[House Hearing, 107 Congress]
[From the U.S. Government Publishing Office]



 
 A REVIEW OF FEDERAL BIOTERRORISM PREPAREDNESS PROGRAMS FROM A PUBLIC 
                           HEALTH PERSPECTIVE
=======================================================================

                                HEARING

                               before the

                            SUBCOMMITTEE ON
                      OVERSIGHT AND INVESTIGATIONS

                                 of the

                    COMMITTEE ON ENERGY AND COMMERCE
                        HOUSE OF REPRESENTATIVES

                      ONE HUNDRED SEVENTH CONGRESS

                             FIRST SESSION

                               __________

                            OCTOBER 10, 2001
                               __________

                           Serial No. 107-70
                               __________

       Printed for the use of the Committee on Energy and Commerce










 Available via the World Wide Web: http://www.access.gpo.gov/congress/
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                        U.S. GOVERNMENT PRINTING OFFICE
                                WASHINGTON : 2002
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                    COMMITTEE ON ENERGY AND COMMERCE

               W.J. ``BILLY'' TAUZIN, Louisiana, Chairman

MICHAEL BILIRAKIS, Florida                  JOHN D. DINGELL, Michigan
JOE BARTON, Texas                           HENRY A. WAXMAN, California
FRED UPTON, Michigan                        EDWARD J. MARKEY, Massachusetts
CLIFF STEARNS, Florida                      RALPH M. HALL, Texas
PAUL E. GILLMOR, Ohio                       RICK BOUCHER, Virginia
JAMES C. GREENWOOD, Pennsylvania            EDOLPHUS TOWNS, New York
CHRISTOPHER COX, California                 FRANK PALLONE, Jr., New Jersey
NATHAN DEAL, Georgia                        SHERROD BROWN, Ohio
STEVE LARGENT, Oklahoma                     BART GORDON, Tennessee
RICHARD BURR, North Carolina                PETER DEUTSCH, Florida
ED WHITFIELD, Kentucky                      BOBBY L. RUSH, Illinois
GREG GANSKE, Iowa                           ANNA G. ESHOO, California
CHARLIE NORWOOD, Georgia                    BART STUPAK, Michigan
BARBARA CUBIN, Wyoming                      ELIOT L. ENGEL, New York
JOHN SHIMKUS, Illinois                      TOM SAWYER, Ohio
HEATHER WILSON, New Mexico                  ALBERT R. WYNN, Maryland
JOHN B. SHADEGG, Arizona                    GENE GREEN, Texas
CHARLES ``CHIP'' PICKERING, Mississippi     KAREN McCARTHY, Missouri
VITO FOSSELLA, New York                     TED STRICKLAND, Ohio
ROY BLUNT, Missouri                         DIANA DeGETTE, Colorado
TOM DAVIS, Virginia                         THOMAS M. BARRETT, Wisconsin
ED BRYANT, Tennessee                        BILL LUTHER, Minnesota
ROBERT L. EHRLICH, Jr., Maryland            LOIS CAPPS, California
STEVE BUYER, Indiana                        MICHAEL F. DOYLE, Pennsylvania
GEORGE RADANOVICH, California               CHRISTOPHER JOHN, Louisiana
CHARLES F. BASS, New Hampshire              JANE HARMAN, California
JOSEPH R. PITTS, Pennsylvania 
MARY BONO, California 
GREG WALDEN, Oregon 
LEE TERRY, Nebraska 

                  David V. Marventano, Staff Director
                   James D. Barnette, General Counsel
      Reid P.F. Stuntz, Minority Staff Director and Chief Counsel
                                 ______

              Subcommittee on Oversight and Investigations

               JAMES C. GREENWOOD, Pennsylvania, Chairman

MICHAEL BILIRAKIS, Florida           PETER DEUTSCH, Florida
CLIFF STEARNS, Florida               BART STUPAK, Michigan
PAUL E. GILLMOR, Ohio                TED STRICKLAND, Ohio
STEVE LARGENT, Oklahoma              DIANA DeGETTE, Colorado
RICHARD BURR, North Carolina         CHRISTOPHER JOHN, Louisiana
ED WHITFIELD, Kentucky               BOBBY L. RUSH, Illinois
  Vice Chairman                      JOHN D. DINGELL, Michigan,
CHARLES F. BASS, New Hampshire         (Ex Officio)
W.J. ``BILLY'' TAUZIN, Louisiana
  (Ex Officio)

                                  (ii)













                            C O N T E N T S

                               __________
                                                                   Page

Testimony of:
    Baughman, Bruce P., Director, Planning and Readiness 
      Division, Federal Emergency Management Agency..............    88
    Brinsfield, Kathryn, Director of Research, Training, and 
      Quality Improvement, Boston Emergency Medical Services and 
      Deputy Medical Commander, National Disaster Medical 
      System's International Medical and Surgical Response Team-
      East.......................................................    34
    Heinrich, Janet, Director, Health Care--Public Health Issues, 
      U.S. General Accounting Office.............................    93
    Lillibridge, Scott R., Special Assistant to the Secretary on 
      Bioterrorism Issues and for National Security and Emergency 
      Management, U.S. Department of Health and Human Services...    83
    O'Leary, Dennis, President, Joint Commission on Accreditation 
      of Healthcare Organizations................................    47
    Peterson, Ronald R., President, Johns Hopkins Hospital, on 
      behalf of the American Hospital Association................    42
    Smithson, Amy E., Director, Chemical and Biological Weapons 
      Nonproliferation Project, Henry L. Stimson Center..........    17
    Stringer, Llewellyn W., Jr., Medical Director, North Carolina 
      Division of Emergency Management...........................    38
    Waeckerle, Joseph F., Chairman, Task Force of Health Care and 
      Emergency Services Professionals on Preparedness for 
      Nuclear, Biological and Chemical Incidents, on behalf of 
      the American College of Emergency Physicians...............    26
    Young, Frank E., former Head, Office of Emergency 
      Preparedness, U.S. Department of Health and Human Services.    53
Material submitted for the record by:
    Ataxia: The Chemical and Biological Terrorism Threat and the 
      US Response, report by Amy E. Smithson and Leslie-Anne Levy   164
    Bioterrorism: An Even More Devastating Threat, The Washington 
      Post, September 17, 2001...................................   191
    Commissioned Officers Association of the U.S. Public Health 
      Service, prepared statement of.............................   192
    Daniels, Deborah J., Assistant Attorney General, Office of 
      Justice Programs, Department of Justice, prepared statement 
      of.........................................................   103
    Hospital Preparedness for Mass Casualties, report entitled...   107
    Hospital Preparedness for Victims of Chemical or Biological 
      Terrorism, report entitled.................................   185

                                 (iii)

  








 A REVIEW OF FEDERAL BIOTERRORISM PREPAREDNESS PROGRAMS FROM A PUBLIC 
                           HEALTH PERSPECTIVE

                              ----------                              


                      WEDNESDAY, OCTOBER 10, 2001

                  House of Representatives,
                  Committee on Energy and Commerce,
              Subcommittee on Oversight and Investigations,
                                                    Washington, DC.
    The subcommittee met, pursuant to notice, at 10:15 a.m., in 
room 2322, Rayburn House Office Building, Hon. James C. 
Greenwood (chairman) presiding.
    Members present: Representatives Greenwood, Stearns, Burr, 
Bass, Tauzin (ex officio), Deutsch, Stupak, Strickland, and 
Rush.
    Also present: Representatives Ganske and Buyer.
    Staff present: Tom DiLenge, majority counsel; Peter Kielty, 
legislative clerk; and Edith Holleman, minority counsel.
    Mr. Greenwood. The hearing will come to order.
    Good morning. We welcome you all and apologize for the 
slight delay. The Chair recognizes himself for an opening 
statement.
    Today's hearing is part of this subcommittee's long-
standing interest and oversight of bioterrorism issues which 
led to the unanimous passage of the Bioterrorism Prevention Act 
of 2001 by the full committee just last week.
    Today, we turn our attention to an acutely critical area, 
our Nation's preparedness to deal with the threat of 
bioterrorism. Since May of this year, members of the committee 
and committee staff have been busy investigating the capacity 
of Federal, State and local public health officials to respond 
to these kinds of threats and dangers.
    When this subcommittee announced 5 weeks ago its intent to 
hold a hearing on September 11 to examine the effectiveness of 
Federal bioterrorism preparedness from a local public health 
perspective, a concern at that time was that too little 
attention was being paid to improving the ability of our local 
health care communities to detect, contain, treat and 
effectively manage a terrorist attack using deadly biological 
agents, or for that matter, any naturally occurring disease 
outbreak or disaster with mass care consequences.
    The evil that was visited on our country and the world on 
September 11 has changed all of that. It is now clear that the 
people who perpetrated this deed are unconstrained by any sense 
of morality. The only restraint on their form of ideologically 
inspired madness is the limit of the technology that they can 
acquire. And though the weapons of choice on that day were 
jetliners filed with innocent passengers and not anthrax or the 
plague, September 11 prompted this Nation to seriously 
reexamine how we prepare for all types of terrorist attacks, 
including bioterrorism.
    There is much anxiety. Some of it is fueled by the almost 
daily stories on the networks and in our major newspapers 
detailing our lack of preparedness for bioterror assaults. 
Congressional committees are also busy holding hearings to 
examine this potential threat and the efforts to combat it.
    The detection of the anthrax bacterium in a Florida 
workplace and in two workers at that site, one of whom already 
has died, has raised the temperature on this issue even higher. 
Nevertheless, while there is legitimate reason to be anxious, 
it is the duty of Congress to confront and reduce that anxiety 
by making sound public policy choices. And big questions remain 
unanswered about how best this Nation should approach 
bioterrorism defense.
    Our mission today is to engage in a dialog with the public 
health officials who would be in the vanguard of any response 
to bioterrorism, so that we in Congress build the right kind of 
working partnership between all levels of government, as well 
as assemble the necessary Federal resources that will best 
enable them to address this threat. I hope to accomplish 
several objectives with continuing, indeed increasing, 
importance.
    First, as we embark upon what most likely will be an major 
new Federal initiative to improve our bioterrorism 
preparedness, I think it is critically important that Congress 
hear directly from the health care front lines--the hospitals, 
the physicians, the emergency medical personnel about how they 
view the existing Federal preparedness programs and what some 
of the past barriers have been to successful preparedness 
programs in the health care community.
    Too often the concerns and needs of these groups which will 
constitute our first line of defense in any real bioterrorist 
incident have been overlooked or ignored in our race to do 
something about terrorism. Hopefully, our hearing today will 
help to change that.
    Second, and just as important, I believe it is essential 
that we at all levels of government approach bioterrorism 
preparedness from a broader public health perspective. This 
makes good sense for several reasons, but most of all because 
it will be difficult to justify the costs or sustain 
accomplishments over the long run if we focus too narrowly on a 
threat that many in the health care community may rightly 
perceive as small when compared to the tremendous daily 
challenges facing our health care systems.
    While there is a considerable debate about the likelihood 
of a mass casualty biological terrorist attack, there was near 
universal agreement that our public health infrastructure 
itself is in need of CPR.
    What do we mean when we use the term ``public health''? The 
basic elements are pretty straightforward: clean water, a 
plentiful and uncontaminated food supply, clean air, wastewater 
treatment, and the ability to respond and control epidemics. 
Unfortunately, in recent decades, we have allowed the 
capability of our public health departments, laboratories, and 
hospitals to deal with major disease outbreaks to stagnate or 
even deteriorate. Between 1981 and 1993, for example, State 
public health budgets declined as much as 25 percent. To now 
ask them to take up the additional burden of responding to 
bioterrorism without substantial new resources and direction 
would be to risk a breakdown of the entire system.
    Last, we need to take a good, hard look at how we are 
spending and will continue to spend Federal dollars in this 
area to ensure better allocation of existing and future 
resources devoted to this purpose. Everyone gives lip service 
to the idea that our local communities are and will remain the 
principal responders to terrorist events. Yet most of the 
billions of dollars spent each year on combating terrorism 
never finds its way beyond the Capital Beltway.
    We need to change that reality, particularly given that all 
of the Federal assets and specialty teams that have been 
created for this purpose make two fundamental assumptions in 
their response plans: first, that timely surveillance and 
detection activities will be made at the local level; and 
second, that the local response teams possess the resources and 
capabilities to effectively manage an emerging crisis within a 
critical 12 to 72 hours before Federal assistance arrives on 
the scene.
    As we will hear today, those are two big assumptions.
    Before I conclude, I also want to announce that this 
subcommittee plans to hold another hearing on this topic on 
October 25 to explore the related and equally important issue 
of public health surveillance and detection systems, and how 
technological advances in these areas can help in our battle 
against bioterrorism, as well as against naturally occurring 
disease outbreaks.
    I thank our witnesses today and now recognize the ranking 
member of this subcommittee, Mr. Deutsch, for his opening 
statement.
    Mr. Deutsch. Thank you, Mr. Chairman.
    Last Thursday, I had, I guess, just certain difficulty, as 
this meeting was originally scheduled for September 11, with 
meeting with the county chairperson of Palm Beach County, the 
county chairperson of Broward County, and the mayor of Miami-
Dade County in the early afternoon. At that point, they were 
actually up here in terms of the potential supplemental bill 
and in terms of talking about issues related to it. And in the 
course of our discussion, you know, we were talking about other 
issues. And I was talking about our committee and our 
jurisdiction.
    As many of you are well aware, our committee has 
jurisdiction over the CDC, and we were talking about issues of 
threats of bioterrorism. And I proceeded to go through what I 
was aware of at the time, the sort of plan that exists and how 
good that plan is, and how CDC is supposed to move in 
automatically and provide all sorts of resources.
    And as it so happens, unbeknownst to me at the time, but 
beknownst to the chairperson from the County of Palm Beach, an 
anthrax case was diagnosed in Palm Beach County. And the three 
heads of the three counties in South Florida, where the 
population is close to 6 million people, they didn't go into 
outbreak laughter, but they basically said that what I was 
describing was not reality.
    And it was not reality at that moment in Palm Beach County, 
and it was not reality of what could exist in Broward or Miami-
Dade Counties. And, you know, we understand--and the Secretary 
of HHS has been on television on several occasions since last 
Thursday telling the American people, don't worry, relax, we 
are ready, we can deal with this.
    Based on this sort of empirical thing of the leadership of 
the three counties in South Florida, I have real concerns, and 
I expect that we will have testimony today that will 
essentially substantiate that.
    This issue, though, is obviously much different since 
September 11. I think all of us are much more knowledgeable 
about not just terrorism in general, but bioterrorism, 
bioterrorism in particular. It is no longer theory; it is a 
reality in many ways; and I think, just to put on the table at 
the start of the hearing, chemical weapons were used over 10 
years ago by both Syria and Iraq. And I think there is 
absolutely no reason to think that terrorists don't have 
available those weapons today; and the only restricting factor 
could be a delivery system.
    So we are no longer talking about some esoteric, 
theoretical issue; we are talking about a practical issue. As 
awful as the horrific events that occurred at the World Trade 
Center were, I think all of us understand that the potential is 
far in excess of those events in a direct attack.
    Now, the good news is, there are things that we can do in 
terms of intelligence and also in terms of public health to 
prevent that. And that clearly has become the highest, or as 
high a priority as any that this Congress faces.
    I yield back the balance of my time.
    Mr. Greenwood. The Chair recognizes for an opening 
statement the chairman of the full committee, Mr. Tauzin.
    Chairman Tauzin. Thank you, Chairman Greenwood, for holding 
this very critical and timely hearing on how this Nation can 
best prepare for the possibility, however small, of any kind of 
major bioterrorist event. I believe this committee, as the 
principal public health committee on this side of the Capitol, 
must take the lead to ensure that the Nation can, in fact, 
tackle this very difficult issue.
    Given what we read in the newspapers, what we see on 
television, the American people understandably are concerned 
about the threat of bioterrorism. It is true that--as we will 
hear today, that we need to do more. So we need to do more to 
fully prepare our Nation for this kind of a possibility.
    It is also true, after September 11, that we have all, I 
think, underestimated the evil and the sophistication of our 
enemies, unfortunately, at our own peril.
    That said, we should not allow undue public concern or 
worry to develop over what most experts believe is a relatively 
remote threat and one that is technically very difficult to 
carry out. That is why it is imperative that we approach this 
issue in a very thoughtful and a very measured way. I am glad 
to see that that is exactly the approach that you, as chairman, 
and the subcommittee have agreed to take.
    Let me expand quickly on three points that Chairman 
Greenwood has raised. First, we need to start a serious public 
debate about some of the big questions that he alluded to, the 
questions that remain unanswered today: What are we preparing 
for, and what is the measure of our preparedness? In other 
words, what are we trying to achieve and how do we know when we 
have achieved it? How do we know that we have reached the point 
where we can assure the American public that we are prepared, 
and that we are prepared not only to assure their safety, but 
to react in the worst case?
    Our staff hears over and over about the health care front 
lines, that the people who operate those lines, what is not 
happening, where direction is not being given, where guidance 
from Federal experts to properly prepare for a bioterrorism 
event might, in fact, be helpful.
    We need to change that. We need to make sure the lines of 
communications are clear and that people understand guidance 
and direction in this area as clearly as anything else as we 
face these threats.
    Second, this is not, as some would think, just a question 
of more money. There is a reason that today's hearing is before 
the oversight committee. We have already spent at the Federal 
level billions of dollars in this area and more than $200 
million annually on health-related programs alone. Secretary 
Thompson says he needs at least $800 million more for 
bioterrorism preparedness, probably more in the future. That is 
not small change, and it is incumbent upon this committee to 
make sure that both existing funds and new funds are used in 
the most effective and measured way.
    Again, that means the big questions need to be addressed: 
Where should we be spending our money for the most safety and 
security?
    And third, I want to echo Chairman Greenwood's comments 
regarding the importance of really listening to our brethren in 
local jurisdictions around the country, particularly those in 
the health care community. As one of our witnesses today states 
so well in her written testimony, it is the local emergency 
medical personnel, the hospitals, the health department 
administrators, the doctors and nurses and support staff in the 
communities where we live who are going to be the people whose 
actions and decisions will determine just how contained or how 
damaging any bioterrorism incident ultimately will be.
    There are people who will detect an outbreak and treat 
their fellow citizens often putting themselves at risk as well 
as, and they should not be ignored by the Federal Government 
that so often focuses too much on itself when devising 
responses to bioterrorism.
    One final thought: Our full committee has been briefed very 
deeply by Secretary Thompson on the nature of those potential 
threats. We are not about to join the leakers around town who 
talk about things we shouldn't talk about. But I want you to 
know that as we went into that briefing, my concern levels and, 
I think, the concern levels of every member of this committee 
were extraordinarily high; all of us felt more assured after 
that briefing than before we had it.
    Secretary Thompson and his department are aggressively 
working and private sector components of the effort to prepare 
this country are aggressively working not only to beef up the 
already deployed stocks of vaccines and other pharmaceuticals 
that are important for us to be able to respond to any such 
threat, but also to make sure that there are new quantities and 
new, appropriate steps taken to protect our citizens not simply 
from the advent of the incident, but equally important, to take 
care of our citizens should the worst ever happen.
    Now, look, I got a call from a doctor at home. I am sure 
you all did. And people were calling them because they have 
heard stories and they want to know about what they can do 
personally to prepare themselves.
    The best preparation we can all have in this area, as in so 
many areas, is to be the best citizens we can be, to be on our 
guard, to go about our lives and to conduct our businesses--as 
the President said, to hug our children, but also to be on our 
guard, to be good citizens and to be helpful and supportive of 
the agencies of our government that are trying to make sure 
nothing like this ever happens in this country again, or 
anything like it should happen in the future.
    And the second thing is to have what I have--what I am 
beginning to have in greater degree: a great deal of faith in 
the notion that everybody at this level is working day and 
night to ensure that our preparedness is at its top, its best; 
and the money we will allocate and spend will have been 
directed, as the chairman said, to the most important places 
where our country needs to be prepared.
    This Nation has come together very well. And Mr. Chairman, 
this hearing, I hope, will be another effort to make sure that 
the country knows that its government is not sleeping, that we 
will not rest until we are sure that the American public and 
this Nation are as protected as we can make them and as 
prepared as much as we can for the worst of circumstances, 
should we ever experience them again.
    Thank you, Mr. Chairman.
    Mr. Greenwood. The Chair thanks the chairman for his 
opening statements and for his presence, and recognizes for an 
opening the statement the gentleman from Michigan, Mr. Stupak.
    Mr. Stupak. Thank you for holding today's hearings on the 
subject that I have been interested in working on for the past 
few years. Bioterrorism has suddenly taken center stage, and we 
welcome comments from today's participants on this topic.
    Last year, Congressman Burr and I cosponsored a public 
health and emergencies act, which was rolled into the health 
omnibus bill. It is the logical next step to evaluate our 
Nation's preparedness.
    As a former law enforcement officer, I am well aware of the 
logical difficulties in implementing a country-wide or county-
wide public health response; and I am eager to hear today's 
witnesses and their advice on how best to build on what Mr. 
Burr and I started last year.
    I was especially pleased and gratified to see Secretary 
Thompson recently invoking the law that Mr. Burr and I worked 
so hard to pass last year, specifically relating to 
bioterrorism. It is my understanding Secretary Thompson was 
able to ship medical supplies and assistance to the victims of 
the September 11 terrorist attack in New York City as easily as 
he did because of the language that we inserted in our 
legislation last year.
    The logistical elements of coordinating our efforts are 
staggering, to stay the least. Effective communications mean 
establishing links among public law enforcement, local health 
departments, clinics and hospitals, so that critical data in an 
emergency situation can identify, contain, and respond to an 
emergency efficiently. However, we lack the personnel and the 
resources to do this.
    For example, if a bioterrorism attack occurred on Friday 
afternoon after office hours, there would be no one to report 
it to until Monday morning. The way most health departments are 
currently set up, that would be the situation.
    No one wants to spread unnecessary fear or alarm, but I 
have to question, just how organized is the Nation's public 
health system to respond to bioterrorism? No hospital or 
geographically contiguous group of hospitals can effectively 
manage even 500 patients demanding sophisticated medical care 
and supplies, as would be required in a case of the outbreak of 
anthrax.
    The Bush administration's head advisor on bioterrorism 
testified yesterday morning in front of a Senate panel. He said 
in the event of a contagious disease outbreak such as smallpox, 
far fewer patients could be handled, testified the expert, Dr. 
Donald Henderson, Director of Johns Hopkins's Center for 
Civilian Biodefense Studies. That is a good fact to know and a 
compelling factor to consider in our deliberations today.
    Mr. Chairman, I thank you for holding this hearing and for 
holding a future hearing on October 25, and I look forward to 
hearing from our experienced panels of witnesses on this issue 
today. Thank you.
    I yield back the balance of my time.
    Mr. Greenwood. The Chair thanks the gentleman and 
recognizes for an opening the gentleman from New Hampshire, Mr. 
Bass.
    Mr. Bass. Thank you, Mr. Chairman; and I appreciate your 
holding this important hearing. As the distinguished chairman 
of the committee has mentioned, the issues here are what we are 
preparing for and what measure of preparedness should we take.
    Over 2 years ago, the Intelligence Committee had a public 
hearing on this very subject. I had the pleasure of 
participating in that hearing, and suffice it to say that there 
has been awareness and action undertaken both on the military 
and on the civilian side to prepare for this kind of 
eventuality.
    I think, however, it is important, as we consider the 
issues here, not to scare people or create mass paranoia, but 
to inform and educate the people so that we can be alert and 
aware of what we need to look out for, not for Congress to 
overreact--or government, for that matter--but develop and 
implement good, effective public policy that will be in the 
best interests of the American people.
    This hearing is a good beginning. I look forward to hearing 
the testimony from the distinguished witnesses.
    I yield back.
    Mr. Greenwood. The Chair thanks the gentleman and 
recognizes the gentleman from North Carolina, Mr. Burr.
    Mr. Burr. Thank you, Mr. Chairman.
    We are here today to look at bioterrorism preparedness. We 
are probably a little late, in all honesty. But what we find 
when we examine the issue is, we find a number of entities 
within the Federal Government, a number of different agencies 
with funding and with efforts to address our preparedness--some 
because of the oversight restrictions of committees that fund 
duplicative programs, some where one committee might determine 
that the money is directed in the right place. We see the 
participation of other agencies in the same area.
    And now, since September 11, we have begun to look at it in 
its entirety and, in many cases, with a microscope.
    Let me suggest, had we held this before September 11, we 
would have highlighted one thing today, and we will at this 
hearing: What we had put in place as it relates to the national 
medical response network of four private sector entities that 
could be called up at any time, given that there was threat of 
a bioterrorism attack. Had we had the hearing before September 
11, I am not sure that we would have looked as closely at our 
response capabilities federally and locally like we do today.
    So I think for the American people the benefit of us having 
this hearing post-September 11 is tremendously advantageous.
    Mr. Chairman, we have got a challenge. As a member of the 
Intelligence Committee--Ms. Harman is on the Commerce 
Committee--we understand the efforts that are under way, we 
understand the challenges that we will place on health care 
professionals in every community across this country.
    The only way that Congress can fall down on their job is to 
make sure that the resources that we make available do not get 
to the entities that need the equipment and that need the 
training to respond in a timely fashion to a threat that exists 
somewhere in America.
    Our ability to pinpoint that threat does not exist and will 
not exist, but our capabilities to respond to the threat and to 
minimize the effects exist today. If the Congress of the United 
States can find a way to coordinate the resources, the existing 
resources and the potential future resources, we will have a 
tremendous opportunity with the confirmation of Governor Tom 
Ridge in his newly designed post.
    And, Mr. Chairman, I hope that we will learn a lot about 
our health preparedness and our response capabilities today; 
and I hope that all members will begin to think, and those 
entities that are here to testify will begin to think, how it 
is that we help design this new post for Governor Ridge, so 
that he has the budgetary authority to make sure that the 
dollars are directed where they can do the most good for the 
threat that we perceive and for the comfort of the American 
people.
    Even though we are an oversight arm of the Commerce 
Committee, we are limited to a great degree by the efforts of 
Health and Human Services and to--to their dollars that they 
spend on health. Given that there are eight Federal agencies 
and eight committees of jurisdiction where we don't have 
collaboration between oversight committees, the only way that 
we can function with the degree of confidence that we need to 
have to make sure that American people are, in fact, protected 
and that our response capabilities are the best, is to make 
sure that we have an entity within the Federal Government, like 
Governor Ridge, who is in charge of making sure that every 
agency is held accountable for every dollar that goes into our 
preparedness and our response capabilities.
    I look forward to the panel that the committee has before 
us today. And with that, I yield back.
    Mr. Greenwood. The Chair thanks the gentleman and 
reiterates that this hearing was originally planned for July, 
and we decided to wait for the GAO study. And of course, the 
great irony is that we noticed the hearing for September 11.
    The issues remain the same, only the urgency has changed.
    The Chair thanks the gentleman and recognizes the gentleman 
from Iowa, Mr. Ganske.
    Mr. Ganske. Thank you, Mr. Chairman. I ask consent to 
submit for the record my full statement.
    Mr. Greenwood. Without objection.
    Mr. Ganske. Which would be about 30 to 40 minutes and I am 
sure----
    Mr. Greenwood. I am sure there are no objections.
    Mr. Ganske. I think some of the remarks that have been made 
so far bear repeating briefly; and that is that we should not 
scare people, but we need to be responsibly concerned about the 
threat of bioterrorism, and it is something that this Congress 
has been working on in the past few years.
    A couple of years ago we passed a bill outlining a number 
of ways in which to better combat a potential bioterrorism 
attack. In that legislation, sums were authorized for Federal 
expenditures. We need to fulfill those authorizations, and as 
the chairman pointed out, probably expand those authorizations 
and actual appropriations. Because we are dealing with the 
situation, with bioterrorism, where the first line responders 
will not be policemen or firemen, but they will be doctors and 
nurses and hospitals and public health facilities; and there 
are a number of things that we need do to bolster that public 
health component.
    For many years now, public health services have been not 
funded, I think, at the levels that they should be. They need 
to be better coordinated between Federal, State and local and 
city units. That is something for Governor Ridge to work on and 
for Congress to work on, too, in order to facilitate that.
    We are going to hear something about smallpox and about 
anthrax today. Smallpox, as a physician, I can tell you that 
there is probably no one in this audience today who is 
immunized against smallpox. The immunizations for that were 
discontinued years ago, were effective for a period of time.
    Then, we supposedly eliminated smallpox from the planet, 
except that it was kept in two repositories, that were supposed 
to be secure, both in the United States and in Russia. I think 
it is fair to say that it is possible that there are smallpox 
strains elsewhere in the world, for instance in Iraq, possibly 
in other places in Russia.
    There certainly is expertise among Russian scientists who 
have worked on bioterrorism projects. That is available around 
the world. And we know that the--we are facing increasing 
levels of sophistication in terms of terrorist attacks, so 
these are some things that we need to be concerned with.
    Smallpox is extremely catchy, and it can be 30 percent 
fatal in people who are not immunized. So we need to do things 
about increasing supplies for vaccines, surveillance, things 
like that.
    Anthrax is a little harder to distribute, but it is more 
fatal if you get it in the pulmonary form. I will be interested 
in seeing or hearing testimony today about this strain in 
Florida that, according to newspaper reports, can be traced to 
an Iowa facility from the 1950's.
    But I also want to talk about the bioterrorism attack in an 
economic way, and that is something that I and members of the 
Agriculture Committee have been concerned about for many, many 
months, long before the September 11 attack; that is the foot 
and mouth disease problem.
    We have seen what has happened to agriculture in areas 
around the world where--particularly Europe, where this has 
hit. We have been concerned about proper USDA surveillance, CDC 
surveillance, things like that for this disease. It is not 
particularly harmful to humans, but the economic devastation on 
our agriculture community could be incredibly, incredibly 
devastating.
    I know that there will be some farmers who will be 
listening to my testimony right now that would probably not 
want me talking about this, except for the fact that this has 
now received front page and headline stories in major magazines 
like Time magazine, so this is not something that is secret. We 
need to be looking at ways to secure our agriculture in terms 
of an economic attack on our country, as well.
    And finally, I think that we can all hope and pray that we 
do not see a massive epidemic. I think that with better 
coordination, with better funding of our public health 
services, we certainly could see some additional benefits in 
our ways for our country, and I look forward to the testimony.
    Thank you, Mr. Chairman.
    [The prepared statement of Hon. Greg Ganske follows:]
 Prepared Statement of Hon. Greg Ganske, a Representative in Congress 
                         from the State of Iowa
    Tuesday September 11th is forever seared into our minds. We will 
never forget the images: airplanes flying into buildings and exploding, 
people choosing to jump off buildings rather than burn to death, 
buildings collapsing on rescuers, clouds of vaporized concrete, steel, 
glass and thousands of humans rolling down the streets like a volcanic 
eruption . . . the Stars and Stripes framed by the flaming crater that 
was the pyre of 195 soldiers and civilians at the Pentagon. Our hearts 
go out to the victims and their families.
    We watched those images and they didn't seem real. The spectacle 
almost disguised the human toll. At first the magnitude of this tragedy 
made it hard for most Americans to grasp. But everyday the newspapers 
now put faces on the victims and their families. The shock has worn off 
and we are left with grief, the deepest grief. We read those obituaries 
and find ourselves tearing up. I don't know about you, but I can only 
read a few each day before I must stop.
    We've learned the stories of the brave passengers on United Flight 
93 who bid their loved ones farewell pledging that they were going to 
go down fighting. Their plane crashed but those heroes saved many lives 
in Washington--perhaps even my own. We are humbled by their courage and 
their sacrifice! Ordinary Americans who in 45 minutes became heroes.
    We remember the final recorded words of the men and women 
hopelessly trapped above the fiery inferno of the World Trade Center--
messages of love to their families.
    In Corinthians the Bible teaches; ``So we do not lose heart. Even 
though our outer nature is wasting away, our inner nature is renewed . 
. . for we know that if the earthly tent we live in is destroyed, we 
have a building from God, a house not made with hands, eternal in the 
heavens.''
    Each of us will carry our own memories of 9/11. I will never forget 
the sense of unity as 170 bipartisan members of Congress, not 
Republicans or Democrats but Americans, stood on the front steps of the 
Capitol in the lengthening evening shadows of that Tuesday to say a 
prayer for our country and its victims . . . and then we sang America 
the Beautiful. Our message then--and today--and tomorrow is that we are 
one Republic, united we stand. Terrorists can challenge this nation's 
spirit--but they cannot break it!
    In righteousness, we are hunting down . . . to the ends of the 
earth if necessary . . . the assassins of our brothers and sisters, 
mothers and fathers, husbands and wives, and children. We will do what 
is necessary to win this war that has been declared on us. The victims 
deserve justice and our people deserve security. We are meting out 
justice to these terrorists, and we do distinguish between terrorists 
and those who harbor them and the rest of the Muslim world.
    But Christians, Jews, and Muslims must all understand that the 
Osama bin Ladens, are leading to the destruction of all religion and 
society . . . if the Muslim fundamentalists don't realize that the war 
will go on and on.
    Take the radical Islamic-fundamentalist Taliban regime. This is a 
government so oppressive that it executes little girls for the crime of 
attending school. Girls, aged 8 and older, caught attending underground 
schools are subject to being taken to the Kabul soccer stadium and made 
to kneel in the penalty box while an executioner puts a machine gun to 
the back of their heads and pulls the trigger. Spectators scattered 
among the stands are then encouraged to cheer.
    An Afghani woman was beaten to death recently by an angry mob after 
accidentally exposing her arm. Osama Bin Laden's treatment of women is 
so barbaric that he orders their fingernails and toenails pulled out if 
they are painted. Women have almost no health care because male doctors 
are forbidden to touch female patients and there are very few female 
doctors. The beating, raping and kidnapping of women are commonplace.
    A reporter for CNN recently told of meeting a family of three 
little girls hidden under their scarves and garments while their father 
stared into space. The girls had apparently not moved in weeks . . . 
they had been made to watch as the Taliban militia shot their mother in 
front of them and then stayed in their home for two days while the 
mother's body lay in the courtyard. The reporter asked the girls what 
the Taliban men did to them during those two days . . . they just wept 
silently.
    The Taliban is rounding up men from villages. Those that don't join 
willingly are shot. There are news reports of mass graves--some 
containing as many as 300 Afganis--scattered throughout the country.
    The Taliban is taking more than a few pages from the Nazis. They 
require all Hindus to carry a yellow sticker identifying them as 
members of a religious minority. Hindus are required to put yellow 
flags on their rooftops, as well. The Taliban also controls the heroin 
trade and funds its domestic and international terrorism with drug 
money.
    So what do we do? Well, to quote from British Prime Minister Tony 
Blair's magnificent speech: ``Don't overreact some say. We aren't. 
Don't kill innocent people. We are not the ones who waged war on the 
innocent. We seek the guilty. Look for the diplomatic solution. There 
is no diplomacy with Bin Laden or the Taliban regime. State an 
ultimatum and get their response. We stated the ultimatum; they haven't 
responded. Understand the causes of terror. Yes, we should try, but let 
there be no moral ambiguity about this: nothing could ever justify the 
events of 11 September, and it is to turn justice on its head to 
pretend it could. There is no compromise possible with such people, no 
meeting of minds, no point of understanding with such terror. Just a 
choice: defeat it or be defeated by it. And defeat it we must.'' These 
are words worthy of Churchill.
    I personally will never forget the smell of the smoldering crater 
of the Pentagon or the smoke unfurling into the air of lower Manhattan 
while at ``ground zero'' the firemen poured water onto the ruins of the 
World Trade Center that is the grave of over 5,000 innocent people.
    As I stood looking at the mass of twisted steel and concrete, my 
thoughts turned to the words of a little girl's handwriting I had just 
seen a victims' family center . . . the words, ``I miss you daddy!! 
Love you, Jenny.'' It is indescribably sad.
    So what do we do? Just what we are doing in Afghanistan now: 
destroying the terrorists and their supporters. Our prayers are with 
the brave men and women soldiers of our Armed Forces. It must be 
galling to the Taliban that some of our bravest soldiers are women!
    What else do we need to do? Well, if we didn't realize how 
important airplane security and airport security was before September 
11th, we sure do now. The safety and security of our aviation system is 
critical to our citizens' security and our national defense.
    The tragedy of September 11, 2001 requires that we fundamentally 
improve airport and airline safety. That is why Congressman Rob Andrews 
and I Introduced on September 25th the Aviation Security Act, H.R. 2951 
which is the companion bill to that offered by Senators Hollings and 
McCain. Our bills have bipartisan support in both the House and the 
Senate. Our bill would make planes' cockpits secure; it would place 
federal air marshals on more flights. It puts the FAA in charge of 
airport security operations including increased training for airport 
security personnel and anti-hijacking training for flight personnel. 
The Aviation Security Act would improve the screening of flight 
training so that a terrorist couldn't walk up to the counter, plunk 
down $20,000 in cash and say, ``Teach me to fly a jet and, oh by the 
way, I'm not interested in learning how to take off and land . . . just 
teach me to steer the jet!''
    Our bill would pay for this with a $1 charge on airline tickets. 
When I talk to Iowans, none of them say this is too much to pay for 
increased airline security. I don't want more families writing letters 
like another one I saw at the victim's family center: ``Danny, I will 
love you always--you will always be in my heart. Love Chris and your 
son, Justin.''
    So what do we do about other terrorist threats like the possible 
bio-terrorist anthrax attack in Florida? First of all, we should not 
panic. I am speaking as a Congressman but also as a physician. 
Selecting and growing biologic agents, maintaining their virulence, 
inducing the agents into forms that are hardy enough to be disseminated 
and finding an efficient means of distribution is not easy for a nation 
to do, much less terrorists.
    However, the level of coordination and the profiles of the 
terrorists associated with September 11, mean we must be prepared for 
attempts at bio-terrorism. There are nations such as Iraq that might 
help these terrorists in their evil plans. Clearly, we must try to root 
out terrorist cells before they strike. Our intelligence services must 
be bolstered and given the tools they need. Impoverished scientists 
from countries like Russia that have worked on biological weapons must 
be prevented from selling that knowledge to terrorists.
    But it is important to understand that the first line of defense 
against a biological attack will not be a fireman or a policeman. It 
will be doctors and nurses; it will be the public health system because 
the ultimate manifestation of the release of a biologic agent is an 
epidemic. Smallpox and anthrax are most frequently mentioned as agents 
of bio-terror.
    Officially, only two stores of the smallpox virus exist, for 
research purposes, in secure locations in Russia and the U.S. . . . but 
there may be covert stashes in Iraq, North Korea and in other places in 
Russia. People who were vaccinated before 1972 have probably lost their 
immunity and routine inoculations were halted around the world in 1972. 
Most people would therefore be at risk. Smallpox is very ``catchy'' and 
about 30% fatal.
    The first victims of smallpox would likely be the terrorists 
themselves, but remember, these are people who commit suicide to spread 
terror. Inhaled anthrax is fatal about 90% of the time, 20% of the time 
if infection is from contact with animals. Its spores are resistant to 
sunlight, but manufacturing sufficient quantities and then distributing 
them widely by, say, crop-duster airplane, would be difficult.
    Time Magazine even talks about a terrorist attack aimed at crops 
and livestock that would be easier and less directly harmful to humans, 
but economically very harmful. Foot-and-mouth disease can spread with 
astonishing speed in sheep, cattle and swine. An outbreak in the U.S. 
could be devastating to American agriculture.
    So what can we do? First, we need better coordination between the 
Defense Department, the State Department, the Agriculture Department, 
the Centers for Disease Control, state public health programs and 
directors, and the city-based Domestic Preparedness programs. This is a 
job for the new Director of Homeland Security.
    Second, we must make a systematic effort to incorporate hospitals 
into the planning process. As of today I think it is accurate to say 
that few U.S. hospitals are prepared to deal with community-wide 
disasters for a whole host of financial, legal and staffing reasons.
    There will be significant costs for expanded staff and staff 
training to respond to abrupt surges in demand for care, for outfitting 
decontamination facilities and rooms to isolate infectious patients. 
There will be the costs of respirators and emergency drugs. The first 
serious efforts to implement a civilian program to counter bio-
terrorism emerged in the spring of 1998 when Congress appropriated $175 
million in support of activities to combat bio-terrorism through the 
Department of Health.
    But we must do more to integrate federal, state and city agencies:

1. We must educate family doctors and public health staff about the 
        clinical findings of agents,
2. We need to further develop surveillance systems of early detection 
        of cases,
3. We need individual hospital and regional plans for caring for mass 
        casualties,
4. We need laboratory networks capable of rapid diagnosis,
5. And we need to accelerate the stockpiling and dispersal of large 
        quantities of vaccines and drugs.
    The Public Health Threats and Emergencies Act of 2000 provides for 
increased funding to combat threats to public health and we should 
provide that increased funding this year.
    I recently visited Broadlawns Hospital in Des Moines. Public 
hospitals like Broadlawns and public health agencies have not been 
adequately funded in recent years. They need to be bolstered in order 
to cope with a biological attack. Even if a catastrophic biological 
attack doesn't occur, and we pray it doesn't, the investment will pay 
dividends in other ways.
    Finally, let me return to the question of understanding the causes 
of Muslim fundamentalists' hatred of the United States. President Bush 
asked in his September 20 address to Congress, ``Why do they hate us?'' 
And those of us in the audience and those at home listening to the 
President--still stunned by the magnitude of the attack--wondered what 
degree of poverty or political resentment or religious convictions 
could lead anyone to revel in the deaths of so many innocent people?
    Shortly after the attack I was asked by the Des Moines Register 
newspaper's editorial board why I thought there was so much hatred of 
us in the Middle East. In April I had visited Israel, Jordan and Egypt. 
Our Congressional delegation met with the leaders of these countries 
and the Palestinians, but also met with people from these countries who 
weren't in government.
    I told the editorialists that there was much envy of our wealth and 
dislike of our Western culture, particularly the role of women as 
equals. I also said it was clear that our support of Israel was 
significant.
    But this is an incomplete answer and I do think we need to reflect 
a moment on what we hear when, for example, we hear the translation of 
Osama Bin Ladin's screed. In the end, coping with Islamic anti-
Americanism has to be a component of our ``war on terrorism.''
    As someone who has traveled rather extensively to third world 
countries on surgical trips, let me say that not everyone regards the 
United States as a greedy giant. Even critics in other countries of 
America's foreign policy still often praise U.S. values of freedom and 
democracy.
    But extremism thrives in poverty. Cairo is now a city of 18 
million. In the center of the old city is a huge cemetery called the 
City of the Dead. Years ago the authorities gave up evicting people 
from living in the crypts--today it is home for a million people! And 
population explosion in these countries is unbelievable. The breakdown 
of services such as garbage collection is something few Americans can 
comprehend.
    Since the early 1970s, the populations of Egypt and Iraq have 
nearly tripled. As a result, per capita income in Arab states has grown 
at an annual rate of 0.3%. The labor force in these countries is 
growing faster than that of any other region in the world. This leads 
to large pools of restless, young men with no jobs.
    Globalization has accelerated the pace of economic and social 
change that creates insecurity. Most Islamic states don't have 
democratic governments to mediate these conflicts. Generals, kings, 
leaders for life, and parliaments with no power lead to frustrated 
people.
    When people feel powerless and extremely deprive--either 
economically, politically or psychologically--the ground is fertile for 
terrorism.
    This sense of deprivation is part of the public backlash in those 
countries against globalization, modernization, and secularism. And the 
United States, regardless of its relationship with Israel, is the 
country most benefiting from globalization, it is the most modem and 
the most secular nation on earth. Two thirds of Egyptians and four-
fifths of Jordanians consider a ``cultural invasion'' by the West to be 
very dangerous, according to a 1999 survey.
    So what can we do? First, there is no compromise with people that 
celebrate killing 5,000 people and would celebrate even more if they 
killed 50,000. We will hunt down and destroy these assassins of our 
brothers and sisters, mothers and fathers and our children.
    We must also understand the region better. We do need to help those 
countries tackle their underlying economic woes. We had to fight a 
Second World War because of the failure of the Treaty of Versailles, 
but the Marshall Plan helped us secure a safe Europe after W.W. II. 
President Bush is already starting in this direction with Pakistan. The 
Jordanian Free Trade Agreement is also an important step, especially 
symbolically.
    Education in the region is a problem. Secondary school education is 
low, illiteracy is high, and fundamentalist Islamic sects have filled 
the void. Those fundamentalist sects educate, feed and clothe the poor 
and they win converts to their hatred of the West.
    In Egypt and Jordan the state forbids the teaching of jihad in 
those schools. As a condition of U.S. foreign aid, Pakistan should do 
the same. Many of the Taliban are products of those schools that teach 
hatred of us.
    The United States should do more to promote democracy in the Middle 
East. This means promoting free and fair elections, judicial and 
legislative reform and rule of law. An investment in these countries 
could be well worth the cost. Consider that the Wall Street Journal is 
estimating the World Trade Center Attack to be costing the American 
economy over $100 billion!
    This war that we are in is a fight for freedom and justice. Whether 
it is our military, our intelligence agencies, our resolve to make 
airports more secure and our public health system better, I see around 
this country the will and resolve to win this war. Our parents fought 
World War II. Each generation is called on to sacrifice and I see the 
valor of my fellow countrymen in its soldiers, and firefighters and 
policemen and nurses and ordinary Americans, who in 45 minutes became 
heroes.

