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



                               before the


                                 of the

                              COMMITTEE ON
                           GOVERNMENT REFORM

                        HOUSE OF REPRESENTATIVES

                      ONE HUNDRED SEVENTH CONGRESS

                             FIRST SESSION


                            NOVEMBER 7, 2001


                           Serial No. 107-114


       Printed for the use of the Committee on Government Reform

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


                       U. S. GOVERNMENT PRINTING OFFICE
82-172                          WASHINGTON : 2002
For Sale by the Superintendent of Documents, U.S. Government Printing Office
Internet: bookstore.gpo.gov  Phone: toll free (866) 512-1800; (202) 512-1800  
Fax: (202) 512-2250 Mail: Stop SSOP, Washington, DC 20402-0001


                     DAN BURTON, Indiana, Chairman
BENJAMIN A. GILMAN, New York         HENRY A. WAXMAN, California
CONSTANCE A. MORELLA, Maryland       TOM LANTOS, California
CHRISTOPHER SHAYS, Connecticut       MAJOR R. OWENS, New York
JOHN M. McHUGH, New York             PAUL E. KANJORSKI, Pennsylvania
STEPHEN HORN, California             PATSY T. MINK, Hawaii
JOHN L. MICA, Florida                CAROLYN B. MALONEY, New York
THOMAS M. DAVIS, Virginia            ELEANOR HOLMES NORTON, Washington, 
MARK E. SOUDER, Indiana                  DC
BOB BARR, Georgia                    DENNIS J. KUCINICH, Ohio
DAN MILLER, Florida                  ROD R. BLAGOJEVICH, Illinois
DOUG OSE, California                 DANNY K. DAVIS, Illinois
RON LEWIS, Kentucky                  JOHN F. TIERNEY, Massachusetts
JO ANN DAVIS, Virginia               JIM TURNER, Texas
DAVE WELDON, Florida                 JANICE D. SCHAKOWSKY, Illinois
CHRIS CANNON, Utah                   WM. LACY CLAY, Missouri
ADAM H. PUTNAM, Florida              DIANE E. WATSON, California
C.L. ``BUTCH'' OTTER, Idaho          STEPHEN F. LYNCH, Massachusetts
EDWARD L. SCHROCK, Virginia                      ------
JOHN J. DUNCAN, Jr., Tennessee       BERNARD SANDERS, Vermont 
------ ------                            (Independent)

                      Kevin Binger, Staff Director
                 Daniel R. Moll, Deputy Staff Director
                     James C. Wilson, Chief Counsel
                     Robert A. Briggs, Chief Clerk
                 Phil Schiliro, Minority Staff Director

 Subcommittee on National Security, Veterans Affairs and International 

                CHRISTOPHER SHAYS, Connecticut, Chairman
ADAM H. PUTNAM, Florida              DENNIS J. KUCINICH, Ohio
JOHN M. McHUGH, New York             TOM LANTOS, California
STEVEN C. LaTOURETTE, Ohio           JOHN F. TIERNEY, Massachusetts
RON LEWIS, Kentucky                  JANICE D. SCHAKOWSKY, Illinois
TODD RUSSELL PLATTS, Pennsylvania    WM. LACY CLAY, Missouri
DAVE WELDON, Florida                 DIANE E. WATSON, California
C.L. ``BUTCH'' OTTER, Idaho          STEPHEN F. LYNCH, Massachusetts

                               Ex Officio

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

                            C O N T E N T S

Hearing held on November 7, 2001.................................     1
Statement of:
    Kingsbury, Nancy, Managing Director for Applied Research and 
      Methods, General Accounting Office, accompanied by Betty 
      Ward-Zukerman, Assistant Director, Applied Research and 
      Methods, General Accounting Office; and William W. Cawood, 
      Assistant Director, Defense Capabilities and Management, 
      General Accounting Office..................................     9
    Winkenwerder, William, Assistant Secretary of Defense for 
      Health Affairs, Department of Defense, accompanied by Lt. 
      General Paul K. Carlton, Jr., the Surgeon General, U.S. Air 
      Force, Department of Defense; Lt. General James B. Peake, 
      the Surgeon General, U.S. Army, Department of Defense; and 
      Read Admiral Donald C. Arthur, Jr., Deputy Surgeon General, 
      U.S. Navy, Department of Defense...........................    31
Letters, statements, etc., submitted for the record by:
    Kingsbury, Nancy, Managing Director for Applied Research and 
      Methods, General Accounting Office, prepared statement of..    12
    Kucinich, Hon. Dennis J., a Representative in Congress from 
      the State of Ohio, prepared statement of...................     5
    Winkenwerder, William, Assistant Secretary of Defense for 
      Health Affairs, Department of Defense, prepared statement 
      of.........................................................    34



