL HEALTH 
                       OFFICIALS [ASTHO]

    Dr. Johnson. Good morning, and thank you for the 
opportunity to be here today.
    As mentioned, I am Dr. David R. Johnson, deputy director 
for public health and chief medical executive for the Michigan 
Department of Community Health.
    I am here today representing the Association of State and 
Territorial Health Officials [ASTHO] which is an alliance of 
chief health officers in each of the States and territories. My 
testimony also reflects perspectives of two of our affiliates, 
the Council of State and Territorial Epidemiologists and the 
Association of Public Health Laboratories, as each of us plays 
a role in ensuring the readiness of local and State public 
health systems to respond to a weapons of mass destruction 
event.
    My testimony will briefly address the readiness and 
capacity of health care systems to respond to events involving 
weapons of mass destruction, the critical role of public 
health, and we'll close with some policy recommendations.
    Successful preparation for a weapons of mass destruction 
emergency will depend on the development of a well-orchestrated 
plan to be used in responding to an event. Regardless of the 
nature of the attack, the role of public health in the planning 
process will include identification of existing assets and 
assessment of needs, resource allocation for preparedness, 
stockpiling of supplies, medical training for treatment, and 
media training for communication with the public.
    Other critical roles in planning include the development 
and implementation of training and education programs and 
communication plans.
    Health officials are often the first medical personnel to 
be contacted by the press when an epidemic or other type of 
public health threat occurs; therefore, rapid, reliable 
information and communication systems between local health 
authorities, police, fire fighters, emergency management 
services, emergency personnel, and Federal agencies are 
essential.
    Currently, CDC is providing a handful of State health 
departments with funding for emergency preparedness planning to 
serve as models for the other States. These grants hopefully 
will also make it easier to work with other relevant agencies.
    In Michigan, to use our State for an example briefly, our 
communicable disease epidemiology division facilitates a 
relationship between State and local public health communicable 
disease epidemiology programs somewhat analogous to the 
relationship between CDC and the States.
    Local health departments provide routine onsite monitoring 
and case investigation. State epidemiologists operate 
specialized surveillance systems and provide consultive and 
onsite assistance for the more unusual and life-threatening, 
urgent situations.
    State health departments will coordinate assistance to 
local health departments to help their facilities as affected 
localities become overwhelmed.
    Because of the likely number of victims involved, State 
health departments will coordinate the distribution of victims 
around the State in medical treatment facilities and across 
State lines to nearby localities.
    In a covert event from a suspect biologic or chemical 
agent, public health's first efforts would be laboratory and 
epidemiological analysis through the public health surveillance 
system.
    Under most circumstances, the initial detection and 
response would take place at the local level.
    This type of active surveillance is dependent upon the 
ability of the laboratory to rapidly and accurately analyze 
samples for evidence, requiring staff with technical expertise, 
equipment, and supplies, including biosafety level three 
containment facilities.
    Public health laboratories, ideally suited for this 
critical role, will need constant upgrading of staff skills, 
equipment, and reagents to perform this function. This will 
clearly require additional resources, since half of the State 
public health laboratories, as a recent GAO report noted, do 
not have enough staff to conduct laboratory analysis of 
currently known emerging infectious diseases, such as hepatitis 
C virus and penicillin-resistant Streptococcus pneumoniae.
    Training by State and public health laboratory staff of 
hospital and private clinical laboratory personnel to recognize 
an unusual pathogen or bacterium is another critical public 
health role in emergency preparedness. The capacity to rapidly 
determine if a substance contains a deadly microbe or harmless 
powder is essential if we want to prevent unnecessary 
decontamination and expensive courses of antibiotics.
    In closing, preparing to meet the needs of civilian victims 
of a weapons of mass destruction incident requires a 
coordination of the entire health care community, as well as 
experts in agencies at all levels of government.
    Planning for these types of events requires special 
emphasis on certain functions not normally included in disease 
plans. Those functions include special surveillance operations, 
delivery of vaccines and anti-microbial agents, and other 
mitigation efforts.
    In summary, State and local public health agencies need 
preparedness planning and readiness assessment, adequate 
epidemiological resources for disease surveillance, appropriate 
laboratory capacity and state-of-the-art diagnostic 
capabilities for biologic and chemical agents, and 
establishment and maintenance of adequate communications and 
information networks.
    State health departments have demonstrated skill and 
experience to rapidly mount mass immunization campaigns, 
administer medications on a large scale, respond to disasters, 
and generate emergency public communications.
    Thank you for this opportunity to testify. I'll be happy to 
respond to your questions.
    Mr. Shays. Thank you very much, Dr. Johnson.
    [The prepared statement of Dr. Johnson follows:]
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    Mr. Shays. Chief Plaugher, we welcome your testimony.

STATEMENT OF EDWARD P. PLAUGHER, FIRE CHIEF, ARLINGTON COUNTY, 
    VA, AND DIRECTOR, METROPOLITAN MEDICAL RESPONSE SYSTEM, 
                         WASHINGTON, DC

    Mr. Plaugher. Good morning, Mr. Chairman and members of the 
committee.
    Before I give my remarks, I would be remiss if I did not 
wish the members of the Fairfax County Urban Search and Rescue 
Team every success and personal safety in their efforts in 
Taiwan. They began this morning.
    I think it is important, as I begin my remarks, to realize 
that today's fire service is vastly different than yesterday's 
fire service, and today's needs are vastly different.
    In March 1995, after the attack on the Tokyo subway system 
and prior to the Oklahoma City Federal Building bombing, the 
Washington, DC Council of Governments Fire Chiefs Committee 
requested assistance to better prepare the Nation's Capital and 
the first responder community for a weapons of mass destruction 
event.
    Efforts have been underway since that time and progress has 
been made in several important areas. Your community now has 
additional response services and a team that has received 
specialized training. Equipment has been designed and field 
exercises have been concentrated at several key facilities or 
targets, such as the Pentagon.
    Some first responder departments have received additional 
Federal resources, and in those communities even more has been 
done to assist and prepare the first responders.
    In relation to the Metropolitan Medical Strike Team, the 
partnership with the Office of Emergency Preparedness, U.S. 
Department of Health and Human Services has been outstanding. 
With very limited resources, their program has made a 
difference in our ability to deal with critical life support 
issues, such as immediate access to essential pharmaceuticals.
    The Metropolitan Medical Response System, as it is now 
know, has, and will continue, with the support of the Office of 
Emergency Preparedness, to improve our response capability, and 
is a model program that utilizes a partnership approach to 
provide essential response capability in incidents of 
terrorism.
    Our partnership, which utilizes the resources and talents 
of local, Federal, and State assets developed well beyond our 
original expectations. Further development of the system is 
underway at this time and will, with continued support of the 
partners, continue to see improvements.
    Several key areas, however, are problematic, to which I 
will focus the remainder of my remarks.
    Early in the development of the Metropolitan Medical Strike 
Team, now the Metropolitan Medical Response System, the 
hospital medical community was deemed critical. In the Tokyo 
incident, self-referral to a medical facility of the incident 
victim was a major issue, and in most incident pre-planning has 
been deemed to be a major factor.
    Today's hospitals, with few exceptions, have limited or no 
ability to manage the effects of manmade or natural disasters 
with large numbers of casualties.
    Immediate first response means hospital and medical care, 
not just law enforcement, fire, and EMS responders. We have not 
developed the necessary infrastructure to support this critical 
need.
    First responders will do their best to save lives, only to 
see the lack of facilities, equipment, and trained staff fail 
to maintain or support the saved life.
    Managed care has streamlined the medical system for 
efficiency and is a system from which we have all benefited. 
Managed care, in fine-tuning the medical resources are, 
however, the wrong approach to develop hospital-based 
resources. This resource is so critical that we must not allow 
the corporate bottom line to dictate the outcome.
    I propose that this need be viewed as similar to other 
infrastructure needs of critical importance to our Nation, such 
as interstate highways and air traffic control, both of which, 
as I understand, are operated by Federal trust funds. These 
trust funds, which can only be spent to support those program-
specific needs for which we, as first responders and 
communities asked to prepare this community, need critically.
    I propose that $2 per day be assessed per occupied hospital 
bed, which would be used to fund the development of a hospital-
based resource system. Every hospital could and would then have 
the financial resources to support the efforts of the first 
responders in the event of a disaster, both weapons of mass 
destruction and terrorism incidents and natural disasters.
    Just in the last 30 days, one of Arlington County's three 
hospitals and its associated emergency room closed its doors. 
Almost 45 percent of our hospital-based disaster response 
capability just vanished in less than 48 hours. This erosion of 
our emergency medical system must be stopped and reversed or 
the success of the world's best medical care will slide to an 
unacceptable level.
    In addition, research and development must proceed on the 
development of a detector to aid first responders. My 
department has had discussions with Oak Ridge National 
Laboratory regarding this issue and have produced positive 
preliminary results. However, funding has prevented the concept 
from moving forward.
    The detector would vastly expand the early warning 
capability of today's smoke detector and could, if applied to a 
first responder's protective clothing, greatly enhance the 
protection of our response community and to every occupancy to 
which it is applied.
    Acts of terrorism have vastly changed the community in 
which we live. We cannot utilize the approach of the past to 
deal with this very real threat.
    As individuals with whom the citizens have placed public 
trust, we cannot ignore these vital shortcomings to our ability 
to save lives. Public trust is earned every day.
    Thank you for this opportunity to address the committee, 
and I will be glad to answer any questions.
    Mr. Shays. Thank you, Chief Plaugher.
    [The prepared statement of Mr. Plaugher follows:]
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    Mr. Shays. Dr. Waeckerle, we'll now hear from you.

   STATEMENT OF JOSEPH F. WAECKERLE, M.D., EDITOR IN CHIEF, 
 ``ANNALS OF EMERGENCY MEDICINE,'' FELLOW, AMERICAN COLLEGE OF 
  EMERGENCY PHYSICIANS, AND CHAIRMAN, DEPARTMENT OF EMERGENCY 
    MEDICINE, BAPTIST MEDICAL CENTER, MENORAH MEDICAL CENTER

    Dr. Waeckerle. Good morning, Chairman Shays and Congressman 
Allen and Congressman Tierney. It is a pleasure to be here.
    As said earlier, I'm Joe Waeckerle. I'm a practicing board-
certified emergency physician in Kansas City. I currently serve 
as editor in chief of ``Annals of Emergency Medicine,'' which 
is a leading journal in emergency medicine. More importantly, I 
currently serve as the chair of the task force for the American 
College of Emergency Physicians which is developing strategies 
for training physicians, nurses, and other personnel. It is a 
multidisciplinary task force of health care personnel who are 
focusing on issues which heretofore have not been addressed.
    I am here today to testify on behalf of ACEP, the American 
College of Emergency Physicians, which represents over 20,000 
practicing emergency physicians and over 100 million patient 
visits per year.
    Recent U.S. Government initiatives have recognized the 
threat of weapons of mass destruction and have appropriated 
funds for initial planning and response programs. To date, 
these response programs are well founded and provide an 
important foundation for defense, but, unfortunately, they are 
incomplete.
    ACEP believes that, prior to further program development 
and implementation at the Federal level, there needs to be a 
reconsideration and modification to our current approach to 
domestic planning and preparation.
    The contemporary model that serves as a planning framework 
for our community is the hazardous material or HAZMAT model. 
The HAZMAT model approach emphasizes a sentinel event 
occurring, the expectation of rapid detection and 
identification of the offending substance and reliance on 
decontamination, especially on scene by first responders to 
alleviate the situation.