    This is our generation's challenge. It is our turn to fight for 
freedom and justice. We will do our duty.

    Mr. Greenwood. The Chair thanks the gentleman for the 
abbreviated version of his opening statement and recognizes the 
gentleman from Florida, Mr. Stearns.
    Mr. Stearns. Good morning and thank you, Mr. Chairman. Like 
my other colleagues, I wanted to commend you for holding this 
hearing today. Looking at the two panels, of course, we have 
folks from the private sector and folks from the government, so 
we will be able to get a good cross-section of answers on some 
of our questions.
    How should our Federal Government shore up our defenses 
against enemies who would harm us not with bullets but using 
bacteria or viruses in our streets, subway cars, crops or water 
supply? We have had several what-if scenarios recently. In 
Florida, of course, one individual contracted the anthrax 
bacterium and now a coworker has also been tested positive for 
anthrax as well.
    The FBI and CDC, of course, do not believe there is any 
relationship to the September 11 attack, but I think all of 
America has felt a collective shiver upon learning this news 
last week, and this occurrence, this so-called ``random 
illness'' so soon after the September 11, was quite a concern.
    I think the fundamental questions we have for those 
panelists is, do we have preparedness? Are we prepared to deal 
with this crisis in America? And do we even have a definition 
that the public health community is working off of, State, 
Federal, and local, in dealing with these types of viruses and 
bacteria?
    Also, do we have the resources that are properly placed for 
both the State and local governments in the health care 
communities to sufficiently help solve this problem and clear 
up and provide specific guidance about how we are going to deal 
with bioterrorism situations?
    And so I think, Mr. Chairman, just airing those two ideas 
about what constitutes preparedness and whether we have the 
resources available in this country and at the State, Federal, 
and local level, and do the health care communities have the 
specific instructions on what to do, is extremely important. So 
I commend you for putting this hearing together.
    And to--ultimately, not to overreact but put in perspective 
what we can do to prepare, and to make sure that all of us are 
safe.
    And I yield back, Mr. Chairman.
    Mr. Greenwood. The Chair thanks the gentleman from Florida 
and would note, on our second panel, we will hear from Dr. 
Scott Lillibridge from to the Office of the Secretary, 
Department of Health and Human Services, who will give us an 
update on the Florida situation.
    That concludes the opening statements.
    [Additional statements submitted for the record follow:]
Prepared Statement of Hon. Ted Strickland, a Representative in Congress 
                         from the State of Ohio
    I would like to thank Chairman Greenwood and Ranking Member Deutsch 
for holding this hearing on an issue that has always been important but 
has added urgency after the September 11 attacks. On that day, we saw 
the almost unimaginable happen. I am glad the Subcommittee is today 
addressing what the needs of our country will be should a bioterrorism 
attack causing an epidemic occur. In addition, I would like to thank 
the witnesses for sharing with us their expertise about local 
communities' readiness and needs.
    First, I want to echo the sentiments of my colleagues who warn that 
confronting the threat of bioterrorism with anything short of calm and 
thoughtfulness will lead to a response that is both ineffective and 
wasteful of taxpayer money. Bioterrorism agents are difficult to turn 
into weapons of mass destruction and easily degrade in the environment: 
simply, science does not currently hold the mechanisms needed to easily 
create the threat of a likely bioterrorist attack. However, as science 
advances, the risk of such an attack will increase, and our country 
must be prepared. It is essential that our approach to deal with such 
an act enhances the ability of our local agencies by giving them the 
resources they need to monitor and respond to all public health 
threats, including bioterrorism, flu epidemics, and other challenges to 
the health of our entire population. And by coordinating the many 
Federal programs that have a role in mitigating the effects of any 
bioterrorism attack, we will improve our nation's ability to respond 
and potentially save many lives.
    As a representative of a rural district, I am particularly aware of 
the workforce shortage concerns expressed by the hospitals in my 
district and the effects of these shortages on our preparedness in the 
event of a bioterrorist attack. This concern is also elevated because 
as reservists who also serve their communities as physicians, nurses, 
or specialists are called to military duty, many rural and other 
hospitals already struggling with a workforce shortage may be further 
challenged to have the staff they need to provide routine patient care. 
From both the perspective of a bioterrorism threat and the long-term 
needs of our nation's health care delivery system, it is essential that 
we strengthen programs to encourage more people to serve as physicians 
and nurses. It would surely be a tragedy if certain regions of the 
country could not respond to a bioterrorism attack because its 
hospitals lack health professionals.
    In conclusion, I want to commend the successes of all members of 
the health care community for their response to the September 11 
attacks. Physicians, nurses, medical supply distributors, and mental 
health care professionals were all integral parts of the quick response 
that was needed. I look forward to the witnesses' testimony.
                                 ______
                                 
Prepared Statement of Hon. Bobby L. Rush, a Representative in Congress 
                       from the State of Illinois
    Mr. Chairman, thank you for holding this timely hearing on the 
federal government's preparedness to deal with bioterrorism. The two 
Florida anthrax cases which occurred so soon after the September 11 
terrorist attacks have thrust the issue of bioterrorism to the 
forefront.
    I would like to begin my remarks by pointing out that it is due to 
the vigilance of Florida state public health officers who detected and 
reported the first case of anthrax in Florida on October 3 that the 
federal government was able to spring into action. I commend them for 
their good work.
    This incident, whether the act of terrorism or merely a natural 
case of this disease, underscores the necessity of having a strong 
network of local public health departments. The same local public 
health officials that we rely on to respond to naturally occurring 
disease outbreaks are the same officials that are responsible for 
bioterrorism preparedness and response. Local public health officials 
are the front line soldiers in the war against domestic bioterrorism. 
They will be the first to come into contact with those infected and 
they are responsible for alerting the federal government of any 
possible bioterrorist attack.
    However, there are serious questions of whether the federal 
government is adequately preparing local health departments for a 
bioterrorist attack. Too often, we have inadequately funded local 
public health efforts. The key to preparing for a bioterrorist attack 
is not just in funding bioterrorist programs, but in creating a strong 
overall public health system. Unfortunately, some federal dollars are 
tied to narrow programs and do not address public health as a whole.
    While the topic of this hearing is the federal government's 
readiness for a bioterrorist attack, it is clear that the swiftness of 
the federal governments response to an attack is inextricably tied to 
the strength of our local departments of public health.
    Thank you.
                                 ______
                                 
    Prepared Statement of Hon. John D. Dingell, a Representative in 
                  Congress from the State of Michigan
    Today's hearing on the level of preparedness of our public health 
system for a bioterrorism attack or a pandemic caused by an unknown 
organism is particularly important because it focuses on the very 
serious deficiencies in our public health system at the local, state 
and federal levels. Improvements in our public health system can save 
lives lost every day to such diseases as new strains of infectious 
tuberculosis that are resistant to antibiotics, undetected hanta virus, 
and gastrointestinal illnesses. They also will better prepare us for 
potential biological attacks.
    To date, the Federal Government's approach has been highly 
fragmented and focused on training police, firefighters, and emergency 
medical personnel. This has worked well for chemical disasters; it does 
not for biological disasters. The first responders to a biological 
attack will most likely be hospital emergency room personnel and 
medical staff in clinics and doctors' offices. These people have been 
almost totally ignored in response planning and training. It also 
appears that there may not be sufficient stockpiles of antibiotics, 
antidotes and other medical supplies to respond to a bioterrorism 
attack because of the ``just-in-time'' inventory that hospitals, 
pharmacies, and other health care facilities have implemented.
    The fragility of the response system has been demonstrated by the 
anthrax incident in Florida. Because of one case of anthrax, 700 people 
are being tested and treated with antibiotics. There were not enough 
antibiotics available from local sources to treat even 300 people so 
the National Pharmaceutical Stockpile was activated. What would happen 
if there were 50 cases of anthrax and 35,000 people to be tested and 
treated in a very short time frame? The answer is clear: the system 
would break down.
    But we know how to fix our public health infrastructure. We know 
that increased funding is required, as well as improved federal 
direction and coordination. Now it is a simple and direct question of 
political will, given greater urgency because of the implications of 
the tragic events of September 11. We need money for training, for 
developing new vaccines and antibiotics, and for developing stockpiles 
of pharmaceuticals and other medical supplies. We need money for public 
hospitals and community health centers. And we need leadership from the 
Federal Government.
    We must be prepared to defend all our citizens from domestic or 
foreign enemies and from a variety of threats that now include 
biological agents. Undue haste and panic are unwarranted and, in fact, 
are counterproductive. But we need to begin significant and serious 
efforts to rebuild our public health system, and I look forward to 
working with my colleagues on them.

    Mr. Greenwood. The Chair would call forward the our first 
panel of witnesses. They are Dr. Amy E. Smithson, Senior 
Associate of the Henry L. Stimson Center here in Washington; 
Dr. Joseph Waeckerle, who is the Chairman of the Task Force of 
Health Care and Emergency Services Professionals on 
Preparedness for Nuclear, Biological and Chemical Incidents 
with the American College of Emergency Physicians; Dr. Kathryn 
Brinsfield, Associate Medical Director and Director of 
Research, Training and Quality Improvement, Boston Emergency 
Medical Services.
    We have Dr. Lew Stringer, Medical Director of the North 
Carolina Division of Emergency Management; Mr. Ronald R. 
Peterson, President of the Johns Hopkins Hospital, on behalf of 
the American Hospitals Association; and Dr. Dennis O'Leary, 
President of the Joint Commission on Accreditation of 
Healthcare Organizations; and Dr. Frank E. Young, former head 
of the Office of Emergency Preparedness, Department of Health 
and Human Services.
    We thank all of the witnesses for your testimony today, in 
advance, and for your patience in waiting for us to begin. You 
are hopefully all aware that this committee is holding an 
investigative hearing, and when doing so, we have the practice 
of taking testimony under oath.
    Do any of you have objection to testifying under oath?
    Seeing no such objection, I would advise you that under the 
rules of the House and the rules of the committee you are 
entitled to be advised by counsel. Do any of you desire to be 
advised by counsel during your testimony?
    Seeing no such interest, I ask you then to please rise and 
raise your right hand, and I will give you the oath.
    [Witnesses sworn.]
    Mr. Greenwood. We will recognize Dr. Smithson first for 
your testimony. Welcome. You are recognized for 5 minutes to 
offer your statement.

      TESTIMONY OF AMY E. SMITHSON, DIRECTOR, CHEMICAL AND 
 BIOLOGICAL WEAPONS NONPROLIFERATION PROJECT, HENRY L. STIMSON 
  CENTER; JOSEPH F. WAECKERLE, CHAIRMAN, TASK FORCE OF HEALTH 
 CARE AND EMERGENCY SERVICES PROFESSIONALS ON PREPAREDNESS FOR 
 NUCLEAR, BIOLOGICAL AND CHEMICAL INCIDENTS, ON BEHALF OF THE 
 AMERICAN COLLEGE OF EMERGENCY PHYSICIANS; KATHRYN BRINSFIELD, 
DIRECTOR OF RESEARCH, TRAINING, AND QUALITY IMPROVEMENT, BOSTON 
   EMERGENCY MEDICAL SERVICES AND DEPUTY MEDICAL COMMANDER, 
 NATIONAL DISASTER MEDICAL SYSTEM'S INTERNATIONAL MEDICAL AND 
   SURGICAL RESPONSE TEAM-EAST; LLEWELLYN W. STRINGER, JR., 
    MEDICAL DIRECTOR, NORTH CAROLINA DIVISION OF EMERGENCY 
   MANAGEMENT; RONALD R. PETERSON, PRESIDENT, JOHNS HOPKINS 
   HOSPITAL, ON BEHALF OF THE AMERICAN HOSPITAL ASSOCIATION; 
DENNIS O'LEARY, PRESIDENT, JOINT COMMISSION ON ACCREDITATION OF 
  HEALTHCARE ORGANIZATIONS; AND FRANK E. YOUNG, FORMER HEAD, 
OFFICE OF EMERGENCY PREPAREDNESS, U.S. DEPARTMENT OF HEALTH AND 
                         HUMAN SERVICES

    Ms. Smithson. Thank you, Mr. Chairman. And I thank the 
other members of the committee for their appearance here today, 
because I hope we all become more educated about what is 
obviously a very confusing subject for the American public and 
for some of our policymakers.
    In a continuing effort to separate fact from fiction, what 
I would like to do is start with a topic that has been in the 
news quite a lot lately. Let's talk crop dusters.
    There are many people in this country that are under the 
impression that crop dusters are suited to disperse biological 
warfare agents. Quite frankly, that is not the case. Crop 
dusters disperse materials in 100-micron particle sizes and 
larger.
    The size of a biological warfare agent particle needed to 
infect the human lung is 1 to 10 microns. So let's hopefully 
cut down on some of the apprehension about crop dusters as an 
instrument of biological terror.
    As far as the case in Florida is concerned, let's also get 
right to it. Rubbing some type of an anthrax substance on a 
keyboard is not a mass casualty dispersal attempt. So I hope 
that even though the timing of these two things, the September 
11 conventional attacks and a very unusual and possibly 
criminal case in Florida, has put us all on edge that we will 
be able to calm down and begin to consider the nature of this 
threat in a bit more, shall we say, calm atmosphere. Because 
there are important things that Washington needs to do to 
prepare this country better for a biological disaster, and 
quite frankly, this needs to be done regardless of whether or 
not terrorists overcome the significant technical hurdles 
involved in dispersing these materials in a way that would 
cause massive casualties.
    Mother Nature is out there and occasionally she wreaks 
havoc with the human population. Not only are we talking about 
emerging infectious diseases, but the increasing antibiotic-
resistant diseases that our public health officials on this 
panel can speak to much better than I.
    So this country needs to be prepared to deal with a 
biological disaster regardless of whether or not terrorists 
ever figure this out.
    I would focus the remainder of my remarks on what I 
consider to be the division of labor that needs to be achieved 
between Washington and the rest of the country, the Federal 
Government and the rest of the country.
    There are several important missions for the Federal 
Government. At the top of that list would be the need to 
enhance our programs involved in the research and development 
of vaccines and antibiotics. You will find a few remarks in 
that regard in my written testimony. In addition, the other 
thing that the Federal Government will need to provide is 
emergency medical manpower in the event that there is some type 
of significant disease outbreak in this country.
    At present, in the survey that I did for Ataxia, which 
encompassed officials from 33 cities across this country, it is 
very clear that our hospital systems and health care systems 
cannot handle the patient load of a regular influenza outbreak 
season. So they are going to probably need in very quick order 
outside medical assistance in order to cope with the incredible 
burdens on the health care system that would result from a 
major disease outbreak.
    Now, there have been statements that 7,000 medical 
personnel could be put on the spot in fairly short order. If 
you are to examine the outcome of the mid-May 2000 Top Off 
drill, you will see that the conclusion from the slated release 
of plague in Denver is that 2,000 outside medical personnel 
needed to be put on the ground within 24 hours or the local 
health care system would collapse.
    Well, I couldn't find anybody in any survey that felt like 
the Federal Government could meet just the 2,000 goal, much 
less the 7,000. I would recommend that Congress sponsor annual 
medical mobilization exercises to see whether or not the 
Federal Government can deliver what is on paper.
    There are other roles that I would recommend for the 
Federal Government, but most important the resources that are 
spent on enhancing public preparedness have to get outside of 
Washington, DC's Beltway. Right now, in this area, $8.7 billion 
are being spent on readiness, but only $311 million is making 
it outside of the Beltway. That is simply an unsuitable balance 
of where the resources are being spent.
    There are a few important things I would like to highlight 
in terms of local readiness. If our health care systems are 
going to be able to withstand the patient burden of a disease 
outbreak, they need to have in place an agreement among 
entities that are now competitors in most of our communities. 
Hospitals are private entities. They need to have regional 
hospital planning where there is a pre-agreed burden-sharing 
arrangement so that some hospitals convert over to infectious 
disease hospitals, others will take trauma patients, ladies 
having babies and heart attack victims, because these things 
will continue to occur, so those types of plans need to be 
established.
    And there were only a couple of cities that I surveyed for 
Ataxia where this type of planning was even beginning. So I 
would encourage you to support regional hospital planning 
grants.
    In addition to continuing to strengthen traditional public 
health capabilities such as the improvements being made to our 
laboratories, I would also encourage you to look at what may 
give our physicians and our laboratories that heads-up early 
warning that something is going wrong in the community, in the 
health of their metropolitan community.
    There are a few cities across the country that are engaged 
in what is called syndrome surveillance, disease syndrome 
surveillance. They are taking data that is available and 
putting it to the purpose of giving us that heads-up. This is 
another wise investment for Congress to make in the days ahead.
    I thank you for your time, and would be glad to answer your 
questions.
    Mr. Greenwood. I am sure that we will have very many 
questions. The surveillance aspect which you referred to last 
will be the subject of a hearing on this subcommittee on 
October 25.
    [The prepared statement of Amy E. Smithson follows:]
     Prepared Statement of Amy E. Smithson, Director, Chemical and 
  Biological Weapons Nonproliferation Project, Henry L. Stimson Center
    When a major, complex problem comes to light, even the most learned 
and experienced can find it tough to think calmly and rationally about 
the reasonable, constructive steps that government should take to 
address it. When the problem identified is as frightening and 
potentially devastating as a bioterrorist attack, rationality can take 
a backseat. In the last few years, indeed in the weeks since September 
11th, countless government officials have extolled their terrorism 
response capabilities, only to ask Congress in the next breath for just 
a few million more dollars so they can better address the problem. A 
few million here and a few million there soon adds up to serious money. 
Already, the General Accounting Office and some nongovernmental 
researchers like myself, have issued warnings about overlapping and 
short-sighted terrorism preparedness programs.
    The convening of this hearing is a positive sign that Congress may 
soon begin to exercise more rigorously its oversight functions 
regarding terrorism prevention and response programs. The appointment 
of Governor Tom Ridge as Director of the new Office of Homeland 
Security would seem to be a constructive step that could put improved 
coordination and streamlining of the federal response bureaucracy on a 
fast track, but that may not be the case if he is not given strong 
budgetary authority. An initial review of section 3(k) of the Executive 
Order establishing the Office of Homeland Security and the Homeland 
Security Council does not appear to vest sufficiently strong budgetary 
authority in this new office. As a matter of priority, the Office of 
Homeland Security and Congress must work together to tame the unwieldy 
federal bureaucracy and to get preparedness resources flowing to the 
nation's cities and long-neglected public health system. To aid 
Governor Ridge in his efforts, Congress should grant him czar-like 
budgetary authority. Unless this occurs in tandem with a consolidation 
of the number of congressional oversight committees, a few years from 
now a great deal of money will have been spent with marginal impact on 
reducing the threat of terrorism and mitigating the aftereffects of an 
unconventional terrorist attack.
      grasping for perspective in the aftermath of september 11th
    Despite what you might have heard in recent weeks, there are 
meaningful technical hurdles that stand between this nation's citizens 
and the ability of terrorist groups to engage in mass casualty attacks 
with chemical and biological agents. Between the misleading statements 
that have been made about the ability of crop dusters to disperse 
biological agents and the recent death of a 63-year old man in Florida 
from inhalational anthrax, the public is understandably spooked about 
the whole subject of bioterrorism. Facts often get overlooked in such 
an atmosphere, but I will resort to them nonetheless. Crop dusters 
disperse materials in a 100 micron or greater particle size, which is 
significantly larger than what would be required for the effective 
dispersal of a biowarfare agent. Another fact that has been glossed 
over is that the sheer mechanical stresses involved in putting a wet 
slurry of biowarfare agent through a sprayer can kill 95 percent or 
more of the microorganisms, to say nothing of the sensitivity that some 
agents have to environmental stresses once released. In order for an 
aerosol spray of biological agent to infect a person, the agent must 
arrive in the human lung alive, in a 1 to 10 micron particle size.
    As for the developing situation in Florida, the investigation is 
ongoing and conclusions cannot be drawn at this point. In the end, this 
sad situation may fit into a pattern typical of past terrorist activity 
with chemical and biological substances. Data compiled by the Center 
for Nonproliferation Studies at the Monterey Institute of International 
Studies show that over the past 25 years instances where subnational 
actors actually used a chemical or biological substance relate mostly 
to disgruntled workers, domestic disputes, or others with some type of 
vendetta against political figures or rivals. The substances of choice 
tended to be household, industrial chemicals and the scope of intended 
harm included one or a few individuals, not dispersal at public 
locations or in a manner where mass casualties could result. In 96 
percent of these cases where terrorists used chemical or biological 
substances, three or fewer people were injured or killed. Difficult 
though it may be, one should not jump to the conclusion that what has 
occurred in Florida is related to the horrific events of September 
11th. In the headquarters building of American Media Inc., anthrax was 
reportedly found on an individual's computer keyboard, a dispersal 
approach that does not enable mass casualties. Should the investigation 
reveal that the perpetrator(s) who introduced Bacillus anthracis into 
this building employed a dry, microencapsulated form in the requisite 
microscopic particle size, then concern would be warranted. That would 
indicate that a subnational actor had indeed scaled technical obstacles 
that other terrorists had previously been unable to overcome. Greater 
detail about terrorist activities with chemical and biological 
substances can be found in Chapter 2 of Ataxia: The Chemical and 
Biological Terrorist Threat and the US Response, which is available on 
the internet at: www.stimson.org/cwc/ataxia.htm.
    When one retreats from the hyperbole and examines the intricacies 
involved in executing a mass casualty attack with biowarfare agents, 
one is confronted with technical obstacles so high that even terrorists 
that have had a wealth of time, money, and technical skill, as well as 
a determination to acquire and use these weapons, have fallen short of 
their mark. Chapter 3 of Ataxia addresses this point at some length, 
examining the lessons that should be learned from the very terrorist 
group that got the hyperbole started, Aum Shinrikyo. To summarize, 
although the results of the cult's 20 March 1995 sarin gas attack were 
tragic enough--12 dead, 54 critically and seriously injured, and 
several thousand more so frightened that they fled to hospitals--Aum's 
large corps of scientists hit the technical hurdle likely to stymie 
other groups that attempt to follow in its wayward path toward a 
chemical weapons capability. They were unable to figure out how to make 
their $10 million, state-of-the-art sarin production facility work and 
therefore were unable to churn out the large quantities of sarin that 
would be needed to kill thousands. As for Aum's germ weapons program, 
it was a flop from start to finish because the technical obstacles were 
so significant.
           the compelling need for disease outbreak readiness
    No matter where one comes out in the debate about whether 
terrorists can pull off a biological attack that causes massive 
casualties, the fact of the matter is that the debate itself is moot. 
One need only consult public health journals to understand that it is 
only a matter of time before a strain of influenza as virulent as the 
one that swept this country in 1918 naturally resurfaces. Further 
confirmation of a looming public health crisis can be secured through a 
steady stream of reports from the World Health Organization and the 
National Institutes of Medicine, which describe how an increasing list 
of common diseases (e.g., pneumonia, tuberculosis) are becoming 
resistant to antibiotics. These public health watchdogs are also 
justifiably worried about the array of new diseases emerging as mankind 
ventures more frequently into previously uninhabited areas. Microbes 
have an astonishing capability to humble the human race: scourges such 
as plague, polio, and smallpox have devastated generations past. Even 
with everything that is in the modern medical arsenal, public health 
authorities will find it difficult to grapple with disease outbreaks in 
the future. Rapid global travel capabilities will facilitate the 
mushrooming of communicable diseases through population concentrations 
and will in turn hinder use of the traditional means of containing a 
contagious disease outbreak, namely quarantine.
    An even grimmer picture materializes when one consults those on the 
forefront of health care in America. The best medical care in the world 
can be found in this country, but US hospitals are at present poorly 
prepared to handle an epidemic. To illustrate the point, US hospitals 
already have difficulty handling the patient loads that accompany a 
regular influenza season. Ambulances wait for hours in emergency 
department bays, unable to unload patients until bed space is 
available. The press of genuinely ill and worried citizens clamoring 
for medical attention in the midst of a plague or smallpox epidemic 
would so far outstrip a normal flu season that local health care 
systems would quickly collapse.
    Ataxia, the afore-mentioned report that I released last October 
with my co-author, Leslie-Anne Levy, presents a series of 
recommendations on how to improve federal terrorism preparedness 
programs. Ataxia is based largely on interviews with first responders 
from 33 cities in 25 states conducted over a period of 1\1/2\ years, so 
this report is steeped in candor and the common-sense wisdom borne of 
experience. Drawing from this research and the feedback that continues 
to come my way in the aftermath of Ataxia's publication, I would like 
to address a few issues critical to an effective response to a major 
disease outbreak, whether caused intentionally or naturally. Those 
issues could be listed as the ability to detect an eruption of disease 
promptly, the need to establish response plans among regional health 
care facilities that could be quickly activated, and the ability of the 
federal government to provide timely delivery of emergency supplies of 
medicine and medical manpower. Any response, however, would be thrown 
off track if there is not a clear agreement on lines of authority, so I 
will start there.
              leadership in confronting disease outbreaks
    How many FBI special agents or Federal Emergency Management Agency 
(FEMA) officials know off the top of their heads the appropriate adult 
and child dosages of ciprofloxacin for prophylaxis in the event of a 
terrorist release of anthrax? Darned few, if any. No, the FBI excels at 
catching criminals and FEMA at providing mid- and long-term recovery 
support to communities stricken with all manner of disasters. An 
outbreak of disease is first and foremost a public health problem, so 
let's not be confused about who should be calling the shots in an 
epidemic--public health officials. Yet, this simple fact is certainly 
not reflected in what is taking place with regard to bioterrorism 
preparedness, inside or outside the beltway.
    Inside of Washington's beltway, concepts of crisis and consequence 
management not only linger, they predominate. With an apparent lack of 
budgetary authority and proposals circulating anew to have the Justice 
Department retain a leadership and coordination role despite the Bush 
administration's earlier appointment of FEMA in this capacity, it is 
fair to say that Governor Ridge's office will have difficulty presiding 
over the tug of war about which federal agency should lead the federal 
component of unconventional terrorism response. In America's cities, 
counties, and states there is also a fair amount of jostling as to who 
exactly would have the authority to make certain decisions during an 
epidemic. Only a handful of states, unfortunately, have untangled the 
cross-cutting jurisdictions left over from more than a century of 
contradictory laws passed as authorities scrambled to deal with the 
different diseases that were sweeping the country. Prompt, decisive 
action could make a lifesaving difference in the midst of an outbreak, 
but the experience of various terrorism exercises and drills gives 
ample reason to believe that precious time would be squandered as 
local, state, and federal officials squabbled over who has the 
authority to do what. These circumstances beg for a clear vision and a 
firm hand to untangle this mess and put the people who know the most 
about disease control and eradication--public health officials--
unquestionably in charge of any biological disaster, whether natural or 
manmade. FEMA, the FBI, the Pentagon, and other federal and local 
agencies should be playing support roles, not reshaping and second-
guessing the directions of public health professionals as they manage 
the crisis and consequences of a major eruption of disease.
 addressing problems of disease outbreak detection and overall medical 
                               readiness
    Perhaps the first challenge facing the health care community would 
be figuring out that something is amiss. Many diseases present with 
flu-like symptoms, and the physicians and nurses who could readily 
recognize the finer distinctions between influenza and more exotic 
diseases are few in number indeed. Thus, in a spot test conducted in 
mid-February 2000 in Pittsburgh, Pennsylvania, only one out of 17 
doctors correctly identified smallpox after hearing a case history and 
being shown photographs of the disease's progression. Smallpox, it 
should be recalled, presents in a most visible manner, with pustules 
covering the body. That sixteen doctors would not correctly diagnose 
smallpox can be attributed to the success of public health authorities 
in eliminating scores of diseases in America. Subsequently, medical and 
nursing schools concentrated training on ailments that health care 
givers are more likely to see.
    In another illustration of the problem, there have been far too 
many reports in recent weeks of physicians prescribing antibiotics for 
patients worried about a possible bioterrorist attack. Of all people, 
physicians should understand how such prescriptions could backfire, not 
just in adverse reactions to the antibiotics if citizens begin self-
medicating their children and themselves when they come down with the 
sniffles, but in the lessened ability of those very drugs to help their 
patients in a time of true medical need.
    The exotic disease recognition problems are not limited to the 
medical community. In the nation's laboratories, microbiologists and 
other technicians who analyze the samples (e.g., blood, throat 
cultures) that physicians order to help them figure out what ails their 
patients are much more likely to have encountered exotic diseases in 
textbook photographs rather than under their microscopes. Thanks to the 
laboratory enhancement program initiated by the Centers for Disease 
Control and Prevention, the ability to identify out-of-the-ordinary 
diseases more rapidly is on the rise in several dozen laboratories 
across the country. However, such is not the case in the 158,000 
laboratories that serve hospitals, private physicians, and health 
maintenance organizations are the backbone of disease detection in this 
nation. In conjunction with the Centers for Disease Control and 
Prevention and the Association of Public Health Laboratories, the 
American Society of Microbiology is developing protocols to assist 
clinical microbiology laboratories in identifying bioterrorist agents. 
Although the protocols have yet to be published, volume number 33 in 
the Cumulative Techniques and Procedures in Clinical Microbiology 
series addresses bioterrorism issues and is available from the American 
Society of Microbiology. As of yet, there is no national guideline 
requiring private laboratories to enhance their ability to identify 
such diseases, a component of the preparedness framework that should be 
weighed carefully by public health authorities.
    To date, the domestic preparedness training program, now 
administered by the Justice Department, has managed to draw some 
medical and laboratory personnel, mostly emergency department 
physicians and nurses, into the classroom in the cities where training 
is being provided. To enhance the disease detection and treatment 
skills of the medical community nationwide, however, a different 
strategy is required. If a long-term, systemic difference is to be made 
in the skills of medical and laboratory personnel, then more 
comprehensive instruction in medical, nursing, microbiology, and other 
pertinent schools is required. Knowledge of exotic diseases should be 
required to obtain diplomas, and the topic should become a mainstay of 
the refresher courses offered to maintain professional credentials. 
Those involved in setting the curricula for pertinent schools should 
waste no time in heeding the long-standing warnings of the Institute of 
Medicine and the World Health Organization and adjusting their course 
offerings, requirements, and other professional activities accordingly.
    With modern data collection and analysis capabilities, however, one 
need not rely solely on the ability of laboratories and medical 
personnel to pick up the telltale early signs of a disease outbreak. In 
a few areas in the United States, public health and emergency 
management officials are teaming to test concepts to get a head start 
on detection. The concept focuses on early signs of syndromes (e.g., 
flu-like illness, fever and skin rash) that might indicate the presence 
of diseases of concern. They are compiling historical databases to 
supply a baseline of normal health patterns at various times of the 
year, against which contemporary developments can be measured. Since 
people feeling ill tend to take over-the-counter medications, consult 
their physicians, or request emergency medical care, some areas are 
beginning to track the status of health in their communities via select 
Emergency Medical Services call types (e.g., respiratory distress, 
adult asthma); sales of certain medications (e.g., over-the-counter flu 
remedies); reports from physicians, sentinel hospitals, and coroners 
about select disease symptoms or unexplained deaths; or some 
combination of these markers. Once a metropolitan area has compiled 
data to understand normal patterns activity patterns at various times 
of the year, abnormal activity levels can be detected. For instance, 
when EMS calls rise above the expected rate in the fall season, public 
health officials and emergency managers would get the earliest possible 
indication that something was amiss, which would enable them to cue 
medical personnel and laboratories to search more diligently for what 
might be causing a possible disease outbreak. This concept of syndrome 
surveillance will be key to allowing public health officials to get the 
jump on prophylaxis or whatever other control measures might be in 
order.
    Nationwide, syndrome surveillance is being done in several 
locations, drawing in no small part upon the path breaking work done by 
New York City's Department of Public Health and Office of Emergency 
Management. Their efforts are summarized in box 6.7 of Ataxia, which 
again is available online so that policy makers and public safety and 
public health officials around the United States and elsewhere can have 
the benefit of the composite knowledge of the individuals who shared 
their expertise and experiences with me.
    What is now called for is a more systematic approach to 
institutionalizing syndrome surveillance across the nation. A model for 
syndrome surveillance should be refined and then made available 
nationally, along with funds to allow metropolitan areas to conduct the 
necessary historical analysis and establish the computer database, 
communications, and other components needed to put syndrome 
surveillance in place. Again, the data and the computing capabilities 
are available, it is just a matter of harnessing them for the purposes 
of early disease outbreak recognition. In their own ways, the Kennedy-
Frist and the Edwards-Hagel bills address these matters. Coordination 
of congressional action is called for so that the most readiness can be 
gained for taxpayers' dollars.
                the need for regional hospital planning
    The next challenge facing a metropolitan area in the midst of a 
major disease outbreak would be contending with the flood of humanity 
that would seek health care services. As already noted, hospitals would 
be quickly overwhelmed, so it will be critical for regional health care 
facilities to have a pre-agreed plan that divides responsibilities and 
locks in arrangements to bring emergency supplies in the interim until 
federal assistance can arrive. In the era of managed health care, 
hospitals compete with each other for business and rely on just-in-time 
delivery of supplies, keeping an average of two or three days supplies 
in inventory. Since community-wide hospital planning has fallen by the 
wayside, precious time could be wasted if hospitals lack prior 
agreement as to which facilities would convert to care of infectious 
disease cases--particularly important if a communicable disease is 
involved--and which ones would attend to the other medical emergencies 
that would persist throughout an epidemic. Business competitors, in 
other words, must convert within hours to work as a team.
    This regional hospital plan must also contend with how to handle 
the overflow of patients and provide prophylaxis to thousands upon 
thousands of people. Whether the approach involves auxiliary facilities 
near major hospitals, the conversion of civic or sporting arenas to 
impromptu hospitals, or the use of fire stations or other neighborhood 
facilities to conduct patient screening and prophylaxis, such a plan 
needs to be put in place. Other factors that regional hospital planning 
must address are how to tap into local reserves of medical personnel 
(e.g., nursing students, retired physicians), how to break down and 
distribute securely the national pharmaceutical stockpile, and how to 
enable timely delivery of emergency supplies of everything from 
intravenous fluids to sheets, tongue depressors, and food.
               federal roles in biodisaster preparedness
    Washington's willingness to fund regional hospital planning as well 
as programs that institute disease syndrome surveillance nationally 
will be critical to biodisaster readiness. In addition, the federal 
government has important roles to play in the development and 
production of essential medicines, in the provision of medical manpower 
during an emergency, and in general mid- to long-term recovery disaster 
recovery assistance. With regard to the latter role, FEMA's 
capabilities have risen steadily over the last decade and little, if 
anything, would need to be added to its existing capabilities and 
regular Stafford Act assistance activities.
    Long before the current concerns about bioterrorism, I was at a 
loss to explain how the federal government could have known about the 
extent of the Soviet Union's biowarfare program--including the 
production of tons of agents such as smallpox and antibiotic resistant 
plague and anthrax--as early as 1992 and not kicked this nation's 
vaccine research, development, and production programs into a higher 
gear until 1997. The extent of the problem is illustrated by the fact 
that only one company is under contract to produce the anthrax vaccine, 
no company currently produces the plague vaccine, and it was not until 
recently that steps were taken to meaningfully jumpstart smallpox 
vaccine production. Such matters should have been promptly addressed if 
only to enable protection of US combat troops, not to mention producing 
enough vaccine to cover the responders on the domestic front lines, 
namely the medical personnel, firefighters, police, paramedics, public 
health officials, and emergency managers who would be called upon to 
aid US citizens in the event of a biological disaster.
    As for the effort that was mounted, many nongovernmental experts 
have been taken aback at the structuring and relatively meager funding 
of the Joint Vaccine Acquisition Program. With a $322 million budget 
over ten years, this program aims to bring seven candidate biowarfare 
vaccines through the clinical trials process. Giving credit where it is 
due, one must acknowledge that this program as well as Defense Advanced 
Research Projects Agency-sponsored research into innovative medical 
treatments are making headway. However, the federal government must 
find ways to shrink the nine to fifteen year timeline that it takes to 
bring a new drug through clinical trials to the marketplace. Food and 
Drug Administration officials are already wrestling with how to adjust 
the clinical trials process for testing of new vaccines and additional 
bumps are to be expected on the road ahead.
    Next, the National Institutes of Health and the pharmaceutical 
industry, not the Defense Department, are this country's experts at 
clinical testing and production of medications. My point is not that 
the Defense Department should not have a role--perhaps even a lead role 
since the candidate vaccines originated with the US Army Medical 
Research Institute for Infectious Diseases--but these other important 
players need to be at the table if an accelerated program is to be 
achieved. As I noted, Governor Ridge will have his hands full, no 
matter which direction he turns. Moreover, close congressional 
oversight of this particular aspect of the nation's biological disaster 
readiness is warranted.
    On the chemical side of the house, by the way, the picture is 
similarly discouraging. The Pentagon now turns to one company for 
supply of the nerve agent antidote kits, known as Mark 1 kits, that the 
Health and Human Services Office of Emergency Preparedness has 
encouraged cities participating in the Metropolitan Medical Response 
System program to purchase. Many a city is still waiting to receive the 
Mark 1 kits ordered long ago, and when they do, these kits will have a 
considerably shorter shelf life than the kits made available to the 
military.
    emergency medical manpower needs during a major disease outbreak
    Secretary of Health and Human Services Tommy Thompson stated on 
September 30th in an interview with ``60 Minutes'' that his department 
has ``7,000 medical personnel that are ready to go'' in the event of a 
bioterrorist attack. While that statement may be true in theory, in 
practice it may not hold. Somewhat lost in the late 1990s rush to soup 
up federal teams for hot zone rescues was the one major non-FEMA 
federal support capability that would clearly be needed after an 
infectious disease outbreak and perhaps after a chemical incident as 
well--medical assistance. The National Disaster Medical System was one 
of several improvements made to federal disaster recovery capabilities 
over the last decade, a time during which the federal government 
demonstrated that it could bring appreciable humanitarian and 
logistical assets to bear after natural catastrophes and conventional 
terrorist bombings. While these events flexed the muscles of the FEMA-
led recovery system, including the deployment of Disaster Medical 
Assistance Teams, they did not even approach the type of monumental 
challenge that a full-fledged infectious disease outbreak would 
present. Prior to Secretary Thompson's recent statement, officials from 
the Health and Human Services Department and the Pentagon have also 
stated that they could mobilize significant medical assets quickly.
    Yet considerable skepticism exists that these two departments 
combined could have met the medical aid requests made from Denver after 
the release of plague was simulated during the mid-May 2000 TOPOFF 
drill, much less a call for even more help. During that hypothetical 
event, health care officials quickly found their medical facilities 
sinking under the patient load and concluded that 2,000 more medical 
personnel were needed on the ground within a day to prevent the flight 
of citizens that would have further spread the disease. Getting that 
number of physicians and nurses to a city and into hospitals and field 
treatment posts would be a tremendous logistic achievement. No one that 
interviewed for Ataxia, including members of the Disaster Medical 
Assistance Teams and other medical and public health professionals, 
felt that the federal government could deliver 2,000 civilian medical 
professionals within the required timeframe. For its part, the Pentagon 
has yet to articulate clearly or commit to civilians at the federal or 
local level just how much medical manpower it could deliver and in what 
timeframe.
    Quite frankly, the time has come for the Pentagon to stop being coy 
about what medical assets it could bring bear in a domestic emergency. 
Articulation of this capability, even if it needs to be done in 
classified forums, is necessary for sound planning on the civilian 
side. Furthermore, there have been no large-scale dress rehearsals to 
confirm whether civilian or military medical assets could muster that 
many medical professionals that quickly, or even over a few days. Even 
so, the 2,000 figure from the Denver segment of TOPOFF seems almost 
quaint when compared to one US city's rough estimate that 45,000 health 
care providers--many of whom would have to be imported--would be 
required to screen and treat its denizens.
    The only way to find out whether the federal government is truly up 
to the most important role it may have to perform after a bioterrorist 
attack or a natural disease outbreak is to hold a large-scale medical 
mobilization exercise. Despite the expense, Congress should mandate a 
realistic test of how much civilian and military medical assistance can 
be delivered, how fast. Unlike TOPOFF, where federal assets were pre-
picked and pre-staged, the terms of the exercise should specify that 
teams deploy as notified. While the general nature and identity of the 
exercise location(s) would certainly be known beforehand and the 
timeframe of the drill agreed within a window of several months, local 
officials should trigger the onset of the exercise. In short, dispense 
with the tabletop games that allow everyone the comfort of claims of 
what they could do and see what a real exercise brings. A genuine and 
probably sobering measure of federal capabilities could be taken, and 
the lessons of the exercise could inform the structure of federal and 
local plans and programs.
                              conclusions
    One need not resort to hyperbole when it comes to how difficult it 
would be for major US cities to handle a pandemic; the truth is 
sobering enough. Even though the basic components of the ability to 
handle a disease outbreak--hospitals, public health capabilities at the 
federal, state, and local levels, and a wealth of medical 
professionals--are already in place, there is ample room for 
improvement. The pragmatic steps that the federal government should 
take are clear. Mr. Chairman, Members of the Committee, Washington can 
take the smart route to enhance biodisaster preparedness nationwide or 
it can continue to go about this in an expensive and inefficient way. 
The keys to biodisaster readiness are as follows:

 The sufficiency of existing federal programs, response teams, 
        and bureaucracies needs to be assessed and redundant and 
        spurious ones need to be eliminated. In the interim until an 
        assessment of the sufficiency of existing assets is made, a 
        government-wide moratorium on any new rescue teams and 
        bureaucracies should be declared, with the exception of the 
        enhanced intelligence, law enforcement, and airport security 
        measures that are being contemplated.
 Defense Department programs related to the development and 
        production of new vaccines and antibiotics need to be put on a 
        faster track and incorporate expertise in such matters from 
        outside the Pentagon.
 The federal government should continue to revive the nation's 
        public health system, an endeavor that involves sending funds 
        to the local and state levels, not keeping them inside the 
        beltway. In addition, the federal government should fund 
        regional hospital planning grants and additional tests of 
        disease syndrome surveillance system, followed by plans and 
        funds to establish such capabilities nationwide.
 Appropriate steps should be taken to see that physicians, 
        nurses, laboratory workers, and public officials benefit from 
        training that is institutionalized in the nation's universities 
        and schools.
 Last, but certainly not least, Washington needs to develop a 
        plan to sustain preparedness over the long term. Drills at the 
        local and federal levels are necessary because plans that sit 
        on the shelf for extended periods of time are often plans that 
        do not work well when emergencies occur.
    I will wrap up with one more essential task to which each 
individual member of Congress must attend. Since September 11th, I have 
received numerous calls from offices on both sides of the Hill and both 
sides of the aisle, asking me to brief them on these issues and to help 
fashion legislation that would put Representative ``X's'' or Senator 
``Z's'' stamp on the legislation that is taking shape. While I have 
responded as quickly as possible to such requests, they are in some way 
indicative of the problem that Washington faces if it is to craft 
meaningful, cost-effective preparedness programs.
    With all due respect, I would point out that while the attacks of 
September 11th occurred in New York City and Northern Virginia, they 
were attacks on this nation as a whole. Those who risked their lives 
that day to save the lives of others were not thinking about themselves 
or their future, they were selflessly acting in the interests of 
others. Put another way: this is no time for pet projects, whether they 
be to benefit one's home district constituents or a particular branch 
of government. This is not about job employment, it is about saving 
American lives. The future well-being of each American, I would 
contend, is equally important.
    On behalf of the local public health and safety officials who have 
shared their experience and common sense views with me, I urge Congress 
to waste no time in passing legislation that brings the burgeoning 
federal terrorism preparedness programs and bureaucracies into line and 
points them in a more constructive, cost-effective direction. The key 
to biodisaster preparedness lies not in bigger budgets and more federal 
bureaucracy, but in smarter spending that enhances readiness at the 
local level. Even if terrorists never strike again in this country, 
such investments would be well worthwhile because they would improve 
the ability of hometown rescuers to respond to everyday emergencies.