                      WEDNESDAY, NOVEMBER 7, 2001

                  House of Representatives,
Subcommittee on National Security, Veterans Affairs 
                       and International Relations,
                            Committee on Government Reform,
                                                    Washington, DC.
    The subcommittee met, pursuant to notice, at 10:04 a.m., in 
room 2154, Rayburn House Office Building, Hon. Christopher 
Shays (chairman of the subcommittee) presiding.
    Present: Representatives Shays, Putnam, Gilman, Lewis, 
Schrock, Kucinich, Allen, Lantos and Tierney.
    Staff present: Lawrence J. Halloran, staff director and 
counsel; Kristine K. McElroy, professional staff member; Jason 
Chung, clerk; Michael Bloomrose, intern; David Rapallo, 
minority counsel; and Earley Green, minority assistant clerk.
    Mr. Shays. Good morning. I would like to call this hearing 
to order and welcome our witnesses and our guests.
    The modern battleground can be a toxic and biological 
minefield. In far-flung deployments, indigenous diseases, 
parasites and environmental exposures pose unique health 
threats. Fighting and surviving in battle space contaminated by 
chemical and biological weapons demand medical countermeasures 
and treatment capabilities beyond those needed to deal with 
bullets and bombs.
    To be ready to prevail on distant and increasingly dirty 
battlefields, the Department of Defense [DOD], is charged to 
recruit, train--retrain, train, equip and motivate a force 
capable of meeting diverse missions. One critical element of 
that readiness mandate is the capacity of medical personnel to 
protect the health of the men and women in uniform and, when 
necessary, treat the wounds of modern warfare.
    The Gulf war brought home some hard lessons about the 
adequacy of medical readiness in the face of microbial as well 
as military assault. Baseline medical data on deployed troops 
was found lacking. Records on the use of vaccines and drugs 
against chemical and biological [CB], threats were not kept. 
The military services appeared to have different approaches to 
health surveillance, training of medical personnel, and 
treatment protocols.
    Soon after the war, the General Accounting Office [GAO], 
and the DOD inspector general [IG], identified a number of 
shortcomings in DOD's capacity to provide medical support for 
the numbers of contaminated casualties anticipated. In 1996, 
the GAO and IG found many of those same problems persisted; so 
the subcommittee requested GAO determine what the Department is 
doing to adapt military medical force structure and training to 
meet emerging CB threats. We asked GAO to assess whether DOD is 
augmenting medical rosters with the specialists needed to 
diagnose and treat CB casualties, and we wanted to know the 
extent all medical personnel are receiving mandatory 
standardized training in the treatment of chemical and 
biological warfare exposures.
    The GAO findings released today indicate DOD has some 
efforts under way, but has yet to succeed in reshaping 
conventional medical planning to address the unique challenges 
of chemical and biological warfare. Training in medical 
management of CB casualties is limited, and treatment scenarios 
are almost never included in combat exercises.
    One intractable aspect of the longstanding disconnect 
between the Department's assessment of the CB threat and 
medical readiness to meet it appears to be an inability or 
unwillingness to approach the problem jointly. The service 
branches cling to different assumptions about casualty 
estimates and evacuation rates. Based on those assumptions, 
each service reaches different conclusions on which and how 
many medical personnel will be needed to treat CB injuries.
    The war against terrorism is being fought against an 
unconventional enemy with no compunction about using 
unconventional weapons. Those being sent to fight the war 
deserve to know medical support will be available whether they 
face tanks or toxins, mines or microbes. To help ensure they 
have that support, GAO today made several specific 
recommendations to clarify planning assumptions and improve 
medical readiness. The Department of Defense will address those 
proposals and describe current and planned capabilities to 
protect the health of deployed forces.
    Our witnesses this morning bring important information and 
insights to our oversight of defense medical readiness. We 
anticipate their being here--we appreciate their being here and 
look forward to their testimony.
    At this time I would like to recognize the ranking member, 
Mr. Kucinich.
    Mr. Kucinich. Thank you, Mr. Chairman.
    Good morning, and let me welcome all those who will be 
witnesses from the General Accounting Office and the Department 
of Defense. I am glad you could be with us today.
    Mr. Chairman, thank you for holding this hearing. The topic 
is extremely important. Our military has recognized a grave 
threat, the threat that chemical or biological agents might be 
used against them in the theater of war. They've made some 
movement toward dealing with this contingency, but as we will 
hear in a few moments, it appears they have not been fully able 
to realign and prepare the medical force for this threat.
    The General Accounting Office report lays out some 
disturbing findings, and the Department of Defense appears to 
agree with the majority of them, that the Pentagon leadership 
is not providing adequate guidance. They should not have 
developed tools--they have not developed tools to determine how 
the medical force should be structured, and the services 
disagree among themselves on a host of issues. Medics are not 
trained sufficiently, and even those that have received 