    Today, however, we believe that this approach is no longer 
adequate for some chemical agents and nearly all biological 
agents. Decontamination may not be indicated in many chemical 
incidents, as we once thought it to be. Decontamination is time 
and labor and personnel intensive and requires tremendous 
resources. It is impractical to decontaminate every individual 
involved. But perhaps the most important flaw in our current 
model is the fact that the HAZMAT approach does not address the 
use of biologic weapons, possibly the greatest threat facing 
our Nation.
    There are four critical links to effective response missing 
from this approach.
    First, we must consider all potential weapons, notably 
biologics, their specific characteristics, and a different 
approach to detection, identification, and defensive protective 
measures.
    Second, sophisticated surveillance systems must be 
established and integrated with our public health 
infrastructure and our Nation's emergency departments. The 
development of modern technology supporting epidemiological 
warning networks at the local, regional, and national level can 
provide real-time valid information critical to early detection 
and identification. In an additional benefit, it would be 
useful for many of the public health issues of importance to 
our society today.
    Third, specific training for emergency health care 
personnel is absolutely vital. For biologic weapons, the first 
responders will not be fire and police but will be health care 
professionals, especially emergency physicians and nurses. And 
the scene will not be the streets, but local emergency 
departments and clinics.
    To have an effective emergency medical response to a 
terrorist attack in the United States, a focused educational 
effort on health care professionals, especially emergency 
physicians, nurses, and EMS personnel, is paramount. Only 
through to be and practice will health care professionals 
develop the clinical knowledge and degree of suspicion 
necessary to initiate an effective response.
    Fourth and finally, a central Federal coordination office 
is essential to the development of an effective national 
response to terrorist attack.
    No matter what type of incident, the local community, 
whether large or small, must respond quickly and appropriately 
and must have the ability to be self-sufficient for 24 hours as 
outside assistance may not be available.
    Only through adequate planning will the community response 
be successful. Centralized coordination of the many important 
Federal initiatives will allow local and State professionals 
the opportunity to obtain valuable planning, training, and 
resource information efficiently.
    In conclusion, although a terrorist attack is a low 
probability event for any one city or town, America's emergency 
medical community believes it is not a matter of if or where 
but when. The price of freedom in our country is our 
vulnerability.
    We have recognized the threat of terrorism, and we have 
again to implement deterrent and response strategies 
appropriately based on existing fire and emergency services.
    ACEP believes that we must now modify our approach to 
include current and future threats of biologic terrorism and 
other chemical weapons. This more-comprehensive approach will 
require knowledgeable emergency health care professionals 
supported by a sophisticated medical surveillance 
infrastructure at the local level.
    ACEP urges Congress to implement education, planning, and 
response programs facilitated by a central Federal office 
designed to meet these challenges so that we can all better 
protect our patients and our country.
    Thank you for the opportunity to present to you all.
    Mr. Shays. Thank you, Dr. Waeckerle.
    [The prepared statement of Dr. Waeckerle follows:]
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    Mr. Shays. Dr. O'Toole.

  STATEMENT OF TARA O'TOOLE, M.D., SENIOR FELLOW, CENTER FOR 
  CIVILIAN BIODEFENSE STUDIES, THE JOHNS HOPKINS UNIVERSITY, 
             SCHOOLS OF PUBLIC HEALTH AND MEDICINE

    Dr. O'Toole. Thank you, Mr. Chairman.
    I am Tara O'Toole. I am a physician and public health 
professional. I am here today as a member of the Johns Hopkins 
School of Health Faculty, where I am a senior fellow in the 
Hopkins Center for Civilian Biodefense Studies.
    I am going to confine my remarks to preparedness for acts 
of terrorism involving biological weapons, only.
    The Hopkins Center for Civilian Biodefense was founded 
about a year ago under the leadership of D.A. Henderson, in 
large part out of concern that the distinctive features in 
responsiveness to acts of terrorism using biological weapons, 
were not being clearly recognized within the Federal 
preparedness programs.
    Supported by both the Schools of Public Health and Medicine 
at Johns Hopkins, the center is focused on three strategic 
areas.
    First, increasing awareness of the threats posed by 
bioterrorism amongst professionals in the medical and public 
health communities.
    Second, building the knowledge base that is needed to 
respond appropriately to biological weapons of greatest 
concern. As Dr. Waeckerle mentioned, there is much yet to learn 
about how best to respond to such events.
    Third, we are trying to catalyze the development of 
operational systems, and particularly public health systems, 
that would enable us to respond effectively to intentional 
epidemics.
    The center is responsible for convening a national working 
group that published consensus recommendations on how to 
medically respond to anthrax and smallpox in the ``Journal of 
the American Medical Association.'' Additional recommendations 
on other pathogens of high concern will be forthcoming.
    We are also beginning a project to design a template to try 
and identify the essential elements needed to create the 
institutional capacity to allow hospitals to respond 
effectively to bioterrorism.
    A terrorist attack on U.S. civilians using biological 
weapons will cause an epidemic. As Congressman Allen noted in 
his remarks, the response to such an event would be 
fundamentally different and involve different kinds of 
professionals and organizations than a response to terrorist 
attacks using chemical weapons or conventional or nuclear 
explosives.
    If we are going to construct effective response programs, 
we must recognize these essential distinctions between 
bioterrorism and other types of terrorist attacks.
    Were a covert bioterrorist attack to occur, it would most 
likely come to light gradually, as astute clinicians became 
aware of an accumulation of inexplicable deaths among 
previously healthy individuals.
    Regardless of the specific scenario or the scope of the 
attack, the medical community and hospitals will be key 
components of any effective response. In addition, State and 
local public health agencies will also have vital roles to play 
in managing an intentional epidemic.
    Indeed, how effectively and how rapidly these public health 
and medical professionals respond will have critical impacts on 
the scope and the outcome of the epidemic.
    There are now a number of very laudable Federal programs 
underway which address the challenges associated with 
bioterrorism. All of these programs--all of them--are designed 
to support local response efforts. In fact, most analyses and 
exercises to date, as Dr. Waeckerle alluded to, indicate that 
Federal resources cannot be mustered for 24 to 48 hours after a 
terrorist attack; thus, for the first day or two cities and 
States will be on their own.
    To date, there has been very limited involvement on the 
part of clinicians and hospital leaders in the drills and 
exercises sponsored by the Federal preparedness programs. This 
is not because the people running these programs have failed to 
try to get these participants to the table, but it is the case 
that to date most doctors have never seen a case of anthrax or 
smallpox or plague, and most hospital laboratories are not 
equipped to definitively diagnose those pathogens.
    State and local public health agencies have been under-
funded for decades, as the Institute of Medicine pointed out in 
1988. They have got to be upgraded. This will not be simple. It 
will require a concerted, long-term effort. There are no silver 
bullets.
    The ability of public health agencies to conduct rapid 
epidemiological analyses, to identify and track and, if 
necessary, vaccinate or isolate infected persons, or get them 
appropriate antibiotics will have a critical impact on our 
ability to manage the epidemic and limit suffering and death.
    I would suggest four areas of attention for your 
consideration.
    First, we need to continue to enhance existing Health and 
Human Service programs' upgrade for local public health 
capacity. The recent initiatives of the Centers for Disease 
Control are critically important in this regard and should be 
continued and, in fact, enhanced.
    A coherent 5-year plan that identifies the most important 
essential elements of public health response and that helps to 
ensure the capacity to coordinate regionally among different 
institutions that will be involved in bioterrorism response 
would be very helpful.
    Again, there will be no quick fix.
    Second, we have got to get the medical community and 
hospitals engaged in response planning and preparedness 
efforts. Given the financial pressures and competing priorities 
that beset clinicians and hospitals today, this will not be 
easy.
    It is important, first of all, that the medical community 
become aware of the threat posed by biological weapons and able 
to diagnose the most likely pathogens that might be used as 
weapons.
    We would suggest that the effort to make this happen 
proceed via professional societies such as the American College 
of Emergency Physicians, and that selected groups within the 
medical profession, such as emergency doctors, infectious 
disease specialists, internists, and so forth, be taught, 
through their professional societies, how to recognize and 
treat the pathogens of highest concern.
    Again, the professional societies have a distribution 
system and a history of teaching physicians that is likely to 
be more efficient than curricula developed by for-profit 
contractors.
    Hospitals, as we all know, are beset by many competing 
pressures, as Mr. Plaugher pointed out. In order to get 
hospitals to participate in planning efforts, we are going to 
have to construct a careful menu of incentives and programs 
that allow them to do so. They are not looking for another 
mission to pursue. And we have got to make the case that the 
consequences of a biological attack would be so calamitous that 
even the low probability of such an event warrants their 
attention.
    We must get hospital leadership engaged, which has been 
difficult to do to date.
    We believe that, in order for that to happen, Federal 
leadership will be necessary from both the Congress and the 
executive branch.
    Third, as all of my colleagues on the panel have mentioned, 
coordination and collaboration is essential.
    A biological attack is going to provoke the efforts of a 
huge panoply of agencies and institutions at all levels of 
government. Coordinating such an affair is not easy, as we all 
know. There have been mighty efforts made to date to accomplish 
that on the Federal effort, which I know will continue.
    Let us remember that coordination requires resources, time, 
and money. I would suggest that a deliberate effort to create 
structures that would allow coordination and collaboration on 
the local level and would connect those efforts to Federal 
structures might be very helpful and deserving of 
consideration.
    Finally, human disease is always a social phenomenon with 
important ethical, legal, and cultural implications. An 
intentional epidemic will raise difficult questions such as the 
authority of governments to impose quarantines or isolates 
individuals with contagious illness, the legal liability 
associated with vaccinations, the use of military personnel on 
American soil, and so forth.
    Many of the relevant public health laws that would be 
invoked in such situations date back to the Civil War. 
Moreover, such authorities differ from State to State quite 
considerably.
    Examination and consideration of these matters should be 
undertaken now, not in the midst of a national disaster, and I 
think it would be helpful to get scholars from academia, as 
well as legal experts in the Department of Justice, and from 
HHS involved in such a matter.
    That concludes my remarks. I'd be happy to answer 
questions.
    Mr. Shays. Thank you, Dr. O'Toole.
    [The prepared statement of Dr. O'Toole follows:]
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    Mr. Shays. We're going to start with Congressman Allen, and 
we'll have a number of questions to ask all of you. Thank you.
    I appreciate the fact that you all tried to summarize your 
statements, but I think you still got the main points out. 
Thank you.
    Mr. Allen. I want to thank you, also. I have been to a lot 
of congressional hearings, but I have to say that you all did a 
very good job of making suggestions for areas in which we need 
to work, an excellent job of pointing to the areas where we 
need to pay some attention.
    You've left me with a whole range of areas I'd like to talk 
about.
    I think what I'll do is just flag for you the areas of 
institutional capacity that a couple of you have raised, and 
the question of how to engage the medical community. I think 
that is the absolutely central issue.
    Let me flag that and leave it aside for a moment and go to 
questions about laboratories. It seems that part of the problem 
in incidents of bioterrorism is how do we figure out what is 
going on. And so that raises issues about the capacity of State 
labs, hospital labs, to detect some of these agents.
    Can you sort of--and I think this is open to any one of 
you--even if every State had a laboratory capable of analyzing 
these agents, aren't we still talking about delays and travel 
time and--should every State have one hospital or one State 
public health department that is capable of doing this? What do 
you envision as a way to deal with this detection issue as 
quickly as possible?
    That's for anyone who would like to answer.
    Dr. Johnson. A couple of thoughts on that from a State 
public health perspective.