    Mr. Greenwood. Dr. Waeckerle.

                TESTIMONY OF JOSEPH F. WAECKERLE

    Mr. Waeckerle. Good morning.
    Mr. Greenwood. You are recognized.
    Mr. Waeckerle. Good morning to all of the members and my 
fellow panelists. I am Joe Waeckerle; I am a Board certified 
emergency physician in Kansas City, practicing. I have been 
involved in this area for the last 8 or 9 years as a consultant 
to the FBI, the Defense Science Board and CDC and Office of 
Emergency Preparedness.
    I also serve as the task force chair, as you spoke to 
earlier. I am passionate about domestic preparedness and have 
spent too much time in the area, as we all must now.
    America has been targeted. America has been attacked and 
America has suffered, and we all mourn as we should. But we 
need to do more than mourn to better protect our country and 
honor those who have suffered and died. We need to be prepared 
and, especially, prepared against biologic weapons.
    We are extremely vulnerable. Numerous analyses of the 
escalating risks to America and the considerable deficiencies 
have been presented before you and other Members of Congress, 
both internal, external and from distinguished people, like Dr. 
Smithson to my right. They have demonstrated considerable 
deficiencies which the government has appropriately addressed, 
but there are many that still linger.
    Careful consideration of the lingering major deficiencies 
are obvious points of interdiction requiring urgent reform that 
we can address, and I hope to do so for some today.
    The failure to recognize biowarfare is a national threat 
that has resulted in a lack of a comprehensive national 
strategy. I therefore ask Congress to demand a specific 
comprehensive and sophisticated strategy of deterrence and 
defense against bioweapons. This currently does not exist and 
has not trickled down to the local community.
    The failure to mandate and implement a centralized Federal 
authority has resulted in a void in leadership which, as you-
all alluded to, is remarkable and causes fragmented, 
uncoordinated, redundant and inefficient planning and 
preparation.
    Please authorize and fund a central Federal management and 
oversight group, whether it be in Governor Ridge's office or 
another, so that we can develop and implement a comprehensive 
deterrent and defense strategy, and we can have better 
communication and cooperation and integration between the 
Federal family and the local first responders who will be the 
first people to protect our country.
    I will not discuss planning or detection deficits, you will 
discuss those, but I will tell you that I served on the Defense 
Science Board's recent task force, and that report was given to 
you, I believe, 2 weeks ago. It is remarkably well done. I 
apologize for saying so. And I urge you to look at it.
    I would like to talk about three other issues.
    The failure to maintain our public health system: Not 
having a public health infrastructure in this country has 
severely retarded our ability to detect, identify and 
investigate epidemiologic--appropriate epidemiologic studies. 
The Congress, therefore, must ensure that the public health 
system be retooled with appropriate capabilities and capacities 
for biowarfare, and be linked to emergency and other health 
care professionals so we have better detection and better 
notification.
    This is an added value to the natural epidemics and 
infections occurring today that it will benefit such retooling. 
The failure to engage hospitals in this endeavor is a severe 
problem.
    Hospitals are certainly financially frail. There is 
overcrowding. There are too few beds, too light staff, and too 
little supplies and resources due to financial frailty. There 
is no surge capacity. Congress must recognize that emergency 
departments and their hospitals are the critical component of 
the infrastructure of biodefense, along with public health, and 
must take steps to necessarily fortify their abilities.
    Finally, the failure to engage emergency health care 
professionals has resulted in the lack of awareness of national 
strategy, a lack of clinical acumen of the bioagents and a lack 
of understanding of their vital roles.
    Patients will come to the emergency departments, as you 
correctly pointed out. The ER is where we always go. That will 
be the incident scene in contrast to the tragedies in New York 
City. The first responders will now be emergency physicians, 
emergency nurses and emergency medical technicians. So they 
must be able to detect and diagnose and notify our system and 
implement treatment quickly. Unfortunately, we are not prepared 
to do such, as our task force pointed out.
    Also, because of that, we may be not only the first 
responders, but the second victims, further destroying the 
infrastructure of our health care in this country. Congress 
must therefore authorize and implement an overall plan for 
providing, sustaining and monitoring appropriate educational 
experiences for these essential emergency care professionals.
    An overarching strategy that our task force recommends you 
consider is to no longer fund private contractors through DOD 
or DOJ, but to allow HHS or the new office to directly partner 
with the professional organizations of all health care 
professionals, who communicate, educate, monitor and regulate 
their own members on a day-to-day basis.
    Don't reinvent the wheel. The wheel is there.
    In conclusion, to deter or mitigate any terrorist action 
against our country or our people, Congress must provide the 
leadership, financial support and organizational and logistical 
support requisite to developing a comprehensive national 
strategy, preparation and response.
    Certainly such preparation is costly, both financially and 
personally to all of us. However, America must remain resolute. 
For what is the price of our freedom, of our country's well-
being and our citizens' lives?
    Thank you for the opportunity.
    [The prepared statement of Joseph F. Waeckerle follows:]
  Prepared Statement of Joseph F. Waeckerle, Chairman, Task Force of 
 Health Care and Emergency Services Professionals on Preparedness for 
 Nuclear, Biological, and Chemical Incidents, The American College of 
                          Emergency Physicians
                              introduction
    Chairman Greenwood and members of the Subcommittee, good morning. I 
am Dr. Joseph F. Waeckerle, Editor in Chief of the Annals of Emergency 
Medicine, the Journal of the American College of Emergency Physicians. 
I am a Board of Emergency Medicine certified physician, and the 
Chairman of the American College of Emergency Physicians' Nuclear, 
Biological, and Chemical Task Force. I am here today testifying on 
behalf of the American College of Emergency Physicians (ACEP), which 
represents more than 22,000 emergency physicians and their more than 
one hundred million patients.
    I want to thank you for the opportunity to appear before you today 
to discuss the readiness and capacity of the federal programs to 
provide needed health related services in the event of a biological 
terrorist attack.
    The focus of the nation since September 11 has been on the tragic 
and senseless loss of lives caused by terrorists willing to fly air 
planes into buildings. I want to talk to you today about the new 
weapons of war that have emerged in our modern world which perhaps 
represent the greatest long-term threats to our national security. 
Preeminent among them are biological warfare agents. To date, our 
nation has had very little experience with threatened bioweapon use. 
What experience we have had has involved small, isolated events not 
indicative of the true potential devastation of bioagents.
    The use of biologic agents as weapons of war could approximate the 
lethality of a nuclear explosion, can decimate a large population, and 
thereby destabilize a nation. It can inflict psychological and economic 
hardship and political unrest by attacking small populations in 
multiple sites over a protracted period. America's citizens, national 
security and international stature are at risk should a bioweapon be 
used.
                      america's state of readiness
    There have been numerous analyses of the escalating risks to 
America and the considerable deficiencies in our responses to the 
threat of any weapon of mass destruction much less biologic warfare. 
Internal reports from the Federal government (Defense Science Board, 
Defense Threat Reduction Agency, General Accounting Office), external 
assessments by august panels such as Hart-Rudman and the Gilmore 
commission, and private testimonies including the Smithson report and 
individuals before Congress repeatedly warn of the serious deficiencies 
in our planning and preparation. Authorities have acted on these 
deficiencies, but we must decisively improve much more. Careful 
consideration of the existing strategies and response protocols reveals 
major deficits that are obvious points of interdiction.
                        national strategy deficit
    A comprehensive national strategy must be predicated on an in-depth 
analysis of threats and risks. By identifying credible threats, 
available assets, and resultant vulnerabilities, a cogent national 
strategy can be generated. To date, the approach has centered on an 
``all-hazards'' approach. Most of our nation's hospitals have policies 
to respond to hazardous materials (HAZMAT) incident, which are 
inadequate for responding to some chemical agents and nearly all 
biologic agents. Certainly, conventional weapons are and should be our 
main focus. Current planning has also focused on chemical weapons with 
many federal agencies and departments specifically addressing these 
threats. This is appropriate to a degree because there are currently 
about 850,000 facilities in the US using hazardous or extremely 
hazardous materials. Better preparation for possible hazardous 
materials incidents whether they are the result of industrial accidents 
or perpetrated by terrorists is beneficial to our country.
    Many governments and civilian authorities rightly believe that 
biologic agents suitable for warfare are readily available. The 
dissolution of the USSR has led to the cessation of funding for their 
once formidable bioweapons facilities and financial hardship for the 
employees. As such, security is minimal and personal motivation to 
survive, much less profit, is utmost, so bioagents may be ``on the 
market.'' Compared with conventional weapons, research and development 
of bioagents are economically feasible today for many other nations as 
well. Research and development is now where once only a few had the 
capability and resources to pursue these avenues. As a result, many 
nations/states have aggressively and successfully pursued their own 
biowarfare research and development.
    There is also legitimate scientific application of microbiology, 
which could be used to develop biologic agents. The pharmaceutical 
industry, beverage industry, and others pursue research in biology to 
benefit mankind. Because of the overlapping assets used for producing 
legitimate products and bioweapons, it is extremely difficult to 
estimate and regulate research and development activities to prevent 
legitimate research from falling into the wrong hands. Today, any 
bidder may easily procure samples of bioagents from a variety of 
sources both legitimate and illicit.
    Even if only small samples of a bioagent are available, technologic 
advancements make it possible for nations or organizations to culture 
and harvest adequate quantities of an agent relatively inexpensively 
and virtually anywhere. Bioagents can also can be easily stored and 
transported. Dissemination, which may be most problematic in using 
these agents, is now more easily accomplished as well.
    For those individuals seeking to gain competency in this area, 
knowledge is readily available. Educational opportunities are offered 
in the formal education process including high school, college, and 
graduate level courses and informally through widespread availability 
of knowledge via the Internet. In addition, motivated researchers using 
advanced techniques can now build engineered pathogens that are even 
more suitable for biowarfare.
    The list of agents that could be used in a biological attack is 
formidable and growing. Legitimate and nefarious researchers have 
scrutinized the naturally occurring agents as to what clinical and 
biologic effects are most requisite. Also, newly engineered bioagents 
are now more than ever viable threats against which the US is 
vulnerable because they are custom built as weapons.
    The capability is there, and today's world fosters malcontents, 
extremists and malicious opportunists that view the United States with 
hostility. These groups include nation/states, groups, and 
individuals--both domestic and international--that are motivated by 
political, social, economic, religious, or criminal intent. Nations who 
could not challenge the United States because of the high cost of 
conventional warfare now have the capability through the use of 
biologic weapons to challenge our dominance as the sole remaining 
superpower. Individuals and groups of zealots, extremists and criminals 
also view the recent availability of bioagents as an opportunity to 
wage asymmetric warfare in order to exert influence and manipulate the 
system for their own gain.
    Some authorities have argued that moral constraints will limit the 
use of such particularly lethal weapons (weapons of mass destruction) 
especially if civilians are exposed. However, the September 11 assaults 
on America have shown the contrary.
    The inevitable conclusion is that the availability of biowarfare 
agents and supporting technologic infrastructure, coupled with the fact 
that there are many who are motivated to do harm to the US means that 
America must be prepared to defend her homeland against biological 
agents. Denial of this threat or the excuse that this threat is too 
difficult to plan for is no longer tenable.
    Although the probability of a bioattack is difficult to measure, 
the consequences are high. Biowarfare is a multidimensional problem due 
to the diversity of bioagents each with particular threat 
characteristics, plethora of vulnerable targets and varied routes of 
dissemination. As such, there is no typical presentation, no easily 
recognizable signature to allow easy detection or identification, 
limited treatment options and a disturbing array of sequelae. A 
biological attack on America will impose unparalleled demands on all 
aspects of our government and our societal infrastructure that must be 
met.
    The consequences of poor preparation are not tenable. 
Considerations for the use of potential biological weapons are the sine 
qua non of future defense readiness. Biological weapons are such 
formidable weapons of uniqueness and complexity that a specific defense 
strategy is essential. The triumvirate of research, preparedness and 
response issues pertinent to biowarfare are central to the formulation 
of a robust strategic blueprint. Congress must demand a specific, 
comprehensive and sophisticated strategy of deterrence and defense.
              command, control and communication deficits
    The United States must designate and give adequate authority to a 
central office to coordinate the various agencies involved in emergency 
response. A single line of authority is traditional in the Defense 
Department and law enforcement for good reason. Yet the United States 
has a multitude of federal agencies and departments with vested 
interests in WMD preparation, and there is no authority structure. The 
result is efforts in formulate and implement a national strategy are 
fragmented, uncoordinated, redundant and inefficient. Unfortunately, 
the absence of unity not only decays the Federal effort it undermines 
the critical partnership between Federal authority and State and local 
authorities.
    Communication is also a major problem in domestic preparation 
today. Due to the lack of an overreaching authority, there is little 
communication among active Federal participants in domestic 
preparedness. Equally disturbing, the lack of communication among the 
Federal families trickles down to the state and local communities. As a 
result, preparation for the possible use of WMD especially biological 
weapons without Federal assistance is not achievable for most 
communities in America. Our communities desperately need guidance and 
support but little communication results in little progress. This is an 
unacceptable outcome given the risks.
    Until authority is mandated, centralized and implemented, turf 
battles, egos, pettiness and power and money struggles will preclude 
effective use of our dollars and prevent a collaborative and integrated 
preparedness process on a national level or local level. Congress 
should authorize and fund a centralized Federal management and 
oversight office.
                           planning deficits
    Any response to a weapon of mass destruction on American soil will 
first be local and community-based perhaps for an extended period of 
time. This means that communities must have plans that are well 
conceived and effectively coordinated. Although a general plan in most 
communities today, the local response is currently not well informed, 
not well financed, not well trained or drilled, and not properly 
integrated into the overriding federal response. Federal authorities 
must ensure coordinated ventures with the local communities but they 
must first cooperate among themselves to do so.
    Furthermore, current disaster preparedness programs in US 
communities are often insufficient in their design in that they are 
generally inappropriate for specific preparation and response against 
biowarfare. A biological agent incident requires a vastly different 
response with regard to management and personnel and resources needed. 
The multi-agency, multi-jurisdictional character of the many 
uncoordinated strategies being delivered by the Federal family to the 
local community makes success against biowarfare a remote possibility. 
Congress must direct the centralized the federal management and 
oversight office to provide preparedness and response, education, 
guidance, and financial support directly to State and local 
communities.
                           response deficits
    The cornerstone of the Nation's response will lie in the medical 
and public health communities. It is critical they be actively involved 
in the threat-assets-risk analysis and subsequent national and local 
preparation efforts. They are essential to controlling disease 
outbreaks through appropriate and timely detection and identification, 
investigation and management.
Detection and Identification Deficits
    The United States must establish, strengthen, and expand 
sophisticated surveillance systems that are integrated with the public 
health systems and the nation's emergency departments. Efforts to 
detect bioagents in the environment before people become infected 
currently face significant technical obstacles. This is unfortunate 
because the best defense is to detect the agent prior to its infecting 
individuals. Likewise, the current technology has not matured to the 
point that rapid and reliable diagnostic testing of individuals is 
available. The absence of such capabilities will significantly impede 
timely response and appropriate management.
    At present, the detection of a disease outbreak depends on alert 
clinicians--or human surveillance. However, most health care 
professionals are not trained to recognize the symptoms of most of 
diseases from bioweapons agents nor do they have any experience with 
these agents. Patients may only exhibit non-specific flu-like symptoms 
during the early stages of their infection, and clinicians probably 
would recognize an outbreak only after a number of patients presented 
with highly unusual symptoms or died of unusual circumstances.
    The United States must improve the partnership between health care 
system and public health agencies. Physicians are not prone to 
reporting puzzling cases of illness to health officials. Moreover, few 
public health departments have the personnel or resources to conduct 
real-time disease reporting or provide expert advice.
    The absence of real-time surveillance and simple, quick and 
reliable diagnostic testing further complicates matters. It will be 
difficult for clinicians to determine the location and scope of the 
attack. Infected individuals could move about without overt 
manifestations during the incubation period of infection. Depending on 
the agent, contagion could be spread unknowingly, further amplifying 
the peril. The ability to determine who is actually infected so needs 
treatment and who is not infected so needs only reassurance is 
paramount. Potentially, the ``worried well'' may overwhelm the health 
care system just as it needs to be entirely focused on the truly 
infected. The inability to distinguish the infected victims also does 
not allow appropriate disease containment.
    Complicating this, most hospital and commercial labs cannot 
definitively identify the bioweapons pathogens of greatest concern, 
such anthrax or smallpox. There are also serious concerns about the 
capacity of laboratories to cope with increased demands, and the 
capacity of hospital emergency departments that are already operating 
at critical capacity to respond. The CDC has been working with state 
public health laboratories to augment their abilities and capacities 
and foster a national laboratory system.
    Congress must support public and private research for the 
development of real-time alerting and tracking surveillance systems 
with analytical capabilities as well as rapid and reliable diagnostic 
tests for bioagents.
Investigation Deficits
    Suspicion that a bioterrorist attack has occurred will provoke 
public health officials to begin an immediate investigation. 
Epidemiologic investigations are essential to managing outbreaks of 
contagious disease. However, the U.S. public health infrastructure is 
fragile and in much need of rebuilding as has been previously reported. 
State and local health departments often lack sufficient professional 
staff, office support and equipment, and the laboratory capacity to 
perform the basic public health functions much less respond to a large-
scale incident.
    As noted above, the absence of real-time electronic surveillance 
systems is a serious problem. These systems could provide information 
and analysis of data from key testing and monitoring sources thereby 
allowing up-to-date understanding of an incident. Better understanding 
will result in more focused and presumably more successful 
interventions.
    Congress must ensure that the public health system be retooled with 
the appropriate capabilities and capacities needed for biowarfare, and 
be linked to emergency healthcare systems.
                           management deficits
Personnel Deficits
    The United States must train emergency healthcare personnel to 
recognize and treat victims of a biologic attack, as well as to report 
incidents. This is vital to our nation's preparedness for a successful 
response to a bioagent, medical personnel and medical resources are 
paramount. Local civilian medical systems--both out-of-hospital and 
hospital--are the critical human infrastructure. These professionals 
will be integral in recognizing a bioagent and minimizing the 
devastation. As in any emergency, concerned or infected patients may 
come to the ``ER'' seeking medical help. Emergency physicians and 
nurses and emergency medical technicians will therefore be the ``first 
responders.'' Thee first and most critical line of defense for 
detection, notification, diagnosis, and treatment of a bioincident. 
However, this may be delayed if the treating emergency physicians and 
nurses do not have the clinical knowledge and high index of suspicion 
to recognize the features of a biologic attack and activate a response.
    Emergency physicians and nurses along with other health care 
professionals in current preparedness programs. Emergency health care 
professionals need to be integrated and educated. These professionals, 
in turn must understand the need to become active participants in the 
preparedness arena. This specifically includes understanding of local 
disaster plans, including incident command systems and hospital 
disaster plans.
    An overall plan must be implemented for providing, sustaining, and 
monitoring appropriate educational experiences for these emergency 
health care professionals in the field of biologic warfare. Unless this 
training is forthcoming, a critical link in the management of a 
bioincident will be missing.
    To that end ACEP's Task Force of Health Care and Emergency Services 
Professionals on Preparedness for Nuclear, Biological, and Chemical 
Incidents assessed the needs, demands, feasibility, and content of 
training for emergency physicians, nurses, and paramedics for nuclear/
biological/chemical (NBC) terrorism. The task force recommended that 
training programs and materials need to be developed and incorporated 
into these professionals' formative education and into their continuing 
education. The task force developed the core content essentials for 
incorporation into
    Educational programs and recommended that each of the three groups 
be trained relative to their particular job responsibilities and 
anticipated levels of involvement.
    It was suggested that a multidisciplinary oversight panel of 
content experts, educational specialists, and representatives of major 
professional organizations representing each of the three audience 
groups implement these educational strategies. The oversight panel 
would be tasked with the responsibility for the consistency, quality, 
and updating of the products developed. Additionally, the oversight 
group would work to establish partnerships with organizations and 
institutions to assist with the implementation of the recommendations 
discussed in this report. The multi disciplinary oversight group is an 
integral part in the development of each recommendation for each of the 
target audiences. They also formulate and manage formal plan for 
evaluating each educational product. To support the work of the 
oversight group, a national clearinghouse or repository should be 
established to collect relevant information, including articles, books, 
reports, research, instructional materials, and other media.
    An important overarching strategy to support the proposed 
recommendations is to work with national professional organizations and 
associations to increase all health care professionals' understanding 
of the necessity of this type of education.
    Working through national professional organizations and 
associations, Congress must authorize an implement an overall plan for 
providing, sustaining, and monitoring appropriate educational 
experiences for emergency healthcare professionals in the field of 
biologic warfare.
 Hospital Deficits
    Unfortunately, civilian health care facilities are not, in general, 
integrated into a community or regional disaster response system. 
Hospitals tend to be autonomous, competitive institutions so most are 
not committed to cooperative efforts that would be needed during a 
community-wide disaster. Furthermore, hospitals do not possess or 
regularly exercise requisite communications networks.
    Hospital capacity and capability are very real dilemmas today. Many 
American hospitals are financially frail. They have responded to 
financial pressures by cutting staff, reducing inventory and 
eliminating money-losing operations. ``Just-in-time''' staffing and 
supplies flow models now govern the number of personnel working and the 
resources available on a given day. These cost-cutting measures have 
reduced hospitals' flexibility; they have no surge capacity in the face 
of sudden or sustained stress. As a result, it would not take many 
casualties presenting for evaluation and specialized treatment to 
overwhelm the hospital system of a large American city. Nowhere is this 
more evident than in the emergency departments where overcrowding, and 
lack of critical resources are the norm.
    Staffing issues are also challenging. Although many if not most, 
physicians and nurses hold hospital privileges at several facilities so 
this will be available to only one institution. Hospital staff 
privileges requirements and state licensing restrictions are barriers 
to doctors and nurses from outside the community assisting. Further 
complicating the local shortage, many health care professionals are 
committed to military duty as reservists or have volunteered to serve 
on medical assistance teams or at emergency operations centers.
    In addition to professional staff, hospital operations depend on a 
wide array of skills--the absence of lab technicians, security guards, 
food service, or housekeeping personnel would significantly affect the 
efficiency and effectiveness of the whole institution. Furthermore, a 
significant proportion of a hospital's staff may fail to report to work 
in the midst of an epidemic due to fear of a deadly, contagious 
bioagent.
    Congress must recognize that hospitals and their emergency 
departments are critical components of the infrastructure of America's 
biodefense system, and must take these steps necessary to fortify their 
ability to respond.
Medical Treatment Deficits
    For almost all of the bioagents thought to represent a serious 
threat, the speed with which appropriate medical treatment is 
administered is critical, i.e. early detection. Different bioweapons 
agents will require different medical treatment and in some cases there 
are scant scientific and clinical data available to support treatment 
decisions. The effectiveness of existing antibiotics and vaccines to 
prevent or limit the severity of diseases caused by bioweapons 
pathogens is quite limited as well. For some bioagents, antibiotic 
treatment is effective but in some cases only if given before symptoms 
begin or become severe. In other instances, the mainstay of care is 
supportive which can be very labor intensive.
    Currently, there are no effective vaccines for many important 
bioweapons agents. When available, some vaccines have undesirable 
features and in other cases, existing vaccine supplies are limited. 
Special populations, such as children, pregnant women, and immune-
compromised persons may be a particular risk or have contraindications 
for specific therapies. The possibility of bioengineered weapons 
resistant to traditional therapies must also be considered.
    It is clear that there is major shortfall in the readily available 
capacity of drugs and vaccines. It is also clear that there are many 
vaccines yet to be developed. This is due to the lack of existing 
commercial partners interested in undertaking the production, minimal 
excess capacity within the drug and vaccine industry even if there were 
interested parties, and the regulatory and technology transfer issues 
that need to be overcome in order to rapidly manufacture critical 
supplies.
    In addition, there is a lack of a coherent acquisition strategy for 
national pharmaceutical and vaccine stockpiles. The federal government 
has recognized that the availability of necessary vaccines and 
antibiotics is a critical component of an effective bioterrorism 
response and has taken steps to create a National Pharmaceutical 
Stockpile (NPS) of medicines and supplies. However, significant 
logistical problems were encountered in the handling and distribution 
of the supplies during Operation Topoff that must be remedied.
    Congress should direct the centralized federal management and 
oversight office to partner with private industry interested in 
undertaking the research, development, and production of necessary 
pharmaceuticals; maintaining some surge capacity. Congress should also 
address the regulatory and technology transfer barriers that impede 
rapid development and availability of critical supplies.
                              conclusions
    The United States homeland is vulnerable. We are a free society; 
our greatest right is our greatest liability. We are an inherently 
trusting and tolerant people so we are not overly suspicious. We are 
peace loving; we do not act offensively but only respond when provoked. 
Finally and fortunately, we have had essentially no first hand 
experience with any form of modern warfare waged in our country until 
recently
    An attack against the homeland using a biological weapon would 
severely test us. Foremost, the ability to mitigate the consequences of 
a bioterrorist attack is directly tied to the deficits of the civilian 
medical and public health systems. The importance of limiting 
casualties and minimizing interference with daily life is obvious. In 
addition, failure to deliver adequate medical care or to execute 
appropriate public health measures could lead to loss of public 
confidence in the government's ability to protect our citizens, raise 
the possibility of profound, even violent, civil disorder, and possibly 
diminish America's position internationally.
    Americans must now commit to not allow such heinous acts to occur 
in our country. We must all vow to become involved. Our goal is to 
deter or mitigate any terrorist action against our people or our 
country. Federal authorities must provide the leadership, the financial 
investment and the organizational and logistical support requisite to 
develop a comprehensive national strategy, solid domestic preparedness 
and appropriate response plans. Health care professionals and state and 
community leaders must pledge dedication and involvement. Such 
preparation is very costly, financially, and personally. There is never 
enough time. But American must remain resolute, for what is the price 
of our freedom, of our country's well-being, of our lives.

    Mr. Greenwood. Thank you very much for your testimony, Dr. 
Waeckerle.
    Dr. Brinsfield, you are recognized for 5 minutes.

                 TESTIMONY OF KATHRYN BRINSFIELD

    Ms. Brinsfield. Mr. Chairman, members of the subcommittee. 
My name is Kathryn Brinsfield. I am the Director of Research, 
Training, and Quality Improvement for Boston Emergency Medical 
Services, a practicing Emergency Medicine physician, and the 
Deputy Medical Commander of the National Disaster Medical 
System's International Medical and Surgical Response Team-East.
    As the youngster on this panel, I would like to thank you 
for inviting me here to speak me on this topic.
    On March 20, 1995, Sarin was released in the Tokyo subway 
system. The incident started at 7:55 a.m. And the last patient 
was treated before noon.
    On September 11, 2001, the terrorist events at the World 
Trade Center killed over 6,000. The last live victim was 
rescued within 36 hours. All disasters are local. And terrorist 
disaster response is a local response.
    Federal programs have helped prepare localities for dealing 
with these disasters, but there is still more to do. While 
Federal response provides important relief in the forms of 
specialized experience, credentialed personnel and supplies, 
the ability of a locality to rescue, treat, transport and 
provide definitive care to its own citizens weighs the balance 
between life and death. This holds true for bioterrorism, 
although in nontraditional ways.
    Treatment and stabilization of a bioterrorist event is 
dependent on recognition that an event is under way, and 
recognition is dependent on the ability of local responders in 
the local public health office.
    In Boston, we are lucky to have a strong Public Health 
Commission with Cabinet-level input into the operations of the 
city. This has allowed our local CDC office to take the lead in 
organizing a citywide hospital volume surveillance system which 
has, 2 years running, detected the onset of influenza in the 
State prior to laboratory isolation.
    Our recent exposure to the West Nile virus proved that 
incident command training for public health professionals pays 
off and that the public health director can act as incident 
command with police, fire, EMS and other city agencies 
participating in a unified command structure.
    In bioterrorism, the ability to respond is dependent on the 
education and equipment of the prehospital personnel and 
hospital providers.
    In Boston, we are also fortunate to have an Emergency 
Medical Service with strong city support. This has allowed us 
to train all of our EMTs and paramedics in hazardous materials 
and bioterrorism. Even though the training materials are 
provided free to agencies, training and salary costs are not. 
Annual recurring training and fixed costs supported by the city 
are close to a half million dollars for a small agency alone.
    For every 1,000 people exposed to anthrax, the cost of 
treating the victims prior to the arrival of a national 
pharmaceutical stockpile is $25,000.
    In Boston, we are lucky to have funding through the HHS 
Office of Emergency Preparedness MMRS program. We are also 
fortunate to have the support of local hospital pharmacies and 
pharmacy colleges, who agreed to rotate the stock of 
antibiotics and provide pharmacists for us.
    We also have a strong Conference of Boston Teaching 
Hospitals, which has a long history of working together to 
improve the health care in the city. Those relationships proved 
invaluable in pulling hospitals and physicians into the 
terrorism planning process through Emergency Medical Services 
over the last 5 years.
    In Boston, we consider ourselves fortunate to have been one 
of the initial cities trained under the Domestic Preparedness 
program. Although not perfect, the DP program did several 
things well. It required all city public safety agencies to sit 
at the table and submit a unified training and equipment plan 
before training would be scheduled.
    Second, it trained the personnel locally, allowing city 
workers to brainstorm at the breaks and in the sessions and 
meet people that they may be working with in the event of a 
disaster.
    It provided adequate awareness training.
    And it allowed instructors and students to share 
information and gain knowledge of other cities' plans.
    Unfortunately, the program failed by its stand-alone nature 
and its sometimes ``foster child'' status among the various 
Federal agencies who have been responsible for its 
implementation. New programs need strong, clear Federal 
leadership that reflects interagency cooperation at the 
national level.
    In a bioterrorist incident, the emergency department and 
medical clinic providers are truly first responders. In the 
initial DP bioterrorism tabletop exercise, cities were 
encouraged to do an anthrax hoax letter drill, testing the fire 
department HAZMAT response. In Boston, we went against the tide 
and held a tabletop with seven hospitals and all public safety 
agencies that tested our ability to respond to a pneumonic 
plague event.
    As the events of September 11 have unfolded, many who were 
previously skeptical are now requesting training. Let's not 
lose this opportunity. Based on the Boston experience, I 
recommend that new programs: Should include a lessons-learned 
format; Should include hospitals in addition to city public 
health and safety agencies; Standardized funded training and 
protective equipment should be provided for hospital-based, 
public health, EMS, as well as police and fire personnel.
    Money should be tied to a universal citywide approach to 
the disaster. This would require several Federal agencies to 
either work together or outside their usual funding schemes. I 
believe this consolidation on the Federal level is critical to 
avoid a splintering of response on the local level.
    In closing, I share with the committee that I was proud and 
honored to be a member of the Massachusetts 1 Disaster Medical 
Assistance Team that responded to the World Trade Center. 
Although, as a health care provider, it was frustrating to have 
so few live victims to treat, our mission to treat the rescuers 
was rewarding and awe-inspiring.
    Nonetheless, I will be very happy if I never again find 
myself working across the street from 6,000 dead.
    It is clear there's only so much the medical response 
community can do in an event of this size. My thoughts and 
hopes are with the law enforcement agencies that can prevent 
these tragedies.
    [The prepared statement of Kathryn Brinsfield follows:]
    Prepared Statement of Kathryn Brinsfield, Director of Research, 
  Training, and Quality Improvement, Boston Emergency Medical Services
    Mr. Chairman, members of the subcommittee, my name is Kathryn 
Brinsfield, MD, MPH. I am the Director of Research, Training, and 
Quality Improvement for Boston Emergency Medical Services, a practicing 
Emergency Medicine physician, and the Deputy Medical Commander of the 
National Disaster Medical System's International Medical and Surgical 
Response Team-East. I would like to thank you for inviting me here to 
speak on this topic.
    On March 20, 1995, Sarin was released in the Tokyo Subway system. 
The incident started at 7:55 am; the last patient was treated before 
noon.
    On September 11, 2001, the terrorist events at the World Trade 
Center killed over 6,000 and injured fewer than 2,000. The last live 
victim was rescued within thirty-six hours.
    All disasters are local.
    Terrorist disaster response is a local response.
    Federal programs have helped prepare localities for dealing with 
these disasters but there is still more to do.