training do not feel they are proficient; that is, if the 
military leadership can locate them without a functioning 
tracking system in place.
    I am glad that the Assistant Secretary is with us today to 
respond to these comments and provide us with his view of the 
steps DOD must take to overcome these challenges. In his 
position he no doubt will play a key role in advocating for 
these changes within the Pentagon.
    I would highlight, however, one important observation in 
the GAO report. While the Assistant Secretary's commitment is 
essential, most exercises are controlled by those responsible 
for warfighting. As GAO points out, ``concurrence of the 
military operation staff will be essential if medical 
participation is to be included in combat exercises and not the 
first they cut when it gets in the way of other goals or 
becomes too hard.'' So in addition to having a task of his own 
to focus on as he returns to the Pentagon, I hope the Assistant 
Secretary carries this additional message back with him.
    Finally, Mr. Chairman, I would like to raise an issue that 
I believe is an urgent priority for members of this 
subcommittee. As you know, the administration announced last 
spring that it was considering reversing the previous 
administration by opposing the ongoing international 
negotiations for mandatory facility inspections under the 
Biological Weapons Convention. I was concerned when I heard 
this because I believe that inspections are the core component 
of these negotiations. They force proliferators to either hide 
their activities at legitimate locations or go underground into 
rudimentary and dangerous facilities. Either way their lives 
are made more difficult. In fact, Ambassador Mahley himself, 
the State Department official in charge of the negotiations, 
previously testified before this subcommittee in favor of 
inspections, and he said, ``actually talking to scientists and 
production workers on the ground as well as observing the 
atmospherics at a facility are ways for experienced observers 
to detect anomalies. One can never discount either the 
whistleblower prospect of an employee or the ineptitude of a 
coverup of an elicit activity. While there is no way to judge 
the likelihood of such an outcome, the deterrence component is 
useful since it complicates the life of a potential 
    When the new administration came in, however, Ambassador 
Mahley ordered an interagency review of the negotiations. 
According to recent press accounts, this review is what spurred 
the administration's reversal. Although I was concerned by the 
administration's reversal, I was somewhat heartened that this 
subcommittee will have the opportunity to conduct its oversight 
role and examine the rationale behind the decision.
    At a hearing in July, Congressman Tierney asked Ambassador 
Mahley to deliver to the subcommittee a copy of the interagency 
review he ordered. Congressman Tierney's request would have 
allowed us to better understand why the administration saw no 
value in continuing to negotiate. Ambassador Mahley agreed to 
provide the report, and Mr. Tierney's request was adopted on 
the record without objection. Unfortunately this was 4 months 
ago, and we've received nothing from the administration in the 
meantime. And particularly in light of recent events, I would 
have expected the administration to seriously have rethought 
its position, but from the press I've seen, it appears they're 
going full throttle in an effort to kill the negotiations for 
mandatory inspections.
    Congresswoman Schakowsky also asked about this at our last 
hearing. While acknowledging the State Department officials 
were busy with counterterrorism efforts, Ms. Schakowsky rightly 
questioned why it had taken the Department so long to deliver 
the analysis. This subcommittee recognized Ms. Schakowsky's 
concerns and promised they would be addressed. That was over 3 
weeks ago, and still the administration has not provided that 
    This issue has become even more urgent, Mr. Chairman, 
because the United States is about to send Ambassador Mahley to 
Geneva in 2 weeks to convince the world of our newly reversed 
position. We will be telling them that inspections are not 
necessary anymore, even though the United States originally 
called for them, and even though Ambassador Mahley himself once 
listed a litany of reasons we urgently needed them. We will be 
telling them that inspections are not necessary anymore even 
after September 11th attacks and even after multiple anthrax 
    The administration is sending the Ambassador to Geneva with 
a reverse foreign policy predicated on the executive analysis 
that Congress has had no opportunity whatsoever to review. Mr. 
Chairman, you are planning a December delegation to Geneva for 
subcommittee members to discuss these very negotiations, but 
without cooperation from the State Department, participation in 
such a delegation will be fruitless. I'm really concerned about 
how this committee can conduct adequate oversight of 
administration policies if the most basic requests are not met 
with cooperation. This is a vitally important issue of 
inspections under the Biological Weapons Convention. It 
definitely needs to be addressed. I hope that all members of 
the committee will join in demanding full cooperation from the 
administration, and we are certainly at a link between that and 
the issue of medical readiness, because if we don't do 
something to control the proliferation of biological weapons, 
all these hearings are going to be in vain because you will 
never be ready. We have to try to stop these weapons at their 
    Thank you, Mr. Chairman, for your time.
    Mr. Shays. I thank the gentleman.
    [The prepared statement of Hon. Dennis J. Kucinich 