    Mr. Shays. If I could interrupt, it would probably make 
sense for all of you to answer, because you all have different 
perspectives on the issue, even if it is a short response.
    Dr. Johnson. There are several levels to a response to that 
important issue.
    First of all, obtaining the appropriate samples, both 
environmental samples and human specimens, is something for 
which training will be needed. That has to happen at the local 
level. It has to happen both from public health authorities, 
but, more importantly, from medical first responders and 
emergency medical personnel. Knowing what specimens to get and 
where to send them, who to call, is an important part of this 
whole process.
    I think clearly our perspective would be that, at a 
minimum, at a State level, and certainly even at below the 
State level at certain metropolitan areas, and so forth, there 
has to be the laboratory capacity to rapidly assess both 
biological and chemical agents.
    We're pleased that we are just now beginning to receive 
some Federal support to develop that capacity in the State of 
Michigan, and other States are, as well.
    But I'd say at this point my quick assessment would be that 
there is a great deal of variability across the country as to 
the level of that capacity presently.
    Mr. Plaugher. Mr. Allen, I have been very fortunate for the 
last 2 years in working with Oak Ridge National Lab on the 
reinvention of the household smoke detector. We have 77 million 
smoke detectors in this country that are more than 10 years old 
and need to be replaced, and now is the time to look at new 
technology to see if we can avoid false alarms and those type 
of things associated with it.
    I also have an obligation to try to return home every night 
to 64 people who protect Arlington County, and that's the fire 
fighters and paramedics, so that if there is some way that I 
can design a detector that will provide them personal 
protection, as well as better protection for our residents--and 
so I went to Oak Ridge and asked them could they, in fact, do 
that, knowing full well that that was a huge, huge obstacle.
    It was amazing, because their response was, ``Absolutely, 
and we can use existing technology to do that.''
    And so we've continued to explore with Oak Ridge a couple 
of very exciting technologies, but we have run into a funding 
issue, and we no longer can pursue the project because we 
simply don't have the funds to do that. And it will do both of 
those items with--they are different technologies, but 
remember, now, we threw out to them this quest of ours to do 
the two-pronged approach in our dialog with them.
    I've had a chance to actually visit in Florida the Oak 
Ridge Lab that is designed to do detector enhancements, 
primarily for the Department of Energy facilities, but it is 
pretty remarkable the concepts they're talking about. They're 
talking about a detector that is similar to what we know as 
today's smoke detector that would be able to detect over 40,000 
different substances, and we are also talking about a detector 
that would be capable of detecting bios and other type of 
things that--again, there are two entirely different 
technologies.
    So we think this is critical. We think the detector's 
capability is absolutely essential.
    Mr. Allen. Are you saying you wouldn't need different 
detectors for different biological agents?
    Mr. Plaugher. They have started research on what are called 
``forescens,'' and forescens are individual microorganisms that 
are designed to specifically react to certain presence of 
certain things, such as anthrax and those types of things, and 
then they simply glow. The task is to measure the glow to make 
sure that you're not getting false positives and that sort of 
thing.
    It is some pretty exciting stuff, but, again, they've run 
into a funding problem.
    Mr. Allen. Thank you.
    Dr. Waeckerle. I've had the unfortunate experience of 
actually responding to some events, both chemical and biologic, 
in my career. The crux of a response is, as we've all stated to 
you, detection and identification of the offending substance.
    To date, the Institute of Medicine emphasizes in a recent 
report that was requested by the Office of Emergency 
Preparedness that we have no current technology that allows us 
to detect and identify rapidly, with high sensitivity and 
specificity, meaning accurately and validly, any chemical or 
biologic agents in the field.
    We therefore must rely on technology of the future to help 
us.
    Preston, in his book, ``The Cobra Event,'' talks about a 
black box that identifies DNA sequencing of biological agents. 
Well, it's great for a book and it sold a lot of copies, but it 
is not real yet. I would like it to be real, as I think we all 
would.
    That, therefore, to answer your question, Congressman 
Allen, requires us to go to conventional methods such as 
gathering cultures and submitting them to State and Federal 
labs.
    In our responses, we've been hamstrung because of the fact 
that we had no State labs or local labs which can rapidly and 
validly identify organisms while we are at the scene, which 
therefore causes us not to know what we are dealing with and 
whether or not we should be administering antibiotics 
prophylactically or appropriately to the victims.
    We now have the capability of calling the CDC and the FBI, 
because they have lab capabilities, but it still takes 8 to 24 
hours to receive information.
    So you are correct in your question, which is pointing out 
what are the deficits and where do we need to go. We need to go 
to two areas. One is to develop better technology, and the 
other is to have a better infrastructure in public health labs 
and agencies to support us at the local level.
    The problem with responding to--having the Federal family 
respond is that they may not be able to get there, depending on 
the incident--again I reiterate--for 24 to 48 hours, and the 
past history of every natural and terrorist event in the United 
States has demonstrated that to be a very real concern.
    Dr. O'Toole. Well, there's no question that the labs need 
upgrading. I think, though, it is very difficult to answer 
simply whether there should be one lab in each State. One could 
certainly argue that a State like California needs more than 
one and perhaps you can regionalize the effort in other areas 
of lesser populations.
    My understanding----
    Mr. Allen. I always am thinking about the State of Maine.
    Dr. O'Toole. Lucky you, Congressman.
    I understand that the State laboratory directors have been 
working with the Centers for Disease Control to come up with 
such a strategy, and your question might be well directed 
toward Dr. Lillibridge when he testifies.
    I will point out, however, that, again, in terms of 
bioterrorism, no one is going to be sending a lab sample 
anywhere unless a clinician has a suspicion that there is a 
diagnosis that might be related to a biological weapon.
    I have great respect for the national laboratories. I 
served as Assistant Secretary for Energy for 4 years. 
Nonetheless, I think there is very limited usefulness for these 
rapid detection systems in the context of bioterrorism, as 
opposed to rapid laboratory diagnostic systems.
    Again, a strategy has to take into consideration specific 
aspects of the different organisms.
    It is quite feasible, for example, to train every hospital 
laboratory to be able to diagnose anthrax definitively. That is 
not a good idea in the case of smallpox. Among other reasons, 
you don't want just anybody handling smallpox and contaminating 
a laboratory of a hospital.
    So, again, one needs to have a very measured strategy. 
Figuring out that strategy has to be a matter of thoughtful 
consideration.
    Mr. Allen. Thank you very much.
    Mr. Shays. Thank you, Congressman Allen.
    This committee is the National Security Subcommittee that 
oversees national security and veterans affairs for programs, 
and we have special responsibility to look at terrorism, both 
at home and abroad. And we're probably one of the committees 
that actually has that responsibility both on an international 
and national level, and local, as well.
    It is really the primary focus of the committee. I am 
almost overwhelmed, the more we get into this, the different 
groups that we need to set up. I mean, we have metropolitan 
medical response systems, we have disaster medical assistance 
teams, we have the National Guard teams, we have special forces 
and their ability within an hour to go to almost any area of 
the country. I mean, all of this is reassuring, in one way, 
because it tells me we are thinking about it.
    In all of our view--and I think all of us share that we 
have a long way to go.
    What interests me is that this is a hearing on nuclear, 
chemical, and biological, and all of you kind of have focused a 
bit on the biological, which isn't a criticism but is kind of, 
in a sense, an affirmation that the biological represents the 
most mysterious, I think.
    You have a fire, you can basically assess it. You have a 
flood, you can basically assess it. If a building collapses, 
you basically can assess it. A chemical explosion, horrific, 
long-term, incredible implications, but you know what happened.
    The chemical and biological, though, could happen--both 
chemical and bio could happen without our knowing, correct? 
It's not just biological. What represents the threat with 
biological is that it would continue to grow and fester, where 
the chemical would basically be an event that would happen. We 
would know about it pretty soon.
    Let me ask you this first part. Would we know chemical 
before we would know biological?
    Dr. Waeckerle. There are characteristics, sir, that you 
would look for in a chemical event that are unique and would 
guide you to an appropriate response in a more timely fashion 
than a biological event.
    The characteristics of a chemical event, for the most part, 
is it will be a sentinel event, as you correctly pointed out. 
Despite the fact that it could be clandestinely spread, it will 
manifest itself pretty quickly through what we call 
``toxidromes,'' in other words, a toxic substance demonstrated 
in patients by presentation that is fairly characteristic, and 
therefore we can address it.
    Unfortunately, for most chemical incidents, all its 
reliance heretofore on antidote and contamination may not be 
correct or warranted to the degree that we thought.
    Mr. Shays. Let me not get into that. I just want to--in 
terms of detection, because we didn't have the reassurance for 
the Gulf war veterans that we were on top of whether our Gulf 
war veterans were exposed to chemicals.
    My sense is that if you don't respond within a few days to 
the chemical, the damage is done, and then you may not even be 
able to know it happened.
    Dr. Waeckerle. Actually, if you don't respond within a much 
shorter timeframe than that for most chemical warfare--
weaponized chemical agents, then the patient will, 
unfortunately, suffer death or disease and you can no longer 
intervene. There is a very short time window of opportunity.
    Mr. Shays. I think we all have a sense of how horrific a 
nuclear explosion would be and the implications of that both in 
the short term and long term.
    I'd like to just have you define to me the difference, and 
then I'm going to ask the respondents how they would deal with 
it. Maybe that will be my next round. Just in terms of chemical 
and biological, short answers, the differences. I want the 
differences.
    Dr. Waeckerle. Well, I'll start, and Dr.----
    Mr. Shays. Let me just tell you what I think is the 
obvious, and then----
    Dr. Waeckerle. Please.
    Mr. Shays. The chemical and biological both may not be 
detectable right away.
    Dr. Waeckerle. I think, for the most part, chemical events 
using the agents that we are aware of will be manifest within 
minutes to hours; biologic agents, contrast, you're right, are 
insidious and may not manifest for days to weeks.
    Mr. Shays. Both can be introduced into the community in 
small dosage and have horrific effects.
    Dr. Waeckerle. Certainly more so biologics than chemicals. 
Chemicals have to have a certain dose effect, and to do so they 
have to be spread or dispersion methods have to be used for 
these chemicals to affect large populations.
    Chemical events are dramatically different because they 
will manifest themselves quickly. They are best utilized by a 
terrorist in a confined space to capture a confined population, 
and they will manifest themselves--at least the ones that we 
have been exposed to and ones--for example, the sarin gases and 
et cetera, and the weaponized agents--they will manifest 
themselves almost, relatively speaking, almost immediately, and 
the astute clinicians that are well-trained and health care 
professionals should be able to identify, from the symptoms and 
signs of the patients, what chemicals have been used.
    Mr. Shays. Would a chemical linger like biological?
    Dr. Waeckerle. A chemical enter?
    Mr. Shays. Would a chemical exposure--would the exposure of 
the chemical linger indefinitely?
    Dr. Waeckerle. Only certain chemicals, because most of the 
chemicals that are weaponized will either kill you or not kill 
you, depending on your exposure and the chemical, itself. There 
are only a couple of chemicals that have long-term, lasting 
effects, and those are a couple of the pulmonary agents and the 
skin--what we call ``blister agents.''
    Mr. Shays. You make an assumption, though, that a terrorist 
would choose to have it be a pretty high dosage. There's also a 
concern that you could have low dosage that would have a long-
term negative impact.
    Dr. Waeckerle. That's correct, but that would not--at least 
in the scenarios that I'm sure you've considered, that wouldn't 
necessarily be a benefit of them in the weapon because it won't 
manifest high death and disability in a sensationalized 
fashion.