 Ensure that significant funding goes directly to localities so 
        we can have the flexibility to plan our response based on our 
        unique needs
 Enable local health and public safety agencies to work 
        together with hospitals to coordinate a response
 Coordinate among agencies at the federal level to ensure 
        unified interagency guidance, materials and funding.
 Follow-up Domestic Preparedness training with concrete 
        information and lessons learned based planning guides.
    From floods to fires to bombings, the initial minutes and hours of 
a disaster largely determine the number of victims that will survive. 
While federal response provides important relief in the forms of 
specialized experience, credentialed personnel and supplies, the 
ability of a locality to rescue, treat, transport and provide 
definitive care to its own citizens weighs the balance between life and 
death.
    This holds true for bioterrorism, although in nontraditional ways. 
Treatment and stabilization of a terrorist event is dependent on 
recognition that an event is underway, and recognition is dependent on 
the ability of local responders and the local public health office.
    In Boston, we are lucky to have a strong Public Health Commission, 
with Cabinet level input into the operations of the city, and strong 
funding and support. This has allowed our local CDC office to take the 
lead in organizing a citywide hospital volume surveillance system, 
which has two years running detected the onset of influenza in the 
state prior to laboratory isolation. If this type of system can detect 
influenza, it should be able to detect the flu like illness that may be 
a harbinger of bioterrorism. In addition, we have been able to develop 
a consortium of Boston hospital based infectious disease and emergency 
medicine providers, poison control center representative, and zoo 
veterinarian, who meet quarterly, and have the ability to share 
information and alerts over the Internet. Our recent exposure to the 
West Nile Virus proved that Incident Command training for public health 
professionals pays off, and that the Public Health Director can act as 
Incident Command with Police, Fire and other city agencies 
participating in a Unified Command Structure.
    Many localities are not so lucky, and rely on antiquated 
information systems, scarce personnel, and minimal recognition from the 
public safety agencies.
    In bioterrorism, the ability to respond is dependent on the 
education and equipment of the prehospital personnel and hospital 
providers.
    In Boston, we are also fortunate to have an emergency medical 
service with strong city support. This has allowed us to train all of 
our Emergency Medical Technicians and Paramedics to the hazardous 
materials operations level and domestic preparedness EMS-technician 
level. Even though the training materials, and sometimes the training, 
are provided free to agencies, training costs are not. We are also 
fortunate to have respiratory protective equipment provided. Annually 
recurring training and fit testing costs supported by the city are 
close to a half million dollars a year for our small agency alone. In 
an anthrax exposure for 1000 people, assuming the National 
Pharmaceutical Stockpile arrives and can be unloaded in seventy-two 
hours, the cost of antibiotics that must be on hand in a city to 
immediately treat exposed victims is 25,000 dollars. In Boston, we are 
lucky to have funding through the HHS Office of Emergency Preparedness 
MMRS program. We are also fortunate to have the support of the local 
hospital pharmacies, who have agreed to rotate this stock of 
antibiotics for us, so that they do not out-date, wasting our 
investment if no event happened in two years time. However, training 
and fit testing costs are renewable and supported by federal funding; 
while these costs may be small compared to a federal budget, they are 
large costs for local agencies.
    We are also fortunate to have a strong Conference of Boston 
Teaching Hospitals, which has a long history of working together to 
improve health care in the city. This organization supports a hospital 
disaster committee and hospital EMS committee. These relationships 
proved invaluable over the last five years, in pulling hospitals and 
physicians into the terrorism planning process through EMS. In 
addition, we applaud the local hospital CEO's, who have been long 
sighted enough to recognize the importance of this issue, and provided 
funds for the construction of decontamination areas and staff training 
in the emergency departments.
    Many private and hospital based EMS agencies do not have the 
funding or support to receive the necessary training or equipment, or 
to stockpile the necessary antibiotics. Many hospitals do not work in 
this type of collaborative environment, and are not able to participate 
in citywide planning. Few physicians receive any training in 
bioterrorism. Emergency Department and hospital overcrowding is a very 
real issue that will only be exacerbated in an event of any magnitude. 
Future preparedness funding should take these things into account.
    In Boston, we consider ourselves fortunate to have been one of the 
initial cities trained under the Domestic Preparedness program. 
Although not perfect, the DP program did several things well.
    First, it required all city public safety agencies to sit at the 
table, and submit a unified training and equipment plan before the 
training would be scheduled. Second, it trained the personnel locally, 
allowing city workers to brainstorm at the breaks and in the sessions, 
and meet people they may be working with in the event of a disaster. 
Third, it provided an adequate awareness training of terrorism. 
Finally, it allowed instructors and students to share information, and 
gain knowledge of many other cities' plans.
    Unfortunately, the program failed by its stand-alone nature, and 
its sometimes ``foster child'' status among the various federal 
agencies who, at one time or another, have been responsible for its 
implementation. New programs need strong, clear federal leadership that 
reflects interagency cooperation at the national level.
    Domestic Preparedness was an awareness level program, and should 
have been followed by more concrete information and coordinated 
planning guides. Every locality is different, but every locality can 
learn some lesson from each other. Planning guides were produced 
separately by various agencies, and no other effort took into account 
the need for fire, police, and emergency medical personnel to 
collaborate on a single city plan.
    At the time the program was started, the importance of 
bioterrorism, and the delayed manner in which it would appear was not 
appreciated. We now realize that in a bioterrorist incident, the 
Emergency Department and Medical Clinic providers are truly the first 
responders. In the initial DP bioterrorism tabletop exercise, cities 
were encouraged to do an anthrax hoax letter drill, testing the fire 
department HAZMAT response, but ignoring the hospitals and public 
health system. In March of 1999 in Boston, we went against the tide and 
held a tabletop with seven hospitals, all public safety agencies, and 
several state and federal agencies participating that tested our 
ability to respond to a Pneumonic Plague event.
    As the events of September 11th have unfolded, many who were 
previously skeptical are now requesting training. Let's not lose this 
opportunity. Based on the Boston experience, I recommend that

 New programs should include a lessons learned format, with 
        concrete references and examples to help localities plan.
 New programs should be planned to include hospitals in 
        addition to city public health and safety agencies
 Standardized, funded training and protective equipment should 
        be provided for hospital based, public health, EMS, police and 
        fire personnel.
 Monies should be tied to a universal, citywide approach to the 
        disaster. This would require several federal agencies to either 
        work together or outside their usual funding schemes. I believe 
        this consolidation on the federal level is critical to avoid a 
        splintering of response on the local level.
    In closing, I share with the committee that I was proud and honored 
to be a member of the Massachusetts 1 Disaster Medical Assistance Team 
that responded to the World Trade Center. Although as a health care 
provider it was frustrating to have so few live victims to treat, our 
mission to treat the rescuers was rewarding and awe-inspiring.
    Nonetheless, I will be very happy if I never again find myself 
working across the street from 6000 dead. It is clear there is only so 
much the medical response community can do in an event of this size. My 
thoughts and hopes are with the law enforcement agencies that can 
prevent these tragedies
    Thank you.

    Mr. Greenwood. Thank you very much, Dr. Brinsfield.
    Dr. Stringer, you're recognized for 5 minutes for your 
statement.

             TESTIMONY OF LLEWELLYN W. STRINGER, JR.

    Mr. Stringer. Good morning, Mr. Chairman, members of the 
committee. Thank you for allowing me to be here today.
    I have long experience in emergency management as a local 
EMS Medical Director, commanding officer of the disaster 
medical team in North Carolina. I am the Medical Director of 
the North Carolina Division of Emergency Management, and for 
the last 10 years I've served as the Medical Director for ESF-8 
or the U.S. Public Health Service's response to many natural 
and now man-made disasters.
    Back in 1995 when the initiatives on weapons of mass 
destruction was started, I was one of about 16 people that Dr. 
Frank Young brought to the Office of Emergency Preparedness to 
look at what was it from the health side that Federal ought to 
do. Two things we came up with.
    No. 1, as you've heard before, it's local. So we felt that 
we needed to coordinate, train and equip a unified local 
medical response team which is now known as the Metropolitan 
Medical Response System.
    The second thing was to form some federally sponsored 
medical teams known as the National Medical Response Team for 
weapons of mass destruction. They would be highly trained, 
highly equipped, fast to go and assist the local community in 
such an event.
    All of these have gotten started. 120 cities, as you know, 
have been picked for Nunn-Lugar-Domenici training courses. Of 
those, as of December 2000, 68 cities have been completed, and 
37 more have been started. After the Nunn-Lugar-Domenici 
training, then the Office of Emergency Preparedness for the 
U.S. Public Health Service gives an award or a contract of 
approximately $600,000 to each city to finish their training.
    Remember, the first one was trained to train only, to 
finish that training, to develop a team, to have a unified 
training program, a plan that included even the health 
departments and the hospitals and to purchase the equipment. As 
of September 1, 2001, 97 cities have been partly--correction--
97 cities have received or are in the process of receiving 
these grants. Of those 97, 49 are considered to be partially or 
fully functional.
    Disturbing thing to me is, of those 49, not but 26 have 
purchased their medications. In my opinion, it's going to be 
another 5 or 6 years before all 120 cities truly are 
functional, ready to roll.
    But what about the other communities in this country that 
are not funded, that are not trained? The Office of Justice 
program has instituted 1999, 2000, 2001 monies to help the 
States and the communities that weren't included in this, try 
to get their training and equipment. The assessment part was 
extremely confusing that they required us to fill out. Only 
four States have turned in their assessments and three are 
planned. North Carolina, we've been working on this for a year 
and a half, and it's going to be the end of this year before we 
can even turn our paperwork in. It's too restrictive.
    When questions are asked of OJP, you get many different 
answers. There was not enough funding to the States to assist 
the locals with trying to efficiently develop their needs 
assessment and what their problems were and where we needed to 
go. You don't get your 2000 and 2001 monies till the assessment 
and 3-year plan is turned in. Many areas in my State won't get 
any money, and the cities that we determine that are high risk 
are not going to get what they need.
    We need more money. We need to get the 2000 and 2001 funds 
turned loose to the State now. We need to let the States decide 
what's needed and where and not tie our hands with so many 
restrictions. I think States know how to best help their 
communities.
    As far as the health and the health initiatives, you've 
heard today the first responders are cops, firemen, HAZMAT and 
EMS. They're also docs and nurses. We've got to include the 
hospitals and the health care system in this training, in the 
equipping and in the planning for not just bioterrorism but for 
just handling a pandemic. It's got to happen.
    There's not much in the way of Federal initiatives for the 
health care community; and the health care community, as you've 
heard, on a day-to-day basis functions in the crisis mode. As 
the Medical Director of North Carolina State Emergency 
Management, I can tell you now they have decided that they need 
not to consider this a ``hope-not'' plan, but they need to get 
some help. They are very concerned, as everyone in this country 
is.
    CDC has developed an excellent program on bioterrorism. 
It's a template that the hospitals can start with and work 
with.
    Also, the Office of Emergency Preparedness has a health 
care WMD training program at the Noble Training Center at Fort 
McCullen, which is just getting off the ground; and I think 
it's going to go a good job with that. It needs some more 
support. It's going to be like Emmitsburg for FEMA.
    The four national medical response teams, which are the 
only assets that are available within the Federal Government's 
Office of Emergency Preparedness to go and assist communities 
in time of an NBC event, are inadequately funded. They're 
highly trained professional medical personnel who do around 100 
extra hours of training in addition to their requirements for 
their job a year at no payment at all. We have consistently 
asked for more funding for maintenance and readiness of the 
four response teams to go help the local community, but there's 
been very little increased support for us.
    Since there are just four teams in the Nation like this, I 
think it would be rather cheap insurance to improve the funding 
so that we can at least name four entities that can get off the 
ground or go by ground in less than 4 hours response, any time, 
day or night, to help a community.
    I've heard 7,000 quoted medical professionals that NDMS has 
that could go help people. They need job protection, sir. Right 
now, they have none. They need to know that they can leave when 
they are activated to go help, and they need to know that I 
have got a job when they get home, which does not happen at 
present. Please pass House bill 2233 to give these people some 
job protection.
    After reading about, hearing about all the money that 
Congress has been appropriating these activities, in my job as 
both the local, State and Federal responder, I just don't 
understand where all the money has gone.
    Thank you for allowing me to be here.
    [The prepared statement of Llewellyn W. Stringer, Jr. 
follows:]
  Prepared Statement of Llewellyn W. Stringer, Jr. Medical Director, 
            North Carolina Division of Emergency Management
    Mr. Chairman and Members of the Committee, thank you for inviting 
me here today to discuss the issue of Weapons of Mass Destruction 
Preparedness. I am Dr. Lew Stringer, Medical Director of the North 
Carolina Division of Emergency Management. I have a long history of 
emergency management experience that ranges from services as a local 
EMS Medical Director for 27 years, Director of the Special Operations 
Response Team a disaster organization in North Carolina and involvement 
with the National Disaster Medical System through the Office of 
Emergency Preparedness, USPHS since 1990.
    In 1995, because of concerns regarding Weapons of Mass Destruction 
(WMD) in the US, I was one on sixteen people asked by the Office of 
Emergency Preparedness, USPHS, to advise and develop strategies to deal 
with the consequence management of a WMD event. PDD 39 and the Nunn-
Lugar-Demenici initiative were enacted during this time. Our group 
concluded that from the consequence management side, a WMD event was 
primarily a local issue. Local agencies needed to be trained, organized 
in a uniform manner and equipped to deal with the initial response in 
order to save lives. Mutual aid agreements needed to be in place with 
surrounding communities and state agencies should be immediately 
involved. The state agencies should respond to assist the ``locals'' in 
dealing with this complex and unusual emergency event that would 
rapidly overwhelm most local communities. Our group concluded that law 
enforcement, fire, HAZMAT, EMS, hospitals, Public Health, and local 
emergency management had to be brought together to assess additional 
training, organizational and equipment needs. These agencies needed to 
develop a plan. And, they needed assistance from the federal 
government.
    Our committee named this new local entity the Metropolitan Medical 
Response Team, MMRT. In 1997, the first MMRT was formed in Washington, 
D.C. From that team concept, came the resource material to be used by 
OEP/USPHS for the other cities in the system. 120 of the largest cities 
in the US were selected to receive the Nunn-Lugar-Demenici training 
grants administer by DoD and then to receive the grants administered by 
the OEP/USPHS to organize and equip these MMST's. They are now known as 
Metropolitan Medical Response Systems, MMRS. It was our recommendation 
that several regional specialized medical response teams be formed and 
equipped by the National Disaster Medical System, OEP/USPHS to respond 
rapidly to assist communities affected by the WMD event. These teams 
were founded as Nation Medical Response Team, NMRT/WMD. I developed the 
first SOP for the NMRT's early in 1996. There are four teams. I am the 
commander of the NMRT/WMD East, in Winston-Salem, N.C.
    As of December 21, 2000, of the 120 designated MMRS cities/
metropolitan areas, DoD had completed the training for 68 cities and 
had begun the training of 37 additional cities before the program was 
turned over to the Office of Justice Program (OJP) to administer. After 
a city completed the NLD Domestic Preparedness Program ``Train the 
Trainer'', OEP/USPHS contracts with the city's metropolitan area, 
providing a $ 600,000 grant for the development of plans, additional 
training, and equipment purchases to give the metropolitan area a 
unified multi-discipline team capable of responding to a terrorist 
event. According to OEP/USPHS, as of September 2001, 97 cities have 
received or in the process of receiving funding from OEP. OEP states 
that 49 cities are fully or partially functional. Only 26 cities have 
purchased the pharmaceuticals necessary to treat the victims. It is my 
opinion, looking at information I have received from several federal 
agencies, that it will be 5-6 years before all 120 cities are fully 
functional.
    In 1999, OJP initiated a nationwide assessment of vulnerability, 
threat, risk, capabilities, and needs. Each state with their local 
jurisdictions was to complete this assessment and develop a long-range 
plan that was to include federal funding for the purchase of needed 
equipment. I have been told, that by September 2001, only four (4) 
states (give names) have turned in their completed assessment making 
them eligible for the 2000-2001 monies. Funding is not released until 
the completed assessment along with a three-year strategic plan is 
returned to OJP.
    It has taken my state of North Carolina 1 + years to complete the 
assessment and the 3-year plan. I have found the assessment to be 
complex and difficult to complete. NC does not have the resources to 
collect the data in a timely fashion. Local jurisdictions needed help 
in amassing the information. There is much diversity within the state, 
large cities and small rural counties made completing complicated.
    The plan for North Carolina includes:

1) Equipping our 6 regional HAZMAT response teams, our highway patrol, 
        and our state disaster team
2) Assisting financially our largest cities or highest risk cities 
        (metropolitan area affecting 20 counties). Of our 100 counties, 
        80 counties will receive no financial assistance. Charlotte, 
        NC, the second largest banking center in the US, will not 
        receive funding through our plan, because they received 
        separate financing from Congress.
    In an explosive, chemical or nuclear event, victims are 
concentrated in that area. First responders will rescue, decontaminate, 
treat, and transport victims to health care facilities. With a 
biological event, victims will not likely be concentrated in any one 
area. Victims will receive most of their treatment at health care 
facilities. In this biological scenario, health care workers will be 
the first responders.
    Until the horrendous events at the World Trade Center and the 
Pentagon and in the past history of disasters, victims have self-
triaged to health care facilities bypassing the EMS system. In our 
present structure, ONLY law enforcement, fire, HAZMAT and EMS are 
considered First Responders by the federal government and eligible for 
funding in WMD Preparedness. This shortfall was pointed out to Congress 
in the 2000 Gilmore Report. The Noble Training Center, OEP/USPHS at 
Fort McCullen in Alabama is the only federally funded WMD training 
support for health care workers that I know in existence today.
    CDC has an excellent program, well received by the states, to 
assist states and local communities with a WMD event:

1) The National Pharmaceutical Stockpile, NPS, delivered on site in 6-
        12 hours.
2) State grants to improve and upgrade laboratories and improve 
        reporting of disease patterns. These grants assist state and 
        local public health services to upgrade labs for agent 
        identification, develop Bio-terrorist planning, implementation 
        of the electronic surveillance programs of the Health Alert 
        Network, and collect epidemiological information.
    The health care community has been a difficult player to bring to 
the WMD planning table. Sadly, the health care systems operate in a 
``crisis mode'' of staffing and financial problems on a daily basis. 
Several health care facility managers in my state of North Carolina 
have told me, ``I have no time or finances for a hope not activity''. 
This attitude must change. (We) in emergency management must help the 
health care system with planning, training and equipment to enable 
these dedicated individuals, be prepared to safely receive and 
effectively treat WMD victims.
    I look at the support provided by the OEP's National Disaster 
Medical System for the four National Medical Response Teams for WMD. 
The 4 teams, staffed by volunteers who have to train without pay, 
receive limited funds for additional equip purchases and maintence. 
This funding is not enough to maintain the NMRT's proper readiness 
state to respond to assist state or local communities. It would be 
proper, in my opinion, to increase the funding for the NMRT program.
    I believe that the health care system must be funded and supported 
to become an active player in order to resolve the consequences of a 
WMD event. I am concerned that many cities will not be able to 
effectively manage the consequences of a WMD event for the next 4-5 
years. I have pointed out to you that in my state of North Carolina, 
like many other states, little or no training or equipment is in place 
to respond to a WMD event if it occurred today.
    As a state and a local emergency management official, I understand 
that it will be the state and local governments that will respond and 
manage the consequences of such an event for many hours and even after 
the federal assets arrive.
    I have read about all of the money appropriated by Congress to the 
many federal agencies for WMD Preparedness. Frankly, I wonder and do 
not understand where all that money has gone?

    Mr. Greenwood. Well, thank you, Dr. Stringer. We thank 
Congressman Burr for bringing you and your expertise to the 
attention of the committee and assure you that a large part of 
our effort here is to find out exactly where all the money is 
going and how well it's being spent.
    Mr. Peterson you're now recognized for 5 minutes for your 
statement as well. Thank you.

                 TESTIMONY OF RONALD R. PETERSON

    Mr. Peterson. Mr. Chairman, good morning. Thank you.
    I am Ron Peterson, President of The Johns Hopkins Hospital 
and Health System in Baltimore. I'm here today on behalf of the 
5,000 hospitals, health systems, networks and other health care 
provider members of the AHA. We appreciate the opportunity to 
present our views on an issue of great concern to hospitals and 
communities across America, namely the readiness for a 
potential terrorist attack utilizing chemical or biological 
weapons.
    On September 11, hospitals in New York, New Jersey, 
Connecticut, Virginia, Washington, DC, Maryland and 
Pennsylvania all relied on their training and experience. 
Shortly after the crash at the Pentagon, Secretary Tommy 
Thompson called to tell us that we might receive casualties at 
The Johns Hopkins Hospital. We immediately activated our 
disaster control centers at our three hospitals, ceased 
elective surgeries at all three hospitals and began to identify 
candidates for early discharge to increase capacity.
    Our Baltimore Regional Burn Center was placed in a high 
state of readiness. That afternoon we sent burn supplies to the 
Washington Hospital Center and to Walter Reed Hospital.
    Some of our emergency physicians with Oklahoma City 
experience were called on by FEMA to assist at the Pentagon, 
and we sent teams to augment the Red Cross blood drive across 
from the White House.
    Our health care workers, like others, grieved when they 
could not do more, but our emergency plans were in place and 
worked effectively. We were ready.
    But now we must plan for the extraordinary. To help 
America's hospitals with this planning, the AHA has created a 
disaster readiness site on its Web page engaged in frequent 
communication about biological and chemical preparedness and 
sent two advisories on hospital readiness. Our recommendations 
have included the following:
    First, hospitals must be more highly integrated in the 
local public safety infrastructure with police, fire, EMS and 
public health.
    Hospitals need to increase inventories of drugs and 
antibiotics to combat the effects of chemical and biological 
weapons.
    Hospitals need to increase the supplies of ventilators and 
respirators, gloves, gowns and masks, the basic ingredients 
needed to treat victims of a mass disaster, as well to protect 
health care workers.
    Hospitals need to establish better communications with 
public safety entities to coordinate care.
    Hospitals must improve surveillance and detection to watch 
for potential biological outbreaks.
    Hospitals also need backup water supplies, auxiliary power, 
sources and increased fuel storage.
    We need our hospitals to be secure and safe and be able to 
lock down if necessary.
    Hospitals need to enhance their current decontamination 
capability, and hospitals may need to filter and otherwise 
modify the air circulation systems of buildings that are 
designated to receive patients that might be infected with 
contagions so that infections are not spread through the air.
    The Federal Government can provide financial assistance to 
help ensure that hospitals and local agencies are able to 
respond to potential attacks. These funds would help meet the 
challenges outlined above, including inventories of drugs and 
equipment.
    Now, at The Johns Hopkins Hospital and Health System, we 
are aggressively pursuing the recommendations that I've just 
addressed. The Johns Hopkins Hospital alone will need to spend 
at least $7 million to prepare for these kinds of attacks. As 
an example of the expense that we will incur, we plan to 
purchase 1,000 powered air purifying respiratory masks at a 
unit cost of $300 dollars, a total of $300,000. That figure 
will get those masks to just one-seventh of our total employee 
population, those who are most likely to come in contact with 
infected patient. We will add 50 ventilators to our ventilator 
fleet, for a total price tag of $1.5 million. We will stock 4 
days worth of vital antibiotics and other medication antidotes 
to treat 100 victims at a cost of about $600,000. These are but 
three practical examples that buildup cumulatively to the 
number, the $7 million figure that I suggested. These are three 
of about a dozen major categories.
    In order to meet the challenges I've outlined, hospitals 
also need staff support. You should be aware that right now 
American hospitals are facing a severe workforce shortage, 
particularly for skilled help. For example, hospitals 
nationwide have 126,000 vacancies for registered nurses. This 
shortage cuts right to the heart of communities across America 
and our ability to be ready for any need.
    Legislation has been introduced to address the workforce 
shortage, and we urge its passage.
    You have our commitment, Mr. Chairman, to work with you to 
address the many challenges hospitals will face as they prepare 
for what was once the unthinkable. Our Nation's nurses, doctors 
and other health care workers are caring, committed, 
compassionate people who are devoted to their communities. They 
answered the call on September 11, and they stand ready to do 
so again.
    Thank you, sir.
    [The prepared statement of Ronald R. Peterson follows:]
   Prepared Statement of Ron Peterson, President, The Johns Hopkins 
    Hospital and Health System, on Behalf of the American Hospital 
                              Association
    Mr. Chairman, I am Ron Peterson, President of The Johns Hopkins 
Hospital and Health System in Baltimore, Maryland. I am here today 
representing the American Hospital Association (AHA) and it's nearly 
5,000 hospitals, health systems, networks, and other providers of care. 
We appreciate this opportunity to present our views on an issue that is 
dramatically affecting hospitals and communities across America: 
readiness for a potential terrorist attack utilizing chemical, 
biological or radiological (CBR) weapons.
    September 11 introduced a new consciousness to the collective 
American mind. We find ourselves faced with the task of preparing for 
new threats that once seemed unimaginable. Among those threats is the 
potential use of CBR against our citizens.
                        hospital disaster plans
    To answer these and other threats, hospitals nationwide, like those 
that directly responded to the September 11 tragedies, have disaster 
plans in place that have been carefully developed and tested. The plans 
are multi-purpose and flexible in nature because the number of 
potential disaster scenarios is large. As a result, hospitals maintain 
an ``all-hazards'' plan that provides the framework for managing the 
consequences of a range of events. Hospitals conduct at least two 
drills a year: one may be focused on an internal event, such as a 
complete power failure. Another must be focused on an external event, 
such as a major highway crash, a hurricane or an earthquake. A hospital 
near an airport, for example, might focus on responding to an airplane 
crash, while a hospital near a nuclear plant or an oil refinery would 
focus on responding to the consequences of incidents at those sites. It 
is important to remember that all incidents are local, and that local 
agencies and organizations must work together so that response 
mechanisms are tailored to the needs of their community.
    A good example of how hospitals worked with their communities to 
prepare for a wide range of possibilities was the change of the 
calendar to the year 2000. Throughout 1999, hospitals across the nation 
engaged in a major preparedness effort: Y2K readiness. While Y2K was 
easier to address than mass casualty readiness, because it had a known 
time . . . midnight of December 31 . . . and place . . . the hospital . 
. . the consequences were unknown. Hospitals were ready.
    Mass casualty preparedness is similar, because the possibilities 
are many. But it is also different because of its uncertainty. No one 
can accurately predict when an incident will occur, where it will 
occur, or what will be its cause and consequences. That is why the all-
hazards plan, tailored to suit the needs of each individual hospital 
and its community, has provided an excellent framework for doctors and 
nurses forced into action by a wide range of events. Nowhere was this 
better reinforced than on September 11.
                    september 11: hospital reaction
    When hospitals in New York received the call to expect thousands of 
injured patients, triage teams were immediately set up, rehabilitation 
centers were transformed into auxiliary emergency rooms, and hundreds 
of off-duty nurses and doctors swarmed the hospital to offer 
assistance. Hospitals in New Jersey and Connecticut were also at the 
ready. In Washington, readiness paid off as regional hospitals in 
Virginia, the District of Columbia and Maryland launched into their 
disaster modes. And in Pennsylvania, facilities in the southwest part 
of the state were ready to provide care for victims of the airplane 
crash there. When the emergency plan went into effect, everyone was in 
their place, doing their jobs. Nurses, doctors, and others, working 
side by side, communicating effectively, relying on teamwork and 
training to assist the incoming wounded.
    Different cities, different hospitals, hundreds of miles away from 
each other, each responding efficiently to a direct hit of terrorism. 
Each reacted in a positive, planned manner that not only saved lives, 
but also proved that America's health care heroes are dedicated, caring 
professionals who are ready for the worst of circumstances. The health 
care professionals and volunteers at all the sites were prepared to 
treat far more patients than actually came to them. Death tolls were 
simply too high, and health care workers grieved that they couldn't do 
more.
                             learning tools
    It is important to realize each incident is used to improve our 
preparedness. Disaster managers use the term ``after action analysis'' 
to describe the types of activities that are conducted to study what 
happened, what worked and what did not. The AHA and its state, regional 
and metropolitan associations work with our member hospitals to share 
throughout the field critical information that can be derived from 
responses to events. The following are important facts that we already 
know:

 By definition, a mass casualty incident would overwhelm the 
        resources of most individual hospitals. Equally important, a 
        mass casualty incident is likely to impose a sustained demand 
        for health care services rather than the short, intense peak 
        customary with many smaller scale disasters. This adds a new 
        dimension and many new issues to readiness planning for 
        hospitals.
 Hospitals, because of their emergency services and 24-hour a 
        day operation, will be seen by the public as a vital resource 
        for diagnosis, treatment, and follow up for both physical and 
        psychological care.
 To increase readiness for mass casualties, hospitals have to 
        expand their focus to include planning within the institution, 
        planning with other hospitals and providers, and planning with 
        other community agencies.
 Traditional planning has not included the scenario in which 
        the hospital may be the victim of a disaster and may not be 
        able to continue to provide care. Hospital planners should 
        consider the possibility that a hospital might need to 
        evacuate, quarantine or divert incoming patients.
 Readiness could benefit from exploring the concept of 
        ``reserve staff' that identifies physicians, nurses and 
        hospital workers who are retired, have changed careers to work 
        outside of health care, or now work in areas other than direct 
        patient care (e.g., risk management, utilization review). The 
        development of a list of candidates for a community-wide 
        ``reserve staff'' will require that we regularly train and 
        update the reserves so that they can immediately step into 
        various roles in the hospital, thereby allowing regular 
        hospital staff to focus on taking care of incident casualties.
 Hospital readiness can be increased if state licensure bodies, 
        working through the Federation of State Medical Boards, develop 
        procedures allowing physicians licensed in one jurisdiction to 
        practice in another under defined emergency conditions. Nursing 
        licensure bodies could increase preparedness by adopting 
        similar procedures or by adopting the ``Nursing Compact'' 
        presently being implemented by several states.
                              bioterrorism
    The threat of chemical, biological and radiological agents has 
become a focus of counterterrorism efforts because these weapons have a 
number of characteristics that make them attractive to terrorists. 
Specifically, biological agents pose perhaps the greatest threat. 
Dispersed via the air handling system of a large public building, for 
example, a very small quantity may produce as many casualties as a 
large truckful of conventional explosives, making acquisition, storage 
and transport of a powerful weapon much more feasible. Some CBR agents 
may be delivered as ``invisible killers,'' colorless, odorless and 
tasteless aerosols or gases.
    The distinguishing feature of some biological agents--such as 
plague or smallpox--is their ability to spread. The victim may even 
become a source of infection to additional victims. The effects of 
viruses, bacteria and fungi may not become apparent until days or weeks 
after initial exposure, so there will be no concentration of victims in 
time and locale to help medical personnel arrive at a diagnosis. 
Exposure to biological agents may cause a variety of symptoms, 
including high fever, skin blisters, muscle paralysis, severe 
pneumonia, or death, if untreated.
                           hospital readiness
    Because September 11 redefined the meaning of disaster, hospitals 
are now upgrading their existing readiness plans to meet the new needs 
of their communities. Since the risk of chemical and biological attacks 
is now an obvious concern, hospitals are reassessing their current 
plans. The AHA so far has sent two Disaster Readiness Advisories to all 
of America's hospitals with information and resources to help them in 
this effort.
    The following are among the key items that we believe need to be 
addressed to help hospitals as they update their disaster plans to meet 
the challenges of a threat that, until recently, seemed hypothetical: 
an attack using chemical, biological or radiological agents.
    Medical and pharmaceutical supplies--Hospitals must be properly 
stocked with antibiotics, antitoxins, antidotes, ventilators, 
respirators, and other supplies and equipment needed to treat patients 
in a mass casualty event.
    Communication and notification--There is a need for greater 
coordination of public safety and hospital communications, the ability 
of different entities to communicate with each other on demand. In 
addition, alternative and redundant systems will be required in case 
existing systems fail in an emergency.
    Surveillance and detection--Improving hospital laboratory 
surveillance and the epidemiology infrastructure will be critical to 
determining whether a cluster of disease is related to the release of a 
biological or chemical agent. The ability to rapidly identify the agent 
involved is vital.
    Personal protection--Hospital supplies of gloves, gowns, masks, 
etc. would quickly be used up during an attack, and equipment like 
canister masks is rarely kept in adequate numbers to meet demands of a 
large casualty attack.
    Hospital facility--Among the capabilities hospitals will need in 
the event of an attack: lockdown ability; auxiliary power; extra 
security; increased fuel storage capacity; and large volume water 
purification equipment.
    Dedicated decontamination facilities--Hospitals need a minimal 
capability for small events and the ability to ramp-up quickly for a 
larger event.
    Training and drills--Staff training is needed at all levels for all 
types of potential disasters. Additional disaster drills beyond the two 
per year required by JCAHO, particularly community-wide drills, would 
enhance the level of hospital readiness.
    Mental health resources--Mass casualty events trigger escalated 
emotional responses. Hospitals must be ready to treat not only patients 
exhibiting these symptoms, but others, such as family members, 
emergency personnel and staff.
                  communication/transportation issues
    To truly solidify response readiness, the federal government should 
help establish an emergency communication and transportation strategy. 
During the recent attacks, street closings and clogged roads impeded 
EMS workers as they tried to reach the affected areas, and hindered 
quick access to hospitals. No-fly zones were implemented to prevent 
other air attacks, but those zones hindered med-evac helicopters and 
other air transports that shipped blood and bandages to hospitals in 
dire need. Hospitals need assistance from Federal Aviation 
Administration officials to keep the skies open to critical medical 
aircraft.
    In addition, any biochemical attack will require the coordination 
of local, state and federal agencies. In response, the Centers for 
Disease Control and Prevention have invested in and upgraded state-of-
the-art labs to identify and monitor reports of suspicious cases of 
illness across the country. Working in conjunction with state and local 
epidemiologists, they will communicate their findings to government 
agencies.
                          readiness resources
    Realistically, America can never afford to prepare every hospital 
in the country for every possibility of attack. However, the federal 
government can provide assistance to help ensure that hospitals and 
their local agencies are best able to respond to potential attacks. 
These funds would be earmarked to meet the challenges outlined above, 
including inventories of the necessary drugs and equipment needed to 
help victims of terrorist attacks. Communities need the funding to 
assist their hospitals and expand their emergency relief teams, as well 
as to establish or implement new systems of readiness.
                          hospital challenges
    There is no more important strategy in this domestic war on 
terrorism than to help our hospitals reach a state of readiness. But if 
America's hospitals are to enhance their readiness for a new world of 
possibilities, they must have in place the people they need to do the 
job. However, America's hospitals are experiencing a workforce shortage 
that will worsen as ``baby boomers' retire. Currently, our health 
systems have 126,000 open positions for registered nurses, for example. 
The United States Department of Health and Human Services predicts a 
nationwide shortage of 400,000 nurses by 2020. There also are shortages 
of other key personnel, such as pharmacists. This shortage cuts to the 
core of America's health care system, because dedicated, caring people 
are the heart of health care.
    Fortunately, Congress has recognized the importance of this issue. 
Legislation has been introduced that can help hospitals attract and 
maintain the health care workforce that is needed to ensure that our 
patients receive the right care, at the right time, in the right place. 
For example, the Nurse Reinvestment Act (S.706/H.R. 1436) offers the 
right step to ensure health care professionals avert the collision 
course we face with lack of hospital staff.
                               conclusion
    The United States has been thrust into a new era. Our hospitals 
have always been ready for the foreseeable. Now we must plan for the 
previously inconceivable. Hospitals are upgrading existing disaster 
plans, and continue to tailor their disaster plans to suit the 
individual needs of the community in the face of new threats.
    America can be comforted that, as we have witnessed over the last 
few weeks of our national tragedy, highly trained, caring doctors, 
nurses and other professionals are the heart of our health care system. 
They perform heroic, lifesaving acts every day. And, in the face of the 
unexpected, they can be depended on to rise to the needs of their 
communities.
    The AHA has worked closely with the administration on this 
important issue, especially with Sec. Thompson. We look forward to 
working with Congress as we help ensure that the people we serve get 
the care they need in any and all circumstances.

    Mr. Greenwood. Thank you very much for your remarks.
    Dr. O'Leary you're recognized for 5 minutes for your 
opening statement, please.