    Mr. Shays. Mr. Schrock is next in line, but I understand he 
doesn't have a statement; so I would call on Mr. Gilman.
    Mr. Gilman. Thank you, Mr. Chairman.
    Chairman Shays, I want to thank you for holding today's 
hearing in conjunction with the other hearings you've held on 
medical readiness in the event of a bio or chemical attack. We 
have to truly examine the overall state of the Department of 
Defense's ability to treat casualties resulting from any 
chemical or biological attack on U.S. military personnel, and 
we're all very much concerned about making certain our military 
personnel are properly taken care of as they address some of 
the problems confronting our Nation today.
    For many years the armed services have placed, regrettably, 
a minimal amount of resources into training medical personnel 
in the treatment of chemical or biological injuries. While the 
possibility existed that these weapons could be used against 
our personnel in the field, the fact remained that such forces 
had not encountered the use of such agents during World War I 
or World War II, and ever since, regrettably and sadly, the 
terrible events of September 11th as well as the anthrax 
episode last month have sharply focused our national attention 
on terrorism and underscored our vulnerability to future 
chemical and biological attacks. Indeed the bioterrorism debate 
has been transformed from a question of if to the inevitability 
of when.
    We're dealing with an evil enemy that's fanatical in its 
beliefs and apparently has no qualms whatsoever about using any 
and all weapons at its disposal, not only nuclear, but 
including chemical and biological agents. Given this, it makes 
sense for the armed services to adjust their training for 
medical personnel to incorporate a greater emphasis on the 
diagnosis and treatment of chemical and biological casualties.
    Initial examinations of the services' medical structures, 
however, are not encouraging. None of the armed services, the 
Army, the Navy, the Air Force, even the Coast Guard, have 
updated their medical requirements--have not updated their 
medical requirements to include chemical/bio scenarios, and 
while specialized training is offered, only 37,000 of the more 
than 203 medical personnel have received any specialized 
chemical/bio warfare training in the past 4 years.
    Mr. Chairman, while we cannot expect the military to 
overhaul its entire medical training program overnight, we 
would expect to see some major changes being planned in the 
wake of the events that have occurred since September 11th. We 
look forward to hearing from our witnesses today on the 
progress that the Department of Defense has made in this now 
sadly necessary new requirement as we fight a fanatical enemy.
    Thank you, Mr. Chairman.
    Mr. Shays. Thank the gentleman.
    Mr. Lantos. Not here.
    Mr. Tierney.
    Mr. Tierney. Mr. Chairman, thank you, but I'm going to put 
remarks on the record if I decide to do that, and we will move 
this along for you. Thank you.
    Mr. Shays. Mr. Allen.
    Mr. Allen. Mr. Chairman, I want to thank you. I'll do the 
    Mr. Shays. And we have Mr. Lewis.
    OK. Thank you. I appreciate the Members being here. I know 
many of you have many other committee meetings today. Wednesday 
is not the day we should have hearings, frankly.
    Let me recognize our witness, and we'll swear her in. Her 
name is Dr. Nancy Kingsbury, Managing Director for Applied 
Research and Methods, U.S. General Accounting Office. Is there 
anyone, Doctor, who would possibly be responding to a question 
that should stand when we swear you in? If so, that would make 
sense to have them do that.
    Ms. Kingsbury. Betty Ward-Zukerman and Bill Cawood, who 
have done a lot of work on chem/bio issues.
    Mr. Shays. OK. Why don't we have them stand up as well, and 
we'll swear you all in. Raise your right hands, please.
    [Witnesses sworn.]
    Mr. Shays. Note for the record all three have responded in 
the affirmative. And just before I recognize you to begin your 
testimony, I'll take care of some housekeeping here.
    I ask unanimous consent that all members of the 
subcommittee will be permitted to place an opening statement in 
the record, and that the record remain open for 3 days for that 
purpose. Without objection, so ordered.
    I ask further unanimous consent that all witnesses be 
permitted to include their written statements in the record, 
and without objection, so ordered.
    What we do, Doctor, as I think you know, is we keep the 
clock on for 5 minutes, and then we roll it over for another 5 
minutes and hope you would finish before you get to 10.
    Ms. Kingsbury. I will plan on it, thank you.