    The other thing, of course, is that to chronically expose 
people to chemicals would require a dispersion method that is 
not readily available.
    Mr. Shays. Usually terrorists want a quick impact. I 
understand that. But, going now to biological, biological can 
start small and just continue to grow and fester almost 
indefinitely. And then is the concern that it goes up 
proportionately or geometrically?
    Dr. O'Toole. Again, it depends upon the agent. A contagious 
disease, which can spread from person to person----
    Mr. Shays. I thought any biological would be contagious. I 
made a wrong assumption?
    Dr. O'Toole. No. All biological agents are infectious in 
the sense that, you know, they affect the human body once they 
are inhaled or injected or imbibed, but not all are 
transmissible from person to person. That would be a contagious 
disease. Smallpox is a highly contagious disease. Were someone 
to use smallpox----
    Mr. Shays. Anthrax is not?
    Dr. O'Toole. Anthrax is not.
    Mr. Shays. And both are biological?
    Dr. O'Toole. Correct. So, in the case of an anthrax attack, 
you would see a sudden number of very sick and dying 
individuals some time between 24 hours to 48 hours after the 
attack, and then people would continue to get sick, depending 
upon when they fall ill, which is highly variable in anthrax 
infection for the next 60 days. But you would get this sudden 
boom and people who are deathly ill coming into your emergency 
departments, unlike smallpox, which would start with the 
trickle of people looking like they had chickenpox or some 
other viral illness with fever and malaise.
    But if you didn't catch the smallpox, isolate the people 
and the contacts who had been infected early on, then the 
infection would grow and grow.
    During the smallpox eradication campaign the WHO held in 
the 1970's, each case of smallpox infected between 10 and 20 
contacts. So the number of people infected goes up by a log 
with each generation.
    Mr. Shays. That is pretty much geometric.
    Dr. O'Toole. Yes.
    Mr. Shays. I'm going to recognize Mr. Tierney after I allow 
Dr. Johnson and Chief Plaugher to just respond to the question 
I've asked from your perspectives, but then, when I come to my 
second round of questions, I would love to visualize the impact 
of a biological or chemical effect on the public health 
network, because, you know, what I wondered is if you--how many 
medical centers we are going to need, medical response areas, 
in light of your point about extra bed spaces. That would be a 
gigantic loss. And would we want to imagine a system where we 
could literally transport people who are in hospitals who are 
getting other services out of those hospitals to other 
hospitals around the country so that then those hospitals could 
just focus on the biological response, or something like that. 
I'd love to have you walk me through that.
    Maybe, Dr. Johnson and Chief Plaugher, you could respond to 
the question that I asked.
    Dr. Johnson. Certainly. Just very briefly, in terms of the 
differences between chemical and biological, I agree with what 
my colleagues have said about those important differences.
    I'd emphasize once again that detection in the case of 
biological agents being used is extremely important, and we 
heard a description of a couple of potential scenarios where, 
if we don't have a high index of suspicion and we don't have 
clinicians or others in the health care field thinking that 
this may be a possibility and putting together sometimes some 
subtle clues about a small series of patients they may 
encounter, if that doesn't happen, then we don't trigger our 
other systems. We don't trigger our public health system.
    And so that training and that ability to recognize that 
something unusual is going on and then the willingness and the 
understanding to report to local, State and other health 
authorities, those are very critical links with the biological 
attack.
    Mr. Shays. I think I was most interested--the thing that 
caught my eye the most was the fact that we, in some 
metropolitan areas, have public health specialists who just 
monitor the types of events in terms of pharmaceutical needs or 
the type of entries into hospitals, is there an over-event of a 
certain kind of illness that then would trigger a concern.
    I imagine that is happening in some metropolitan areas but 
not in others?
    Dr. Johnson. I would agree with that assessment. I think 
there is a great deal of variability about how closely this 
kind of monitoring is taking place.
    Mr. Shays. But since Federal dollars pay for that, I would 
think it would be a good way to start getting to the detection 
area.
    Chief, do you want to respond?
    Mr. Plaugher. Yes. Your question was about the difference, 
chemical and biological----
    Mr. Shays. How it impacts.
    Mr. Plaugher. And how it impacts. I think you also have to 
add in whether there is a warning or whether, you know, it is 
without warning or is yet to be detected with just the event, 
itself.
    I also think you have to throw into the matrix the issue of 
the hoaxes, which can also be equally devastating to a 
community, just the panic. If somebody says, ``I have done 
this,'' and, in fact, we have no way to know whether they have 
or have not, and we might have to mass inoculate a large number 
of people for just a simple hoax issue.
    So I think it is a very complicated matrix that we are 
trying to deal with, with little if any--the resources 
necessary to be successful. You know, we're continuing to 
basically shoot in the dark at several of our concepts.
    But I think that, obviously, from what we have known in 
recent events, such as the Tokyo, and you have a chemical event 
that's very noticeable, people were immediately down, the 
responders also went down. People suffered in medical 
communities. They also went down because of a lack of 
preparedness to deal with those type of things.
    You know, the pandemics that we've had in this Nation from 
the biologics, as well as the recent development of very 
sophisticated biologics, also gives us concern for our ability 
to detect, but also to then adequately respond with the medical 
care necessary.
    National stockpiles of pharmaceuticals, to the extent and 
the size and capacity of those, how do we administer those, 
they are all very, very complicated issues that we, as part of 
the responder community--because then we have to step out of 
our first responder role, but we are still part of the response 
community, and how do you deal with mass treatments of folks 
and that sort of stuff. And we have folks who are licensed to 
administer medicines and that sort of thing, paramedics, those 
types of things. So it is a very, very complicated thing.
    So your question is simple and straightforward, but the 
answer is very complex and very difficult because of the 
nuances of the situation.
    Mr. Shays. Thank you.
    Mr. Tierney. Mr. Chairman, this is an interesting issue and 
we could be here all day.
    I want to thank all of you for your testimony and the 
seriousness with which you present this issue.
    I have, obviously, a range of interests. Let me try to get 
to them.
    We have, obviously, an issue of protection aspect of that. 
Chief, you indicated that on the technology part of it you've 
already got Oak Ridge working on that. I assume that we're 
talking Federal dollars there for the most part?
    Mr. Plaugher. That's correct, and there are a couple of 
issues, not only in Oak Ridge but Sandia and in some of the 
other national labs that are working on several protective 
capabilities, as well as decontamination substances and those 
types of things.
    Mr. Tierney. So what we need to do here is to make sure 
that it has been adequately funded and that those efforts go 
forward?
    Mr. Plaugher. Absolutely.
    Mr. Tierney. With respect to personnel who would be 
obligated to identify or at least recognize that, I would 
assume that those go back a little bit to the training exercise 
here. What are we doing about the curriculum at various medical 
colleges, public health people that teach public health or 
paramedics, or whatever? Are we doing anything about having 
that become part of the curriculum.
    Dr. Waeckerle. Actually, that's the task force that I'm 
chairing is the Multidisciplinary Consortium of Health Care 
Professionals. It currently includes doctors, nurses, 
paramedics, EMTs, fire, police, toxicologists, and, 
unfortunately, a few groups who are invited to come to the 
table. But, as each of my colleagues has stated to you, we are 
not--the clinicians, which will be essential in the detection 
of especially biologic attacks, are not properly prepared.
    I might add to that the hospitals and hospital personnel 
and the administrators and some of the major organizations in 
the country have not seen the wisdom of being involved and 
signing up, as well.
    Mr. Tierney. Let me try to break this in two parts, if I 
can. The first part is those people coming into the system as 
people that will treat people or diagnose people. Is there 
anything now to deal with the curriculum at those institutions?
    Dr. Waeckerle. We have just completed the first phase of 
our grant process when this multidisciplinary has defined the 
core content essential to health care professionals who would 
be faced with these challenges.
    The second part was soliciting funds for--we hope to obtain 
them through HHS and CDC to establish the core curriculum.
    The third phase would be then to offer to the professional 
societies, which we believe, as Dr. O'Toole has suggested, is 
the best strategy and not through private companies, education 
of all the health care professionals based on----
    Mr. Tierney. Let me break in. I want to get back to that 
level of people entering the system, so we're talking about the 
institutions that will be teaching these new people as they 
come through.
    You are developing a curriculum. It hasn't been implemented 
yet.
    Dr. Waeckerle. That's correct.
    Mr. Tierney. I would guess that we would want to have some 
assurance it was implemented right across the board. Since many 
of these institutions are private, you know, it is going to be 
difficult to require them to add this to their curriculum.
    Dr. Waeckerle. That's a major challenge of the strategy 
that--we looked at these and we called these ``barriers and 
challenges.'' I would be happy to supply the committee with the 
report if you so wish. But the major barrier is how to ask--
notice I used the word carefully--the health care professionals 
to obtain this information so that they are competent.
    The strategies----
    Mr. Tierney. These are people that want to be 
professionals. These are people that aren't professionals yet. 
These are the people that are in school training to become 
that. So the question is how do you get those institutions to 
require that they take that kind of background training?
    Dr. Waeckerle. Well, Congressman, that's very observant. 
The issue with that is we have to train the people in bits in 
the emergency departments----
    Mr. Tierney. How do we get at that?
    Dr. Waeckerle. The medical students? Is that what you're 
getting to?
    Mr. Tierney. I mean, getting to the fact that there are two 
different tracks to go on--people that are coming up through 
the pipeline and the trained people that are already in the 
pits.
    So my question on this part of it right now is, What are we 
going to do about having a curriculum that those people have to 
take so that they don't become people that have to be trained 
later. Do you get all that?
    Dr. Waeckerle. I have it, and I appreciate it. Thank you.
    Mr. Tierney. So that's the idea. And I guess where I'm 
leading with this is it is something that we ought to think 
about conditioning Federal education aid to these institutions 
to have them adding this to their curriculum once it gets 
developed as appropriate.
    Dr. O'Toole.
    Dr. O'Toole. Yes. I think awareness is growing amongst 
educational institutions that this has to be done. The board 
that licenses or grants certification to internists, for 
example, this year inserted questions involving biological 
weapons into its licensing and certification exam, and we have 
had conversations with other similar entities who are looking 
around for guidance on what they should do here.
    There isn't, as Dr. Waeckerle suggested, any simple way of 
plugging new curricula into already overcrowded medical school 
curricula, but that is where, you are quite right, things have 
to start flowing from.
    Mr. Tierney. So that would be one point, and you're already 
looking at that.
    The other point would be adding on the your favorite 
subject, which is people that are already in the pits. That is 
something that I think was recommended to be done through the 
professional organizations.
    What kind of a role would you envision State or Federal 
Government having on that effort, or would they have none and 
just leave it to the professional organizations, in your view?
    Dr. O'Toole. Well, professional organizations will need 
money to develop the curricula that are tailored to emergency 
physicians or to internists and so forth, such as the curricula 
that Dr. Waeckerle developed to help people in the pits.
    There are a number of different-flavored pits out there in 
medicine these days, and the curricula should be tailored to 
different specialists' concerns.
    Mr. Tierney. Let me ask this. I have a number of States 
that I'm aware of around the country that are sitting on 
incredibly large surpluses in their budgets. Is there an effort 
afoot to educate these State governments, the legislatures and 
the Governors' offices, and get them focused on this issue so 
that their resources are directed in this way?
    I think people tend to think it is going to be a crisis in 
biological agents and chemical and look to the Federal 
Government, when, in fact, as you are pointing out, a lot of 
the response is very, very local.