                   TESTIMONY OF DENNIS O'LEARY

    Mr. O'Leary. Thank you, Mr. Chairman.
    I'm Dennis O'Leary, President of the Joint Commission on 
Accreditation of Healthcare Organizations. We appreciate the 
opportunity to testify on the ability of this country's 
infrastructure to deal with acts of bioterrorism.
    The medical and public health systems deserve particularly 
close examination. Their effective integration would not only 
enhance our terrorism response capacity, it would also expand 
our ability to deal with a broad range of public health threats 
such as emergent infectious diseases and epidemics. It is my 
intent to make a case for the development of integrated 
community approaches to preparedness that flow from Federal 
leadership.
    The Joint Commission has long accredited most of this 
country's hospitals. We also evaluate and oversee home care 
agencies, ambulatory care centers, behavorial health programs, 
nursing homes, clinical laboratories, and managed care plans, 
among other health care delivery entities.
    The scope of our involvement in the health care delivery 
system places us in a unique position to both set expectations 
for readiness across the entire spectrum of provider services 
and to measure adherence to these expectations. For many 
decades, the Joint Commission has required that accredited 
health care organizations meet established disaster 
preparedness standards, but several years ago we decided to 
develop new standards that would expand the ability of 
individual health care organizations to deal with rare events 
through broad engagement with their community.
    First, we have shifted the focus of the standards from 
simple emergency preparedness to emergency management. Now 
health care organizations are expected to address four specific 
phases of disaster planning: mitigation, preparedness, response 
and recovery. This means planning as to how an organization 
would lessen the impact on its services following an emergency, 
how organization operations might need to be altered in the 
heat of the crisis and how to return the organization to normal 
functioning once a crisis has passed.
    Second, the new standards require accredited organizations 
to take an all-hazards approach to planning. Organizations must 
develop a chain of command approach that is common to all 
hazards which are credible threats in their community. This 
planning starts with a vulnerability analysis against an 
unconstrained list of extreme events, including terrorism, and 
then critically appraises their probability of occurrence, 
their risk to the organization and the community and the 
capacity for responding to each potential threat.
    The last new requirement is the expectation that each 
health care organization annually participate in at least one 
community-wide practice drill relevant to its vulnerability 
analysis. Large-scale drills can be extremely instructive in 
plotting out the typical effects of bioterrorism over a period 
of weeks and in identifying unanticipated planning gaps. 
Because these drills are time-consuming and expensive to 
conduct, government financial incentives should be used to 
leverage ongoing engagement in such activities.
    We as a Nation are not unprepared to deal with 
bioterrorism, but our Nation's public health and medical 
systems could be better prepared than they are today. To that 
end I would like to offer a series of recommendations for 
upgrading our system capabilities.
    First, more medical care workers must be trained to become 
familiar with pathogens that may be used in bioterrorism, aware 
of the symptoms they produce, knowledgeable about their route 
of transmission and alert to the possibility of their use.
    The reality is that most practicing physicians would not 
recognize a case of anthrax, tularemia or smallpox, nor would 
they know what kinds of specimens to collect for testing, how 
to handle such specimens or which clinical laboratories possess 
the expertise to detect the rare agents that could be used as 
terrorist weapons.
    Second, it is essential that a single integrated system of 
response be created that will be effective in addressing a full 
range of diseases and rare events, whether of terrorists or 
natural origins. This system should be a blueprint for action 
that is also scalable to the extent of the emergency and to the 
settings that are involved. The framework should be community-
wide and utilize common concepts so that it is transportable.
    Third, a public health surveillance system should be 
established that can promptly detect naturally occurring 
epidemics as well as terrorist activity. The rapidity with 
which a rare disease or terrorist weapon is recognized at the 
provider level and communicated to the public health experts 
will largely determine the extent of its spread and the overall 
mortality rate. A surveillance system should be designed for 
the routine collection of automated data and presenting 
symptoms and laboratory findings that points of delivery system 
entry. Monitoring the data would provide an early warning 
system for potentially disastrous trends that might otherwise 
go undetected.
    Finally, it is essential that the national funding policies 
which have progressively reduced the elasticity of the medical 
system to respond to peak demands be reevaluated. For more than 
two decades, public policymakers have taken clear steps to 
reduce the excess delivery system capacity, but we are entering 
a new era that requires a reexamination of fiscal public policy 
on emergency preparedness. We are not advocating an unfettered 
buildup of delivery system capacity but rather a strategic 
reassessment of the resources needed to assure necessary system 
elasticity in the face of national or local crises.
    In conclusion, local emergency management requires 
government support that goes well beyond the availability of 
vaccines, antibiotics and medical technology. There are 
definitive needs for investment in the conduct of risk 
analyses, in the development of community infrastructures, in 
the training of key health personnel and an information 
gathering, monitoring and dissemination; and, in the end, 
government must set national priorities for resource deployment 
and ensure that emergency management efforts are carried out 
effectively at the local level.
    It is essential that this country start to address the 
identified needs with all due haste. In this regard, the Joint 
Commission stands ready to commit additional resources toward 
meeting our collective national readiness goals.
    Thank you.
    [The prepared statement of Dennis O'Leary follows:]
 Prepared Statement of Dennis O'Leary, President, Joint Commission on 
               Accreditation of Healthcare Organizations
    I am Dr. Dennis O'Leary, President of the Joint Commission on 
Accreditation of Healthcare Organizations. We very much appreciate the 
opportunity to testify on this critically important ``Review of Federal 
Bioterrorism Preparedness Programs from a Public Health Perspective.'' 
The tragic events of September 11, 2001 have served as an unwelcome 
catalyst for focusing on this country's ability to deal with acts of 
terrorism. All aspects of our nation's infrastructure have received 
renewed, and in some cases, heightened attention to their particular 
vulnerabilities and response capabilities. The medical care and public 
health systems perhaps deserve exceptional attention because they will 
assuredly be the centerpiece of any response to--and therefore be 
severally strained by--any terroristic event involving substantial 
illness or injury to multiple individuals. However, these systems also 
deserve close examination because our citizens can reap significant 
benefits from strengthening this interface even if bioterrorists do not 
strike. The value of a well-integrated medical and public health 
infrastructure transcends terrorism and expands our capacity to deal 
with a broad range of public health threats, such as emergent 
infectious diseases and epidemics.
    I am here today to speak specifically about how the Joint 
Commission fits into the framework for bioterrorism preparedness and 
how we see ourselves playing a continuing, significant role in 
facilitating the readiness of our nation's health care organizations to 
respond to untoward events. I will be raising for consideration some 
vulnerabilities in the current ability of the medical system to respond 
effectively to bioterrorism and making suggestions about solutions. It 
is my intent to make a strong case for the development of system-wide, 
integrated community approaches to preparedness that flow from federal 
leadership. And I want to underscore that a strong nexus between the 
medical and public health systems is critical to improving and 
maintaining our preparedness.
    For those of you who are not familiar with the Joint Commission, we 
are the nation's predominant health care standard-setting and 
accrediting body. The Joint Commission is a not-for-profit, private 
sector entity that was founded in 1951, and is dedicated to improving 
the safety and quality of care provided to the public. Our member 
organizations are the American College of Surgeons; the American 
Medical Association; the American Hospital Association; the American 
College of Physicians-American Society of Internal Medicine; and the 
American Dental Association. In addition to these organizations, the 28 
member Board of Commissioners includes representation from the field of 
nursing, and public members whose expertise covers such diverse areas 
as ethics, public policy, and health insurance.
    The Joint Commission accredits approximately 18,000 health care 
organizations, including a substantial majority of hospitals in this 
country. Our accreditation programs also provide quality oversight for 
home care agencies; ambulatory care centers and offices whose services 
range from primary care to outpatient surgery; behavioral health care 
programs; nursing homes; hospices; assisted living residencies; 
clinical laboratories; and managed care entities. The Joint Commission 
is also active internationally and, in fact, has provided consultation 
services on bioterrorism preparedness overseas.
    The scope of our involvement in the health care delivery system 
places us in a unique position to both set expectations for readiness 
across the entire spectrum of provider services and to measure 
adherence to those expectations. However, leadership and resource 
commitments at the federal, state and local levels are also essential 
to any effective bioterrorism response capacity.
        the joint commission's standards on emergency management
    For many decades, the Joint Commission has required that its 
accredited health care organizations meet established disaster 
preparedness standards. Not surprisingly, these standards have focused 
on natural disasters such as tornadoes, floods, hurricanes and 
earthquakes; and on certain uncommon accidents such as power plant 
failures, chemical spills or fire-related disasters. Organizations have 
been required to develop internal response plans and conduct periodic 
staff drills to determine that these plans actually work. During on-
site surveys, our surveyors review these plans as well as the results 
of the staff drills.
    Several years ago, in a move that now seems prescient, the Joint 
Commission decided to develop new standards that would broaden the 
ability of individual healthcare organizations to deal with rare 
events. At that time, we had become concerned that the medical system 
was inadequately prepared to deal with the rare threat of bioterrorism, 
and perhaps equally unprepared for the greater possibility of 
infectious outbreaks arising from an increasing global inventory of 
virulent infectious agents. Regardless of the source of the threat, 
readiness for managing biological events has certain common elements.
    The Joint Commission's accreditation standards were modified in 
three important ways, all of which infused the concept of community 
involvement into the preparedness process. First, we shifted the focus 
of the standards from simple emergency preparedness to emergency 
management. That modification may not sound significant, but it has far 
reaching implications. Now, health care organizations are expected to 
address four specific phases of disaster planning: mitigation, 
preparedness, response, and recovery. This means engaging in planning 
as to how an organization would lessen the impact to its services 
following an emergency; how organization operations might need to be 
altered during the heat of the crisis; and how to conduct consequency 
management to return the organization to normal functioning once a 
crisis has passed.
    Further, emergency management requires that when organizations are 
addressing each of the four phases of disaster planning, they must 
broaden their preparedness and their perspectives to take into account 
how the community around them may be affected during a rare event. 
``Community'' may be viewed as the population at large, the other 
medical institutions in the area, and/or relevant community structures 
and agencies. This more outward and proactive way of thinking should 
better position health care organizations to play an effective role in 
bioterrorism preparedness.
    Second, the new standards, which were effective on January 2001, 
require accredited organizations to take an ``all hazards approach'' to 
planning. What this means, is that organizations must develop emergency 
management plans that contain a chain of command approach that is 
common to all hazards deemed to be credible threats--an approach that 
also can be easily integrated into their community's emergency response 
structure. Hospitals must start this aspect of planning by considering 
a wide variety of threats that could befall their community, including 
terrorism. Hospitals, for example, are now required by these new 
standards to do a hazard vulnerability analysis that starts with an 
unconstrained list of extreme events, and then critically appraises 
their probability of occurrence, their risk to the organization and the 
capacity for responding to each potential threat. Inherent in this 
analysis is having an understanding what the community itself, rather 
than just the health care organization, considers to be a realistic 
threat.
    While this vulnerability analysis is obviously important, the 
abilities of the individual organizations, and indeed of communities, 
to prepare for and respond to the full array of potential threats is 
seriously constrained by the major cost restraints in most health care 
organizations. This will obviously lead to important priority judgments 
about risk that will condition future response capabilities. There is 
also a risk of fragmented priority setting--healthcare organizations 
and communities may view the risk differently between and among 
themselves, leading to uncoordinated preparedness. To do their jobs 
effectively, individual health care organizations should take their 
lead from responsible federal and state government authorities. This is 
rather problematic at present because the United States has not 
articulated its own national threat and risk assessment. As stated in 
the recent GAO report on Homeland Security, ``a threat and risk 
assessment is a decision-making tool that helps define the threats, to 
evaluate the associated risk, and to link requirements to program 
investments.'' It is clearly essential that governmental agencies 
involved with assessing the threats from bioterrorism communicate their 
analyses down to the local level so that the medical system has a 
blueprint for appropriate action and can construct a reasonably 
consistent strategy of preparedness throughout the United States.
    The last new requirement of the standards is the involvement in at 
least one annual community-wide practice drill by those health care 
organizations whose all hazard risk assessment identifies credible 
community threats. These drills must evaluate the interoperability of 
the response structures developed by the health care organization and 
the community. Responding to a bioterrorism attack will require 
unprecedented communication, coordination, and attention to chain of 
command structures. Therefore, these drills, if effectively executed, 
are time consuming and expensive to conduct. Moreover, thorough mock 
attacks must consider how the effects of bioterrorism would typically 
play out over a period of weeks, constantly changing the landscape of 
issues and decision making for health care leaders. Given the 
complexity and cost of these essential drills, we believe that 
governmental financial incentives should be considered as a means of 
leveraging on-going engagement in such activities.
    Drills also can be extremely instructive. Large-scale ones such as 
TOP-OFF have elucidated unanticipated planning gaps and have exposed 
the need for unconventional thinking in times of emergency. To 
elaborate, we rightly consider our hospitals the first place to go when 
people are severely ill. In fact, in this country we go to great 
lengths to ensure that everyone has access to hospital emergency care. 
Yet in the throes of a biological disaster, we may not want to admit 
everyone who arrives at the hospital door. First, if individuals are 
infected with a virulent pathogen, they will then infect physicians, 
nurses and other staff, and thus limit the availability of critical 
medical personnel. Under such circumstances, it may be prudent to keep 
the hospital free from contamination by setting up off-campus isolation 
units and treatment modalities outside of the hospital that are 
overseen by properly protected staff. This would permit the hospital 
itself to remain a safe haven for management of other injuries and 
illnesses.
    Further, if--in the face of a biological threat--everyone were 
accepted into the hospital for evaluation, there is a real risk of 
overwhelming facility capabilities. Experience with drills has shown us 
that even the largest hospitals would be unable to handle the onslaught 
of people who are concerned that they may have the dreaded agent. This 
raises the real potential need for off-site evaluation and triage of 
individuals in a fashion different from the usual conduct of emergency 
services.
    The new Joint Commission accreditation standards for emergency 
management represent a significant step toward improving the nation's 
readiness for a biological emergency, but national leadership in the 
area of risk analysis will be necessary to convince many organizations 
that bioterrorism threats are worthy of their serious attention. The 
Joint Commission is participating in an Agency for Healthcare Research 
and Quality funded project with Science Applications International 
Corporation to investigate the linkages among key entities in response 
to a bioterrorism event. This project will not be completed until next 
year, so I am unable to share any final results with you. However, as 
part of our contribution to the project, we conducted a survey of a 
sample of hospitals to assess their community linkages for purposes of 
mounting a bioterrorism response. Among the obstacles identified by 
those hospitals which did not have effective community linkages were 
the lack of community awareness of the issue and therefore, interest in 
planning; and inadequate funding for bioterrorism planning, training 
and resources at both the community and organizational levels.
    vulnerabilities in the medical and public health care readiness
    Much additional progress needs to be made. Given the outstanding 
training we provide to our medical and public health personnel in this 
country, and given our scientific know-how, state-of-the-art 
technology, and high level of health care spending, it is reasonable 
for the American public to expect that this country is ready to respond 
to the worst of disasters that terrorists could bring to our doors. 
This perception has been reinforced by the admiral way in which New 
York City medical and public health personnel handled themselves in the 
face of the massive disaster last month. But is should be pointed out 
that the medical care and public health systems were not tested for the 
level of stress that would result from a bioterrorist event, because 
sadly there were many more deaths from the World Trade Center calamity 
than there were persons needing medical attention.
    Some people believe that the health care delivery system--if faced 
with a bioterroism event--will somehow be able to accommodate the 
thousands of ill, injured and worried well who will seek health care in 
that situation. The unfortunate truth is that we have much to do before 
such a belief can be fulfilled. This is not intended as an alarmist 
statement, but there are some stark realities that must be faced about 
the current capacity and integration of our public health and medical 
care systems and the readiness of governmental agencies to assume 
authoritative leadership roles.
    To that end, I would like to offer a series of recommendations for 
upgrading our system capabilities and for weaving together a tighter 
response fabric among responsible parties. This fabric should be 
pattern recognizable to all those who comprise the cloth, because its 
essential elements will be comprised of effective coordination, 
communication, cooperation, chain of command, and capacity building.
     More medical care workers must be trained to become 
familiar with pathogens that may be used in bioterrorism, aware of the 
symptoms they produce, and alert to the possibility of their use. 
Medical personnel must also become knowledgeable about routes of 
transmission, the transmission vectors for various biologic agents and 
the effective therapeutic approaches to these agents. The reality is 
that most physicians would not recognize a case of anthrax, tularemia, 
or smallpox that presented to them in the emergency room or in their 
office. Nor would they know what kinds of specimens to collect for 
testing, how to handle such specimens or which clinical laboratories 
possess the expertise to detect some of the rare agents that could be 
used by terrorists. Such education is essential to a prompt response to 
any bioterrorism attack.
     It is essential that a single, integrated system of 
response be created that will be effective in addressing a full range 
of diseases and rare events whether of terrorist or natural origins. 
Because it will serve multiple purposes, a single system is less likely 
to wither from inattention or nonuse. This system should be a blueprint 
for action that is also scalable to the extent of the emergency and to 
the settings that are involved. The framework should be community-wide 
and utilize common concepts so that it is transportable. For example, 
we should be reliance upon a consensus-based ``chain of command'' 
construct that has interoperability common to all states. This would 
make emergency management plans quickly and easily understood by all 
who are engaged in emergency activities. The system should be 
periodically tested and evaluated for its currency and feasibility.
     Community or state-wide capacity analyses of preparedness 
that include available medical facilities and delivery sites must be 
carried out. We are pleased that the CDC is working to identify the 
core capacities that state and local health departments must have in 
order to be adequately prepared for a biological attack. However, this 
evaluation needs to be expanded to include the core capacities of the 
medical infrastructure within each geographic area. This should lead to 
a gap analysis that addresses issues of supplies at hand, which 
additional personnel may be needed, transfer agreements during times of 
system overload, and other identified medical system vulnerabilities. 
Such assessments should be integrated into any other assessments being 
undertaken by state and local authorities.
     A medical/public health surveillance system should be 
established to promptly detect naturally occurring epidemics as well as 
terroristic activity. The rapidity with which a rare disease or 
terrorist weapon is recognized at the provider level and communicated 
to public health experts will largely determine the extent of its 
spread and the overall mortality rate. With today's technology, the 
reporting system should not rely upon an astute clinician to pick up 
the telephone and know whom to call about an unusual case, or number of 
cases. Rather, a surveillance system should be designed for the routine 
collection of automated data on presenting symptoms at points of 
delivery system entry and of health care utilization and laboratory 
data. Such information should be provided to public health officials 
for ongoing surveillance. Public health epidemiologists might then be 
able to detect ``spikes'' in the data and take investigatory action if 
warranted. A system of this nature could also communicate 
electronically with CDC and could be used in time of bona fide 
bioterrorism to inform decision-makers about disease spread.
     Issues of national supplies and their disbursement need to 
be evaluated and resolved. Determinations as to how much vaccine, 
pharmaceuticals, medical equipment and other supplies are needed for 
stockpiling should be made at the national level after a credible 
threat and vulnerability analysis. Equally important is how supplies 
are prioritized for distribution and how fast they can be deployed. It 
may be that there is no effective way to expeditiously distribute to 
localities the massive amount of supplies that may be needed if there 
is as large-scale bioterrorist attack, especially if the transportation 
infrastructure is also affected. The practicalities of needing to act 
quickly require considerations as to when regionalized supplies are 
preferable, who will have the authority to disburse them, and what 
criteria will be used to make dispersal decisions.
     It is essential that the national funding policies which 
have progressively reduced the elasticity of the medical system to ramp 
up to a peak demand be re-evaluated. For more than two decades, public 
policy makers have taken clear steps to reduce excess delivery system 
capacity (e.g., hospital beds). During this time many emergency 
departments and satellite clinics have closed. But we are entering a 
new era that requires a reexamination of fiscal public policy on 
emergency preparedness. We are not advocating an unfettered build-up of 
delivery system capacity, but rather a strategic reassessment of the 
resources needed to assure necessary system elasticity in the face of 
national or local crises.
    The Joint Commission stands ready to work with many others on the 
aforementioned recommendations, because we believe that our 
organization has a key role in the strategic planning for medical and 
public health systems' response to terrorism.
                               conclusion
    It is said that all health care is local. That maxim ultimately 
applies to emergency management. Indeed, local readiness planning will 
need to be scaled and tailored to the characteristics and capabilities 
of individual communities. However, it is equally important that there 
be strong leadership at the federal and state levels that directs 
particular attention to the issues raised in our testimony. The 
resources needed to support effective emergency management at the local 
level are not simply vaccines, antibiotics, and medical technology. 
There are definitive needs for government investment in the conduct of 
risk analyses, in the development of community infrastructures, in the 
training of key health care personnel, and in information gathering and 
dissemination. And in the end, government must set national priorities 
for resource deployment and assure that emergency management efforts 
are carried out at the local level.
    We as a nation are not unprepared to deal with bioterrorism and 
natural disaster and epidemics, but our nation's public health and 
medical systems could be better prepared than they are today. We 
therefore need to start addressing the identified needs with all due 
haste. In this regard, the joint Commission standards ready to commit 
its own resources to work alone and with others to meet our collective 
national readiness goals.

    Mr. Greenwood. Thank you very much, Dr. O'Leary.
    Dr. Young for 5 minutes.

                   TESTIMONY OF FRANK E. YOUNG

    Mr. Young. Mr. Chairman, thank you very much for the 
ability to be here today. I would like to submit my testimony 
for the record and summarize some points that have not been 
made completely by my other colleagues.
    Mr. Greenwood. That will be fine. Your full statement will 
be made a part of the record.
    Mr. Young. Thank you. I'm particularly pleased to testify 
with two of my colleagues, Dr. Lew Stringer and Dr. Kathy 
Brinsfield, who were in my command when we served and began, as 
Dr. Stringer outlined, the entire approach to bioterrorism. I'd 
like to remind this committee that this is not an old issue 
that we are regrinding over and over again but an issue that we 
have been trying to address since 1995, and I've provided for 
the committee a copy of the first biological and chemical 
terrorism study that was conducted at that time. It was then 
that Dr. Stringer and others joined together to build a local 
system.
    I'm also releasing for the first time as attachment 2 the 
letter that was submitted to President Clinton on May 6, which 
is the result of an ad hoc committee that I chaired in response 
to looking at bioterrorism, and you will note that most of the 
things that were spoken of today are outlined there in 1998 as 
well.
    The budget is the ultimate instrument of policy, as you 
know, sir. These requests have been made year upon year upon 
year. Dr. Stringer knows the many times that I have come before 
Congress pleading for funds and the many times in which they 
were not answered. Now is the time to act, and I urge your 
dispatch to be matched with a passion of the day, with the 
actuality of the funding.
    I have a number of urgent recommendations that I would like 
to bring to your attention that cobble together the needs that 
I believe are necessary to fix the system.
    First, develop a command and control system for public 
health that interfaces seamlessly with the Office of Homeland 
Defense and integrates the State and local regional activities. 
Nothing is more important than the ability to communicate well. 
At a time of disaster, it is not the time to exchange business 
cards for the first time. We must know each other, and we must 
trust each other.
    Second, you can see the problem displayed in Florida of the 
lack of laboratory facilities to rapidly diagnose infectious 
agent. I'm a microbiologist. It is not necessary to do, as we 
did there, to look for 48 hours at culture and sensitivities. 
There must be rapid diagnostic materials made available that 
can detect these pathogens in hours to minutes, not days to 
weeks. The laboratory facilities at USAMRIID and at CDC are 
woefully inadequate for high containment work, as are the 
laboratories around the Nation.
    FDA has been urged in 1998 to finalize a regulation that 
would enable new drugs for bioterrorism agents to be approved 
based on suitable animal tests. That regulation was posted in 
1999 and is languishing to this date. It is a simple thing to 
finalize. All the comments are in. I urge you, see to that.
    The augmentation of the mass casualty response teams can be 
built by, one, augmenting the National Guard medical systems, 
which are in a poor state of repair; creation of disaster 
responders through the Commissioned Corps of the Public Health 
Service that would be able to respond at a moment's notice to 
augment the local teams. At the moment, just as Lew pointed 
out, with the State and local teams you have to get permission 
to deploy. You need to be able to be up and out the door in 4 
hours or less. Otherwise, you are ineffective.
    Next, to train people locally with the capacity to manage 
the medical consequences of weapons of mass destruction; to 
train medical and environmental health personnel through 
distance learning so that it would be possible to understand 
how these systems should work. There is an excellent course at 
USAMRIID that has trained over 50,000 people for this purpose; 
and I would urge that that be continued, funded and made 
available to the Nation.
    Develop an integrated system of field hospitals and 
identify structures within communities whereby patients could 
be brought in. As pointed out by the President of Johns 
Hopkins, it is difficult to bring in large numbers of 
contaminated people within the hospital system. There are only 
five field hospitals in DOD and less than one to two adequate 
field hospitals in the HHS and few scattered around the Nation. 
You need to make sure that we have those hospital facilities, 
portable hospital facilities that can be used at time of 
crisis.
    There is a need to be sure that all types of therapies are 
developed, including immunotherapies that are just-in-time 
immunotherapies; and I've given information on one novel 
approach in Appendix 3.
    It is important to protect our health responders with the 
adequate equipment and clothing and ability to find them in the 
event that they are incarcerated in rubble or other material, 
and I've given you information on that in Appendix 4.
    Death management is critical. I was there in Oklahoma City, 
and I managed that from a medical standpoint. That was small in 
comparison to New York City. My heart goes out to the many 
people that are trying to deal with the large number of dead 
people there. It is a special activity. We do have disaster 
mortuary teams. They have been overstressed.
    I now serve as a pastor. It was interesting that--to me 
when the call came to testify I was preparing my Sunday 
materials on the good Sermon on the Mount, Matthew 5:1-15; and 
I want to urge you with every fervor that I can to make a team 
of trained chaplains, grief counselors and other professionals 
that can go in and make an impact in the lives of people when 
they are suffering. I know a call went out, but when the call 
went out, there was ``send as many people as you can who are 
not trained and not experienced.'' and I've seen the difficulty 
in counseling individuals dealing with large-scale deaths, and 
we need to be prepared, and that type of training needs to be 
done as well.
    Media communications are key, Mr. Chairman. We have seen a 
lot of talking heads and experts that are nonexperts. I've been 
in weapons of mass destruction for a quarter of a century, and 
it is important for me to emphasize that I'm one of the young 
and retired people of the field that is no longer extant within 
the United States. We need to train people in this expertise 
and have people nursed and rehearsed and capable of bringing 
public messages.
    Let me give you an example. In the Midwest flood, it 
involved five States, some of you know, from Michigan. I was 
there on the ground. The State health departments could not 
decide how long to boil water. Some said, 3 minutes. Others 
said 1 minute. Others said 30 seconds. Then there came a 
concern about hepatitis. And they said if these fools can't 
tell us how long to boil water, we can't believe them on 
infectious hepatitis.
    We've got to have a message that is similar, that is 
accurate, that's done by experts and coordinated across the 
land. To do less is not appropriate.
    Finally, Mr. Chairman, it's up to you. The budget is the 
ultimate instrument of policy. To not act and bring these 
medicines as we have been shouting for to the local communities 
for years represents, in my pastoral opinion, a sin.
    Mr. Chairman, I'd be happy to answer any questions I can.
    [The prepared statement of Frank E. Young follows:]
   Prepared Statement of Frank E. Young, Former Director, Office of 
    Emergency Preparedness, National Disaster Medical System, Vice 
       President Reformed Theological Seminary, Metro Washington
                              introduction
    Dear Mr. Chairman and members of the Committee: Thank you for the 
opportunity of testifying before your committee concerning the 
``Federal Preparedness for Bioterrorism from a Public Health 
Perspective''. As a microbiologist and a physician focusing on 
infectious disease, I have been involved in research on non-pathogenic 
and pathogenic organisms related to those used in bioterrorism for over 
a quarter of a century. In government I participated in the defense 
from the effects of organisms involved in bioterrorism since 1984 when 
I served as Commissioner of the Food and Drug Administration to 1996 
when I completed my service as Director of the Office of Emergency 
Preparedness and the National Disaster Medical System. From 1993-1996, 
I represented the Department of Health and Human Services on the 
Council of Deputies of the National Security Council, coordinated the 
Emergency Support Function 8 for Health and Medical response in the 
Federal Response Plan and participated in many training exercises to 
test response to disasters caused by weapons of mass destruction. My 
testimony will focus on the reality of the threat, the two basic types 
of threats, the requirements for effective management; the progress 
made to date and additional needs for enhancement of our capabilities.
    The call to testify before your Sub-committee came while I was 
preparing for an adult ministries class in the church where I serve as 
associate pastor. It was a remarkable kaleidoscope of ideas as I 
pondered the attributes of a Christian disciple from the Sermon on the 
Mount I taught last Sunday to my church (the Gospel of Matthew 5:1-15) 
as compared with terrorism-the essence of evil. The sinfulness of 
mankind is revealed in the wanton destruction of civilian life. None of 
the major world religions preach the violent slaughter of innocent 
people.
                               the threat
    Most experts in bioterrorism would agree that the threat is smaller 
than the use of bombs and bullets, but this low probability event is of 
high consequence. While a large number of microorganisms could be 
utilized, the more plausible organisms are summarized in attachment 
1.1 Of these, anthrax is the easiest to prepare and 
disseminate particularly in confined spaces. It also, under appropriate 
conditions, can produce the highest morbidity and mortality. A 
comprehensive analysis of the current threats can be obtained from the 
excellent publication of the Institute of Medicine and National 
Research Council entitled ``Chemical and Biological Terrorism: research 
and development to improve civilian medical response''.
---------------------------------------------------------------------------
    \1\ D.R. Franz et al. Clinical Recognition and management of 
patients exposed to biological warfare agents, JAMA 278: 399-411
---------------------------------------------------------------------------
    Two general types of release can be perfected. First and easiest, 
is the release of organisms in an enclosed environment such as a 
building, subway or ship. Small amounts of microbes are required, the 
dispersal conditions are not so rigorous and the agent recycles in the 
air system until it settles out. The agent is also less exposed to 
harsh environmental conditions. This type of release is designed more 
to produce terror than a large kill. Second, the organisms can be 
released as an aerosol into the atmosphere through a spray such as a 
crop duster airplane, or a truck with an insect sprayer (fogger). The 
sprayers are more difficult as they require a dispersal agent to keep 
the particles below 10 to ensure particles are inhaled into 
the lungs. Effective release is highly dependent on climatic 
conditions. It is important to note that the Aum Shinriko was 
unsuccessful in causing death form an aerosol release.
    Fortunately the United States has excellent medical capacity to the 
management of infectious disease. However, there is limited hospital 
surge capacity. The growth of managed care, cost containment 
procedures; reduction in hospital beds and reduction in hospital staffs 
has limited markedly the excess capacity of the health system in 
responding to large-scale emergencies. A visit to a metropolitan 
emergency room on a Saturday evening will show the strain on resources 
required for daily needs let alone an emergency. Systems need to be 
developed to make beds rapidly available.
    The primary issues to be addressed are: intelligence to minimize 
surprise and interdict the terrorists; crisis response to mobilize 
investigative forces and consequence management. Frequently crisis and 
consequence management occur at the same time. Bioterrorism events will 
likely be discovered after a number of people have become sick or died 
therefore rapid response is of the essence. With appropriate commitment 
of resources and organization skills illness and death can be reduced 
60-to100 fold but deaths will occur at the initial site of release and 
continue until the infectious agent(s) are brought under control.
    requirements of a robust system for defense against bioterrorism

1. An integrated Federal, State and local civil response system.
2. A single command and control system at the Federal level
3. A robust Public Health infrastructure that includes the military and 
        civilian sectors.
4. Rapid diagnosis tests for the most common threat agents.
5. Enhanced reference laboratory capabilities including sufficient 
        numbers of BSL 2-4 containment facilities in both USAMRIID and 
        CDC
6. Surge capacity of the medical system.
7. Stockpiles of therapeutic agents.
8. Training of medical response system with particular emphasis on 
        local response capacity using both exercises and distance 
        learning
9. A regulatory system within FDA that can evaluate therapeutics using 
        surrogate markers and sufficient resources to accomplish the 
        reviews expeditiously.
                      progress since the gulf war
    During the Gulf War, I had the responsibility for training the 
local fire-rescue and emergency response system for a possible anthrax 
attack. We had little of the above listed capacity. Together with 
William Clark, presentations were made on the various biologic agents 
and with the support of the Assistant Secretary for Health, James 
Mason, I stored sufficient medicine inside the beltway to treat 51,000 
people for 48 hours with antibiotics. Liaison was established with both 
FBI and FEMA. The system was totally inadequate.
    Following the Gulf war, The Public Health Service (PHS), through 
the Office of Emergency Preparedness which I directed sought the 
support of FEMA for the first Federal bioterrorism training exercise 
(CIVIX 93) that simulated an anthrax attack on a large metropolitan 
subway system. This exercise revealed widespread weaknesses in the 
response system at all levels. It also demonstrated the need to include 
military assets at USAMRIID and the research capacity of DARPA to 
develop certain applied research projects. However, attempts to obtain 
adequate funds to address the deficiencies were unsuccessful within the 
Administration and Congress.
    The attack of the Aum Shinriko on the Tokyo subway system in 1995 
with sarin led to middle of the night discussions during which I 
reported rapidly to Mr. Richard Clarke, National Security Council that 
the agent was most likely sarin based on the symptoms. The difficulties 
involved in preparing to defend against a coordinated attack on the 
United States and other countries are well described in the recent 
publication by Miller, Engelberg and Broad.2 The magnitude 
of the Aum Shinriko operations and the discovery that they experimented 
unsuccessfully with anthrax provided a wake up call to our nation. In 
the aftermath of the incident, there was a great deal of activity led 
by Richard Clarke that culminated in PDD 39, and the designation of the 
PHS as the lead Federal Agency in consequence management for biologic 
agents. Broad Federal cooperation occurred in the meetings that I 
chaired and assignments were completed on time. Trust and close working 
relationships are required for success. We all recognized that we 
should not exchange business cards for the first time at the site of a 
disaster. The planning actions of representatives from American Red 
Cross, DOD, DOJ, EPA, FBI, FEMA, PHS, VA, and USDA resulted in the 
completion of the integrated Health and Medical Services Support Plan 
for the Federal response to terrorism in September 1995. Unfortunately, 
adequate funds for implementing this plan were not forth coming despite 
appeals both to the then Principle Deputy Assistant Secretary for 
Health and her staff and in the PHS and the Congress. There were two 
initiatives that were seminal and have had a marked impact on training 
nationally. First, the Secretary of DHHS made monies available for the 
first time to local communities enabling both local and integrated 
Federal, State and local training exercises to occur. Second, the 
Metropolitan Washington response agency (Council of Governments) wrote 
to President Clinton describing the inadequate preparation of the 
region. Subsequently, the Office of Emergency Preparedness with the 
advice of State and local health personnel developed a concept of 
Metropolitan Medical Strike Teams to augment the capability of local 
public safety, public health, fire rescue, hazmat and medical emergency 
responders to be able to address successfully biological and chemical 
terrorism.
---------------------------------------------------------------------------
    \2\J. Miller, S. Engelberg and W. Broad Germs, Biological Weapons 
and America's Secret War Simon and Schuster, New York 2001, pg151-152
---------------------------------------------------------------------------
    The next major change in the preparedness system resulted from a 
concern by President Clinton. He concluded that there was weakness in 
the current response to bioterrorism based on world conditions and 
requested briefing from non-governmental experts. During the meeting 
with the President and selected senior staff, the Attorney General, the 
Secretary of Defense and the Secretary of DHHS, a comprehensive 
analysis of the current statue of preparedness and recommendations for 
improvement were presented. The President requested that the analysis 
be submitted expeditiously. The document with the attached budget is 
submitted as attachment 2. Particularly relevant was the focus on 
emergency response and research. The DOD, DHHS and DOJ were requested 
to examine their programs, propose enhancements to overcome the noted 
deficiencies and submit an appropriate budget. The positive response of 
the departments led to substantial improvements.
                        progress since may 1998
    The increased budget for the PHS has resulted in substantial 
improvements. However the most significant recent event was the 
appointment of Governor Tom Ridge as Director of Home Defense. If he is 
successful in developing a coordinated approach to the threat of 
terrorism in general and bioterrorism in particular, it will greatly 
improve the response. A coordinator in HHS for all of the former PHS 
agencies with budget authority and coordination responsibility could 
aid the Director's efforts.
    Training has been greatly strengthened through the provision of 
funds to the States. The concept of Metropolitan Medical Strike Teams 
has been continued though renamed (Metropolitan Medical Response 
System). A total of 97 systems have been funded in cities or locales. 
Coordination between Federal and State and local public health agencies 
has been heightened through monies for joint training exercises. The 
National Disaster Medical System has been enhanced through additional 
development of teams that can respond to both chemical and 
bioterrorism.
    The public health infrastructure at the local, State and Federal 
level is still not sufficiently robust. For example at the Federal 
level, the containment facilities and staff trained to study highly 
infectious pathogens at the BSL 2- 4 level in USAMRIID are inadequate 
to meet the needs for contained management of highly infected cases and 
research of pathogens. They need to be doubled in size. Similarly, the 
facilities at the Centers for Disease and Prevention and NIH are 
inadequate. Other regional facilities need to be developed. The public 
health laboratories, while able to diagnose bacterial infections, have 
insufficient facilities for viral diagnosis. Finally, there is 
insufficient graduate training in this field. The most experts who were 
involved in the bioterrorism field like myself are retired!
    Most telling is the inability to diagnose infectious agents 
rapidly. The recent fatal case of anthrax in Florida is illustrative. 
It took at least 48 hours for the diagnosis. Probably classical culture 
and antibiotic sensitivities were employed. This is simply 
unacceptable. To have effective treatment to reduce toxemia, it is 
imperative to make the diagnosis more expeditiously through 
immunological means. Adequate laboratory facilities are required to 
meet emergency requirements. Anthrax may not always be easily diagnosed 
clinically, as textbook cases are rare in real life. Additionally, 
although USAMRIID and CDC and other state laboratories can do careful 
epidemiological work through plasmid determination or bacteriophage 
sensitivities, these too need to be done in hours not days. Public and 
private sector research and development and expeditious evaluation by 
FDA is required to meet these needs. Similarly, rapid detection of 
other an agents that could be used in bioterrorism is imperative.
    Great progress has been made in developing stockpiles of 
antibiotics and other medical supplies. However the supply of vaccines 
against anthrax and smallpox remains insufficient. The production of 
vaccines needs to be accelerated and Federal facilities may be 
necessary if the private sector cannot respond adequately. Because most 
people will not be immune and antibiotic resistant strains can be 
utilized, there is a need for just in time therapy to neutralize toxin 
and microbial agents in bioterrorism. The Biotechnology Company Elusys 
on whose Board of Directors I serve is developing one such promising 
approach. This therapy can neutralize the anthrax toxin after exposure 
and when used in combination with antibiotics should be highly 
effective (attachment 3).
    Surge capacity of the medical system has been enhanced but only 
marginal progress has been made since 1998. This is a highly 
significant though correctable deficiency.
    Research on pathogenic model systems for the common infectious 
agents has proceeded but remains inadequate.
    The ad hoc committee that reported to the President emphasizes the 
need for regulations to facilitate the development of therapeutic 
agents and diagnostic agents for organisms that cannot be tested in 
human volunteers. Because there are insufficient natural cases of 
infections with agents like smallpox and anthrax, it is imperative to 
evaluate these in appropriate animal models. Additionally, it was 
recommended that a special division be formed and funded to provide the 
personnel to expeditiously determine the safety and efficacy of such 
therapies. FDA proposed a rule Docket No. 98N-0237 ``New Drug and 
Biological Drug Products; Evidence Needed to Demonstrate Efficacy of 
New Drugs for use against Lethal of Permanently Disabling Toxic 
Substances When Efficacy Studies in Humans Ethically Cannot Be 
Conducted'' (FR Vol. 64: 53960-53970). The comment period closed 
December 20,1999, comments have been posted on the FDA web site however 
the rule is languishing. This rule is important because it would enable 
FDA to approve for marketing on the basis of appropriate well-
controlled animal studies.
                         urgent recommendations
    When I managed the emergency medical system there were difficulties 
in: understanding what to do, convincing the government to fund the 
infrastructure, and developing a system to coordinate the major 
agencies in PHS, DOD, VA FBI and FEMA. Much progress has been made 
since 1995 in addressing the response to terrorism with weapons of mass 
destruction. Funds can now be allocated to enhance the response system 
thereby saving many lives. Although there are especial nuances among 
them, the response to biological terrorism must be viewed in concert 
with an all hazards response system. Based on past professional 
experience, I urge the following recommendations for immediate 
implementation.

1. Develop a command and control system for Public Health that 
        interfaces seamlessly with the Office of the Director of Home 
        Defense and integrates all of the relevant organizations in the 
        civilian agencies of government, the military and the private 
        sector.
2. Enhance the rapid diagnosis system through the development of rapid 
        immunological procedures. The recent delays in identifying the 
        organism in Florida illustrate this need. Local laboratories 
        can be overwhelmed by requests for mass screening. Therefore, 
        it is necessary to ensure that communities have access to 
        containment laboratories and surge capacity to meet large 
        diagnostic loads.
3. Finalize the FDA regulation on Drugs to treat diseases where ethical 
        considerations prevent the use of human subjects. The proposed 
        regulation is Docket No. 98N-0237 ``New Drug and Biological 
        Drug Products; Evidence Needed to Demonstrate Efficacy of New 
        Drugs for Use Against Lethal of Permanently Disabling Toxic 
        Substances When Efficacy Studies in Humans Ethically Cannot Be 
        Conducted (FR Vol. 64: 53960-53970). Provide 2-million dollars/ 
        year for FDA to meet this critical mission.
4. Augment the mass casualty response system through:
     Augmentation of the medical systems in the National Guard 
            to enable them to rapidly deploy to the disaster site.
     Creation of a dedicated health disaster personnel system 
            with 750 officers within the Commissioned Corps of the 
            Public Health Service under the direction of the Secretary 
            and the Surgeon General. While these physicians, nurses, 
            epidemiologists and support personnel can work in agencies 
            while not deployed their primary responsibility is to the 
            emergency management
     Support training of individuals capable to manage the 
            medical consequences of weapons of mass destruction both in 
            the military and civilian sectors.
     Training of medical and environmental health personnel 
            through distance learning and exercises to ensure each 
            community can respond appropriately. The excellent course 
            at USAMRIID has trained over 50,000 people
     Develop a similar civilian training program for all 
            hazards
     Develop an integrated system of field hospitals and 
            identified facilities that can be used for mass casualty 
            management. DOD has only approximately 5 such units and the 
            equipment for field hospitals in DHHS is inadequate to meet 
            the civilian need specially since the military units may be 
            on deployment.
     Augment the containment facilities in hospitals to ensure 
            that the hospital will not be rendered useless through 
            needless contamination.
     Ensure that the emergency response teams can be protected 
            through proper equipment and protective clothing. One 
            recent development is a shirt developed through a research 
            grant from DARPA that can determine heart rate, respiratory 
            rate, temperature, blood oxygenation and locate people 
            under 60-80 feet of rubble through geopositioning and two 
            way communications (attachment 4). This would enable 
            trapped workers to be located
     Provide sufficient training in containment and 
            decontamination of infectious agents within the 
            environment. The emergency response capacity of EPA should 
            be enhanced.
5. Ensure sufficient medicines to respond to mass casualties through 
        stockpiles at strategic locations. Where supplies are 
        insufficient the Federal government should support research 
        into new therapies and production of just in time 
        immunotherapies and vaccines.
6. Mass death management. The events in Oklahoma City and the World 
        Trade Center have taught us how difficult it is to identify 
        bodies. Massive deaths from a major terrorist attack require 
        sensitive treatment of the remains of loved ones.
7. Development of a reserve system of grief counselors and chaplains 
        that can be trained through distance education and local 
        exercises. As a Pastor, I can attest that at a time of mass 
        casualties, the faith and the emotional well-being of the 
        victims may be fragile and in need of significant support.
8. Media communications must be accurate and informative. Public Health 
        officials should be trained and exercised in communication. The 
        confusion of facts in the recent Florida anthrax case is an 
        example of this need.
9. Support genomic research to enable rapid analysis of novel organisms 
        including those with mutations to antibiotic resistance and 
        genetically engineered toxin production.
10. Support development of ``just in time immune therapies'' to treat 
        the potential threat agents
                                summary
    While the threat of bioterrorism is a significant, it can be 
overcome through coordinated civil defense, a robust public health 
system and research on the genomes and mechanism of pathogenicity of 
threat agents. Of particular need are methods of rapid diagnosis, 
enhanced containment facilities and new modalities of therapy. It is 
important to note that the proposed measures will strengthen our 
response to emerging pathogens as well as meet the threat of 
bioterrorism. Thus funds to address the issues identified in this 
testimony will be well spent.