    Ms. Kingsbury. I very much appreciate being here, Mr. 
Chairman and members of the committee, to share with you our 
work today, and I'm going to give you the very short version of 
the main points of our work here this morning since we have the 
report that's just out. Everybody can see the details.
    You asked us to determine how DOD had adapted its medical 
personnel to emerging chemical and biological threats. 
Specifically we looked at two things, how DOD and the services 
had addressed chemical and biological threats in planning for 
medical personnel in their distribution across medical 
specialties, and the training provided to medical personnel in 
the treatment of chemical and biological casualties.
    We found that neither DOD nor the services had 
systematically examined the current distribution of medical 
personnel across specialties with respect to their adequacy for 
chemical and biological defense. Although the services had 
begun a review of the staffing of deployable medical units for 
chemical warfare scenarios, they had not done so for biological 
warfare scenarios. General assessments of requirements have at 
best roughly extrapolated from the results of modeling for 
other medical requirements to factor in chemical and biological 
warfare requirements.
    As recommended by DOD studies, joint protocols for treating 
chemical and biological casualties have recently been 
completed, but agreement has not been reached among the 
services on which medical personnel are appropriate to provide 
treatment. This is important to provide integration of medical 
treatment in the event of an attack.
    DOD officials attributed the lack of systemic efforts to 
several factors, including the failure to establish chemical 
and biological readiness as a medical priority in defense 
planning guidance, data and methodological constraints that 
complicate the task, disagreements among the services about the 
capacity to implement evacuation policy, and pessimism that 
medical personnel could effectively treat substantial numbers 
of chemical and biological casualties.
    In general, service medical planning officials maintain 
that specialized training rather than systematic assessment of 
needed specialties is the appropriate way to address any need 
for additional medical skills in the military setting. However, 
we found that the extent of training as well as testing and 
exercises for medical management of chemical and biological 
casualties is limited. While progress has been made since the 
Gulf war in increasing the availability of such specialized 
training, the courses are voluntarily and, except for basic 
training and daunting chemical protective gear, not widely 
attended. From 1997 to 2000, as Mr. Gilman suggested, fewer 
than a fifth of the uniformed medical personnel completed any 
specialized training, and only about 2\1/2\ percent have taken 
the 7-day onsite medical management of chemical and biological 
casualties course, which is the most comprehensive training 
    We note that most training does not currently include 
individual proficiency testing, and in one study that we are 
aware of where proficiency testing was conducted, proficiency 
was not demonstrated in a number of key tasks, such as clearing 
airways or controlling bleeding. Notwithstanding these negative 
results, however, we think the effort to do proficiency testing 
is encouraging.
    Even medical personnel who have been trained cannot readily 
be identified in the event of an emergency because tracking 
systems either do not exist or are not currently functioning. 
Thus the availability of trained personnel in a given situation 
is uncertain.
    Another way the DOD provides combat readiness training is 
the conduct of field exercises. However, exercise scenarios 
that include chemical and biological defense elements have been 
almost nonexistent. For example, the last joint chemical and 
biological medical exercise that was completed was in 1994, and 
the next one is not planned until 2005. Officials told us that 
exercises involving medical support for chemical and biological 
casualties were rare because of conflicting priorities 
encountered by both warfighters and medical personnel and 
because of the difficulty and expense of conducting them. 
Officials also said that such exercises are not planned because 
of the potential that the chemical or biological elements would 
overwhelm the exercise and prevent the other objectives from 
being achieved.
    In our report we make a number of recommendations to DOD to 
resolve these issues, including clarification of the 
requirements for chemical and biological contingencies in 
defense planning guidance, reaching agreement among the 
services and joint staff about which medical personnel are 
qualified to provide specific treatments to ensure consistent 
approaches in joint activities, developing medical training 
requirements for chemical and biological contingencies, 
assessing the effectiveness of training with rigorous 
proficiency standards and tests, and tracking individual 
training and proficiency, and increased chemical and biological 
exercises involving medical personnel to an extent commensurate 
with current chemical and biological threat assessments.
    Given the threat of mass casualties in a chemical and 
biological event, exercises should explore the extent of 
medical capabilities and the full consequences of scenarios 