    I don't know of a lot of States that are focusing on this 
or putting parts of their budget toward this issue.
    Dr. Johnson.
    Dr. Johnson. I think that is beginning to happen, and I 
think that the national leadership on this, we're starting to 
recognize or appropriate that, and that's stimulating some of 
that education and awareness at the State level.
    Mr. Plaugher. I agree. I have written two letters to my own 
State, the State of Virginia, and asked them for assistance in 
this regard. The first letter they lost. The second letter 
they've chosen to not respond to.
    But then, because I am very stubborn, I said, ``Well, I 
won't accept that,'' so I started talking to a couple of my 
Senators that I know in my community, State Senators I know in 
my community, and asked them to work through legislation in the 
last legislative session in Richmond to even study the issue, 
and so they proposed a resolution before the State Senate 
asking the State Health Department to study this issue.
    The response that came back was that we don't have the 
$50,000 to study our capacity to deal with this in the State of 
Virginia, chemical or biological, and it just died for lack of 
funding.
    So, you know, again, I hear what you're saying and I agree 
with you absolutely that the States have an absolutely critical 
role in this whole issue.
    I find it difficult to get the proper emphasis on it, and 
so I appreciate that.
    Mr. Tierney. The last question, I'm very concerned with 
what is going on with our community hospitals, even before we 
get into this issue. In State after State they are being 
gobbled up, in many cases by for-profits. They are being 
consolidated, and people have to travel a great distance to get 
to an emergency room, great distance to get to a hospital bed.
    That seems to be directly in contravention to the needs 
that we have here if some sort of crisis sets in.
    Are you aware of any effort afoot to have individual States 
develop a plan of available emergency areas and hospital beds 
so that they are reasonably spread throughout the respective 
States and would address a situation like this? And, if not, 
what do you think we could do to help facilitate that?
    Dr. O'Toole.
    Dr. O'Toole. The State of Maryland has done fairly 
extensive analysis of how they would respond to a weapons of 
mass destruction and has surveyed the resources and 
availability of hospital beds, and the picture is fairly 
alarming, even in as relatively rich a State as Maryland.
    I would suggest that, given the many demands on the State 
health departments, it is going to be very difficult for them 
to muster the resources to actually address the kind of 
response needs that come up in these weapons of mass 
destruction scenarios. Politically, I think it is going to be 
very difficult for that to ever take place.
    We have begun conversations with various hospital groups 
and people from hospitals. We've gotten a lot of interest from 
some hospital leadership in being engaged in conversations that 
would move toward an understanding of what needs to be done.
    It is very complicated. On a given day, it might not be 
prudent to move everybody out of the intensive care unit at 
Johns Hopkins and make that the center of a response to a 
smallpox attack, for example. There probably has to be some 
flexibility in any plan.
    Whether you want to designate one or a group of hospitals 
in a region to be the centers of response to a weapons of mass 
destruction attack or put all hospitals to some minimum 
threshold level of capacity is still an open question.
    What you do with the staff in an attack is going to be 
very, very problematic. You have, first of all, to protect them 
from being afflicted with the same malady that is besetting 
your patients. Many people are probably going to leave their 
posts out of fear for their own health or to go and make sure 
their families are OK. Many of the people who staff hospitals 
today are working women, and if you are going to put them on 
12-hour shifts to handle an emergency you have to figure out 
what you are going to do with their kids meanwhile.
    So there is a whole host of questions that are just 
beginning to be investigated. Again, no simple answers yet. 
What we need to do is, first of all, muster the resources to 
address those questions thoughtfully and get everybody to the 
table who needs to be there to discuss them.
    Mr. Shays. Thank you very much.
    Mr. Plaugher. To answer your question, every day in 
northern Virginia, which is probably one of the most prosperous 
places in the Nation, runs out of hospital beds for us to take 
emergency patients to. It is an acute crisis, particularly not 
only the day-to-day aspect of trying to find a bed for a 
patient that is suffering a heart attack or any other type of 
unfortunate incident, but I know last winter, when we had a 
mini flu situation going on in the Washington metropolitan area 
we couldn't find any beds. We were really trying to figure out 
what to do with people. It was horrible, and I am, as a fire 
chief, also responsible for emergency medical services in my 
community, and I've got patients and no place to take them to.
    This is without the terrorist incident. I mean, this is 
without the catastrophic event. I mean, this is just day in and 
day out.
    Mr. Tierney. I think the problem I see in many States is 
that there has not been the kind of planning that the State 
convention is doing. I don't see the greater majority of States 
getting out there and taking an analysis of how these hospitals 
are consolidating, how they are shutting down, what the picture 
looks like.
    In my own State, we've gone from over 130 hospitals to less 
than 60. And there is no plan for those 60 that remain, whether 
they're all in one place, one part of the State or another, 
what their services provide.
    I think it is incumbent on us to somehow encourage some 
real sensible planning that takes into account, among just the 
ordinary needs day-to-day, and this kind of catastrophic event 
that might occur and we reasonably should be planning for.
    Mr. Plaugher. Again, as in my previous remarks, I said 45 
percent of our emergency room capacity just up and closed 1 
day. They came to us and said, ``We're going to give you a 60-
to 90-day notice.'' Forty-eight hours they closed the doors 
because of advice of legal counsel and said there's too much 
liability because our staff was walking away and getting better 
jobs and that sort of thing, so they just closed.
    Again, that means we have to readjust how we deal with the 
day-in and day-out needs, much less--if we were right now, to 
this day, to have another incident where a group of visiting 
dignitaries visiting the Pentagon are injured in an incident, 
which we had about 15 of them, the local hospital that we used 
that day would not be there. So, I mean, this is a pretty 
serious, serious situation.
    Mr. Tierney. I agree.
    Mr. Shays. We want to get to our next panel, but I would 
like to just visualize, if someone wants to run through a 
scenario. I want to pick--let's pick a city that--Dr. Johnson, 
you are based where?
    Dr. Johnson. I'm based in Lansing, MI, the capital city.
    Mr. Shays. OK. How many hospitals are there?
    Dr. Johnson. We have four hospitals in the city.
    Mr. Shays. And the population?
    Dr. Johnson. Population, several hundred thousand. It sort 
of depends on which communities you include in that.
    Mr. Shays. OK. So it is around 200,000, give or take?
    Dr. Johnson. In the cities.
    Mr. Shays. Give me a biological event. This is East 
Lansing?
    Dr. Johnson. This is Lansing.
    Mr. Shays. Lansing. In Lansing, give me a biological event 
that could happen.
    Dr. O'Toole. OK. Terrorist releases anthrax at a football 
game. How many people----
    Mr. Shays. And Michigan State is right next door, right?
    Dr. Johnson. Michigan State is in East Lansing. Right. 
There would be 75,000 people at the football game.
    Mr. Shays. And how far away is that?
    Dr. Johnson. They're contiguous.
    Mr. Shays. OK. Can we do it at the football game?
    Dr. O'Toole. We're at the football game. People, presumably 
from all over the State, and, indeed, maybe from all over the 
country, are at this game.
    Mr. Shays. Yes.
    Dr. O'Toole. Some time between 24 and 48 hours later, 
people start getting sick. Within a period of time, depending 
upon the astuteness of the clinicians in the emergency 
department, doctors start noticing that they have previously 
healthy people coming in with cough, fever, in large numbers. 
They send them home thinking it is some kind of common viral 
illness.
    Twenty-four hours later they come back and they are dying. 
They are very desperately ill. No one knows why.
    Dr. Johnson. I'll just interrupt to say that this won't be 
in East Lansing, necessarily, or in Lansing.
    Dr. O'Toole. Right. This will be all over the area.
    Dr. Johnson. Right.
    Mr. Shays. And some who might have flown back to St. Louis 
or something.
    Dr. O'Toole. Absolutely.
    Mr. Shays. It wouldn't be a high incidence there, so they 
wouldn't maybe pick that up.
    Dr. O'Toole. No.
    Mr. Shays. But in this case, I don't want to say ``at 
least,'' it is not contagious, correct?
    Dr. O'Toole. Correct.
    Mr. Shays. In this circumstance.
    Dr. O'Toole. Correct. Depending upon the astuteness of the 
clinicians and what the informal mechanisms doctors in 
different hospitals have for talking to each other, and how 
connected the medical community is to the public health 
community, eventually--probably pretty quickly, within a matter 
of hours, I would think, doctors are going to realize that 
something very unusual was going on. At that point, at the very 
latest, the public health agencies will be contacted.
    Mr. Shays. How does that happen?
    Dr. O'Toole. Well, that's a good question. It mostly 
doesn't happen. There has been a tremendous disconnect between 
the medical community and the public health community over the 
past decade, for all kinds of reasons, including the diminution 
in resources available to the public health agencies.
    Hopefully, somebody will think to call the public health 
people at the State or local level, but it is unlikely that 
they are going to call and say, ``Listen, I think I have 
anthrax,'' which in most States is a reportable disease. They 
are going to say, ``There's something strange going on here. 
Can you help me? Have there been any other cases around town 
that look like this?''
    Mr. Shays. Describe for me how many people in your hospital 
beds--you have 40, probably have 800 hospital beds in your 
community or----
    Dr. Johnson. Probably a touch more than that, but that's 
the right number.
    Mr. Shays. And two-thirds of them would be full?
    Dr. Johnson. At any given time in the middle of flu season 
and----
    Mr. Shays. Football season?
    Dr. Johnson. Football season.
    Mr. Shays. OK. So now how many would probably be knocking 
on the door of that hospital?
    Dr. Johnson. Well, I suppose it would depend. To carry out 
this scenario, it would depend on the efficiency with which the 
organism was dispersed at the football game. You could 
potentially have hundreds to thousands of people.
    Mr. Shays. Let's just stay there are six entrances and the 
terrorists cover two entranceways or two exits, so let's just 
say one-third of the people really were exposed.
    Dr. O'Toole. First of all, it is important to----
    Mr. Shays. Let's just say 20,000.
    Dr. O'Toole. Let's say only 10 percent of them are in East 
Lansing getting sick on this given day. It is important to 
realize that there hasn't been a mass disaster involving a lot 
of sick people, as opposed to a sudden accumulation of dead 
bodies, in American history in recent times. How a hospital 
would respond even to 200 sudden very sick people is an open 
question, I think, in most communities.
    Also, at that point you're not----
    Mr. Shays. A hospital to respond to 2,000 would be----
    Dr. O'Toole. It would be overwhelming.
    Mr. Shays. Chief?
    Mr. Plaugher. They'd shut their doors.
    Mr. Shays. They would shut their doors?
    Dr. O'Toole. Absolutely. Security would become a major 
problem.
    At that point, the public health community will come into 
the picture. In the recent outbreak of St. Louis encephalitis 
in New York, for example, it was an astute clinician who 
realized she was seeing two cases of something unusual, called 
Marcy Layton in the New York City Health Department. Dr. Layton 
and her colleagues came down, talked to the patients and their 
families to find out if there was any commonality between these 
patients. Somewhere in the course of taking the history of the 
patients and the public health investigation, it would probably 
be determined that everybody who is sick was at the football 
game, so now we know something happened at the football game.
    Mr. Shays. And, to continue that story, the dead crow in 
Greenwich, someone noticed it and wondered why and gave it to 
the examiner, and they found encephalitis there, but that's--
someone might not have taken that route.
    Dr. O'Toole. That's right. So some of this is 
circumstantial, it is happenstance, and it is going to vary 
from situation to situation. But that points out why awareness 
among many different kinds of professionals is so critical.