    Mr. Greenwood. Thank you, Dr. Young; and let me assure you 
that this committee hears your prayers.
    The Chair recognizes himself for 5 minutes for questioning.
    If I were to dispatch any one of you to a city, Washington 
DC, Philadelphia back in my State of Pennsylvania, Los Angeles, 
wherever, and said to you I want you to go there and I want you 
to report back to me as to the preparedness of that city for a 
bioterrorist event, the question that I have for you is, would 
you know where to find the checklist? Do you think that we have 
developed or that you have access to a comprehensive definition 
of what would make a city prepared against which those local 
officials can measure themselves so that you could report back 
that, in fact, the preparations are adequate?
    And let me ask any or all of you who wish to comment. We'll 
start with Dr. Smithson.
    Ms. Smithson. This is exactly what I had in mind when I 
fanned out across the country in reviewing individuals from 
various response disciplines, and you'll see that in chapter 6 
of the Ataxia. They feel that they're much better prepared to 
deal with a chemical disaster and that they've got a much 
further way to go when it comes to responding to a biological 
disaster.
    Now I separate those two responses because they're very 
different things. And you'll also see in that narrative their 
key points about what is entailed in biological disaster 
preparedness, from detection to training, institutionalization 
of this training across the various response disciplines. Not 
just hopping from city to city, but it's got to be in all of 
our universities, nursing and medical schools, as well as the 
other response disciplines.
    Mr. Greenwood. Let me just make sure I'm clear about my 
question. My question is, is do we know what constitutes 
preparedness? In other words, is there a universally accepted 
checklist that you could take to the city of Philadelphia and 
say, training of EMTs, check; training of ERs, check; supplies 
of vaccines, check; et cetera? Do we have an agreed-upon--not 
even getting to the question yet of are we prepared, and we 
know very well that we have a long way to go in that regard, do 
we have a definition that's agreed to within the profession, if 
you will, that would enable us to measure our cities in terms 
of their preparedness? Dr. Waeckerle.
    Mr. Waeckerle. Thank you, sir. There are components of what 
you asked for available through certain previous workings of 
the Nunn-Lugar-Domenici Act, some through DOJ, OJP, some 
through DOD, and some through HHS and CDC. As Dr. Smithson 
alluded to, most are related to chemicals, but there is no 
protocol, templates or ability to bring anything from the 
Federal level to the local community for all hazards that we 
currently face available to any city in America. The MMRS 
effort is as close as I am aware to get to that currently, but, 
as they admitted in testimony in the GAO report, they still 
focus more on chemicals, and we need to have a great deal more, 
especially for biologics.
    Mr. Greenwood. Did you want to----
    Ms. Smithson. The MMRS effort has basically focused on 
allowing the cities to make their own plans, and that's put----
    Mr. Greenwood. That doesn't seem to me to be adequate 
because we can't assume that every city has the expertise to do 
that, to know what constitutes readiness.
    Ms. Smithson. They have some of the expertise there, but it 
forces all these cities to push the same rock up the same hill 
independently. While there's resistance at the local level to 
having a model, there ought to be some type of a model out 
there for them to follow; and I would say that perhaps New York 
City's biodisaster readiness efforts would be the model that, 
most of the places where I went, they were following that 
model.
    Mr. Greenwood. Thank you.
    Mr. Young. Mr. Chairman.
    Mr. Greenwood. Let me go to Dr. Stringer. We'll go from 
left to right.
    Mr. Stringer. There have been excellent examples of unified 
planning and working together with the MMRSs. The MMRS has done 
one thing for emergency management. It's brought the health 
departments and the hospitals to the table, as the Superfund 
law did in 1986, and required them to come to the LAPCs. So 
they're all working together. They even know each other now.
    That's a start, sir, because, before, that didn't exist, 
and most communities--some will not agree with me on that, but 
I think that's probably overall true--each city is allowed to 
do it the way they sort of think it ought to be best for them. 
There have been a couple models that are excellent out there 
that the OEP has tried to provide to the cities, and I think 
many of them are using--they're not all starting from scratch, 
but they do have the right to have what's best for them, which 
may not be the example of what's in the next city, say even in 
that State, that was approved on MMRS.
    Mr. Greenwood. Thank you, sir.
    Dr. Young.
    Mr. Young. Mr. Chairman, I think it's important to realize 
that when we started the program we wanted to recognize, as Dr. 
Stringer said, the local capability, but Dr. Lederberg and I 
were asked by Dr. Hamburg and through her from Mayor Guiliani 
to go with him the first month of his office and brief him on 
bioterrorism. I also briefed the Mayor of Boston.
    So the answer to your question specifically, in those 
cases, all the appropriate officers of the city government were 
in the room and plans were developed, and that was the 
beginning of this local team approach. A single unified plan 
for bioterrorism and chemical terrorism does exist, and that 
Lew Stringer was helpful in developing for the Olympics that we 
had in Georgia. Because at that time we had both helicopters, 
response teams, outside and you noticed how rapidly, when the 
bomb went off, there was response within that area with teams. 
They were prepositioned, supplied and equipped; and I believe, 
Lew, those lists and the supplies, equipment and plans still 
exist in the Office of Emergency Preparedness.
    Mr. Stringer. That has been one of the initiatives that 
started the equipment catch list that most cities have in 
talking about whether it's a thousand or 10,000 patients or X 
number of thousand--the same equipment.
    Mr. Greenwood. Thank you. Let's see. Dr. O'Leary.
    Mr. O'Leary. Yeah. I think the issue is that--others have 
said more than a checklist issue. It is a plan issue. And I 
don't think we can assume that there is one single model. I 
think that we are talking about cities, we're talking about 
suburban communities and may be talking about rural areas. 
These things can happen anywhere, and the models, the templates 
will not be used unless they are adaptable to the realities of 
these communities, and there is a crying need to develop these 
so that they are going to actually be usable.
    Second, I would comment that a plan itself is not 
sufficient, that we have to make sure that these plans are 
being tested and carried out. It is a functionality that we 
should be evaluating; and there is, I think, eventually a case 
to be made for some third-party oversight of these. That could 
be done by State agencies, it could be done at a national 
level, but I don't think we can assume because they have a plan 
that it's working. I think the public will want some external 
validation that these plans are working, and that a checklist 
is part of that.
    Mr. Greenwood. I understand. Mr. Peterson.
    Mr. Peterson. Although I think you're hearing that we can't 
give you comfort that there is one uniform, elegant approach 
that's being deployed, it's my observation that one of the 
things that's going on is that we have a serious effort under 
way for folks to be talking to each other.
    I know at our local level, the Mayor of Baltimore has been 
very actively involved in convening the appropriate agencies, 
hospitals and so forth and, in turn, has communicated via video 
conference, teleconference with other mayors of large cities to 
share best-demonstrated practices. So you should glean from 
this the sense that there is a lot of collegial activity under 
way, but I think it is fair to say--I would agree with all of 
my colleagues here at the panel that, in fact, there is not one 
uniform approach that's being deployed across all of the 
jurisdictions.
    Mr. Greenwood. Thank you. My time has long since expired.
    The Chair recognizes the ranking member, Mr. Deutsch, for 5 
minutes to inquire.
    Mr. Deutsch. Thank you, Mr. Chairman.
    You know, maybe I'm looking at it differently than people 
on the panel. And we can talk about the incident in Florida, of 
whether it is a criminal case or a case of bioterrorism, and we 
could talk about definitional terms, but obviously something is 
happening, and it's very much I think on the minds of Americans 
and not just Americans, people around the world. Dr. Simpson, 
you, you know, talked about it specifically, and if you can 
maybe elaborate in terms of the response that's actually going 
on now, in terms of CDC, in terms of the local health agency, 
in terms of HHS, in terms how they are responding to the cases 
of anthrax that have been disclosed in Florida. You know, are 
they doing a good job? Should they be doing more? What should 
they be doing? If you're able to do that.
    I mean, because I guess we've talked about the theory of 
bioterrorism. We've talked--you know, we've had all of you talk 
about the theory of response. As far as I'm concerned, there is 
a potential bioterrorism incident that is occurring right now 
in the United States of America. You can describe it as a 
criminal act. I think it's still open of whether or not it's 
bioterrorism, whether it's related to September 11, we don't 
know. My understanding is that, you know, 700 additional people 
have been tested.
    Again, one of the issues that Dr. Young mentioned, which is 
I guess really frustrating, is that there still seems to be a 
24/48 hour incubation period before we know if there are any 
additional cases. So that's not the case; it is the case. 
That's what CDC said to us yesterday in a nonclassified 
briefing that they gave Members and staff. But we have 
something going on.
    And I will tell you that, you know, we can really get into 
this, what the definition of terrorism is. I will tell you, I'm 
going to submit this to the record--I wasn't aware of this 
until this morning--a letter that was sent by American Media, 
which is the company where the two cases were uncovered, and 
their building has been basically cordoned off.
    A letter that was sent from that office to an office in 
Montreal, the building in Montreal was evacuated. The entire 
building was evacuated. People in that building were tested for 
anthrax, and at least we're getting reports at this point--and 
this is a local company in Florida. I represent Florida, and 
I'm familiar with the company--that at this point they are 
having problems distributing their newspaper because people are 
afraid that their newspaper is covered with anthrax, and in 
fact people apparently--we're getting reports that people are 
apprehensive of going into supermarkets where their newspapers 
are distributed for fear of getting anthrax. So, I mean, you 
know, we have a public health crisis right now. I mean, if you 
can respond. I mean, because--just respond in terms of what's 
going on now, if you can.
    Ms. Smithson. This country was viciously attacked on 
September 11, and in much of what I have seen in the media in 
the succeeding weeks with regard to bioterrorism, we've been 
traumatized all over again. I have to echo Dr. Young's remarks 
in that regard. There have been a lot of people on TV saying 
things that I don't recognize to be technically true.
    With regard to the case in Florida, first of all, it is 
clear, at least as far as I understand from people that I've 
talked with and involved with the investigation, that this was 
a substance on a computer keyboard. If this were an attempt at 
mass casualty terrorism, the delivery method would have been 
much, much different.
    Second of all, I think that it would be appropriate for me 
to actually turn your question about the response over to 
others who have been involved in that system, but, before I do, 
I would encourage you to look at what terrorists have actually 
been doing with these substances and to perhaps keep your mind 
open that this is the type of case that would be a grudge or a 
vendetta or a disgruntled worker.
    We've had disgruntled workers sprinkling Shigella on the 
breakfast donuts in a hospital not so long ago, so occasionally 
individuals do turn to these substances to harm other people.
    Mr. Deutsch. There is no question about disgruntled 
employees is also the theory. All of us have become experts in 
theorizing and movie writers over the last couple of weeks, but 
I guess, you know, first of all, in terms of the job of this 
committee, you know, we have continuously been told that this 
is a very difficult substance to obtain. We're now told that 
this is a substance which is nonnaturally occurring, so, you 
know, it is in a very limited capacity. So, you know, there are 
very smart, very vicious people out there; and I don't doubt 
it's possible that this is a case of a disgruntled employee, 
but this is a real case going on.
    No. 1, you know, if the only substance--and we're not aware 
of this at this point in materials of this committee. If the 
only location of that anthrax in that building was on the 
keyboard, you might have more information than any of us have 
right here; and, if that's the case, I'd be happy for you to 
elaborate on it. So that would be No. 1.
    No. 2, though, there's still the issue of how it became 
inhaled. If it was on a keyboard, the person who died inhaled, 
which again apparently is a very, very bizarre, you know, 
unusual case of anthrax. I mean, there have been many cases of 
the--through skin?
    And I still question, just--you know, we have a situation 
that now this occurred last Thursday. We still don't know. I 
mean, today is Wednesday. You know, it goes back to the 
question Dr. Young mentioned. If you have the response which is 
Cipro or whatever in terms of preventing mass casualties, then, 
you know, we're almost a week later, and again my understanding 
is that once you got it, you got it. I mean, you can do 
prophylactic antibiotics, but you can't do it afterwards.
    Dr. Brinsfield, do you want to respond?
    Ms. Brinsfield. Although I'm certainly not the most expert 
in this of people in this room, anthrax is a naturally 
occurring organism that occurs throughout the world. It is not 
as difficult to obtain as it is to aerosolize and cause a mass 
casualty incident.
    The other thing that I think is important to say is that 
when you define terrorism as the creation of fear, you know, 
maybe we have to look at ourselves and wonder what we're doing 
to stop that spread of fear. The idea that they decontaminated 
an entire building based on one letter sent to them is a 
colossal waste of money, time and the public's attention; and 
it just really I think behooves us to look at controlling how 
people know about this and how they respond to prevent the 
creation of fear.
    Mr. Deutsch. If I can just respond, and obviously not 
having as much medical training as anyone or disaster training 
as anyone on the panel, I'll tell you that one of the problems 
is misinformation, not just in terms of pundits but 
misinformation in terms of the government. We're getting 
reports back, and they almost become circular. We get reports 
that it's naturally occurring. Now we're getting reports that 
apparently it was not naturally occurring anthrax, which seems 
to be the latest situation. Then we're getting reports that it 
can't be, you know, ascertained, the aerosol issue, but this 
gentleman clearly had inhaled anthrax. Right. So he--but 
apparently you can't get it by taking your finger and touching 
your nose. I mean, there's 5,000 spores that you would have to 
get into your nose and breathe in. So, you know, you're the 
experts here, and you can't tell me anything--or you can try.
    Again, I know time is up, but the last two responses. Yes, 
Dr. Waeckerle.
    Mr. Waeckerle. I guess there are two issues here. The first 
issue is I'm reluctant to speculate on information that is 
tenuous with Dr. Lillibridge behind me and knows the answers to 
these questions, but I will tell you that--to some of the 
questions. I don't want to put Scott on the spot here, but--
well, I do, but it's okay. But I do think that there's two 
issues that have come about that you bring up that are terribly 
important.
    The first issue is how do we effectively communicate with 
the media as the authorities--the knowledgeable authorities 
that our citizens look to for reasonable, rational and accurate 
information? And I believe that this hierarchy that we've asked 
you to create in these management protocols, whether they be 
local or national, should address that specifically.
    The second issue that you bring up is an incredibly 
important issue that I believe your committee attends to, and 
that is the dealings with the pharmaceutical industry and the 
availability of drugs and vaccines. And there are significant 
problems with drugs and vaccines that are available for this 
type of an organism and the capacity to produce them, the 
research and development of them and the technical barriers and 
legislative barriers that the pharmaceutical industry must face 
with regard to these.
    So there are some issues that I think you've brought up 
that are terribly important that I hope you pursue, sir.
    I do think that the answer to some of your questions, which 
I believe some of us can speculate on about not having the 
accurate information, we could talk to you about the inhalation 
of spores or what happens when you touch your nose or what 
happens if you open an envelope and smell it or what happens or 
how you spread it, but--and there is accurate information, and 
there also as I understand it maybe some laboratory diagnostic 
tests now that may be available in some areas that are not 
available to all the local communities. So I would hope that 
you'll get some answer from Dr. Lillibridge and others on that.
    Mr. Greenwood. The time of the gentleman has expired.
    Dr. Young, very briefly, if you have a comment.
    Mr. Young. Yeah. I was working with spore farmers while 
Scott Lillibridge was still in knickers. So I want to try to 
answer a little bit on your question directly.
    First of all, it's important to note that you can 
aerosolize spores. They will last a long period of time, but 
you do have to get the amount up into the nose. But the second 
point that's most critical is to get accurate diagnostic 
information and to get it fast.
    There's two parts to the case. One is related to any 
criminal activity, and the other is looking at what the 
organism is, per se. The most important thing for the American 
people to know is that it takes a significant dose of the 
organism to get the disease. You're not going to get the 
disease from a few spores on the keyboard, and you're not going 
the get the disease from a few spores on letters. Will you find 
it in both places and anytime people handle it? The answer is 
yes.
    One time I wanted to get an organism from a Japanese worker 
in Japan who didn't want to send it who was a spore farmer. I 
got his letter. I put it in pen. assay broth, incubated it, and 
I had his organism because he had scratched his face, his nose 
and elsewhere, and I could get the strain from there.
    Finding the organism in a place does not mean disease. 
Having disease does not mean an epidemic. We've got to be very 
careful with the language we use.
    Mr. Deutsch. You know, if I can ask one final question with 
a show of hands, not with an answer. If I gave each of you 
letters from the American Media company right now, if I gave 
you copies of the National Inquirer right now that were 
published at that facility, would you just open them 
automatically, or would you try to get responses? I mean, just 
show of hands, all of you. Would open them automatically?
    Mr. Greenwood. The time of the gentleman has expired.
    Some would argue that the tabloids are toxic by definition.
    I recognize the gentleman from North Carolina, Mr. Burr, 
for 5 minutes.
    Mr. Burr. Mr. Chairman, one of the things that is certain 
is the definition of experts has changed since September 11, 
given the host of individuals that we've seen on and the fact 
that they're not always as consistent as the next one. I want 
to thank each one of you for very thoughtful and very 
informative testimony.
    Dr. Smithson, let me turn to you real quickly, if I could. 
You talked a little bit about the vaccine and antidotes that 
were needed. We've certainly had a number of news reports of 
late as it relates to anthrax vaccines, the slow start that the 
Michigan company has that--not only transitioning that business 
that was owned by the State but receiving the approvals from 
the FDA relative to production outside of the military of the 
vaccine.
    There have been a number of commissions on terrorism. 
Several of them, if not all of them, have come to the 
conclusion that the vaccine manufacturing and potentially the 
antidote manufacturing must be done in a Federal manufacturing 
facility to assure us in some way, shape or form that we have 
the vaccines available and in the right supply. Would you like 
to comment on whether that function should be Federalized or 
not?
    Ms. Smithson. It's not just limited to the anthrax vaccine. 
The plague vaccine is not being manufactured anywhere at 
present, as far as I understand. And even on the chemical side 
of the house, we just have one company in the United States 
that makes Mark 1 kits. We've got to keep, you know, looking 
across the spectrum at our manufacturing capabilities, and I 
think there should be serious consideration given to 
Federalizing some of these manufacturing capabilities, not just 
for the supplies that might be needed to vaccinate our soldiers 
but for the supplies that would be needed to get to the front 
lines at home, to our first responders at home.
    Mr. Burr. Is it your belief that the private sector cannot 
fulfill that function?
    Ms. Smithson. I think we need a public-private partnership 
in this, and there needs to be a Washington-led effort, in 
combination with the U.S. pharmaceutical industry, to bring 
that about.
    Mr. Burr. Let me----
    Ms. Smithson. Surge capacity----
    Mr. Burr. Let me suggest to all of you that there's a very 
fine line there between a Federal entity and a partnership, and 
I know that I think in your testimony I think Dr. Young alluded 
to the fact. We have a budget currently of about $322 million 
over 10 years that was to address the joint vaccine acquisition 
program. Given the fact that a new pharmaceutical runs in the 
neighborhood of about a quarter of a billion dollars from start 
to finish, $322 million looks like a drop in the bucket for the 
funding of an entire vaccine program. Would you agree?
    Ms. Smithson. Yes, indeed I would.
    Mr. Burr. The current timeframe, if I remember correctly, 
is somewhere between 9 and 15 years, relative to the FDA 
approval of a vaccination.
    Ms. Smithson. And that timeframe does not address the fact 
that the clinical trials in these cases must deal with diseases 
that are lethal. So that's why the FDA is having such a 
difficult time wrestling with this.
    Mr. Burr. Dr. Young, you referenced to a date, 1999 or--I 
can't remember what it was--where the FDA was directed I think 
to put together a final regulation or a set of procedures, a 
directive that they receive, and they still haven't put that 
together.
    Mr. Young. That's affirmative, and there has been dialog 
with the docket branch trying to speed that along.
    Mr. Burr. Ambassador Bremer in, I believe, 2000 when the 
National Terrorism Commission gave their report--let me read 
you one of the bullets: A terrorist attack involving a 
biological agent, deadly chemicals or nuclear or radiological 
material, even if it succeeds only partially, could profoundly 
affect the entire Nation. The government must do more to 
prepare for such an event.
    Dr. Stringer, have we done anything different since that 
report came out before September 11?
    Mr. Stringer. I think there's a lot more interest in WMD 
preparedness, WMD training, funding from every level of this 
country. I just hope it won't go away when the televisions go 
away, because that's been the frustrating thing since 1995 when 
we started this, trying to get adequate funding for any of the 
initiatives.
    Mr. Burr. The General Accounting Office on October 10 of 
this year put out a report. Let me read you just a section of 
it. It said: Federal spending on domestic preparedness for 
terrorist acts involving WMDs has risen 310 percent since 
fiscal year 1998, to approximately $1.7 billion in fiscal year 
2001, and may increase significantly after the events of 
September 11. However, only a portion of these funds were used 
to conduct a variety of activities related to research on and 
preparedness for the public health and medical consequences of 
bioterrorist acts.
    Dr. Young, can you shed any light on where the hell this 
money is going?
    Mr. Young. Well, I've been trying to track the same thing, 
Mr. Burr, but I think I can give you two points. One, the funds 
were set out in regards to the teams that Lew spoke of. That 
was a major initiative, about 600,000 for 1997, soon to be 120 
teams. There have been exercises that went from the Federal 
level down to the local level, and that consumed a significant 
amount of the public health monies.
    There's another point that I think ought to be added, and 
when you read the note that--or the letter that I sent to the 
President with the other committee, you can see the emphasis on 
research. One of the things that I've been concerned with is 
just-in-time therapy, and I've given you some information in 
Appendix 3 of just such an approach, because not everyone will 
be vaccinated, and there are therapeutics under development 
that can intervene and detoxify and remove the viruses.
    Those types of efforts in research needs to be coordinated. 
DARPA has done some research in that way. FDA has a little bit. 
NIH has, CDC, but there is not a global look as to what type of 
research is done.
    This is, in a sense, a war. There needs to be a focus, in 
my opinion, just as we did in World War II, to look at the kind 
of research that's needed, fill the gaps, and support the 
grants and contracts to do that.
    Mr. Burr. Well, clearly, there's a renewed interest in 
fulfilling that mission.
    Dr. Stringer, let me ask you one last question. As one of 
four national medical response teams, the pharmaceutical 
inventory that you must have to be able to be deployed and to 
address a potential casualty in a city of 100, 200, 300,000 
people must be massive. Do you have such a drug inventory?
    Mr. Stringer. We carry on board the trucks a thousand 
patient doses and then a stockpile, an additional up to 10,000. 
Then there's the--coming behind, the national pharmaceutical 
stockpile with a lot larger footprint.
    Mr. Burr. But from a standpoint of that national 
pharmaceutical stockpile, that's not at SORD or the other 
three?
    Mr. Stringer. No, sir.
    Mr. Burr. Medical response----
    Mr. Stringer. They're in secured locations across the 
country. They can be in within 12 hours, and it was sort of 
neat to see in New York they didn't get there in 12 hours. It 
was a much shorter timeframe, which we're all proud of.
    Mr. Burr. We're extremely fortunate.
    Mr. Stringer. The birds weren't flying that day.
    Mr. Burr. Well, we were extremely fortunate also that this 
happened in New York, which may have been the best city as far 
as their preparedness.
    I will ask one last question with the chairman's 
indulgence.
    I made a statement during my opening statement that 
Governor Ridge has to have the budget authority and oversight 
responsibilities for every penny that is directed toward 
response and preparation for bioterrorism.
    Is there anybody who disagrees with me on that, on this 
panel?
    I will show that there are no hands raised. Everybody is in 
agreement that that budget authority needs to be extended.
    I yield back.
    Mr. Greenwood. The Chair recognizes the gentleman from 
Michigan, Mr. Stupak, for 5 minutes.
    Mr. Stupak. Sorry I missed some of this, but I ran down to 
do a press conference, because once again--for the last 5 years 
we are trying to do a food safety bill, and actually it is in 
this GAO study about how food safety or foodborne incidents can 
result in terrorism in this Nation. And we put in new authority 
there for the Secretary.
    So I am--just a little reminder to everybody on the panel. 
I hope that they take a look at our legislation, and we can 
move it along, because it is a major concern in this country. 
Our imports of food have gone up 200 percent in the last 5 
years, yet we inspect only 1 percent of food coming into this 
country. So you can see it could lead to some real problems if 
the right substances were added to our food. So we should take 
a look at it.
    But we are talking a little bit about money here, and it 
came up quite a bit, and if you take a look at what is going 
on--Mr. Peterson, you mentioned that Johns Hopkins will spend 
up to $7 million, you said. Will you be reimbursed for any of 
that, for any kind of program through the Federal Government, 
State or local?
    Mr. Peterson. Right now there is no direct source for 
reimbursement other than through our ongoing patient revenues. 
But that is a budgetary item on the expense side of the ledger 
of budgetary impact for which we did not have a plan.
    Mr. Stupak. Sure, you didn't have a plan. What will it cost 
you a year to maintain that, supplies and things you need?
    Mr. Peterson. We have not been able to determine that. But 
that is a one-time startup situation.
    To your very point, there will be ongoing costs to 
replenish consumables. Probably, if I had to guess, at least a 
quarter to a third of that number.
    Mr. Stupak. You're a big hospital complex. I am sure $7 
million is not insignificant. But how about regional hospitals 
around the Nation?
    Take northern Michigan where I am from, we are hundreds of 
miles apart from a regional hospital. How would they be able to 
do it? Just be prepared like you are?
    Mr. Peterson. I think the point is that there will probably 
be different needs at different hospitals. And the other point 
that I would make is that I do endorse the notion that was 
suggested earlier in the day, which is that we do need to 
engage in a more regional approach. There needs to be some 
rational planning that goes on so each and every hospital is 
not engaged in duplicative activities.
    Mr. Stupak. You mentioned the nurses shortage. The 
legislation that is pending before Congress is good 
legislation. Any other suggestion you would make on that 
legislation to increase nurse availability throughout the 
United States?
    Mr. Peterson. I think anything we can do to provide 
incentives for young women and men to enter the health fields 
is a good investment, a good thing to do for this country.
    It is not just nurses. We have evidence that there are many 
other skilled categories of workers in health care for which 
there is a growing scarcity.
    Mr. Stupak. Thanks.
    Dr. Smithson, you had mentioned money in your opening 
statement, and I missed it--something about $1.7 billion or 
something--but very little gets outside of the Beltway. Could 
you explain that again? I missed part of that.
    Ms. Smithson. The Federal funds being spent this year on 
readiness are $8.7 billion, with $311 million getting to the 
local level in training, equipment and planning grants.
    If we are to look at the public health sector and the 
hospital end, even a small fraction of that $311 million makes 
its way there.
    Mr. Stupak. Thanks.
    Dr. Waeckerle, you participated in OPERATION TOP OFF, you 
mentioned, in Denver.
    Mr. Waeckerle. I was asked to oversee it. I didn't 
participate in it, sir.
    Mr. Stupak. It is my understanding that the FBI was in 
charge of the crisis management and FEMA was in charge of the 
consequences management. So where did the public health 
officials come in? Did they have to go through FEMA and FBI to 
do anything?
    Mr. Waeckerle. One of the panels has unanimously 
recommended that you have a central authority with command and 
control and the ability to communicate vertically and 
horizontally, if you will allow military terms, because as 
you--you probably know already that that was a disaster. And 
that was one of the major lessons learned from OPERATION TOP 
OFF.
    And, in fact, there were open disagreements as to who was 
in charge at what point in time, and they adversely affected 
the drill and, theoretically, they would adversely affect any 
real events that might occur in this country. And that is why 
we have implored you all to look at the authority and command 
and control and communications issues.
    Mr. Stupak. Okay.
    Dr. Brinsfield----
    Mr. Waeckerle. I just had one suggestion for your law, and 
I apologize to my colleague for interrupting.
    One of the great issues that the hospitals face in this 
country are credentialing and staff privileging issues, as well 
as State licensure issues. If we wish to supplement an 
institution's nursing staff or radiology staff or physician 
staff--and while I apologize, I haven't read your bill in 
detail, I hope that you have addressed the fact that we have to 
somehow create States that border on each other working 
together, so that they can share licensing, credentialing 
issues, as well as hospital and regions doing that; so we can 
have surge capacity and supplement from an unaffected region to 
an affected region of our country with critical health care 
personnel. And I hope that that is addressed.
    Thank you.
    Mr. Stupak. Thanks. If I may have one more question.
    Mr. Greenwood. We will have a second round. But the Chair 
has been very indulgent.
    Mr. Stupak. Okay. You said the domestic preparedness 
program failed because of its stand-alone nature and the lack 
of follow-up. Could you just elaborate a little bit on that for 
me?
    Ms. Brinsfield. I think that it did several things well. I 
think one of the things that it failed with was that its 
oversight changed over the time that it was put out, and that 
it was a single program and a single day training, and there 
was no follow-up.
    So, in Boston, we received that awareness level of training 
over 5 years ago, and there was no training that came as a 
secondary follow-up to move ahead.
    Mr. Stupak. Thank you.
    Mr. Greenwood. The Chair thanks the gentleman.
    The gentleman from Iowa, Mr. Ganske, is recognized for 5 
minutes.
    Mr. Ganske. Thank you, Mr. Chairman. Appreciate the 
testimony of the panel.
    Last night, when I gave a floor statement on this issue, I 
talked a little bit about the problems with different agents; 
and then I asked the question, what can we do?
    And this is--these were my thoughts last night. I am glad 
the panel is in agreement with them.
    First, we need better coordination between the Defense 
Department and the State Department, the Agriculture 
Department, the CDC, the State public health departments and 
directors, the city-based domestic preparedness programs. And 
that is a job that I gather this entire panel feels would be 
appropriate for the new Director of Homeland Security to 
address.
    Second, we must make a systematic effort to incorporate 
hospitals into the planning process.
    I appreciated your testimony, Mr. Peterson, because I think 
it is accurate to say that there are few, if any, hospitals 
today that are prepared to deal with a community-wide epidemic 
of the type that we could envision for a whole host of 
financial, legal and staffing reasons, some of which you 
entered into, and went on to say there will be significant 
costs for expanded staff and staff training to respond to 
abrupt surges in demand for care--as you mentioned, outfitting 
decontamination facilities, rooms to isolate infectious 
patients, cost of respirators and emergency drugs.
    The first serious efforts to implement that civilian 
program to counter that was in 1998 when Congress started to do 
this. But then I went on to say that we had to do more to 
integrate Federal, State and city agencies.
    First, we have to educate the physicians of public health 
staff about the clinical findings of agents--not that easy 
because, as all of you know, the beginning symptoms on those 
are nonspecific upper respiratory, GI. We need to develop 
further surveillance systems for early detection of cases.
    We need individual hospital and regional plans, as you have 
mentioned, for caring for mass casualties. As you have 
mentioned, Dr. Young, we need laboratory networks capable of 
rapid diagnosis; I think that is really, really important. And 
we need to accelerate stockpiling and dispersal of large 
quantities of vaccines and drugs.
    I recently visited Broadlawns Hospital in Des Moines, Iowa, 
which is a public health hospital. We talked about some of 
these things. For years we have neglected our public health 
hospitals. We need to correct that.
    But I just want to finish by making a--a generalized 
comment. You were here today making these points, and I would 
say that one of the main, overall reasons that you are making 
those points is because under the HMO model of health care in 
this country we have wrung out of the health care system any 
redundancy in the quest for efficiency.
    And I see everyone on this panel nodding their head.
    There is no room for the surge of an epidemic in the health 
care system today, because of the HMOs contracting with the 
health system. Some of us would argue that they have gone too 
far in certain circumstances.
    So my point is this: Because of the way that we have 
financed health care in this country and because of the cost-
cutting measures with managed care, we will be facing increased 
Federal costs.
    And I think everyone on this panel before us, and probably 
every one of the Congressmen and Congresswomen here today, 
would agree that Congress will be appropriating significantly 
increased dollars to cover those problems, which you and I and 
others have outlined.
    So one way or another--you know, the costs are there, and 
they will have to be paid for. If they aren't paid for through 
the private health care system, they are going to be covered 
hopefully through the government.
    And with that I will yield back.
    Mr. Buyer [presiding]. We thank the gentleman.
    Mr. Strickland is recognized for 5 minutes for inquiry.
    Mr. Strickland. Thank you, Mr. Chairman, and thanks to the 
members of this panel.
    As I have listened to you today and looked at your 
testimony, I have heard over and over again the admonition from 
you that you need more resources. And putting that in the 
context of--I just can't help but think of actions that we have 
taken in this Congress over the last few months.
    We have talked--all of us, people in both parties, so I am 
not being partisan here--we have talked over and over again 
about the surplus this country has. Well, there may have been 
an accounting surplus in a budgetary sense, but it is evident, 
I think to all of us now, that we have been woefully neglectful 
in terms of dealing with the real needs of our population.
    We have neglected to fund these kinds of activities as we 
should have, and now we are trying to play catch-up.
    And so I want to thank you. I think you are all incredible 
in terms of the message that you are bringing to us today.
    Mr. Peterson, I have here an article from the American 
Journal of Public Health, and there is a study discussed here 
regarding the preparedness of hospitals to deal with certain 
terrorist incidents and so on. The conclusion is, hospital 
emergency departments generally are not prepared in an 
organized fashion to treat victims of chemical or biological 
terrorism.
    Now, you have stated that hospitals must be properly 
stocked with antibiotics, antitoxins, antidotes, ventilators, 
respirators and other equipment. You have talked about what you 
have done at Johns Hopkins. But the question I would ask, would 
you give us an idea of the volume you are suggesting?
    Who do you think is going to pay for it? And who is going 
to make sure that such supplies and the like are in place? How 
do we guarantee that what you are saying needs to be done is 
actually done? And how do we pay for it?
    Mr. Peterson. First of all, let me respond by saying, I 
think it is important to recognize that at the individual 
hospital level, it is important that we attempt to do two 
things. One is to introduce a rational way of thinking about 
what any one hospital needs to prepare for. And what I mean by 
that is that the hope, of course, is that if any one hospital 
or hospitals in the region are dealing with a catastrophic 
happening that help will be on the way at some point after the 
first couple of days.
    Let me use that frame of reference so that as we are 
thinking about what our responsibility is at the local 
individual hospital level.
    You heard me suggest that perhaps we need to have a stock 
to handle 4 days' worth, and I use that because we think it is 
our responsibility to be able to go for a couple of days. And 
we would plan for that. We would spend for that.
    Beyond that, it is our hope that help would be on the way. 
So one way of responding to you is that the--the order of 
magnitude of planning that is done at any one institution, I 
think needs to recognize that in a catastrophic situation, 
there would need to be augmentation of what any one institution 
could do either in a physical way of thinking of it or in a 
fiscal way of thinking of it. But I would repeat that I would 
endorse the notion of some regionalization in how we think 
about utilizing hospitals and their resources.
    Now to how do we pay for it: It strikes me that given the 
reality that was suggested with respect to how the system has 
been reimbursed for services over the last several years, we 
have been squeezed not just by the managed care phenomena, but 
it is also fair to say that both medical assistance programs 
and Medicare programs over the last few years have also placed 
a squeeze on hospitals. So, in general, hospitals are working 
with very, very slim margins, can barely manage their current 
missions in that regard.
    So I would have to take the point of view that we sit 
before you and suggest, we do need some help. I don't know that 
I can suggest to you that we should turn to the Federal 
Government for 100 percent of that which we need to gear up to 
do it, but I do think that we need to have some consideration 
in the form of some direct grants.
    Perhaps there can be a Federal reserve fund of some sort 
that is developed. But--we can't do it alone, but we have a 
responsibility to temper that which we do.
    So what I tried to do today is provide for you, for a 
fairly large hospital, a realistic depiction of what we think 
we have to do at our local level; and I don't think that number 
is unrealistic for the size of our hospital.
    So I am not going to suggest that you multiply $7 million 
times 5,000 hospitals. I don't mean to scare you in that sense. 
But I do think that it is illustrative of one large hospital's 
requirement, and I think it is a fairly responsible position 
that we are taking in that regard.
    Mr. Strickland. Mr. Chairman, may I ask Dr. O'Leary one 
quick question?
    Mr. Buyer. Yes.
    Mr. Strickland. Dr. O'Leary, in your opinion, how would 
your organization make local hospital planning for possible 
disasters, such as we are discussing today, a part of the 
accreditation process?
    Mr. O'Leary. It is part of the accreditation process now, 
as I mentioned in my testimony. It is part of the process now.
    Mr. Strickland. It has been suggested to me that I ask 
whether or not that includes having adequate supplies in place 
in terms of the things we have talked about.
    Mr. O'Leary. Well, the assessment that we have to make, 
which is a--you know, it is all-hazards analysis and what are 
the vulnerabilities and gaps, then identify the needs that have 
to be fulfilled.
    One of the things I think that we--our standards are 
promoting is an engagement of hospitals with communities, but--
which is a broader statement of the need for integration 
between the medical care and public health systems which is, we 
are well short of that reality in a number of communities 
around the country.
    The fact that planning identifies needs does not 
automatically mean that these needs are going to be fulfilled.
    I think that is the kind of problem that--we can't mandate 
that, but we can certainly advocate for adequate funding to 
provide the supplies and the Federal guidance in terms of 
direction for both risk analysis and setting priorities for 
deployment of those resources.
    Mr. Strickland. Thank you.
    Mr. Buyer. You know, in response to Mr. Strickland's 
comment about neglectful, I am not so certain who he was 
targeting the comment to, but I do know, as a people, as a 
society, there were things that we were--we weren't prepared 
for.
    I can't blame Congress when I look back on this post-
Oklahoma City.
    You know, Bill Clinton and I did not exchange Christmas 
cards. But I can tell you that I have to compliment him because 
he began to help focus the country on weapons of mass 
destruction. He appointed the then-CINC of SOUTHCOM, General 
Hugh Shelton, as his Chairman of the Joint Chiefs of Staff, 
someone who operated in the dark world of Special Operations. 
That was very wise of him to do that.
    When--when Senators Nunn and Lugar then passed their 
measures to focus the country on preparedness for weapons of 
mass destruction, you know, DOD takes up the program, we shift 
it over to the Department of Justice, yet States and localities 
don't prepare their plans.
    There is Federal money available, but they don't even do 
it. Only four States have done that today. So even--even here 
as the Federal Government prepares a program and says, you 
know, offer us your plan, we will help you in your training and 
preparedness for your medical readiness, it wasn't even done.
    So maybe it was the country, Mr. Strickland, when I think 
about that. I even remember Joe Biden, Senator Biden, and I, 
who don't always agree on things were at a conference committee 
under the antiterrorism bill. And we tried to change 
wiretapping from the rotary phone to the person, and we 
couldn't even get it out of conference.
    Now the judiciary passes it in a flash fire.
    Mr. Strickland. Can I respond, sir?
    Mr. Buyer. Sure.
    Mr. Strickland. I wasn't directing that comment to anyone. 
As I said at the beginning, this is a matter that all of us, I 
think, have to assume some responsibility for.
    But the fact is that we haven't in the past been thinking 
as we should have been thinking. And I think we have all 
learned a great deal in the last few days and weeks. And 
growing out of that learning, I hope comes a change of policy 
and setting of priorities these folks can help us with.
    Mr. Buyer. I can even tell you--gosh, I have to look back 
almost maybe 24 to 28 months ago as chairman of the Military 
Personnel Subcommittee--taking the Top Secret briefings, 
talking to General Zinni about the ever-present threat of 
anthrax and then authorizing the anthrax vaccine with regard to 
our soldiers. Very controversial.
    I had--in the last election, I had billboards against me 
for having done that. Can you imagine? And now, I am getting 
the, how come other people can't get the shots? Now, isn't that 
a change?
    And there was--something was brought up by Mr. Burr earlier 
in a comment--Dr. Smithson, you made--about public-private 
arrangements. That is what we have with BioPort.
    Ms. Smithson. It is not working so well.
    Mr. Buyer. We held a hearing on that issue. We cannot find 
a pharmaceutical company that is willing to take that program 
at risk. Are you familiar?
    And I suppose if--if we are going to mandate that, do, you 
know, a population, then you would have all kinds of people 
saying, oh, yes, we would like that public arrangement. But 
when we don't have it, then we--I can tell you the conclusion 
was a sole-source contract in a public-private arrangement, 
i.e., an anthrax vaccine.
    I just wanted to share that with you, what we have been 
doing with regard to our hearings.
    I do have a--my question for you is, you took a lot of time 
to prepare your testimonies. I read them last night. But let's 
sort of concentrate it. Give me a one, two. And we will go 
quickly down the line of the one or two most productive things 
Congress could do right now. Just give me two bullets.
    Dr. Smithson.
    Ms. Smithson. Get the money outside of the Beltway to the 
local response entities.
    Two, and I am going to kind of make this a duo. Please make 
grants for regional hospital planning and institute early 
warning disease syndrome surveillance across this country.
    Mr. Waeckerle. To paraphrase the distinguished Member of 
Congress, I am just a country doc from Kansas City; I am not 
real familiar with all of the politics. But I will tell you 
this, we have been clamoring for years to have a central 
authority to manage the money and get it to the local 
community. We have to have a central authority. It cannot go 
through 50 different Federal agencies, who are redundant and 
don't even talk to each other.
    The second thing is, the money needs to get to the local 
resources. But we have to rebuild the local resources--the 
hospitals, the emergency health care personnel associated with 
them, and the public health infrastructure--at the local level. 
Thank you.
    Mr. Buyer. Thank you.
    Ms. Brinsfield. I think if I have to choose two, it would 
be to make sure that training and equipment and protective 
equipment makes it to the local level, mostly to the emergency 
medical personnel, the hospital personnel and public health 
personnel that are really lacking that right now.
    And the second, these needs to be a coordinated response 
and it needs to stay coordinated to prevent the agencies, on 
the local level, from splintering.
    Mr. Stringer. The funds should go to the States to 
coordinate regionally in the State, county, city efforts. Get 
it out of the Beltway.
    Second, job protection for the Federal response personnel 
so that they have a job when they come home. I have a real 
problem with that, I think this country would be hard pressed 
if you tried to find 7,000 immediately.
    Mr. Peterson. Local hospitals stand prepared to do their 
part, but are at this point in history, deserving of some 
additional fiscal relief to assist in the local planning that 
does need to go on.
    However, having said that, the hospital community would 
welcome the introduction of a more coordinated approach. We 
would stand prepared to participate willingly and would 
welcome, in fact, the opportunity to, if you will, to take 
direction.
    We think there is an indication at this point in time for 
more planning that is actually centrally promulgated.
    Mr. O'Leary. It is pretty clear that we need a national 
coordinated and integrated plan of response. I don't think that 
we can count on our communities to come up, and being isolated 
with the priorities, there needs to be guidance from the 
Federal Government. I think Mr. Ridge has the opportunity to do 
that.
    And then we ought to create the models for planning within 
these communities and hold these communities accountable for 
making sure that necessary plans actually work. That is one.
    Second, you know, it is easier for me to say than some of 
the other panelists, but our medical care delivery system is 
starving. This is not just on the bioterrorism. We see 
understaffing, we see it in emergency overcrowding. It is time 
to wake up to this issue. And it doesn't mean that we need to 
return to where we were in the 1970's and 1980's, but we need 
to think strategically about how to reintroduce resources in 
this system that permit us a surge capacity. That is real.
    Mr. Young. To develop a central command and control at the 
Federal level that extends to the State and local, with each of 
the entities integrated and able to work together. They should 
have control of resources, personnel, training, supplies, and 
the ability that Lew mentioned on protection of jobs.
    I would also urge that Congress to have a single command 
and control on hazard response and that there be a single 
oversight committee, not multiple ones that bring individuals 
as witnesses at different times.
    That is my first recommendation, single command and control 
administration and Congress.
    Second, a rapid diagnostic capability that has the capacity 
through development of new tests from research to identify in 
minutes to hours by immunological means rather than culture and 
sensitivities. We have done that on cerebral spinal fluid, for 
meningococcal infections, pneumonococcal infections and others. 
This is a no-brainer and not that difficult to do.
    Linked with it, a whole concept of just-in-time therapies 
which not only include antibiotics and vaccines, but 
immunotherapies that can be used to interdict toxemia, and 
viremia at the time it is occurring in a nonimmune population.
    Those two issues would go a long way toward solving--and 
Mr. Chairman, you may not have seen, but I did put the letter 
to the President in 1998 which led to the kickoff of the 
terrorism response. And I would go on record that Mr. Clinton 
has done a remarkable job in bringing bioterrorism and chemical 
terrorism to the fore, and echo what you said in that the 
Nation is indebted to him.
    Now is the time to take the next step.
    Mr. Buyer. Thank you.
    Before I yield to Mr. Rush, I want to thank all of you on 
how you answered Mr. Deutsch's question, so there is not a 
panic out there with regard to the anthrax. I really respect 
the way you answered that question.
    Mr. Rush.
    Mr. Rush. Thank you, Mr. Chairman.
    I also want to add my voice of congratulations and 
commendations to all of the panelists in what I have been able 
to ascertain. This has been a very, very important and cogent 
hearing, and I appreciate all of your comments.
    I must say to you that I was a bit tardy coming to this 
hearing because I was upstairs. I had a meeting with a major 
hospital in my area--the president; and they were concerned 
because there is an effort by the VA to close a hospital, major 
VA hospital in my city. And ironically we were meeting at the 
same time, and it just clearly indicates to me the kind of 
disjointed approaches that we take in the Congress and as the 
Federal Government in regards to the whole area of public 
health and the public health system.
    It's indeed contradictory at worst--at best, rather, for us 
to--the VA in this climate to be entertaining closing down a 
hospital dedicated to veterans. And so I just wanted to say 
that.
    I wanted to ask a question. It seems to me that over--since 
I have been a Member of Congress, and even prior to that as a 
member of the city council in the city of Chicago, there has 
been almost a total breakdown in the public health system 
across the board. In my area, hospitals have closed down, 
hospitals that have served the inner city communities; and 
cost-cutting policies have reduced medical care and--medical 
facilities to medical resources to a large portion of our 
Nation's citizens.
    And I am--I--last--I believe it was about a week ago, the 
Nightline Show, I saw this enactment of what would happen if in 
fact a bioterrorist would invade the city with some chemicals 
and what would happen. I saw the buildup in terms of the 
afflicted citizens and how they responded, and I saw how the 
medical profession, the hospitals, started out with a steady 
stream to the point where they became overrun with victims.
    And it really, again, is kind of--it really clearly 
indicated to me that there is a problem in terms of 
preparedness in response to this type of unfortunate event, 
that if it had--would occur in our--in one of our major 
American cities.
    And so, Dr. Peterson, my question to you is, how can we 
balance concerns over cost with the need to be prepared for 
public health emergency? I mean, is there a way that we can--
that you suggest that we try to figure out? How do we deal 
with--certainly cost is a reality.
    Mr. Peterson. As I suggested earlier, I think it--it starts 
with the requirement that we who are currently responsible for 
running the Nation's hospitals, that we need to take the 
responsibility to have a rational approach to what we are doing 
at the local level.
    And that is why--and I don't mean to be repetitive, but I 
would suggest that we need to take, along with governmental 
entities, a leadership role in training, to rationalize how we 
do our preparedness planning as it relates to this kind of a--
of a possible incident. And, therefore, I do not believe that 
it is prudent for each and every hospital to go out and assume 
that they have to--to be prepared at a level that is consistent 
with perhaps what a Johns Hopkins, if I may use the name of my 
own institution, would do.
    So that is the first point.
    We do need to balance, as you suggest in your statement, in 
your question, the reality that we are starting at a baseline 
that unfortunately is much lower from a fiscal health 
perspective than any of us would like. And so, therefore, I 
can't disagree with what has been said among my colleagues on 
the panel or what has been said by the members of the 
committee, that indeed we don't have much surge capacity today.
    So I think what we need to be about, we are trying to do at 
our local level is, we are trying to be as responsible as we 
can. I have authorized a certain amount of, if you will, 
overspending beyond my budget authority, and it is my hope that 
we will be able to solicit some consideration from the Federal 
Government to have some relief. We think some relief is 
indicated, but we have to take responsibility to not go 
overboard in what we are doing.
    We are trying to be as prudent as we can in our response. 
But we have to do more now that we better appreciate, that we 
as a hospital community appreciate a little bit more subsequent 
to September 11, what we may be dealing with.
    I have to suggest to you that if you go back in time, only 
a couple of years ago and maybe even before September 11, for 
many of us the notion of bioterrorism was certainly not on the 
front burner. It needs now to be on the front burner and there 
are some different things that one must do to prepare for that 
eventuality that then--in contrast to what one does for other 
types of disasters.
    So that is the way I would respond to you, sir. And I think 
that we are dealing with a--a terribly complex balancing act, 
given where we are starting from a fiscal point of view.
    Mr. Rush. Mr. Chairman, the doctor wants to respond to my 
question also.
    Mr. Waeckerle. Thank you. I would like to make two 
comments, because I think this is incredibly important, that we 
need to discuss this for your benefit.
    First of all, it would be hypocritical for us as health 
care professionals to come to ask you if we didn't commit. And 
I think, Mr. Peterson, the American College of Emergency 
Physicians and everybody here can promise you that we will 
commit, too. This is a partnership.
    But I think what we are trying to ask you to do is just--
the people trying to do the job, and to add a job on top of it 
is the reason that I want a central authority to oversee and 
manage everything--is all of the money that Dr. Smithson is 
taking about is available to us, but it never gets to us.
    If you get the money to the health care professionals, the 
hospitals, to the public health, to the professional 
organizations that train the nurses and the doctors and the 
EMTs, and you bypass the bureaucracy that heretofore has 
plagued us, it becomes a much more efficient and much more 
effective process; and I believe will garner a greater gain 
than any of us ever dreamed of.
    And that is a challenge we all face together.
    Mr. Rush. Dr. Smithson.
    Ms. Smithson. Actually, in her testimony, Dr. Brinsfield 
illustrated how a Federal-local partnership might work with 
regard to an emergency cache of pharmaceuticals. Under the MMRS 
program the cities were given moneys to purchase 
pharmaceuticals, but what the locals have to figure out how to 
do is put that pharmaceutical cache in a bubble so that it is 
replaced before the dates of expiration. That costs money, and 
that needs to be a commitment on the local level.
    So for each of those different areas, we need to figure out 
how to share that Federal and local burden.
    Washington can go about this the ineffective and costly way 
or they can go about this the smart way in giving the locals 
the money to do the planning that would allow them to overcome 
some of those surge capacity problems, so that the hospitals 
can have a game plan for how to meet a surge of patients that 
need isolation capability by simply transforming wards to that 
type of patient care, as opposed to building new isolation 
capacity.
    There are near-term solutions that are cost effective, as 
opposed to some of these other things that may be considered in 
the long term as advisable. There are ways to get about this.
    Mr. Greenwood. The time of the gentleman has expired.
    The gentleman from Florida, Mr. Stearns, is recognized for 
5 minutes.
    Mr. Stearns. Thank you, Mr. Chairman. The question I have 
is for Dr. Young and perhaps Dr. O'Leary.
    In my hometown we have two major hospitals. And in this 
world of free market, these hospitals will start to grapple 
with these problems and they will start to develop individually 
their own disaster plan dealing with terrorism; they won't be 
consulting, hospital to hospital, with other groups.
    Do you think there is a potential for double-counting of 
the hospitals doing the same thing and perhaps not knowing what 
one hospital is doing, or the other? Is there some way perhaps 
to have the staff and supplies brought together from the two 
hospitals? And should this be done on a national level so that 
hospitals and physicians and everybody cross-pollinates on this 
in the event of a crisis?
    And how could it be done, I guess?
    Mr. Young. That is an excellent question, sir. The reason 
that I think Boston and New York did so well is that they 
focused on working together among the hospitals, as Mr. 
Peterson said. I personally went up to Boston, met with a 
variety of hospitals and the public health and medical facility 
managers and also with the EMS and the MDMS teams. That was a 
very helpful catalyst. It brought us all together, and we began 
regional planning. And Boston made the commitment that they 
would go out and work with the regional hospitals and try to 
build a network.
    What I would suggest, sir, is, just as we have talked 
about, that there be regionalization, that the local people 
have the ability to design their own system within guidelines, 
and that we reward and design the system so that if you work 
together and really don't each do your own competitive thing, 
you get even more resources, rather than each person trying to 
do their own work. I have found that where we have taken that 
approach, in Boston, in New York, and in other places that I 
personally visited that it went quite well and we saw the 
people rise up together.
    In fact, in New York City it was interesting. In the 
meeting that the Mayor convened, as I described, many of the 
people hadn't met each other before. Their responsibilities 
were not outlined. And Dr. Letterberg and I walked through the 
various scenarios. And Dr. Peggy Hamburg, who was then 
Commissioner of Health, later became Assistant Secretary in the 
Department of Health and Human Services, went out then and 
organized the region.
    Mr. Stearns. How should this originate today in my home 
community or in my congressional district? Should I, as a 
Federal elected officer, try to organize something like this; 
or should the Federal Government institute a program, or 
Governor Ridge provide designees that would come down to each 
congressional district to develop a whole consultation program 
much like that you did in Boston and New York?
    I mean, how should this originate on a national basis?
    Mr. Young. I would recommend, based on past experience, 
that it come out of the new Department of Homeland Protection 
and that there be actual visits within the communities.
    Mr. Stearns. By someone from the Homeland?
    Mr. Young. By someone from the Homeland Department in this 
area of public health.
    Mr. Stearns. To give them guidelines and to tell them what 
to do?
    Mr. Young. That is right. And to start coming--just going 
there is an event of forcing action.
    I don't think in a lot of places all of the individuals 
would have gathered and planned if we didn't have an event. 
When we first developed the concept of the metropolitan medical 
strike teams, Lew, Susan Briggs from Boston and a number of the 
other commanders were there, and then we took that program from 
them out to the States.
    Now, with this new organization, I think it would be highly 
effective if there was a way to go into the regions. If you 
were there, sir, that would give it an added, heightened view.
    Mr. Stearns. Maybe congressional-wide consultation to talk 
about how hospitals and emergency facilities and physicians 
would act and use the guidelines from the--Governor Ridge's 
office to debrief everybody.
    Mr. Young. I would definitely think so. And I would be 
interested in what Mr. Ganske says, as a physician. But I would 
think that the joint action of Congress and the administration 
could go a long way toward dispelling fear and mobilizing the 
Nation to meet this.
    Particularly, it brings together the medical, the public 
health communities, the local communities that manage 
emergencies and the teams that are there. And if the Congress 
would join that, I think it would be another way to get the 
proper attention from the media.
    Mr. Stearns. Mr. Chairman, before I close, I have got a 
question for Dr. O'Leary.
    You can answer that one, but I just wanted to--you 
indicated in your testimony that disaster planning is part of 
the accreditation process, if I understand it.
    Mr. O'Leary. That's correct.
    Mr. Stearns. Have you told the staff--told the committee 
what your success rate has been? I understand that you have 
18,000 health care organizations. What has been the success 
rate of these hospitals you inspect in terms of disaster 
planning?
    Mr. O'Leary. Well, the--I would like to come back to the 
original question. The degree of compliance with the disaster 
planning standards is actually quite high.
    But we do have new standards in place--they went in place 
last January--which moved to the issue that you raised 
initially with Dr. Young. And that is the need to engage 
communities as part of the planning process.
    Hospitals are not solos in this process, and while they--
they may compete with each other in various communities, they 
can also collaborate; and I think many of them actually do. Our 
standards create the expectation in this engagement with 
community that ``community'' is other hospitals, it is public 
health agencies, fire fighters, policemen. It is everybody in 
the community.
    And I think it is--it is too early for us to answer your 
question as to how effectively they are doing that. But you 
will not be surprised that we are paying a lot of attention to 
that issue in our survey process.
    I think the question you may be getting at is, we have a 
system of accountability for hospitals, but we do not have a 
system of accountability for our communities. The hospitals are 
like nodes around a command center. But the command center is 
not well defined yet, nor is it accountable. And I think that 
is an issue that merits the consideration of the Congress and 
the new Homeland Security agency, to determine how that 
accountability will be played out once an appropriate model and 
planning is in place, because that really is a crucial issue.
    That is a complimentary aside. The hospitals are only a 
piece of the puzzle. There is a bigger puzzle.
    Mr. Greenwood. The time of the gentleman has expired.
    We thank all of the--the committee thanks all of the 
panelists for being here with us these last 3 hours. We are 
wiser for your testimony and your responses to questions, and 
we will do our best to implement your suggestions.
    We now excuse you and again thank you for your service. You 
are welcome to stay for the balance of the hearing.
    Mr. Greenwood. We now call the second and final panel 
forward, beginning with Dr. Scott Lillibridge, Special 
Assistant for Bioterrorism, Office of the Secretary, Department 
of Health and Human Services; Mr. Bruce Baughman, Director of 
the Planning and Readiness Division of the Federal Emergency 
Management Agency; and Ms. Jan Heinrich, Director of Health 
Care and Public Health Issues for the U.S. General Accounting 
Office.
    You are aware that the committee is holding an 
investigative hearing and that, when doing so, we have had the 
practice of taking testimony under oath. I need to ask you, do 
any of you have any objection to giving your testimony under 
oath?
    No?
    Seeing no objection, the Chair advises you that pursuant to 
the rules of the House and pursuant to the rules of this 
committee, you have the right to be advised by counsel. Do any 
of you choose to be advised by counsel?
    Okay. In that case, would you please rise and raise your 
right hand.
    [Witnesses sworn.]
    Mr. Greenwood. You may be seated.
    Dr. Lillibridge, you are recognized for your statement. 
Thank you for being with us.