that overwhelm them.
    I think I will stop my statement here, Mr. Chairman. I will 
be happy to take your questions.
    Mr. Shays. Short, concise, and right to the point.
    [Note.--The report entitled, ``chemical and Biological 
Defense, DOD Needs to Clarify Expectations for Medical 
Readiness,'' may be found in subcommittee files.]
    [The prepared statement of Ms. Kingsbury follows:]
    [GRAPHIC] [TIFF OMITTED] 82172.004
    [GRAPHIC] [TIFF OMITTED] 82172.005
    [GRAPHIC] [TIFF OMITTED] 82172.006
    [GRAPHIC] [TIFF OMITTED] 82172.007
    [GRAPHIC] [TIFF OMITTED] 82172.008
    [GRAPHIC] [TIFF OMITTED] 82172.009
    Mr. Shays. Mr. Gilman.
    Ms. Kingsbury. I take that as a compliment, sir.
    Mr. Shays. You should.
    Mr. Gilman. Thank you, Mr. Chairman.
    We want to thank GAO for their review at a very critical 
time and for your very alarming review of what has been done to 
date. Why is chemical and biological training not mandatory?
    Ms. Kingsbury. It has not been. I am not actually sure we 
    Do we know that there have been reasons?
    Mr. Gilman. Is there any reason given to you?
    Ms. Kingsbury. I suppose there is only so much training 
that can be done, and you have to prioritize it.
    Mr. Shays. I think you have chairs on either side. This way 
you can whisper in their ears if you want.
    Mr. Gilman. Why don't you bring your assistants----
    Mr. Shays. Hold on 1 second. We will keep the clock 
running. The two I swore in, would you please--whom did I swear 
    Ms. Kingsbury. Bill.
    Mr. Shays. Come on.
    Mr. Gilman. Don't be shy. We won't bite.
    Ms. Kingsbury. Thank you.
    In the overall scheme of things, I think training is 
something that you spend part of your time on, and you spend 
part of your time on your job. It's just the way the priorities 
have been. We have noticed, though, that at the same time the 
training has been voluntary and not been done, the people who 
talk about the threat have been quite alarmist, if you will, 
quite concerned about the threat, and perhaps justifiably so as 
recent events have shown. So I look forward to your asking the 
DOD witnesses about that.
    Mr. Gilman. I note in your report that key readiness--I'm 
quoting from your report on page 3--key readiness evaluations 
used to advise the President on readiness to implement the 
national security strategy had never set a scenario for the 
unified commanders requiring medical support for weapons of 
mass destructions, and officials told you that CB medical 
support is rarely exercised because of conflicting priorities 
encountered by warfighters and medical staff and because it's 
difficult and expensive. Did you explore that any further?
    Ms. Kingsbury. I have personally had a couple of 
discussions about that because I think it's important to 
understand why that happens. My own sense of it, and I have 
actually been told by a couple of officials, that the serious 
chemical and biological scenarios are showstoppers. They stop 
the exercises, and so they just don't do them.
    Mr. Gilman. And you also indicate that in sum, the DOD and 
the services had not fully addressed weaknesses and gaps in 
modeling, planning, training, and tracking or proficiency 
testing for the treatment of CB casualties, and resulting 
medical structures not being rigorously tested for its capacity 
to deliver the required medical support.
    Did you explore that with them to see what was going to be 
done to correct that?
    Ms. Kingsbury. Well, they have agreed with our 
recommendations in that regard and note in our report in their 
comments that they are planning to do some additional things to 
try to address these issues, and I'll be happy to let them talk 
about that. We've been making these recommendations since 1993, 
and we--that's often a role that GAO plays. We make 
recommendations, and agencies do or don't followup on them, and 
this is one where I think the story is still a little 
    Mr. Gilman. Since 1993, you've been making these 
recommendations, and there has been no progress?
    Ms. Kingsbury. There's been some progress. I think that's 
fair to say. They have developed additional training. They are 
training more people as we go along, but we still can see gaps 
between what they seem to say they need and what is actually 
being delivered.
    Mr. Gilman. Well, my time has run, but just one last 
question. Why has the medical training been limited here in 
this area in your----
    Ms. Kingsbury. Some officials have told us it's a matter of 
expense. Some officials have told us it's a matter of 
priorities. It's been limited.
    Mr. Gilman. We gather that. All right. I hope we can 
explore that further.
    Thank you, Mr. Chairman.
    Mr. Shays. I thank the gentleman.
    Mr. Kucinich.
    Mr. Kucinich. Dr. Kingsbury, thank you for your work on 
this report, and I would like to address a practical 
consequence of this report with this question: If we had ground 
troops in Afghanistan, does the Department of Defense have a 
medical training structure in place to adequately protect or 
respond to soldiers who would be injured by a biological or 
chemical weapon attack?
    Ms. Kingsbury. Our work predates the Afghan adventure, and 
I don't think I want us to talk about whether they have 
adequate forces in place. There are representatives in the 
military here to deal with that. That's a very----
    Mr. Kucinich. But you----
    Ms. Kingsbury [continuing]. Sensitive issue, and I would 