    At that point, the ability of the public health department 
to come in and do rapid and accurate epidemiological analyses 
ask what was the common feature that unites all of this? OK. 
Now you've got to get that it was the football game where you 
think something happened. Maybe you've even diagnosed anthrax 
by now.
    What you have to do now is muster a massive logistic 
campaign, get everybody who was at that stadium antibiotics. 
Once you are actually ill from anthrax and manifesting 
symptoms, it is too late for medicine to save you, so you've 
got to go out and find all 70,000 people, now spread probably 
all over the world, and get them antibiotics without causing a 
mass panic.
    Mr. Shays. Let me just kind of rob this question but ask 
you this. Would anthrax with some be like that and with others 
it could be a week or two?
    Dr. O'Toole. Yes.
    Mr. Shays. OK.
    Dr. O'Toole. What happens is you inhale the spores of 
anthrax into your lungs. They then travel to the lymph nodes in 
the middle of your chest, where they germinate, and that's when 
they start causing symptoms.
    Mr. Shays. That's how they germinate differently in others?
    Dr. O'Toole. For different time periods, for reasons we do 
not understand.
    In the Russian outbreak of anthrax in 1979, which was 
caused by an accidental release of anthrax from one of their 
military facilities, people became symptomatic anywhere from 24 
hours to about 40 days afterward.
    Mr. Shays. You may have already had 300 deaths.
    Dr. O'Toole. Absolutely.
    Mr. Shays. I'm prepared to go to the next panel. I mean, we 
could keep you here a long time.
    Let me just give each of you the last word.
    Dr. Johnson.
    Dr. Johnson. I appreciate the opportunity to go through a 
brief scenario like this. I think that highlights the 
challenges that we face, and the support we are all going to 
need from medical care providers all the way through local and 
State health departments to not only detect but to handle 
situations like this. We look forward to working with you on 
that.
    Mr. Shays. Thank you.
    Mr. Plaugher. Operation of a medical emergency disaster 
system, which we call ``MEDS'' is absolutely critical for our 
Nation. We have serious needs across the board for health care, 
and I think that we need to just simply try to figure out an 
approach that makes sense that will make it a consistent 
funding source and a consistent approach so that it is uniform, 
so that as you visit and relax and enjoy your vacation some 
place, you can rest assured that the community is there to 
support you and your family's needs, not based upon how good a 
State does or does not approach this concern.
    Dr. Waeckerle. Thank you for the opportunity to be here. 
There are a number of challenges which we have identified 
today, and it is a multifaceted approach by multidisciplinary 
personnel.
    The only thing I might add to submit to you for your 
consideration is a current issue of the ``Journal'' which I 
serve has devoted the whole content to this area.
    While I know I can't submit for the record a whole issue of 
the ``Journal,'' there are manuscripts written by----
    Mr. Shays. We'll submit it for the record.
    Dr. Waeckerle. Thank you.
    Then the whole issue of the ``Journal'' is available to you 
for your information and perusal.
    Dr. O'Toole. Well, I would just reemphasize the need to get 
the medical community and hospital leadership in the game, 
involved in response preparedness, and also accentuate the 
critical importance of cooperation and collaboration and the 
need for resources to make that happen and, finally, just thank 
you for your attention.
    Mr. Shays. Well, thank you all. We appreciate your being 
here.
    Our final panel is comprised of Dr. Robert Knouss, 
Director, Office of Emergency Preparedness, U.S. Department of 
Health and Human Services; and Dr. Scott L. Lillibridge, 
Director, Bioterrorist Preparedness Response Program, National 
Center for Infectious Disease, Center for Disease Control, 
Department of Health and Human Services.
    Again, I want to say that I appreciate much that our 
Federal officials, who traditionally go first, were willing to 
go second. I think both doctors realize that it will help us 
better understand your testimony. So it is appreciated and it 
is also very beneficial to the committee.
    I will ask you to stand so I can swear you in, as we do all 
our witnesses.
    [Witnesses sworn.]
    Mr. Shays. Dr. Knouss, we'll have you start, and, again, 
thank you for your patience.

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

    Dr. Knouss. Thank you very much, Mr. Chairman. I really 
want to commend you for holding these hearings. These are some 
very important subjects, and obviously, in terms of 
preparedness of our country, we are just now beginning, and 
there is a substantial road ahead of us as we try to address 
the issues that you are already highlighting this morning.
    I am Robert Knouss. I direct the Office of Emergency 
Preparedness. I'm going to try to summarize some of the things 
that I have provided in my testimony, and I want to provide a 
little bit of background.
    Presidential Decision Directives 39 and 62 have given the 
Federal Bureau of Investigation the lead in crisis management 
and the Federal Emergency Management Agency the lead for 
consequence management in the event of the release of a weapon 
of mass destruction.
    The Department of Health and Human Services is the lead for 
health and medical preparedness as one aspect of consequence 
management, and an annex to FEMA's Federal response plan 
describes the role of HHS and other departments and agencies of 
the Federal Government in responding to the threat or the 
actual release of one of these horrific weapons.
    I would like to go to some of our approaches at the present 
time to preparing our country for being able to address the 
challenges of the release of one of these weapons, and I want 
to mention that a fundamental truth in emergency preparedness 
and response is that all disasters are local. This was 
emphasized on several occasions by the previous panel.
    As a result, our approaches for preparedness and response 
have to be part of the developing local and State response 
resources, while assuring that the Federal response 
capabilities are able to support their efforts.
    The detonation of a large bomb or the release of a chemical 
agent will have very serious obvious but localized effects. 
They can produce mass casualties with severe medical 
consequences with high mortality rates.
    Health care, to be effective, must be rapid and 
appropriate. In other words, there would be an immediate 
medical, public health, and environmental emergency. Immediate 
response would be directed at saving lives and reducing the 
longer-term health consequences.
    Biological weapons, on the other hand, require a different 
type of response than that required by chemical weapons, 
particularly if the agent is covertly released.
    Victims may only recognize the need to seek care days after 
their exposure to the biological agent, as was being discussed 
in the example that you used of the release of anthrax at a 
football game in East Lansing.
    There would be no readily identifiable incidents and the 
medical and public health communities could be challenged with 
overwhelming demands for curative and preventive treatment to 
the affected population.
    Determining what the agent is, who may have been exposed, 
and when, and whether or not the agent is transmissible from 
person to person becomes a local challenge with national impact 
particularly if the agent is contagious.
    And, with your permission, Mr. Chairman, I would like to 
just use an illustration. I included this chart in the 
testimony that I presented to you. I don't know what the chart 
number is. I believe it is chart No. 6 in my testimony.
    Basically, it is helpful to try to illustrate the 
differences between a chemical and biological weapon, because 
frequently in our responses and in our response planning we 
tend to lump these all together as a single kind of response to 
a terrorist act.
    The release of a chemical agent will precipitate a very 
rapid requirement on our first responder community, as Chief 
Plaugher was indicating. Therefore, for chemical weapons in the 
initial stages of the response, mainly the public safety and 
fire response communities will be involved for the detection 
and extraction of victims, for administration of an antidote, 
for decontamination of victims at the site, for triage of their 
medical problems, for provision of primary care at the scene, 
and for safe transportation to definitive care facilities.
    On the other hand, the initial response, when we're dealing 
with a biological agent, is going to fall--the burden is going 
to fall--on the public health community. So now we have public 
safety and public health communities at the local level that 
are involved.
    On the right-hand side of the chart, I have indicated are 
really some of the initial challenges to the public health 
community, because of the need to be able to detect that an 
incident has occurred, if there is a silent release. Much of 
that can be done through surveillance systems that would be set 
up and, with the help of enhanced laboratory capability, the 
causative agent identified.
    Then, as part of our response, must be able to offer 
preventive health services or prophylaxis in the form of 
vaccinations or antibiotics for protecting the population that 
may have been exposed but has not yet become ill.
    Both of these kinds of weapons would create an enormous 
demand on the health care system.
    Mr. Shays. Let us just ask a question here.
    Dr. Knouss. Sure.
    Mr. Shays. I love to see parallels. It really on the first, 
the chemical/biological, it is really detection identification 
would be true for both?
    Dr. Knouss. Yes.
    Mr. Shays. OK. So when I see detection on the right, I 
could say detection/identification. So those are two that are 
similar.
    The next thing is extraction of victims in chemical. That 
would be the next thing that would happen in chemical.
    Dr. Knouss. These aren't necessarily given in the sequence 
that they would be happening.
    Mr. Shays. The administration of antidote, that makes 
sense. Decontamination of victims, triage, provision of primary 
care. I guess----
    Dr. Knouss. And all of that would be happening at the 
scene.
    Mr. Shays. Eventually with biological you'd see some of the 
same. Ultimately, you'd have some provision of primary care.
    Dr. Knouss. You may or may not, because the incident scene 
is going to be very different. Mainly----
    Mr. Shays. I say eventually.
    Dr. Knouss. Eventually, yes.
    Mr. Shays. In other words, it's almost like I draw a line 
on the chemical and biological, and then I can start putting 
down some of what I see over chemical. I'm asking, I'm not 
telling.
    Dr. Knouss. They really aren't parallel situations, because 
in a chemical release these are going to be happening very 
rapidly.
    Mr. Shays. That's not the question. I'm just asking this. 
I'm asking if ultimately everything that happens--most 
everything that happens with chemical would happen with the 
biological, it just wouldn't happen as soon. Wouldn't you 
ultimately transport to a care facility in the biological?
    Dr. Knouss. Yes. Now, yes, that's essentially what I'm 
trying to illustrate at the bottom of this, that both of these 
events create an enormous demand on the health care delivery 
system, the hospital system.
    Mr. Shays. OK.
    Dr. Knouss. And so we really have three communities that 
are involved and the level of preparedness has to be enhanced--
the public safety and emergency medical services community, the 
public health community, and the health services delivery 
community.
    Mr. Shays. OK.
    Dr. Knouss. Frequently, what we forget even in a chemical 
incident is that there is going to be an enormous demand placed 
on the health care delivery system, and if events such as a 
mustard exposure occurred, the long-term consequences and the 
long-term impact on the health care delivery system is going to 
be felt for a year or years to come.
    Mr. Shays. Thank you.
    Dr. Knouss. Moving away from this particular illustration 
of the fact that we really have the need to be able to 
emphasize public safety, public health, and health services 
response capabilities, I want to just turn for a moment to our 
metropolitan medical response systems that were mentioned on 
several occasions by the first panel, and that is that in one 
of these events, the traditional roles and relationships of 
emergency organizations are going to be stressed, obviously.
    Mr. Shays. This is chart five?
    Dr. Knouss. This is chart No. 5. Correct.
    For an effective response, law enforcement and emergency 
management and fire, emergency medical services, hospitals, 
public health, mental health, environmental organizations, the 
military, National Guard, and others must be effectively linked 
to all levels of government.
    We have been trying to focus attention on increasing the 
capacity of local jurisdictions to initiate the response to the 
release of a weapons of mass destruction through the creation 
of metropolitan medical response systems. To date, we have 
entered into contracts with 47 metropolitan jurisdictions in 
the United States to help them plan their response to a 
chemical or a biological weapons release, to increase their 
pharmaceutical supplies, to equip their first response 
personnel, and to train their health care providers. We hope to 
be able to do this eventually in 120 large metropolitan areas 
around the United States. In fact, the President has included 
support for an additional 25 cities in his fiscal year 2000 
budget request.
    That gives you a kind of overview of just a few of the 
issues that we are trying to deal with.