  TESTIMONY OF SCOTT R. LILLIBRIDGE, SPECIAL ASSISTANT TO THE 
SECRETARY ON BIOTERRORISM ISSUES AND FOR NATIONAL SECURITY AND 
   EMERGENCY MANAGEMENT, U.S. DEPARTMENT OF HEALTH AND HUMAN 
 SERVICES; BRUCE P. BAUGHMAN, DIRECTOR, PLANNING AND READINESS 
   DIVISION, FEDERAL EMERGENCY MANAGEMENT AGENCY; AND JANET 
  HEINRICH, DIRECTOR, HEALTH CARE--PUBLIC HEALTH ISSUES, U.S. 
                   GENERAL ACCOUNTING OFFICE

    Mr. Lillibridge. Thank you, Mr. Chairman.
    I would like to thank the previous panelists. I learned a 
lot. And I would like to thank Dr. Frank Young for introducing 
me to the preparedness issues around terrorism. He put me on 
airplanes, had me eat bad food and sent me all over the world.
    Mr. Greenwood. Were you indeed in your knickers during that 
time?
    Mr. Lillibridge. I was indeed, perhaps, in my knickers at 
that time and have developed a few gray hairs since then.
    Mr. Chairman and members, I am Scott Lillibridge, Special 
Assistant to the Secretary on Bioterrorism Issues, National 
Security and Emergency Management Issues; and I appreciate the 
opportunity to appear before you today to discuss the 
Department of Health and Human Services' role in State and 
local government preparedness to respond to acts of terrorism, 
particularly those involving bioterrorism.
    Clearly, preparedness and response issues are the order of 
the day. State and local health programs comprise the 
foundation of an effective national strategy for preparedness 
and emergency response. No doubt about that. Preparedness must 
incorporate not only the immediate responses to threats, such 
as biological terrorism, but also must encompass the broader 
components of public health infrastructure which provide the 
foundation for immediate and effective emergency response and 
long-term sustained response.
    Those capabilities include the following--we have heard 
many of these today:
    Clearly, a well-trained public health workforce; Laboratory 
capacity to produce timely and accurate results for diagnosis; 
Disease detective work or epidemiology and surveillance; and 
Secure, accessible communication systems both to and from local 
health departments, to State health departments and from States 
back to Federal entities like CDC. CDC has used funds provided 
by the past several Congresses to begin the process of 
improving the expertise, facilities and procedures of State and 
local health departments to respond to biological and chemical 
terrorism.
    For example, over the last 3 years, the agency has awarded 
more than $130 million in cooperative agreements to cover fifty 
States and at least one territory and four major metropolitan 
health departments as part of its overall bioterrorism 
preparedness and response program. This program is new since 
1999--fiscal year 1999.
    We must continue to work with our State and local health 
systems as part of our ongoing preparedness efforts, 
incorporating many of the components that we have heard today, 
in terms of their vital importance in responding to disease, 
epidemics and large-scale outbreaks of activities such as what 
is occurring in Florida.
    The Health and Human Services Office of Emergency 
Preparedness is also working on a number of fronts to assist 
local hospitals and medical practitioners to deal with the 
effects of biological, chemical and other terrorist acts. Since 
fiscal year 1995, for example, OEP has been developing local 
Metropolitan Medical Response Systems.
    Through contractual relationships, the MMRS system uses 
existing emergency response systems, emergency management and 
medical and mental health providers, public health departments, 
law enforcement, fire departments, and EMS and National Guard 
to provide an integrated, unified response to a mass casualty 
event, drawing them into a centralized planning activity and 
bringing public health and medical folks to the table for the 
first time.
    As of September 30, 2001, OEP has contracted with 97 
municipalities to develop MMRS systems, and the fiscal year 
2002 budget includes funding for an additional 25 MMRS systems.
    MMRS has continued to expand--or refine and expand our 
medical preparedness at the most local level by requiring the 
development of local capacity for mass immunization, mass 
prophylaxis, the capability to distribute and stockpile 
ingredients and local capacity to increase our ability to do 
mass care.
    I would like to mention a few indications from lessons 
learned from previous responses such as the recent TOP OFF 
exercise. This occurred in May 2000. This national drill 
involved scenarios related to a weapons of mass destruction 
attack against our population. However, the exercise that 
simulated a plague outbreak in Denver still applies today to 
many things that have come to light during this hearing. This 
exercise, of course, involved FEMA, the Department of Justice, 
HHS, Department of Defense and many other vital community 
sectors that would play a role in an actual response.
    Several things emerged, and we are still working toward 
these entities. For example, improving the public health 
infrastructure remains a critical focus of bioterrorism 
preparedness and response, and such preparedness is 
indispensable for reducing the Nation's vulnerability to 
terrorism related to infectious agents.
    Second, we need to increase our current and very limited 
surge capacity in our health care system through issues ranging 
from local planning to local health care system expansion 
activities to rapidly expand in the face of an emergency.
    Those two things are certainly things that have come up 
both in this hearing and the previous hearing over the past 
week.
    I would like to just use some plain talk to talk about some 
of the things that Secretary Thompson has been thinking about 
in leading this preparedness effort in Health and Human 
Services, our Department.
    First of all, it seems important as this new Office of 
health--Homeland Security develops that we begin to have strong 
linkage from HHS to OHS, our Office of Homeland Security, and 
that we are in the process of identifying people in our 
Department who can work with Governor Ridge as he begins this 
new endeavor.
    Also the Secretary is in the process of enhancing our 
ability to manage a one-department response in a way that we 
never have tried in the past. For example, getting different 
agencies with different agendas, harmonized to a centralized 
emergency response activity has been a very, new phenomenon for 
our Department and as a consequence, the manifestation of my 
coming to Washington was one of those activities, but only one 
of the most visible.
    Other things have been involving key leadership and 
training, information, briefings, actually reaching out to the 
other interagency intelligence briefings and all of the kinds 
of things that you do for a serious one-department emergency 
response capability.
    The second thing that was mentioned was the development of 
more response teams or rapid response teams, and we are working 
with CDC and our commission core readiness force to have 
additional capacity to put into an emergency should that 
develop.
    Training remains important, and we have recently 
consolidated an interagency agreement with FEMA to expand 
cooperative training activity between HHS and FEMA and have 
worked with entities like Noble Army Hospital at Ft. McClellan, 
Alabama, and conducted regional and distance-based learning.
    In conclusion, I would like to mention that the Department 
of Health and Human Services is committed to ensuring the 
health and medical care of our citizens, and we have made 
substantial progress to date in enhancing the Nation's 
capability to respond to a bioterrorism event. Priorities 
include, in conclusion, strengthening our local and State 
public health capacities, continuing to enhance our national 
pharmaceutical stockpile, and helping support our local 
hospitals and medical professionals to expand their vital surge 
capacity.
    With that, Mr. Chairman, I will conclude my prepared 
remarks, and I would be pleased to answer any questions that 
you or members of the subcommittee may have.
    [The prepared statement of Scott R. Lillibridge follows:]
 Prepared Statement of Scott R. Lillibridge, Special Assistant to the 
Secretary for National Security and Emergency Management, Department of 
                       Health and Human Services
    Mr. Chairman and Members of the Subcommittee, I am Scott R. 
Lillibridge, Special Assistant to the Secretary of HHS for National 
Security and Emergency Management. I appreciate the opportunity to 
appear before you this morning to discuss, from a Public Health 
perspective, the Department of Health and Human Services (HHS) role in 
preparedness to respond to acts of terrorism involving biological 
agents.
    What has HHS been doing to prepare for this kind of event? Our 
efforts are focused on improving the nation's public health 
surveillance network to quickly detect and identify the biological 
agent that has been released; strengthening the capacities for medical 
response, especially at the local level; expanding the stockpile of 
pharmaceuticals for use if needed; expanding research on disease agents 
that might be released; developing new and more rapid methods for 
identifying biological agents and improved treatments and vaccines; 
improving information and communications systems; and preventing 
bioterrorism by regulation of the shipment of hazardous biological 
agents or toxins.
                       preparedness and response
    State and local public health programs comprise the foundation of 
an effective national strategy for preparedness and emergency response. 
Preparedness must incorporate not only the immediate responses to 
threats such as biological terrorism, it also encompasses the broader 
components of public health infrastructure which provide the foundation 
for immediate and effective emergency responses. These components 
include:

 A well trained, well staffed, fully prepared public health 
        workforce;
 Laboratory capacity to produce timely and accurate results for 
        diagnosis and investigation;
 Epidemiology and surveillance, which provide the ability to 
        rapidly detect heath threats;
 Secure, accessible information systems which are essential to 
        communicating rapidly, analyzing and interpreting health data, 
        and providing public access to health information;
 Communication systems that provide a swift, secure, two-way 
        flow of information to the public and advice to policy-makers 
        in public health emergencies;
 Effective policy and evaluation capability to routinely 
        evaluate and improve the effectiveness of public health 
        programs; and
 Preparedness and response capability, including developing and 
        implementing response plans, as well as testing and maintaining 
        a high-level of preparedness.
    The CDC has used funds provided by the past several congresses to 
begin the process of improving the expertise, facilities and procedures 
of state and local health departments to respond to biological 
terrorism. For example, over the last three years, the agency has 
awarded more than $130 million in cooperative agreements to 50 states, 
one territory and four major metropolitan health departments as part of 
its overall Bioterrorism Preparedness and Response Program. In 
addition, CDC currently funds 9 states and 2 metropolitan areas 
specifically to develop public health preparedness plans for their 
jurisdictions. Many of these states and cities have participated in 
exercises to test components of their plans. We must continue to work 
with our state and local public health systems to make sure they are 
more prepared. This will require the interaction of state departments 
of health with state emergency managers to fully integrate the state's 
capacity to effectively distribute life-saving medications to victims 
of a biological or terrorism event.
    HHS is also working on a number of fronts to assist local hospitals 
and medical practitioners to deal with the effects of biological, 
chemical, and other terrorist acts. Since Fiscal Year 1995, for 
example, HHS has been developing local Metropolitan Medical Response 
Systems (MMRS). Through contractual relationships, the MMRS uses 
existing emergency response systems--emergency management, medical and 
mental health providers, public health departments, law enforcement, 
fire departments, EMS and the National Guard--to provide an integrated, 
unified response to a mass casualty event. As of September 30, 2001, 
OEP has contracted with 97 municipalities to develop MMRSs. The FY 2002 
budget includes funding for an additional 25 MMRSs (for a total of 
122).
    MMRS contracts require the development of local capability for mass 
immunization/prophylaxis for the first 24 hours following an identified 
disease outbreak; the capability to distribute materiel deployed to the 
local site from the National Pharmaceutical Stockpile; local capability 
for mass patient care, including procedures to augment existing care 
facilities; local medical staff trained to recognize disease symptoms 
so that they can initiate treatment; and local capability to manage the 
remains of the deceased.
              lessons learned from preparedness exercises
    An indication of the Nation's preparedness for bioterrorism was 
provided by the congressionally mandated Top Officials (TOPOFF) 2000 
Exercise, held in May 2000, and the recent Dark Winter exercise, which 
was held earlier this year. Both of these drills involved scenarios 
related to a weapons-of-mass-destruction-attack against our 
populations. Part of the TOPOFF exercise simulated a plague outbreak in 
Denver, while the Dark Winter exercise simulated a release of smallpox.
Lessons from TOPOFF
    While much progress has been made to date, a number of important 
lessons learned from TOPOFF have begun to shape our plans about 
bioterrorism preparedness and response in the health and medical area. 
They are as follows:

 Improving the public health infrastructure remains a critical 
        focus of the bioterrorism preparedness and response efforts.
 Local health care systems should expand their health care 
        capacity rapidly in the face of mass casualties.
 Local communities will need assistance with the distribution 
        of stockpile medications and will greatly benefit from 
        additional planning related to epidemic response.
 Ensuring that the proper legal authorities exist to control 
        the spread of disease at the local, state and Federal level and 
        that these authorities can be exercised when needed. This will 
        be important to our efforts to control the spread of disease.
Lessons from Dark Winter
    The issues that emerged from the recent Dark Winter exercise 
reflected similar themes that need to be addressed.

 The importance of rapid diagnosis--Rapid and accurate 
        diagnosis of biological agents will require strong linkages 
        between clinical and public health laboratories. In addition, 
        diagnostic specimens will need to be delivered promptly to CDC, 
        where laboratorians will provide diagnostic confirmatory and 
        reference support.
 The importance of working through the governors' offices as 
        part of our planning and response efforts--During the exercise 
        this was demonstrated by Governor Keating. During state-wide 
        emergencies the federal government will need to work with a 
        partner in the state who can galvanize the multiple response 
        communities and government sectors that will be needed, such as 
        the National Guard, the state health department, and the state 
        law enforcement communities. These in turn will need to 
        coordinate with their local counterparts. CDC is refining its 
        planning efforts through grants, policy forums such as the 
        National Governors Association and the National Emergency 
        Management Association, and training activities. CDC also 
        participates with partners such as DOJ and FEMA in planning and 
        implementing national drills such as the recent TOPOFF 
        exercise.
 Better targeting of limited smallpox vaccine stocks to ensure 
        strategic use of vaccine in persons at highest risk of 
        infection--It was clear that pre-existing guidance regarding 
        strategic use would have been beneficial and would have 
        accelerated the response at Dark Winter. As I mentioned 
        earlier, CDC is working on this issue and is developing 
        guidance for vaccination programs and planning activities.
 Federal control of the smallpox vaccine at the inception of a 
        national crisis--Currently, the smallpox vaccine is held by the 
        manufacturer. CDC has worked with the U.S. Marshals Service to 
        conduct an initial security assessment related to a future 
        emergency deployment of vaccine to states. CDC is currently 
        addressing the results of this assessment, along with other 
        issues related to security, movement, and initial distribution 
        of smallpox vaccine.
 The importance of early technical information on the progress 
        of such an epidemic for consideration by decision makers--In 
        Dark Winter, this required the implementation of various steps 
        at the local, state, and federal levels to control the spread 
        of disease. This is a complex endeavor and may involve measures 
        ranging from directly observed therapy to quarantine, along 
        with consideration as to who would enforce such measures. 
        Because wide-scale federal quarantine measures have not been 
        implemented in the United States in over 50 years, operational 
        protocols to implement a quarantine of significant scope are 
        needed. CDC hosted a forum on state emergency public health 
        legal authorities to encourage state and local public health 
        officers and their attorneys to examine what legal authorities 
        would be needed in a bioterrorism event. In addition, CDC is 
        reviewing foreign and interstate quarantine regulations to 
        update them in light of modern infectious disease and 
        bioterrorism concerns. CDC will continue this preparation to 
        ensure that such measures will be implemented early in the 
        response to an event.
 Maintaining effective communications with the media and press 
        during such an emergency--The need for accurate and timely 
        information during a crisis is paramount to maintaining the 
        trust of the community. Those responsible for leadership in 
        such emergencies will need to enhance their capabilities to 
        deal with the media and get their message to the public. It was 
        clear from Dark Winter that large-scale epidemics will generate 
        intense media interest and information needs. CDC has refined 
        its media plan and expanded its communications staff. These 
        personnel will continue to be intimately involved in our 
        planning and response efforts to epidemics.
 Expanded local clinical services for victims--DHHS's Office of 
        Emergency Preparedness is working with the other members of the 
        National Disaster Medical System to expand and refine the 
        delivery of medical services for epidemic stricken populations.
    HHS will continue to work with partners to address challenges in 
public health preparedness, such as those raised at TOPOFF and Dark 
Winter. For example, work done by CDC staff to model the effects of 
control measures such as quarantine and vaccination in a smallpox 
outbreak have highlighted the importance of both public health measures 
in controlling such an outbreak. The importance of both quarantine and 
vaccination as outbreak control measures is also supported by 
historical experience with smallpox epidemics during the eradication 
era. These issues, as well as overall preparedness planning at the 
federal level, are currently being addressed and require additional 
action to ensure that the nation is fully prepared to respond to all 
acts of biological terrorism.
                               conclusion
    The Department of Health and Human Services is committed to 
ensuring the health and medical care of our citizens. We have made 
substantial progress to date in enhancing the nation's capability to 
respond to a bioterrorist event. But there is more we can do to 
strengthen the response. Priorities include strengthening our local and 
state public health surveillance capacity, continuing to enhance the 
National Pharmaceutical Stockpile, and helping our local hospitals and 
medical professionals better prepare for responding to a biological or 
terrorist attack.
    Mr. Chairman, that concludes my prepared remarks. I would be 
pleased to answer any questions you or members of the Subcommittee may 
have.

    Mr. Greenwood. Thank you very much, Dr. Lillibridge.
    Mr. Baughman, you are recognized for your testimony.

                 TESTIMONY OF BRUCE P. BAUGHMAN

    Mr. Baughman. Thank you, Mr. Chairman.
    I am Bruce Baughman, Director of Planning and Readiness 
with the Federal Emergency Management Agency. It is my pleasure 
to represent Director Albaugh at this important hearing on 
bioterrorism. The mission of FEMA is to reduce loss of life and 
property and to assist in protecting our Nation's critical 
infrastructure from all hazards. When disaster strikes, we 
provide a management framework and funding for responding 
units.
    The Federal response plan is the heart of that framework. 
It reflects the labor of interagency groups that meet in 
Washington from all 10 of our FEMA regions to develop a 
capability to respond as a team, the Federal community 
responding as a team. This team is staffed by 26 departments 
and agencies, including the American Red Cross, and is 
organized into interagency functions based upon the authority 
and the expertise of the member organizations, and the needs of 
our counterparts at the State and local level, health and 
medical, is headed by HHS under our plan.
    Our plan is designed to support, not supplement, State and 
local response structures. Since 1992, the plan has been a 
proven framework for managing major disasters and emergencies, 
regardless of cost. It works. It worked in Oklahoma City, it 
worked at the World Trade Center.
    However, biological terrorism would present some unique 
challenges and has already. With an undetected attack, first 
responders would be doctors, hospital staff, animal control 
workers, instead of police, fire and emergency medical service 
personnel. Connections between these nontraditional first 
responders and the larger Federal response is not routine. The 
Department of Health and Human Services is the critical link 
between the health and medical community and the larger Federal 
response.
    FEMA works closely with public health service as the 
primary agency for health and medical function under the 
Federal response plan. We rely on them to bring the right 
experts to the table when we meet to discuss potential 
biological threats, how they spread, and the resources and 
techniques that would be needed to control them.
    We are making progress. As Scott mentioned, Exercise TOP 
OFF in May 2000 involved a chemical attack on the East Coast 
followed by a biological attack in the Midwest. We have 
incorporated the lessons learned in that exercise into our 
response procedures. The procedures--the process is active and 
ongoing. It takes time and resources to identify, develop, and 
incorporate these changes into the system.
    In January 2001, the FBI and FEMA jointly published U.S. 
Government's interagency domestic concept of operation for 
terrorism, or CONPLAN, with the Departments of Health and Human 
Services, Defense and Energy and the Environmental Protection 
Agency. Together, the CONPLAN and the Federal response plan 
provide the framework for managing the response to causes or 
consequences to a terrorist act. It was recognized, however, at 
that time that these plans were inadequate to adequately 
address a biological incident.
    On May 8, the President asked the Vice President to oversee 
the development of a coordinated national effort regarding 
domestic preparedness. The President also asked the Director of 
FEMA to create an Office of National Preparedness to coordinate 
all Federal programs dealing with preparedness for and response 
to the terrorist use of weapons of mass destruction. In July, 
the Director formally established the office at FEMA 
headquarters with elements in each one of the 10 FEMA regional 
offices.
    On September 21 in the wake of the horrific terrorist 
attacks, the World Trade Center and the Pentagon, the President 
announced the establishment of the Office of Homeland Security 
in the White House headed by Governor Ridge. The office will 
lead, oversee, and coordinate a national strategy to safeguard 
the country against terrorism and respond to attacks that may 
occur. It is our understanding that the office will coordinate 
a broad range of policies and activities related to prevention, 
deterrence, preparedness and response.
    This office includes a Homeland Security Council comprised 
of key departments and agency officials, including the Director 
of FEMA. We expect to provide significant support to this 
office in our role as the lead Federal agency for consequence 
management.
    Mr. Chairman, you convened this hearing to ask about our 
preparedness to work with State and local agencies in the event 
of a biological attack.
    Terrorism presents tremendous challenges. We rely heavily 
on the Department of Health and Human Services to coordinate 
the efforts in the health and medical community and to address 
biological hazards. They need your support to increase the 
national inventory of response resources and capabilities.
    FEMA needs your support to ensure that the system the 
Nation uses 65 times a year to respond to major disasters and 
emergencies has the tools and the capacity to adapt to a 
biological attack or any other weapon of choice.
    Thank you, Mr. Chairman.
    [The prepared statement of Bruce P. Baughman follows:]
    Prepared Statement of Bruce P. Baughman, Director, Planning and 
  Readiness Division, Readiness, Response, and Recovery Directorate, 
                  Federal Emergency Management Agency
                              introduction
    Good morning, Mr. Chairman and Members of the Subcommittee. I am 
Bruce Baughman, Director of the Planning and Readiness Division, 
Readiness, Response, and Recovery Directorate, of the Federal Emergency 
Management Agency (FEMA). Director Allbaugh regrets that he is unable 
to be here with you today. It is a pleasure for me to represent him at 
this important hearing on biological and chemical terrorism. I will 
describe how FEMA works with other agencies, our approach to dealing 
with acts of terrorism, our programs related to terrorism, and new 
efforts to enhance preparedness and response.
                               background
    The FEMA mission is to reduce the loss of life and property and 
protect our nation's critical infrastructure from all types of hazards. 
As staffing goes, we are a small agency. Our success depends on our 
ability to organize and lead a community of local, State, and Federal 
agencies and volunteer organizations. We know who to bring to the table 
and what questions to ask when it comes to the business of managing 
emergencies. We provide an operational framework and a funding source.
    The Federal Response Plan (FRP) is the heart of that framework. It 
reflects the labors of interagency groups that meet as required in 
Washington, D.C. and all 10 FEMA Regions to develop our capabilities to 
respond as a team. This team is made up of 26 Federal departments and 
agencies and the American Red Cross, and organized into interagency 
functions based on the authorities and expertise of the members and the 
needs of our counterparts at the state and local level.
    Since 1992, the Federal Response Plan has been the proven framework 
time and time again, for managing major disasters and emergencies 
regardless of cause. It works during all phases of the emergency life 
cycle, from readiness, to response, recovery, and mitigation. The 
framework is successful because it builds upon the existing 
professional disciplines and communities among agencies. Among Federal 
agencies, FEMA has the strongest ties to the emergency management and 
the fire service communities. We plan, train, exercise, and operate 
together. That puts us in position to manage and coordinate programs 
that address their needs. Similarly, the Department of Health and Human 
Services (HHS) has the strongest ties to the public health and medical 
communities, and the Environmental Protection Agency (EPA) has the 
strongest ties to the hazardous materials community. The Federal 
Response Plan respects these relationships and areas of expertise to 
define the decision-making processes and delivery systems to make the 
best use of available resources.
           the approach to biological and chemical terrorism
    We recognize that biological and chemical scenarios would present 
unique challenges. Of the two I am more concerned about bioterrorism. A 
chemical attack is in many ways a large-scale hazardous materials 
incident. EPA and the Coast Guard are well connected to local hazardous 
materials responders, State and Federal agencies, and the chemical 
industry. There are systems and plans in place for response to 
hazardous materials, systems that are routinely used for small and 
large-scale events. EPA is also the primary agency for the Hazardous 
Materials function of the Federal Response Plan. We can improvise 
around that model in a chemical attack.
    With a covert release of a biological agent, the ``first 
responders'' will be hospital staff, medical examiners, private 
physicians, or animal control workers, instead of the traditional first 
responders such as police, fire, and emergency medical services. While 
I defer to the Departments of Justice and HHS on how biological 
scenarios would unfold, it seems unlikely that terrorists would warn us 
of a pending biological attack. In exercise and planning scenarios, the 
worst-case scenarios begin undetected and play out as epidemics. 
Response would begin in the public health and medical community. 
Initial requests for Federal assistance would probably come through 
health and medical channels to the Centers for Disease Control and 
Prevention (CDC). Conceivably, the situation could escalate into a 
national emergency.
    HHS is a critical link between the health and medical community and 
the larger Federal response. HHS leads the efforts of the health and 
medical community to plan and prepare for a national response to a 
public health emergency. FEMA works closely with the Public Health 
Service, as the primary agency for the Health and Medical Services 
function of the Federal Response Plan. We rely on the Public Health 
Service to bring the right experts to the table when the Federal 
Response Plan community meets to discuss biological scenarios. We work 
closely with the experts in HHS and other health and medical agencies, 
to learn about the threats, how they spread, and the resources and 
techniques that will be needed to control them. By the same token, the 
medical experts work with us to learn about the Federal Response Plan 
and how we can use it to work the management issues, such as resource 
deployment and public information strategies. Alone, the Federal 
Response Plan is not an adequate solution for the challenge of planning 
and preparing for a deadly epidemic or act of bioterrorism. It is 
equally true that, alone, the health and medical community cannot 
manage an emergency with biological causes. We must work together.
    In recent years, Federal, state and local governments and agencies 
have made progress in bringing the communities closer together. 
Exercise Top Officials (TOPOFF) 2000 in May 2000 involved two 
concurrent terrorism scenarios in two metropolitan areas, a chemical 
attack on the East Coast followed by a biological attack in the 
Midwest. We are still working on the lessons learned from that 
exercise. We need time and resources to identify, develop, and 
incorporate changes to the system between exercises. Exercises are 
critical in helping us to prepare for these types of scenarios. In 
January 2001, the FBI and FEMA jointly published the U.S. Government 
Interagency Domestic Terrorism Concept of Operation Plan (CONPLAN) with 
HHS, EPA, and the Departments of Defense and Energy, and pledged to 
continue the planning process to develop specific procedures for 
different scenarios, including bioterrorism. The Federal Response Plan 
and the CONPLAN provide the framework for managing the response to an 
act of bioterrorism.
                       synopsis of fema programs
    FEMA programs are focused mainly on planning, training, and 
exercises to build capabilities to manage emergencies resulting from 
terrorism. Many of these program activities apply generally to 
terrorism, rather than to one form such as biological or chemical 
terrorism.
Planning
    The overall Federal planning effort is being coordinated with the 
FBI, using existing plans and response structures whenever possible. 
The FBI is always the Lead Agency for Crisis Management. FEMA is always 
the Lead Agency for Consequence Management. We have developed plans and 
procedures to explain how to coordinate the two operations before and 
after consequences occur. In 1999, we published the second edition of 
the FRP Terrorism Incident Annex. In 2001, the FBI and FEMA published 
the United States Government Interagency Domestic Terrorism Concept of 
Operations Plan (CONPLAN).
    We continually validate our planning concepts by developing plans 
to support the response to special events, such as we are now doing for 
the 2002 Olympic Winter Games that will take place in Utah.
    To support any need for a Federal response, FEMA maintains the 
Rapid Response Information System (RRIS). The RRIS provides online 
access to information on key Federal assets that can be made available 
to assist state and local response efforts, and a database on chemical 
and biological agents and protective measures.
    In FY 2001, FEMA has distributed $16.6 million in terrorism 
consequence management preparedness assistance grants to the States to 
support development of terrorism related capabilities, and $100 million 
in fire grants. FEMA is developing additional guidance to provide 
greater flexibility for states on how they can use this assistance.
    FEMA has also developed a special attachment to its all-hazards 
Emergency Operations Planning Guide for state and local emergency 
managers that addresses developing terrorist incident annexes to state 
and local emergency operations plans. This planning guidance was 
developed with the assistance of eight Federal departments and agencies 
in coordination with NEMA and the International Association of 
Emergency Managers.
    FEMA and the National Emergency Management Association (NEMA) 
jointly developed the Capability Assessment for Readiness (CAR), a 
self-assessment tool that enables States and Territories to focus on 13 
core elements that address major emergency management functions. 
Terrorism preparedness is assessed relative to planning, procedures, 
equipment and exercises. FEMA's CAR report presents a composite picture 
of the nation's readiness based on the individual State and Territory 
reports.
    FEMA's Comprehensive Hazardous Materials Emergency Response 
Capability Assessment Program (CHER-CAP) helps communities improve 
their terrorism preparedness by assessing their emergency response 
capability. Local, State, and Tribal emergency managers, civic leaders, 
hospital personnel and industry representatives all work together to 
identify problems, revise their response plans and improve their 
community's preparedness for a terrorist event. Since February 2000, a 
total of 55 communities have been selected to participate, initiated, 
or completed a sequence of planning, training, and exercise activities 
to improve their terrorism preparedness.
Training
    FEMA supports the training of Federal, State, and local emergency 
personnel through our National Fire Academy (NFA), which trains 
emergency responders, and the Emergency Management Institute (EMI), 
which focuses on emergency planners, coordinators and elected and 
appointed officials. EMI and NFA work in partnership with State and 
municipal training organizations. Together they form a very strong 
national network of fire and emergency training. FEMA employs a 
``train-the-trainer'' approach and uses distance-learning technologies 
such as the Emergency Education Network via satellite TV and web-based 
instruction to maximize our training impact.
    The NFA has developed and fielded several courses in the Emergency 
Response to Terrorism (ERT) curriculum, including a Self-Study course 
providing general awareness information for responding to terrorist 
incidents that has been distributed to some 35,000 fire/rescue 
departments, 16,000 law enforcement agencies, and over 3,000 local and 
state emergency managers in the United States and is available on FEMA 
internet site. Other courses in the curriculum deal with Basic 
Concepts, Incident Management, and Tactical Considerations for 
Emergency Medical Services (EMS), Company Officers, and HAZMAT 
Response. Biological and chemical terrorism are included as integral 
parts of these courses.
    Over one thousand instructors representing every state and major 
metropolitan area in the nation have been trained under the ERT 
program. The NFA is utilizing the Training Resources and Data Exchange 
(TRADE) program to reach all 50 States and all major metropolitan fire 
and rescue departments with training materials and course offerings. In 
FY 2001, FEMA is distributing $4 million in grants to state fire-
training centers to deliver first responder courses developed by the 
NFA.
    Over 112,000 students have participated in ERT courses and other 
terrorism-related training. In addition, some 57,000 copies of a Job 
Aid utilizing a flip-chart format guidebook to quick reference based on 
the ERT curriculum concepts and principles have been printed and 
distributed.
    NFA is developing a new course in FY 2002 in the Emergency Response 
to Terrorism series geared toward response to bioterrorism in the pre-
hospital recognition and response phase. It will be completed with the 
review and input of our Federal partners, notably HHS and the Office of 
Justice Programs.
    EMI offers a comprehensive program of emergency management training 
including a number of courses specifically designed to help 
communities, states, and tribes deal with the consequences of terrorism 
and weapons of mass destruction. The EMI curriculum includes an 
Integrated Emergency Management Course (IEMC)/Consequences of 
Terrorism. This 4\1/2\ day course combines classroom training, planning 
sessions, and functional exercises into a management-level course 
designed to encourage communities to integrate functions, skills, and 
resources to deal with the consequences of terrorism, including 
terrorism. To foster this integration, EMI brings together 70 
participants for each course that includes elected officials and public 
health leaders as well as representatives of law enforcement, emergency 
medical services, emergency management, and public works. The course 
provides participants with skill-building opportunities in 
preparedness, response, and recovery. The scenario for the course 
changes from offering to offering. In a recent offering, the scenario 
was based on an airborne anthrax release. Bioterrorism scenarios 
emphasize the special issues inherent in dealing with both infectious 
and noninfectious biological agents and stresses the partnerships 
between local, state, and Federal public health organizations.
Exercises
    In the area of exercises, FEMA is working closely with the 
interagency community and the States to ensure the development of a 
comprehensive exercise program that meets the needs of the emergency 
management and first responder communities. FEMA is planning to conduct 
Phase II of a seminar series on terrorism preparedness in each of the 
ten FEMA Regional Offices. In addition, exercise templates and tools 
are being developed for delivery to state and local officials.
            new efforts to enhance preparedness and response
    In response to guidance from the President on May 8, 2001, the FEMA 
Director created an Office of National Preparedness (ONP) to coordinate 
all federal programs dealing with weapons of mass destruction 
consequence management, with particular focus on preparedness for, and 
the response to the terrorist use of such weapons. In July, the 
Director established the ONP at FEMA Headquarters. An ONP element was 
also established in each of the ten FEMA Regional Offices to support 
terrorism-related activities involving the States and localities.
    On September 21, 2001, in the wake of the horrific terrorist 
attacks on the World Trade Center and the Pentagon, the President 
announced the establishment of an Office of Homeland Security (OHS) in 
the White House to be headed by Governor Tom Ridge of Pennsylvania. In 
setting up the new office, the President stated that it would lead, 
oversee and coordinate a national strategy to safeguard the country 
against terrorism and respond to attacks that occur. It is our 
understanding that office will coordinate a broad range of policies and 
activities related to prevention, deterrence, preparedness and response 
to terrorism.
    The new office includes a Homeland Security Council comprised of 
key department and agency officials, including the FEMA Director. FEMA 
expects to provide significant support to the office in its role as the 
lead Federal agency for consequence management.
                               conclusion
    Mr. Chairman, you convened this hearing to ask about our 
preparedness to work with State and local agencies in the event of a 
biological or chemical attack. It is FEMA's responsibility to ensure 
that the national emergency management system is adequate to respond to 
the consequences of catastrophic emergencies and disasters, regardless 
of cause. All catastrophic events require a strong management system 
built on expert systems for each of the operational disciplines. 
Terrorism presents tremendous challenges. We rely on our partners in 
Department of Health and Human Services to coordinate the efforts of 
the health and medical community to address biological terrorism, as we 
rely on EPA and the Coast Guard to coordinate the efforts of the 
hazardous materials community to address chemical terrorism. Without 
question, they need support to further strengthen capabilities and 
their operating capacity. FEMA must ensure that the national system has 
the tools to gather information, set priorities, and deploy resources 
effectively in a biological scenario. In recent years we have made 
tremendous strides in our efforts to increase cooperation between the 
various response communities, from fire and emergency management to 
health and medical to hazardous materials. We need to do more.
    The creation of the Office of Homeland Security and other efforts 
will enable us to better focus our time and effort with those 
communities, to prepare the nation for response to any incident.
    Thank you, Mr. Chairman. I would be happy to answer any questions.