rather let the Department of Defense answer that question, sir.
    Mr. Kucinich. But wait a minute. You gave us a report, Dr. 
    Ms. Kingsbury. I did.
    Mr. Kucinich [continuing]. That says as a consequence, 
medical readiness for CB scenarios cannot be insured. Did you 
say that?
    Ms. Kingsbury. In general we support that statement, sir. I 
just can't speak to the situation in Afghanistan.
    Mr. Kucinich. If you say in your report that the Department 
of Defense and services--I am quoting directly--had not fully 
addressed weaknesses and gaps in modeling, planning, training, 
tracking, or proficiency testing for the treatment of CB 
casualties, wouldn't it follow that if we were to have our men 
and women on the ground in Afghanistan, and they were subjected 
to a biological or chemical weapon assault, that we might not 
be able to care for them given this report?
    Ms. Kingsbury. I think the phrase ``we might not be able 
to'' is a fair statement.
    Mr. Kucinich. I thank you. No other questions.
    Mr. Shays. Thank you.
    Mr. Lewis.
    Mr. Lewis. Thank you, Mr. Chairman.
    Thank you, Dr. Kingsbury, for your testimony. Why do you 
think the medical personnel training has been limited--and the 
reason I ask that is because, of course, we're talking about 
chemical and biological here, but after all the years that we 
faced the threat of a nuclear attack, was there any training 
for medical personnel to deal with a major catastrophe in 
regards to the nuclear equation that could be brought around to 
the possibility of a chemical or biological attack?
    Ms. Kingsbury. Well, the military structure--the military 
medical structure serves two purposes. It serves a peacetime 
purpose, and it serves a wartime purpose, and I think those two 
things create a very difficult challenge to make sure you're 
prepared for the perhaps unlikely but nonetheless devastating 
possibilities of a chemical or biological attack. And this is 
made more complicated by the fact that the issues that you need 
to address medically for nuclear, chemical or biological are 
actually quite different and require different skills.
    So it's a very complicated issue, and I wish we saw a 
really clear solution to it. We make some recommendations in 
our report and hope that the Department of Defense can move 
quickly in the right direction.
    Mr. Lewis. What are some of those steps that could bring 
them in a more positive direction in medical training?
    Ms. Kingsbury. Well, we address many of those in our 
report. We talk about the need to track who's had the training; 
the need to do proficiency testing and make sure that the 
people who are there in fact can demonstrate the skills, not 
just say they know it; better planning in defense planning 
guidance, clearer priority for this. That's what drives what 
the warfighters do. That's what drives what DOD ultimately 
thinks is going to happen on the battlefield, and I think 
that's where it has to start.
    Mr. Lewis. OK. Thank you.
    Mr. Shays. Thank the gentleman.
    At this time recognize Mr. Tierney.
    Mr. Tierney. Thank you, Mr. Chairman.
    Dr. Kingsbury, thank you for your testimony. In your report 
you conclude that the persistence of this troublesome situation 
has been caused by one of three factors, a disagreement about 
the significance of the threat, the failure of leadership, or 
an acceptance of a high level of risk. Can you walk us through 
each of those three?
    Ms. Kingsbury. Wait a minute. I've just gone blank.
    Mr. Tierney. OK. Well, the first one was----
    Ms. Kingsbury. What page are you on?
    Mr. Tierney [continuing]. A disagreement about the 
significance of the threat. The second was a failure of 
leadership. The third was an acceptance of a high level of 
risk. You know, each of those would contribute in some degree 
to the persistence of the situation.
    Ms. Kingsbury. Well, let's start with the threat first. I 
mean, I think that although there has been a great deal of 
commentary about the threat and obvious concern about it, if 
you really look in a lot of the places we've looked across a 
whole spectrum of issues related to chemical and biological 
warfare, the resources, the training, the commitment to meet 
the threat doesn't seem to match the level of threat assessment 
that's out there, and we've been sort of puzzling about that as 
we've put this work together, some of the work that Bill Cawood 
has done and others. We really think it starts with that 
    With respect to leadership, I point particularly to the 
difficulties of achieving a joint outcome here. I think it's 
very important because we're fighting jointly increasingly so 
that the services get together and reach agreement on how 
medical casualties in this arena need to be managed.
    And with respect to risk, I think the events of the last 
couple of months clearly have heightened our sense that risk is 
real, and that the medical difficulties are a real challenge. 
Just identifying what's happening is perhaps one of the more 
real challenges.
    I am encouraged actually by a byproduct of the last 2 
months. I am a great believer that if you're looking for 
something, you're more likely to find it, and I think that the 
last couple of months has heightened perhaps our ability to 
detect these things going forward.
    Mr. Tierney. Just as a comment, I have to say that when 
earlier you were talking about there being a reason for the 