    What I'd like to do in the remaining minute or two that I 
have is respond to your request that we try to identify areas 
requiring improvement or challenges.
    First, I truly believe that we need a greater commitment of 
participation of the health sector, particularly the hospital 
community. That need was illustrated in a variety of the 
comments that were made by the first panel.
    The health care systems in most cities are not centrally 
organized, they are not easily accessible for systems planning, 
they are generally unprepared for weapons of mass destruction 
events, and they lack incentives to prepare.
    Many local communities lack a single public official who 
has direct authority over hospital preparedness and response, 
as well as public health systems. This has made developing 
comprehensive systems in cities difficult.
    While first responder systems are receiving significant 
funding, there is little identified for WMD-related medical 
response, let alone hospital facility modifications, equipment, 
staff, training, and exercises.
    Mr. Shays. Why don't you take each of the ones you want to 
talk about, because I think you have, like, five of them, and 
then just ad lib on each of those.
    Dr. Knouss. OK. The second is that linking emergency 
response, public safety, mental health, public health, and 
health care systems will continue to be difficult and will 
require special attention if communities are to be effectively 
organized and prepared to respond to a WMD event.
    I say that for a variety of different reasons. Most of our 
communities have their first responder, their law enforcement 
and their fire/EMS organized in fairly similar ways under a 
public safety structure, even though there are variations 
between communities in that structure, as well. But frequently 
the health systems fall outside. Public health systems have 
very, different organizational structures throughout the United 
States.
    In some cases, States are responsible for local public 
health systems; in other States the local public health 
systems, as in the case of North Carolina, are largely as we've 
seen during these floods, is completely independent from State 
control.
    So with the public health structure we have highly variable 
organizational structures. In the first responder community it 
is a little bit different. And to bring them together at the 
city, metropolitan, or county level is, indeed, sometimes very 
challenging.
    Third, health care professionals require increased weapons 
of mass destruction-related knowledge, skills, and competence, 
including new credentialling and certificate measures.
    Dr. Waeckerle spoke to that issue. I would like to add a 
few more comments if the opportunity presents itself during our 
response.
    But suffice it to say that one of the keys that we think 
exists to being able to encourage health professionals to seek 
an education in the area of treatment of these kinds of 
exposures during a weapons of mass destruction release is to 
try to influence the content of their board certification and 
licensure examinations.
    By doing that, we are going to call more attention to the 
fact that self-education and continuing education, as well as 
curriculum development for their basic professional training 
and continuing education is a professional responsibility.
    We would take the same approach with our hospitals through 
accreditation standards that might be applied by the Joint 
Commission for Accreditation of Health Care Organizations.
    Building local weapons of mass destruction response systems 
through the continued support of metropolitan medical response 
systems is essential and, as I mentioned, we have made a budget 
request for continued development of these systems around the 
United States.
    Finally, I would just mention that we must pursue civilian 
research solutions to technical scientific gaps and problems 
related to weapons of mass destruction detection, prevention, 
and medical treatment. Just recently, through support that we 
have given to the National Academy of Science's Institute of 
Medicine, we have published a research agenda for the Nation 
for dealing with what technological developments are required 
through the coming years in order to be able to best ensure the 
ability of our civilian population to respond.
    Mr. Shays. That has a better cover than the magazine. 
[Laughter.]
    It looks sinister, at least.
    Dr. Knouss. That provides a terrific lead-in, but I think I 
won't spend my time on that. But I would like to leave these 
copies for the committee.
    As I sit here today, Mr. Chairman, in summary, I cannot 
tell you that the Nation is prepared to deal with the large-
scale medical effects of terrorism, but we are working very 
diligently to prepare local medical systems and public health 
infrastructures to enhance the national health and medical 
responses, to provide for a national pharmaceuticals stockpile, 
but I want to mention that there is no silver bullet.
    The issues are complex and cross-cutting between various 
cultures--I talk about that in terms of government cultures--
disciplines in the public and private sectors.
    The Department of Health and Human Services--I want to 
reiterate this--our Secretary is committed to assuring that 
communities across the country are prepared to respond to the 
health consequences of a weapons of mass destruction.
    Again, Mr. Chairman, I want to thank you for this 
opportunity to be here.
    Mr. Shays. Thank you very much.
    [The prepared statement of Dr. Knouss follows:]
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    Mr. Shays. You got me a little concerned when I asked you 
to ad lib, because actually the first one you took longer than 
if you had read it, so you did a nice job. Thank you.
    Dr. Lillibridge, thank you.

 STATEMENT OF SCOTT R. LILLIBRIDGE, M.D., NATIONAL CENTER FOR 
     INFECTIOUS DISEASES, CENTERS FOR DISEASE CONTROL AND 
      PREVENTION, DEPARTMENT OF HEALTH AND HUMAN SERVICES

    Dr. Lillibridge. Thank you, sir.
    I'm Dr. Scott Lillibridge from the Center for Disease 
Control and Prevention. I am the Director of the Bioterrorism 
Preparedness and Response Program.
    I'd like to thank you for the opportunity to be here to 
discuss enhancing national public health capacities to respond 
to bioterrorism and the opportunity to listen to the first 
panel's comments.
    I will describe the actions that CDC is taking as part of 
the DHHS effort to increase public health preparedness, enhance 
laboratory services, and expand disease surveillance to improve 
our Nation's response to this important issue.
    In the past, an attack with a biologic agent was considered 
very unlikely; however, now it seems entirely possible.
    It is CDC's responsibility to provide national leadership 
in the public health and medical communities in a concerted 
effort to detect, diagnose, respond to, and prevent illness, 
including those that occur as a result of bioterrorism or any 
other deliberate attempt on one of our citizens.
    In 1998, CDC issued, ``Preventing Emerging Infectious 
Diseases--'' with a special cover--``A Strategy for the 21st 
Century,'' which describes CDC's plan for combatting today's 
emerging diseases and preventing those of tomorrow.
    The plan also emphasizes the need to be prepared for the 
unexpected, whether it be a naturally occurring event such as a 
worldwide influenza epidemic, or the deliberate release of 
anthrax by a terrorist.
    Increased vigilance and preparedness for unexplained and 
unexpected illnesses are an essential part of the public health 
effort to protect the American people against bioterrorism.
    To this end, as part of CDC's overall bioterrorism plan, we 
are providing approximately $40 million, through cooperative 
agreements with States and large metropolitan health 
departments, to enhance preparedness and response to such an 
attack.
    Because the initial detection of bioterrorism will most 
likely occur at the local level after a period when patients 
have incubated the disease, it is essential to educate and 
train members of the medical community who may be the first to 
examine and treat these victims.
    CDC will promote the development of new disease 
surveillance networks, which will better link critical care 
facilities, components of the emergency medical system, to 
public health agencies and authorities.
    In response to bioterrorism related outbreak, the most 
likely scenario will be that CDC, the Department of Defense, 
Department of Justice, and security agencies will be alerted to 
the event only after State or local health officers, medical 
practitioners, or other workers in the health sector of 
identified a cluster of cases or diseases that are highly 
unusual and potentially unexplained.
    For this reason, CDC will work to provide State and large 
metropolitan health departments with training, tools, financial 
resources for outbreak control and investigations.
    To ensure the ready availability of drugs, vaccines, 
prophylactic medicines, and chemical antidotes and equipment 
that might be needed in a medical response to a biological or 
chemical terrorist incident, CDC is working to establish a 
national pharmaceutical stockpile to be utilized when necessary 
and appropriate to contain the spread of disease in such an 
outbreak.
    In the event of a biological or chemical terrorist attack, 
rapid diagnosis will be critical so that prevention and 
treatment measures can be implemented rapidly.
    CDC is providing assistance to State and major metropolitan 
health departments to improve capacity to diagnose these 
agents. CDC is also working with public health partners, such 
as the Association of Public Health Laboratories, to implement 
a network of laboratories to provide for most immediate and 
local diagnosis in the event of a suspected bioterrorism 
attack.
    In order to assure the most effective response to a 
bioterrorism event, CDC coordinates and communicates closely 
with the Department of Justice, FBI, NDPO, and many others in 
the Federal infrastructure, such as HHS, OAP, FDA, NIH, and 
FEMA, and many other partners in this response effort.
    Strengthening communication among clinicians, emergency 
rooms, infection control practitioners, hospitals, 
pharmaceutical companies, and public health personnel is of 
paramount importance. The health alert network component of the 
CDC, State and local preparedness initiative will provide 
national electronic communications from public health officials 
working to detect and respond to bioterrorism and other 
unexplained health threats.
    CDC is working to ensure that all levels of the public 
health community are prepared to work in coordination with 
medical and emergency response communities to address these 
important threats.
    In conclusion, the best public health method to protect our 
citizens against the adverse health effects of terrorism is the 
development, organization, and enhancement of life-saving 
public health tools. Expanded laboratory, surveillance, 
outbreak response, health communications, and training, and 
public health preparedness resources at the State and local 
level are necessary to ensure that we can respond when the 
alarm is sounded.
    Thank you very much for your attention. I will be happy to 
answer any questions you may have and am delighted to have this 
opportunity to speak. Thank you.
    Mr. Shays. Thank you very much.
    [The prepared statement of Dr. Lillibridge follows:]
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    Mr. Shays. Mr. Tierney.
    Mr. Tierney. Thank you, and thank both of you for your 
testimony.
    I just want to revisit an area that we left off after the 
last panel, and that is the access and availability of hospital 
space, emergency rooms.
    Dr. Knouss, I'm sorry I had to step out for 1 second. You 
may have covered this. Can you talk a little bit about what is 
being done at the national level to encourage the appropriate 
amount of planning for emergency and hospital bed space and 
where do we go from here on that?
    Dr. Knouss. That is a very broad question and a very 
difficult problem to address currently. What was being 
described is is that much of our bed capacity is already taken 
in the country and we don't have the excess, immediately 
expandable, capacity that we used to have in the system.
    In addition, many hospitals have not seen the need to 
invest in being able to be prepared for one of these events. 
There are a variety of different reasons for that, including 
the relative increase in the level of surpluses that are 
available to health care institutions and an assessment that is 
being made, frankly, by many hospital administrators that this 
is a very low probability event in their community; therefore, 
the justification for spending large amounts of money in 
preparation is really not warranted.
    The way we are trying to deal with some of these issues is 
first, through the education of the health professionals, 
because, as they become knowledgeable about what the potential 
impact of one of these events might be, they obviously are 
going to have an influence on how that hospital administrator 
is going to respond to the need to prepare.
    Second, we're looking at trying to deal with accreditation 
requirements, the standards that are going to be applied by the 
Joint Commission on Accreditation of Health Care Organizations, 
to be able to make some engineering recommendations as to how 
hospitals can best address the need to be able to protect 
themselves and, at the same time, provide access to their 
facilities during one of these events.
    But, third, we are trying to fortify, strengthen the 
National Disaster Medical System, which was designed 
essentially during the mid-1980's as part of the contingent 
military hospital system to deal with large-scale casualties 
overseas. If casualties had to be brought back to the United 
States in large numbers for health care here, we would have to 
be able to expand the capability and distribute part of that 
health care burden as a shared responsibility of the entire 
private hospital system in the United States.
    This system was later expanded to include the concept of 
what do we do if we have a large California earthquake with 
100,000 casualties.
    Essentially, it is a system designed to provide for primary 
care at the scene of an incident, transportation of mass 
casualties to distant hospitals, and then provide health care 
in 100,000 hospital beds in a system of over 2,000 volunteer 
hospitals around the United States managed both by DOD, Federal 
coordinating centers, and those of the Department of Veterans' 
Affairs. In this system, we are able to transport victims for 
those hospital care and essentially provide access to a far 
greater number of hospital beds, if necessary.
