[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
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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
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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.]
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