    Mr. Greenwood. Thank you, Mr. Baughman. We appreciate your 
testimony.
    Ms. Heinrich, you are recognized for yours.

                   TESTIMONY OF JANET HEINRICH

    Ms. Heinrich. Mr. Chairman and members of the subcommittee, 
I appreciate the opportunity to be here today to discuss our 
ongoing work on public health preparedness for a domestic 
bioterrorist attack. We recently released a report, that you 
referred to, on Federal research and preparedness activities 
related to the public health and medical consequences of a 
bioterrorist attack on the civilian population.
    I would like to begin by giving a brief overview of the 
findings in our report and then address weaknesses in the 
public health infrastructure that we believe warrant special 
attention.
    We identified more than 20 departments and agencies as 
having a role in preparing for or responding to the public 
health and medical consequences. These agencies are 
participating in a variety of activities from improving the 
detection of biological agents and developing new vaccines to 
managing the national stockpile of pharmaceuticals.
    Coordination of these activities across departments and 
agencies is fragmented, as we have heard in the first panel 
today. The chart we have prepared--I draw your attention to 
this--gives examples of efforts to coordinate these activities 
at the Federal level as they existed before the creation of the 
Office of Homeland Security. We, too, feel that this office 
holds great promise.
    I won't walk you through the whole chart, but as you can 
see, a multitude of agencies have overlapping responsibilities 
for various aspects of bioterrorism preparedness. Bringing 
order to this picture will be a challenge. We do need 
coherence.
    Federal spending on domestic preparedness for terrorist 
attacks involving all types of weapons of mass destruction has 
risen 310 percent since fiscal year 1998 to approximately $1.7 
billion in fiscal year 2001.
    Funding information on research and preparedness of a 
bioterrorist attack, as reported to us by the Federal agencies, 
was difficult to ascertain. We identified increases year to 
year from generally low levels, or zero levels, in 1998. For 
example, HHS-CDC's bioterrorism preparedness and response 
program first received funding in fiscal year 1999; its funding 
has increased from approximately $121 million at that time to 
approximately $194 million in fiscal year 2001.
    While many of the Federal activities are designed to 
provide support for local responders, inadequacies in the 
public health infrastructure at the State and local level may 
reduce effectiveness of the overall response effort.
    Our work has pointed to weaknesses in three key areas--
training of health care providers, communication among response 
parties, and capacity of hospitals and laboratories.
    I think we heard very concrete examples of the problems 
with training, the problems with communication and also the 
lack of capacity, both laboratories and hospitals, very 
eloquently on the first panel, so I'm not going to repeat that; 
only to say in conclusion, although numerous bioterrorism-
related research and preparedness activities are under way in 
the Federal agencies, we remain concerned about weaknesses in 
public health and medical preparedness at the State and local 
levels and, of course, the coordination at the Federal levels.
    Thank you. I'd be happy to answer any questions.
    [The prepared statement of Janet Heinrich appears at the 
end of the hearing.]
    Mr. Greenwood. Thank you, Ms. Heinrich. Appreciate your 
testimony.
    The Chair recognizes himself for 5 minutes. Let me address 
my first question to Dr. Lillibridge, and actually it may be 
appropriate for Mr. Baughman to respond as well. And Ms. 
Heinrich, if you'd like to respond, you may as well.
    In your testimony, you talked about the number of 
metropolitan areas that have participated in your department's 
preparedness programs, how much money you've given out, the 
goals that have been set; but I'm not sure that we get a clear 
sense so far as to whether we're meeting those goals. And I 
think you were present when I asked the previous panel 
whether--if I were to ask them to go out and inform this 
committee as to whether or not a particular city or 
metropolitan area was in fact prepared, would they even know 
the right list of questions or the right checklist to compare 
the efforts against.
    And what do we know about and how do we measure the 
preparedness of cities? Could you respond to that, Dr. 
Lillibridge?
    Mr. Lillibridge. Yes, sir. Let me mention two things that 
we're working on, and we certainly share your concerns about 
municipal preparedness.
    One of the things that we began to do in HHS is, after the 
first year or two of the grant cycle, when it became clear that 
this threat was going to continue and we'd be engaging in a 
long-term preparedness process, began to look at what core 
capacities really equal response and hone down on that. And 
through a 6-month process we've come to the conclusion in the 
key areas of epidemic preparedness and response the kind of 
things that help lead us to capacities that could be measurable 
at the State and local level as you begin to look at this--and 
we intend to anchor those or at least link those to our grant 
process in the near future. Those were developed in concert 
with public health, medical folks, people in the public health 
guilds and workers in disease detective work or epidemiology at 
the State and local level.
    Mr. Greenwood. Mr. Baughman, did you want to comment?
    Mr. Baughman. I think that probably HHS has done a good job 
in getting guidance out to the participating cities for 
guidance as to what an MMRS ought to be and how they ought to 
be able to react to a biological event. I think what we've done 
a poor job on is getting guidance out to area hospitals and 
health care providers as to how they detect and treat these 
types of things in a rapid--and I think you heard that from the 
first panel also.
    Mr. Greenwood. But it seems to me if--if I could refine my 
question, if I were the mayor of Philadelphia and I had the 
ultimate responsibility for the lives of people in that city, I 
would want to be able to ask my cabinet, Are we ready? And that 
would mean somebody would need to tell me how the hospitals--
you know, the hospitals, check; first responders, check; 
vaccines, check; communications system, check; command and 
control, check.
    And if the mayor of Philadelphia called me after this 
hearing and said, How do I--what tool do I use to measure the 
preparedness of the city of Philadelphia, how should I respond 
to him?
    Mr. Baughman. There are a number of checklists out there. 
The Office of Justice Programs has in fact put out guidance as 
to how you evaluate plans, what you ought to be looking for 
when you're evaluating those plans. I'm not sure that those 
plans have been adequately vetted through the community to get 
the expert input that they need to have on them.
    Mr. Greenwood. Ms. Heinrich.
    Ms. Heinrich. I'd just like to say that we've certainly 
been looking for such a list, and measurable indicators.
    To remind you, we are going to be starting--we are starting 
the second phase of our work, which is to assess the 
preparedness at the local and State level. It's part of the 
mandate that we have to do this work. And what we've found is 
that there's--there are a lot of different checks that seem to 
focus on this from an all-hazards approach, a chemical approach 
or a biological approach, and it seems as though there are 
differences, depending on how you view what the threat is.
    Mr. Greenwood. The Washington Monthly's cover is--this is 
from May 2000--``Weapons of Mass Confusion: There's Anthrax in 
Your Subway. Who Are You Going to Call?'' and think that's what 
we're seeing here is that we do have that issue.
    I'm going to yield 5 minutes to the gentleman from Florida, 
Mr. Deutsch.
    Mr. Deutsch. Thank you, Mr. Chairman.
    You know, I think that's a good lead-in to a question that 
in a sense everyone on the previous panel talked about, which 
is the need for a centralized location, and none of you 
testified to that need, where everyone on the other panel 
mentioned it.
    Do you have thoughts? Is there disagreement of a 
centralized location to be coordinating this? Dr. Lillibridge?
    Mr. Lillibridge. Let me begin. After engaging in nearly 3 
years of national preparedness, individually with local 
communities, States and regionally, it's clear that we could 
benefit from central coordination of certain activities. 
Clearly, having a forum, an office or a centralized leadership 
to coordinate issues of implementation, budget and interagency 
things, I believe is going to be extremely important. Our 
department is quite excited about supporting the new Office of 
Homeland Security and Governor Ridge in his effort.
    Mr. Deutsch. So would that theoretically, with the central 
location at this point--I mean, the Office of Homeland 
Security?
    Mr. Lillibridge. We would be glad to coordinate through 
that, and that--as information becomes known and how that's 
going to roll out and be implemented. We're standing by, 
identifying staff and looking at issues that could really 
benefit from that kind of central coordination.
    Mr. Baughman. I'd like to mention, though, there's two 
areas of coordination. There is, one, coordinating the various 
Federal programs that are going down to State and local 
government; and I think that everybody is in favor of a 
centralized need, central location. It's one of the reasons 
that we--lacking anything else, we set up, at the request of 
the President, an office of national preparedness.
    Again, if Homeland Security takes on that responsibility, 
that's a central location. Regardless of where it is, that 
function is needed.
    The other part is preparing the Federal community to 
respond to a situation like the World Trade Center. We have 
been the central coordinating agency, working with the 
Federal--various Federal agencies to bring together the 
existing arsenal of Federal response assets to respond, and I 
think we've done a pretty good job at that.
    But the other one, the central location for coordination of 
the various Federal agency programs, that's needed.
    Ms. Heinrich. The GAO has gone on record as being very much 
in favor of a central coordinating office, but more than 
coordination, it speaks to several principles, a couple of 
examples being budget control and also the whole issue of 
command and control.
    We don't think that anyone knows yet exactly what the 
President is thinking about in terms of inclusion of agencies 
under the Homeland Security office. I think there are a lot of 
unknowns there at this time.
    Mr. Deutsch. Let me go back to the questions I asked the 
first panel, and hopefully you could provide some additional 
information, and maybe get into a couple of specifics.
    First off, Dr. Lillibridge, is there a test available on 
anthrax beyond this 24/48-hour incubation period?
    Mr. Lillibridge. Sir, we have a number of things to draw 
down to look at. The assay--the issue of assay development 
could be discussed at length, but let me in short--in the 
application of public health at the State and local level, we 
have a system of 81 laboratories that we support at CDC, 
throughout the States, that have been trained and received 
reagents--those are the things to conduct the test--and test 
assays from CDC and other Federal entities to have in place to 
do rapid diagnoses at different levels.
    Case in point, the Florida experience that we currently 
spoke of on the earlier panel, the--it's important to note that 
those resources were used on the first day of admission to get 
a presumptive positive and trigger the public health response 
and that that test was reconfirmed at CDC, but that capacity 
and that lab training and those lab tests were already in the 
State, and Florida has that also arrayed regionally.
    Dr. Young alluded to the issue of advancing laboratory 
technology. There are many things we must do and stay focused 
on because there are many more agents. There's opportunities to 
push local diagnosis locally more rapidly, and I think those 
are going to be things that we'll work on in the future.
    Mr. Deutsch. Let me try to be more specific. I mean, 
yesterday we were on a conference call, with CDC saying they're 
testing 700 additional people in Florida. They said that it's 
going to be 24 to 48 hours before it's determined whether there 
are additional cases of anthrax in Florida. I mean, is that the 
best we can do?
    Mr. Lillibridge. You can do several ranges of tests, but 
the test that was selected to do for those folks that were 
potentially exposed, that they brought back for prophylaxis, 
was a culture. That requires that bacteria be grown in culture 
plates; that does take several days.
    You could do presumptive tests on those people on their 
nasal swabs right away, but you would still have a presumptive 
test that would need a bacterial culture confirmation.
    Mr. Deutsch. So the presumptive tests on those 700 people 
have not been done?
    Mr. Lillibridge. What they're doing are the gold standard 
tests, the culture. They're already on medical prophylaxis----
    Mr. Deutsch. Let me ask a follow-up question on this.
    Is it a case--until those cultures grow, we don't know if 
this is a case that is limited to two people at this point in 
time?
    Mr. Lillibridge. Good point. Being colonized is not the 
same as being infected or being a case, and the people who have 
positive nasal swabs may not be cases in terms of being--having 
clinical disease. They may be colonized or they may have 
external contact in their nasal cavity.
    It does help us confirm that they were in a place where 
they might have been exposed; if it turns out, it may help 
guide the investigation to determine where the source of the 
exposure may have been.
    Mr. Deutsch. Right. So the second gentleman which--it's 
unclear whether or not he in fact has developed anthrax. He 
just was exposed.
    In other words, the nasal cavity, there were anthrax spores 
in his nasal cavity; is that correct?
    Mr. Lillibridge. Correct. I was at CDC as early as this 
morning. It's been about--information is about 3 or 4 hours 
dated now, but as of that time, he was getting better. He was 
not considered a case of anthrax. He was considered a surface 
exposure of his nasal swab, which indicated that he had been in 
an area, perhaps, where there had been some contact with----
    Mr. Deutsch. And the limitation of him is that--again, my 
understanding is it would take 5,000 spores sort of as an 
average, or as minimum, to actually acquire the disease?
    Mr. Lillibridge. You need a substantial exposure, as Dr. 
Young said.
    One of the interesting things about this--or at least some 
of the good news is that if this was a massive exposure, there 
should be lot of people sick or earlier presentations of 
pulmonary anthrax. We are not finding that, and we are--still 
have one confirmed case, and we are doing everything possible 
to conduct a dual law enforcement and a public health 
investigation.
    Mr. Deutsch. At this point in time, do we know if that--I 
mean, the press is reporting that that particular strain came 
from a lab in Iowa. Is that accurate?
    Mr. Lillibridge. Well, what we do know is that the strain 
from the man's nose and the patient who died and the keyboard 
from the patient who died are identical. We think that it--it's 
similar to--it has been reported to be similar to other 
strains. However, the confirmation on that was not available as 
of the time I came in.
    I'd like to mention one thing, just to allay the public--
one issue that's extremely important is that the sensitivity of 
this bacteria was such that it was sensitive to penicillin, 
doxycycline and ciprofloxacin, and possibly several other 
drugs. The significance of that is, it doesn't--that is not the 
hallmark of an engineered bioweapon.
    Mr. Deutsch. Right. Because a bioweapon, that is why cipro 
is the only one that works on the bioweapons in the Russian 
labs. Is that correct?
    Mr. Lillibridge. Well, you stack your therapy against what 
you think will work best, and it's one of the newer and more 
powerful antibiotics. You would start with that, wait for 
sensitivity in testing to come back, and then shift to 
something you were sure it was sensitive to.
    Mr. Deutsch. Where would someone get anthrax to use? I 
mean, let's just assume it's a case of a disgruntled employee 
who has, you know, put it on someone's keyboard. I mean, where 
would someone get anthrax?
    Mr. Lillibridge. Well, as mentioned in the previous panel, 
it's ubiquitous. It's in the soil. You could----
    Mr. Deutsch. Right, but this is a non--you know, not 
naturally occurring. So this is in someone's lab in Iowa or 
something. I mean, so it didn't come from the soil is what 
we're being told at this point in time.
    Mr. Lillibridge. Well, one of the things we're looking into 
is trying to nail down where the source is, by location, and 
then get more information about where that might have come from 
in terms of, was it a package? Was it an exposure of an 
airborne variety? Or was it some sort of occupational thing?
    Mr. Deutsch. You're telling us now and you're confirming 
that it was on a keyboard that the gentleman who passed away 
used? Is that accurate?
    Mr. Lillibridge. We have--it's consistent for us to 
understand that it was found in three locations. One, the 
environment; the keyboard is second; a man's nose----
    Mr. Deutsch. The keyboard of the gentleman who passed away?
    Mr. Lillibridge. The keyboard of the gentleman who passed 
away.
    Mr. Deutsch. And again I guess I'm trying to ask a very 
basic question.
    If it's there and, at this point, we're saying that it's 
not a naturally occurring form, someone put it there. I mean, 
is that a fair assumption that someone put it there?
    Mr. Lillibridge. No. It is----
    Mr. Deutsch. It's not a fair assumption?
    Mr. Lillibridge. It's the assumption that all we know is 
that at this point in the investigation--I don't have all the 
elements of the criminal component, but that there's an 
environmental swab that was positive. There was a nasal swab in 
a second person, and the first index patient, or the first 
person who contracted the disease and died, had the same, 
similar pathogen.
    Now, in the context of knowing that and beginning to 
examine patients and looking through the potentially exposed 
folks, you begin to look at people who might be sick, who were 
in the area or who traveled the same pathway.
    Mr. Greenwood. It's theoretically possible that it could 
have--anthrax could have been in the victim's body first and 
the keyboard second?
    Mr. Lillibridge. It is theoretically possible, depending on 
how the original person was exposed.
    Mr. Deutsch. And it would have dropped out of his passages 
and ended up on the keyboard, I mean, and at what levels?
    I mean, let me just tell you, we're in the mood of passing 
out things. This is local papers from south Florida, which I 
represent. I don't represent the location where the hospital 
is, but it's close enough, and the county is just directly 
bordering Palm Beach County.
    I mean, you know, what the press accounts are--are, you 
know, out of a bad movie scene. I mean, people, you know, 
calling up HAZMAT, you know, dozens of times in south Florida 
yesterday whenever they see, you know, a packet of dust or an 
envelope of dust and things like that.
    And, again, I know you're trying to be as helpful as 
possible, but you're not clearing up a heck of a lot. You're 
not clearing up a heck of a lot. And I mean, if you're the guy 
at HHS that is supposed to be in charge of bioterrorism--
whether we're calling this a criminal act or bioterrorism, I 
think we need to at least be thinking of it as potential 
bioterrorism at this point, contrary to what the Secretary 
originally said.
    And whether it's a testing ground, I mean, of--you know, 
what the, you know, people who were living in this neighborhood 
were doing--again, this is just weird that----
    Mr. Buyer. Mr. Chairman, we've got a vote coming on. We've 
been very patient here.
    Mr. Greenwood. The time of the gentleman has expired.
    The gentleman from North Carolina, Mr. Burr--Mr. Buyer.
    Mr. Buyer. I think we could probably clear this up really 
quick for the gentleman from Florida.
    Obviously we know that there are specific strains of 
anthrax. We know what type of strains of anthrax have been 
weaponized by certain countries in the world. Once you culture 
this particular anthrax, we will know whether or not this was 
an anthrax of a strain that was from a weaponized form from 
another country. So at some point in time, an answer is going 
to be made there, I want to share with the gentleman from 
Florida.
    Now, obviously, I don't want to ask you this question, 
because you can't answer this question in a public forum. I see 
a nod by the doctor in the back. It's correct, isn't it?
    Mr. Lillibridge. Well, I can tell you what I know as of 
this time, and let me just review the pathway.
    As this--as more information becomes known--and they're 
double-checking and looking at different ways to do strain 
identification, all that information is not back yet, so it 
would be presumptive or premature to make prognostications, 
whether it came from a foreign state or whether it was a 
bioterrorism attack.
    We do know the following: It wasn't large scale; the 
sensitivity looks relatively modest and not weaponized; it was 
a sensitive strain; and indeed there will be tests to look at 
different types of patterns, to locate it geographically and 
perhaps to locate it to somebody else's library or to look for 
a specific lab.
    If that information were available today, I would tell you. 
I do not have that information, because----
    Mr. Deutsch. I will tell you, CNN is reporting it came from 
a lab in Iowa, not from an overseas lab----
    Mr. Greenwood. The time belongs to the gentleman from 
Indiana.
    Mr. Lillibridge. I would have to have our lab people talk 
with the CNN lab people.
    Mr. Buyer. The only reason I asked the question for 
clarification is that, because these strains are identifiable, 
there will be an opportunity to sort of track this thing down. 
I only brought this up because the gentleman is harping on this 
question between--the difference between criminality or 
bioterrorism, and we do have an ability to identify.
    I want to go to this question to you: With regard to the 
GAO report on bioterrorism, it noted, under current law that 
Federal grant monies cannot go to private entities, such as 
hospitals, for bioterrorism preparedness activities. Do we need 
to change that, or do you recommend we change that? What is 
your counsel to us?
    Mr. Lillibridge. Well, I would recommend the following, 
that--and the Secretary has asked for resources to begin 
hospital preparedness activities that would require some things 
that would--may require resources or structural changes in 
hospitals that would include enhancing medical capacity, 
developing alternative care, dealing with a wider range of 
infected patients.
    And I think--in summary, that answer--I think we ought to 
look, work with you on that. That may be part of the solution.
    Mr. Buyer. Okay. I yield the balance of my time to the 
gentleman from North Carolina.
    Mr. Burr. Doctor, let me go to the heart of what you said. 
The Secretary has asked for additional resources. Everybody has 
asked for additional resources.
    You know, America is in a position where they want to 
respond. One of the functions, if not the primary function on 
this committee right now, is to determine, what do we need to 
fix prior to injecting new funds?
    We've alluded to a lot of numbers, $1.7 billion for fiscal 
year 2001; and I think, another place, we estimated that some 
small portion of that actually made its way to response and 
preparation and equipment and training.
    I think it's extremely easy for Congress to throw more 
money in it and for us to turn around a year, 2 years, 5 years 
down the road, and for Dr. Stringer to tell us that the threat 
is every bit as great and his response is every bit as 
challenging and for everybody that was on the first panel to 
say, look at all the things that are broken.
    Do we have somebody who is going to come with concrete 
suggestions as to what we need to fix legislatively, or what 
can be fixed rulemaking-wise that changes the outlook of our 
capability to respond effectively?
    Mr. Lillibridge. Yes, sir.
    Let me mention that we've mentioned some of the things--
some of the targets have been brought up today by different 
panels and myself about key elements of the public health 
infrastructure. We've talked about some of the hospital surge 
capacity.
    But let me turn then to something--the legislative issues 
that are high on our agenda that--I understand our department 
is working with this committee on several things. But high on 
our agenda includes food safety, things that we might have to 
do to improve our ability to respond. We're looking at issues 
around the select agent legislation that's been out there and 
are looking at a way to enforce certain high-priority agents 
that have come to light that are of public health importance, 
and a way to expedite--I think somebody mentioned earlier the 
FDA process of looking at key pharmaceuticals or vaccines that 
may need to be----
    Mr. Burr. And I think all of us would agree with all the 
points you just made.
    Will you be coming to us with the suggestions as to how you 
want them changed, whether you can do them internally, whether 
we need to do them legislatively?
    Mr. Lillibridge. We will be coming----
    Mr. Burr. The hair on the back of my neck goes up when you 
talk about changes at the Food and Drug Administration, because 
I don't think you understand how big an undertaking that is.
    Mr. Lillibridge. Sir, we agree it's a big undertaking, but 
we will be coming to work with you on that. Secretary Thompson 
made that clear at his last hearing, and it's my----
    Mr. Burr. And trust me, I have more confidence in his 
capabilities than I do in practically everybody else's in 
Washington. But I also know that the task that he has before 
him is one of the biggest tasks he has ever faced, and I don't 
think he understands--and I don't think we understand, by the 
way--everything that we're all going to have to do.
    I just know that the answers and the questions that were 
raised by the first panel, the warnings that were given to us 
by terrorism committees that were chartered by this Congress 
and prior Congresses, the reports to the President, the 
warnings that were out there--we knew this existed. This threat 
was there, and we did a poor job at preparing ourselves for 
what happened in Florida and potentially what could happen 
elsewhere. We all need to get on the same page.
    A last question, and then the chairman can go where he 
wants to.
    Mr. Greenwood. I thank the gentleman.
    Mr. Burr. That was a compliment.
    To all three of you, should Governor Ridge have the budget 
authority over all bioterrorism dollars that are placed at 
these different agencies within the Federal Government?
    Mr. Lillibridge. Sir, I don't know if our department has 
made a statement on that or has an opinion.
    Mr. Burr. This is a tremendous opportunity for you.
    Mr. Lillibridge. And so, at risk of getting out in front of 
our department on this issue, I would say that they have to 
have some capability to weigh in on budget issues, whether 
that's budget authority or whether that's participating in 
budget decisions or participating in planning, whereby things 
are implemented as a result of the budget.
    Mr. Burr. Would you agree that if there's over a billion 
dollars of appropriated dollars out there--and I guess $1.7 is 
this year's number, and $300 million actually makes it into the 
stream of purchasing equipment, training, people to respond--
that that percentage is pitiful?
    Mr. Lillibridge. Well, I'll agree that the preparedness 
effort that has been lined out should include a general 
consideration for equipment, specialized personnel, hospital, 
public health and all the things we mentioned.
    Mr. Burr. Mr. Baughman?
    Mr. Baughman. Our director met with Governor Ridge last 
Friday. We're in the process--we're in ongoing dialog with 
Governor Ridge's office as to what he needs to succeed. I can't 
get into the particulars right now. The director, I'm sure, has 
his own ideas and I think will be forthcoming with those.
    But certainly I think we would agree that as far as Federal 
programs, dealing with first responder training, there does 
need to be a central point of coordination, and I think we 
realized that when we set up 2 months ago our Office of 
National Preparedness.
    Ms. Heinrich. I would just say that at this point in time 
OMB does try to do some coordination, or at least 
identification of dollars that are spent in terrorism, overall. 
They have not--they have not tried to coordinate or actually 
reduce duplication, but only to identify the dollars.
    From GAO's perspective, I think, again we feel that there 
are some areas that overlap in terms of jurisdiction, and, 
therefore, accountability isn't as clear as it could be or 
should be.
    Mr. Burr. You're being a lot more generous than the GAO 
report as it relates to the duplication, aren't you?
    Ms. Heinrich. Well, I'm----
    Mr. Burr. The report was much more specific, that we just 
don't have any coordination of programs, and in most cases, 
can't find where that money went, can we?
    Ms. Heinrich. We had a difficult time really identifying 
all the dollars; and as we said, we used the reports from the 
various agencies and departments. They had difficulty, because 
for bioterrorism, there isn't a particular line item, and they 
also used different--different forums. Some appropriations, 
some dollars, were expenditures.
    Mr. Burr. Let me read you what the report said: ``over 40 
Federal departments and agencies have some role in combating 
terrorism''----
    Mr. Greenwood. I just would like to inform the gentleman 
that the time on the floor for voting has expired, so----
    Mr. Burr. We had better leave.
    Mr. Greenwood. We had better leave.
    Mr. Burr. [continuing] ``and coordinating their activities 
is a significant challenge. We identified over 20 departments 
and agencies as having a role in preparing for or responding to 
the public health and medical consequences of a bioterrorist 
attack.'' I'll stop there.
    I'll only make the statement that, you know, I would feel 
much more comfortable if we had one agency doing it, and I 
think that is the decision. Are we going to have one office 
coordinating it? We may still have 40, but are we going to have 
somebody that is responsible versus 40 different entities?
    I thank the chairman for his time.
    Mr. Greenwood. The Chair thanks the panelists for your 
testimony and for your help and excuses the abrupt conclusion 
of our hearing, but we've got to go see if we can put our votes 
in the record.
    [Whereupon, at 1:40 p.m., the subcommittee was adjourned.]
    [Aditional materal submitted for the record follows:]
 Prepared Statement of Deborah J. Daniels, Assistant Attorney General, 
                       Office of Justice Programs
    Chairman Greenwood, Mr. Deutsch, and Members of the Subcommittee: I 
am pleased to testify on behalf of the Office for Domestic Preparedness 
(ODP) within the Office of Justice Programs. When others from OJP have 
testified before Congress previously about domestic preparedness, they 
were able to talk about our programs and preparations in the context of 
the threat of a potential catastrophic terrorist attack. Sadly, we no 
longer have the luxury of time on our side and the attack is no longer 
merely potential.
    The Office for Domestic Preparedness (formerly the Office for State 
and Local Domestic Preparedness Support) was created within the Office 
of Justice Programs in1998 when Congress authorized the Attorney 
General to assist state and local public safety personnel in acquiring 
the specialized training and equipment necessary to safely respond to 
and manage domestic terrorism incidents, particularly those involving 
weapons of mass destruction (WMD). Congress recognized that these state 
and local personnel are typically first on the scene of any emergency, 
would likely be the first to respond in the event of a terrorist 
attack, and need to be as well-prepared and well-equipped as possible 
for these potentially catastrophic incidents. As was demonstrated so 
dramatically and tragically on September 11, Congress was right. New 
York City Police, Fire and Emergency Services personnel were first on 
the scene at the World Trade Center. Arlington County, and other 
Virginia, Maryland and District of Columbia emergency personnel were 
immediately on the scene at the Pentagon. Local personnel were first at 
the Pennsylvania crash site.
    Over the past three years, ODP has worked to provide coordinated 
training, equipment acquisition, technical assistance, and support for 
national, state, and local exercises to fulfill its mission of 
developing and implementing a national program to enhance the capacity 
of state and local agencies to respond to domestic terrorism incidents. 
OJP and ODP remain committed to reaching as many first responders--
firefighters, emergency medical services, emergency management agencies 
and law enforcement--as well as public officials in as many communities 
as possible to prepare them for the wide range of potential threats.
    ODP's activities are concentrated in the areas of training and 
technical assistance, equipment, planning, and exercises.
    Since 1998, ODP has provided training to over 77,000 emergency 
responders in 1,355 jurisdictions in all 50 states and the District of 
Columbia, and has completed over 2,000 deliveries of technical 
assistance to state and local response agencies.
    ODP's Training and Technical Assistance Program provides direct 
training and technical assistance to state and local jurisdictions to 
enhance their capacity and preparedness to respond to domestic 
incidents. Training is based on National Fire Protection Association 
standards, and provides emergency responders with a comprehensive 
curriculum in the areas of WMD awareness, technician, operations, and 
terrorist incident command. All courses go through a rigorous pilot and 
review process where federal, state, and local subject matter experts 
examine the course materials to ensure accuracy and compliance with 
accepted policies and procedures. Courses are brought directly to 
jurisdictions and taught by an ODP mobile training team or are 
conducted at a specialized facility, such as OJP's Center for Domestic 
Preparedness in Anniston, Alabama. Internet, video and satellite 
broadcast training courses round out the ODP curriculum.
    Last year, ODP assumed responsibility for the Nunn-Lugar-Domenici 
(NLD) Training Program. The NLD Program identified the nation's 120 
largest cities to receive training, exercises and equipment monies to 
enhance their capacity to respond to WMD incidents. Prior to the 
program's transfer from the Department of Defense, 68 of the 120 cities 
received all elements of the NLD Program, and 37 others received only 
the training component. ODP will complete delivery of the program to 
these 37 cities, and deliver all program elements to the remaining 15 
designated cities. As part of the NLD Program, these 52 cities will 
receive a biological weapons tabletop exercise, and the 15 cities will 
also receive briefings on the U.S. Public Health's Metropolitan Medical 
Response System.
    The National Domestic Preparedness Consortium (NDPC) is the 
principal vehicle through which ODP identifies, develops, tests and 
delivers training to state and local emergency responders. The NDPC 
membership includes OJP's Center for Domestic Preparedness, the New 
Mexico Institute of Mining and Technology, Louisiana State University, 
Texas A&M University, and the Department of Energy's Nevada Test Site. 
Each consortium member brings a unique set of assets to the domestic 
preparedness program. ODP also utilizes the capabilities of a number of 
specialized institutions in the design and delivery of its training 
programs. These include private contractors, other federal and state 
agencies, the National Terrorism Preparedness Institute at St. 
Petersburg Junior College, the U.S. Army's Pine Bluff Arsenal, the 
International Association of Fire Fighters, and the National Sheriffs' 
Association.
    ODP provides targeted technical assistance to state and local 
jurisdictions to enhance their ability to develop, plan, and implement 
a program for WMD preparedness. Specifically, ODP provides assistance 
in areas such as the development of response plans, exercise scenario 
development and evaluation, conducting of risk, vulnerability, 
capability and needs assessments, and development of the states' Three-
Year Domestic Preparedness Strategies.
    Working with Congress, ODP has implemented a program in all 50 
states, the District of Columbia, and the five U.S. territories to 
develop comprehensive Three-Year Domestic Preparedness Strategies. 
These strategies are based on integrated threat, risk, and public 
health assessments, conducted at the local level, which will identify 
the specific level of response capability necessary for a jurisdiction 
to respond effectively to a WMD terrorist incident. Once these plans 
are assembled and analyzed, they will present a comprehensive picture 
of equipment, training, exercise and technical assistance needs across 
the nation. In addition, they will identify federal, state and local 
resources within each state that could be utilized in the event of an 
attack. ODP anticipates receiving the majority of these strategies by 
December 15, 2001. Following their submission, ODP will work directly 
with each state and territory to develop and implement assistance 
tailored to the specific needs identified in the plans. Last month, the 
Attorney General wrote to the governors stressing the urgency of 
completing these assessments, and has directed ODP to place the highest 
priority on analyzing and processing these strategies and assisting 
states in meeting identified needs as quickly as possible.
    To date, only one state, Utah, which has heightened needs and 
awareness in preparation for the 2002 Winter Olympics, has completed 
its plan and received its allocated equipment funds. ODP has approved 
the plans for Rhode Island, South Carolina and Hawaii, and these states 
are now eligible to draw down funds. Florida and Pennsylvania have 
recently submitted their plans, which are currently being reviewed. 
States received a total of $54 million in initial planning and 
equipment funds from FY1999 under this program and are scheduled to 
receive an additional $145 million in aggregated FY2000 and 2001 
equipment funds as plans are completed. Each state will, in turn, 
distribute funds to jurisdictions within the state, as well as to state 
agencies, for use in implementing the state's strategy. Currently, 
equipment funding is limited to personal protection (such as protective 
suits), chemical and biological detection devices, chemical and 
biological decontamination equipment, and communications equipment.
    Under the FY1998 and FY1999 County and Municipal Agency Equipment 
Program, large local jurisdictions received approximately $43 million 
in equipment funding. From 1998 through 2001, OJP has provided a total 
of $242 million in equipment grants for 157 local jurisdictions and the 
50 states, the District of Columbia and the five U.S. territories.
    Experience and data show that exercises are a practical and 
efficient way to prepare for crises. They test crisis resistance, 
identify procedural difficulties, and provide a plan for corrective 
actions to improve crisis and consequence management response 
capabilities without the penalties that might be incurred in a real 
crisis. Exercises also provide a unique learning opportunity to 
synchronize and integrate cross-functional and intergovernmental crisis 
and consequence management response. ODP's National Exercise and State 
and Local Domestic Preparedness Exercise Programs seek to build on the 
office's training, technical assistance, and equipment program 
activities.
    The State and Local Domestic Preparedness Exercise Program aids 
states and local jurisdictions in advancing domestic preparedness 
through evaluation of the authorities, plans, policies, procedures, 
protocols, and response resources for WMD crisis and consequence 
management. The program provides funding and technical assistance to 
states and local jurisdictions to support local and regional 
interagency exercise efforts. ODP also provides guidance and uniformity 
in design, development, conduct, and evaluation of domestic 
preparedness exercises and related activities. A number of state and 
local agencies have requested exercise assistance in bioterrorism 
response as part of this program.
    In May 2000, at the direction of the Congress, ODP conducted the 
TOPOFF (Top Officials) exercise, the largest federal, state and local 
exercise of its kind, involving separate locations and a multitude of 
federal, state and local agencies. TOPOFF simulated simultaneous 
chemical and biological attacks around the country and provided 
valuable lessons for the nation's emergency response communities. The 
bioterrorism scenario conducted in Denver, Colorado, involved state and 
local health, fire and HAZMAT agencies, as well as the CDC, the U.S. 
Public Health Service and other federal agencies.
    ODP has begun planning for the congressionally-mandated TOPOFF 2 
exercise, which will be conducted in Spring 2003. TOPOFF 2 will 
incorporate lessons learned from the first exercise into its planning 
and design. TOPOFF 2 will be preceded by a series of preparatory WMD 
seminars and tabletop exercises crafted to explore relevant issues.
    In addition to its National Exercise and State and Local Domestic 
Preparedness Exercise Programs, ODP, in collaboration with the 
Department of Energy, is establishing the Center for Exercise 
Excellence at the Nevada Test Site. The center will deliver a WMD 
Exercise Training Program for the nation's emergency response community 
to ensure WMD exercise operational consistency nationwide. During 
FY2001, the National Guard Bureau agreed to support the center with 
funding to exercise its Civil Support Teams in conjunction with state 
and local emergency responders.
    All ODP programs and policy development include consideration of 
and response to potential bioterrorism, in addition to the full range 
of weapons of mass destruction.
    In keeping with its congressionally-mandated mission, ODP has 
primarily focused program efforts on meeting the needs of traditional 
first responders, which include fire, HAZMAT, and law enforcement 
personnel, and has relied on the medical and public health communities 
to train their traditional constituencies, such as emergency medical 
technicians and hospital personnel. However, ODP has also actively 
worked with and supported other federal agencies in their efforts to 
provide this training and assistance.
    ODP initiated an effort to bring together all of the federal-level 
training representatives to formalize the coordination processes 
already in effect and to capitalize on the diverse expertise and 
specialized training delivered by the respective federal agencies. The 
resulting Training Resources and Data Exchange (TRADE) working group 
includes representatives from the United States Fire Administration's 
National Fire Academy, the Federal Bureau of Investigation, the Federal 
Emergency Management Agency, the Environmental Protection Agency, the 
Department of Energy, the Department of Health and Human Services, and 
the Centers for Disease Control and Prevention. The TRADE group has 
identified and initiated work on several immediate tasks, including the 
development of agreed-upon learning objectives by discipline and 
competency level for federal training efforts, a joint course 
development and review process, joint curriculum assessment and review, 
and coordination of training delivery resources in accordance with 
state strategies.
    Since 1998, ODP and the U.S. Public Health Service (PHS) have been 
engaged in active coordination of their domestic preparedness efforts 
and assistance programs for state and local emergency responders. In 
FY2001, several joint program efforts were initiated: a cooperative 
effort to integrate implementation of the Nunn-Lugar-Domenici Domestic 
Preparedness Program (NLD DP) and the Public Health Service's 
Metropolitan Medical Response System (MMRS) program; review and 
revision of the hospital training component of the NLD DP Program; a 
joint project to enhance awareness of MMRS initiative and the National 
Disaster Medical System, which are critical to the effective delivery 
of health and medical consequence management resources; and a 
partnership effort among ODP, PHS, and the National Domestic 
Preparedness Consortium to assist management and oversight of PHS' 
Noble Training Center in Anniston, Alabama, and to provide for joint 
development, review and delivery of WMD courses for medical personnel.
    In October 2000, ODP held a formal program coordination meeting 
with the CDC. This meeting laid the foundation for cooperation between 
these agencies on a multitude of issues, and has resulted in continued 
follow-up communications and meetings, involvement of CDC subject 
matter experts in ODP course development and review, and better 
coordination of the two agency's programs.
    In the future, ODP will continue to actively coordinate its 
programs with other federal agencies to ensure that the highest quality 
of training and technical assistance is provided to the broad spectrum 
of the nation's emergency response community while also making certain 
duplication of federal resources in these areas does not occur.
    These joint endeavors will present a unified federal effort in the 
eyes of the public safety community and greatly enhance federal 
domestic preparedness efforts and the capacity of the nation as a whole 
to respond safely and effectively to incidents of terrorism involving 
WMD, including biological agents.
    Once again, thank you for the opportunity to describe OJP efforts 
in this vitally important area.
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