    Now, that kind of system will function if the incident is 
concentrated in one geographic area. Obviously, if we're faced 
with something that affects the entire country at the same 
time, all of our resources are going to be pressed, and the 
only alternative that we would have under those circumstances 
is temporary expansion of local hospital capabilities.
    Mr. Shays. Mr. Allen.
    Mr. Allen. Thank you both for being here.
    I want to talk a little bit about anthrax. Two sorts of 
questions. One--let me ask them both, and then you can deal 
with them in turn.
    Is it possible to say with any degree of certainty that 
there are a limited number of biological agents that would be 
likely to be used in any incident of terrorism?
    If you think about kind of the agent, the way it reacts, 
its availability, its cost, you know, as a practical matter--I 
know there must be hundreds or thousands that are potential, 
but, as a practical matter, are there a few that we should be 
concentrating on?
    The related question is that I understand that in the 
Health and Human Service's operating plan for anti-bioterrorism 
there are descriptions of additional funding set aside for 
research into new vaccines, particularly a new anthrax vaccine. 
Obviously, this committee has been interested in that whole 
issue, and the chairman has held hearings on the Department of 
Defense anthrax vaccine.
    Can you talk to us about what future research is planned 
and, in particular, whether we need to develop all sorts of 
vaccines for a variety of agents or even all sorts of vaccines 
for the different strains of anthrax that could be developed?
    Maybe one at a time start with that issue, to the extent 
you can. I'd appreciate it.
    Dr. Lillibridge. Sure. I'd be glad to.
    I think your question raises the issue of priority, which 
agents offer the most opportunities for preparedness or where 
do we have the most vulnerabilities.
    CDC looked at this issue about 3 months ago as we began to 
engage in earnest in this area, and came to the conclusion that 
there were certain biologic agents for which there were 
tremendous vulnerabilities in the public health community in 
terms of hospital preparedness, antidotes, stockpile, 
preparedness, surveillance, and a whole host of activities.
    These biological agents were smallpox, anthrax, plague, 
botulinumtoxin, tulauemia, and the agents of viral hemorrhagic 
fever.
    After looking at the public health impact of a release of 
these agents, caucusing with the appropriate intelligence 
agencies, law enforcement agencies, Department of Defense, 
disease experts, and set about engaging to hone our 
preparedness effort toward getting the antidotes, strategies, 
and programs in place to address we came to the conclusion that 
these agents that would have catastrophic impact were they to 
be released.
    Mr. Allen. Can I just interrupt you and ask a quick 
followup? Why smallpox? I would think, No. 1, it would be hard 
to produce, and I also assume that everyone over 15, or 
whatever it is, has been vaccinated in this country. But maybe 
I'm wrong.
    Female Voice. Not true.
    Mr. Allen. Not true? Then that's part of the answer.
    Dr. Lillibridge. Routine vaccinations for smallpox stopped 
about two decades ago or more.
    Mr. Allen. That long?
    Mr. Shays. You forgot how long ago you were in school. 
[Laughter.]
    Mr. Allen. It was more than two decades ago. [Laughter.]
    Dr. Lillibridge. And, simply put, smallpox exploits unique 
vulnerabilities, one, because it has been eradicated. We have 
no great degree of immunity in the population. We have limited 
response capacities. Third, it is contagious by respiratory 
route, so it can move from person to person without the help of 
terrorists.
    Mr. Allen. Do you want to comment on the need for 
additional research for anthrax?
    Dr. Lillibridge. Let me mention a few things.
    The Department has looked into that issue and CDC is 
looking at recommendations on the use of the anthrax vaccine. 
We have partnered with the Advisory Committee on Immunization 
Practice [ACIP], the organization that sets the gold standard 
for immunization practice for the United States, to begin to 
look at this issue in earnest.
    We have research needs; and, issues related to indications 
in civilian populations for prophylaxis and the use of first 
responders.
    CDC information from this activity to be forthcoming in the 
next 2 to 4 months as ACIP begin to look at research that has 
been unpublished in the past, review the literature, and 
convenes groups of experts in that area.
    Mr. Allen. One quick followup. Is there any effort to look 
at the DOD vaccination program that is underway now and use 
whatever information? I realize it has been questioned, the 
information about side effects or reactions, I should say. Is 
there any effort to look at that big pool of people that is now 
being vaccinated?
    Dr. Lillibridge. That's a good question, and every effort 
is going to be made to look at their research and experience in 
that area as part of this effort.
    Dr. Knouss. I'd just like to add another perspective on 
anthrax vaccine, because we tried to address that issue as we 
were looking at the research agenda, and anthrax is one of the 
two vaccines that we would like to invest some more money in 
further development.
    The difficulty with the current vaccine when we're talking 
about the civilian population, or even parts of the civilian 
population is that the current vaccine requires six doses for 
primary immunization and then annual boosters.
    What would be very helpful at this point is to have a 
vaccine that only requires one or two doses to establish 
primary immunity and, like smallpox, vaccination schedules 
would only require revaccination on a very long-term basis in 
order to maintain immunity.
    So really what we are talking about, if it were deemed at 
some point that we do need to have a wider availability of that 
vaccine and a higher level of immunization within the 
population, is a vaccine that is a far more patient-friendly 
than the one we have now.
    Mr. Allen. Nothing more.
    Mr. Shays. I'm going to just ask a few questions, and I 
don't think they require a lot of response, but preface it by 
saying I was an intern in Washington in 1968 when really the 
first plane was hijacked to Cuba, and then you had a rash of 
planes hijacked for about 10 years, and we don't see it 
happening now. Admittedly, security improved, but still we 
still see pilots leave their doors open sometimes when they fly 
and it doesn't happen.
    The concern, I would think, is not only that--once you had 
a terrorist attack, it might just open the door, just like 
these shootings in schools. All the sudden you start seeing 
crazy people do crazy things.
    So what most feel, that I speak with in government and 
outside, that it is not a matter of would a terrorist attack 
happen, it is kind of when and where, and so it is so important 
that we are talking about these issues.
    In terms of hospital beds, I want to define what is--can we 
have--when you go to a hospital, the reason why hospital beds 
are expensive is all the support staff. It's not the room. In 
fact, I have a hospital that has a whole floor and they have 
rooms, but they don't have hospital beds.
    But in this kind of circumstance, could we actually 
warehouse rooms, beds, shut them off, wall them off, and then 
bring in support staff from around the country? Would that meet 
the hospital bed requirement?
    Dr. Knouss. That is certainly one of the possibilities for 
some communities where that kind of excess physical capacity 
exists but personnel are not available to operate it.
    Mr. Shays. Is anyone suggesting that we literally have a 
whole hospital floor with nurses and so on who will never be 
called on until there is a disease?
    Dr. Knouss. No. No one is suggesting that. But cities are 
looking, including New York City at what kind of alternate 
treatment facilities could be established as extensions of the 
capacity of its public hospital system that could be accessed 
through the existing public hospital system in adjacent 
facilities, that could be readily converted and staffed in the 
event that patient care requirements increased dramatically and 
very rapidly.
    The approach we are taking at the present time, Mr. 
Chairman, is asking each community to try to look at the health 
care alternatives that it has available, because the solution 
for one community may not be the ideal solution for another 
community.
    Mr. Shays. These are very important to ask. I'm just trying 
to really visualize what we mean by emergency hospital bed and 
what would be required to have that.
    Veterans facilities, we need to--I mean, they're where we 
don't need them in some cases and not where we need them in the 
populous, but I have a sense that, because these are government 
facilities, we'd have a little more opportunity here to 
basically stockpile pharmaceutical products, maybe stockpile 
unused bed space.
    Dr. Knouss. Well, the issue of stockpiling unused bed space 
has not come up in any of the conversations that I have 
participated in, but it is an interesting concept, and I think 
it is necessary to take a look at that as we're looking at the 
total scope of the possibilities for expansion of our 
capability.
    Mr. Shays. Is transportation--in this day and age, we can 
transport sick people and still provide them with care in 
transit. Is that accurate?
    Dr. Knouss. Well, the second idea that we've had about 
addressing that requirement--and we talked to the city of New 
York about this--is actually moving out the chronically ill 
patients so that the acutely ill patients from one of these 
incidents might be able to be put in one of those beds near the 
scene. The people that have more stable conditions could be the 
ones transported out of the----
    Mr. Shays. Do we need laws to require that that happen to 
protect hospitals?
    Dr. Knouss. Without asking that question specifically of 
our lawyers, I don't know. I wouldn't want to answer the 
question. I think it is one of the legal issues that we have to 
look at across the board, and there are a whole variety of 
them, including quarantine laws.
    Mr. Shays. When I'm sometimes bored when I'm running I 
think of absurd circumstances, like literally an embassy that, 
over the course of 5 years, they could build a bomb and 
construct a bomb and wonder what are the legal requirements, if 
you were a law enforcement officer, if you would have the 
right, under extreme circumstances, to enter a building without 
having a search warrant and so on if you had to, in event of 
catastrophe.
    I guess my point triggered into that point is, Are we 
starting to think of what kind of laws we need now to 
anticipate events that could potentially be catastrophic?
    Dr. Knouss. Yes, we are. In fact, there is a whole subgroup 
of one of the National Security Council committees that is 
looking specifically at that issue of legal authorities.
    Mr. Shays. I'm all set to conclude, Dr. Lillibridge, but 
would you just have any comments that you would make on the 
questions I asked, or is it kind of out of your area?
    Dr. Lillibridge. Thank you. Just a few comments.
    On the issue of bed utilization, there are two things that 
come up time and time again that we've heard from Dr. Johnson 
and Dr. O'Toole about the need for local preparedness planning 
to get considerations of the health people into the disaster 
management planning so that there are plans for utilization of 
this space and for the rapid development rapidly of additional 
places that maybe don't require hospital level of care. It 
could be hotels, makeshift areas, gymnasiums for patients who 
didn't require the full range of system care.
    That won't happen without preparedness planning on 
bioterrorism at the local level.
    Mr. Shays. Thank you.
    Do you have any final comments you'd like to make?
    Dr. Knouss. My only observation, Mr. Chairman, is that this 
is an enormously challenging area. It requires a level of 
coordination to develop our response capabilities that is 
heretofore unknown, really, at least in my experience, and I 
think almost in anyone else's that one talks to.
    We have a long way to go yet, and I appreciate very much 
this opportunity to be able to share our thoughts.
    Thank you.
    Mr. Shays. Thank you very much.
    Dr. Lillibridge. Thank you, Mr. Chairman.
    Just a few closing remarks.
    This month is the first month of the initiation of the CDC 
grants program to work with States on a cooperative basis. At 
the end of this month we will have 50 States enrolled in a 
preparedness program that will include one of the key areas or 
all five of the key areas that we envision, being preparedness, 
labs, surveillance, health alert network, and that this effort 
will need to be sustained over a period of time as we begin in 
earnest to ensure preparedness at a national level.
    Thank you.
    Mr. Shays. Thank you very much.
    I notice that Massachusetts shows up a lot, and Connecticut 
does. That's something that's----
    Dr. Lillibridge. Must be a typo. [Laughter.]
    Mr. Shays. With that, I'd like to adjourn. Thank you very 
much.
    Dr. Lillibridge. Thank you, sir.
    [Whereupon, at 12:20 p.m., the subcommittee was adjourned, 
to reconvene at the call of the Chair.]
    [Additional information submitted for the hearing record 
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