services not addressing this gap between the appraisal of the 
threats and the Department of Defense medical preparedness to 
meet them, as some people say, it's an expense, and some people 
say it's the priorities, well, at $330 billion plus in that 
Department of Defense budget every year, I would have to say 
that it's a lack of responding to your priorities more so than 
not a lack of having the money. Or God help us if it's the 
other way around.
    Of the three items that we just discussed on which you base 
your analysis, which one of those do you think is the more 
prominent, the primary cause of this situation?
    Ms. Kingsbury. Right now I think I need to go back to the 
starting point. I think it needs to be sorted out in how DOD is 
choosing to plan for warfare going forward. If these priorities 
get into the defense planning guidance, they will get fielded. 
They will get done. All of the services are very capable of 
doing things when they decide to do them. I think it's 
important to start there.
    Mr. Tierney. On page 10 of your report, you said that the 
Army Medical Department officials said they were not authorized 
to structure medical care for biological contingencies. I am 
wondering what do these medics mean when they say they're not 
authorized to prepare for attacks using biological weapons?
    Ms. Kingsbury. I'm sorry, sir, where are you?
    Mr. Tierney. Page 10. Do you--yeah. Why don't you----
    Ms. Ward-Zukerman. I think they were indirectly referring 
to the fact that preparation for biological contingencies was 
not something that the DPG had directed them to do.
    Mr. Tierney. The DPG being?
    Ms. Ward-Zukerman. The defense planning guidance.
    Mr. Tierney. Did you determine any reason why they hadn't 
been directed to do that? I mean, it's pretty amazing at this 
point in time to think that they hadn't been.
    Ms. Ward-Zukerman. We just, you know, looked at the sort of 
the immediate reason that they had not done it.
    Mr. Tierney. On the question of evacuations, at least as I 
understand it, the faster the injured are removed or lifted 
from the area, the fewer medical personnel may be needed in the 
field. Is that a fair assessment?
    Ms. Kingsbury. Yes, sir.
    Mr. Tierney. And in that regard what is the joint and 
strategic capabilities plan?
    Ms. Kingsbury. The joint and strategic----
    Ms. Ward-Zukerman. The joint and strategic capabilities 
plan is developed to provide missions to the commanders-in-
chief in the various areas that DOD operates, and it follows 
the guidance in the defense that's put together by OSD in the 
form of defense planning guidance.
    Mr. Tierney. And is there, in fact--one of the things they 
talk about is following that pattern of getting the people that 
are affected out of the area quickly so that there is less need 
for medics on the front line.
    Ms. Ward-Zukerman. We didn't specifically look at the joint 
strategic capabilities plan, but Army officials did cite 
concerns about the actual speed with which people could be 
    Mr. Tierney. Thank you.
    I see my time is up, Mr. Chairman. Thank you.
    Mr. Shays. It's my intention to come back, but if the 
gentleman would like to ask questions now, he could do that if 
he's not coming back.
    Mr. Allen. I could do it very quickly.
    Mr. Shays. OK. Mr. Allen.
    Mr. Allen. Thank you, Mr. Chairman. My questions will be--
I'll try to keep this well under 5 minutes.
    Based on your analysis of the availability of medical 
personnel in the military services, let's just imagine that the 
outbreak of anthrax was an outbreak of smallpox instead. How 
many military health care personnel are there available to 
treat someone infected with smallpox who's been vaccinated? I 
mean, is there anyone in the services among their health care 
personnel who can walk in and care for a smallpox victim 
without fear of contracting the disease themselves?
    Ms. Kingsbury. Mr. Allen, we did not specifically look at 
that issue, and with three very distinguished Surgeons General 
in the room, I would rather defer that question to them.
    Mr. Allen. Mr. Chairman, is there a way to get an answer to 
that question either later, or can we bring that out?
    Mr. Shays. Let me just ask you. Your response to the 
question is based on what?
    Ms. Kingsbury. Well, we did--as you well know, Mr. 
Chairman, we tend not to want to make observations about things 
that were not included in the scope of our work, and we did not 
specifically ask questions about the preparation to treat 
smallpox victims in the present moment, and I just--I don't 
have any basis at all for answering your question. It's not 
that I don't think it's a fine question.
    Mr. Shays. But I do think that we can ask the next panel 
and pursue that.
    Ms. Kingsbury. I would prefer that. Thank you, sir.
    Mr. Allen. Mr. Chairman, my point was we've been talking 
about training of personnel, and that's sort of one area, but 
having personnel who can treat patients without being 
themselves subject to getting the disease, it seems to me at 
least equally important.
    Ms. Kingsbury. I would agree with you, and it applies not 
only to smallpox, but any other number of biological toxins out 
there. I think that's an important part of the bigger picture.
    Mr. Shays. We're going to stand at recess. We just have one 
vote, and we'll be back----
    Ms. Kingsbury. Yes, sir.
    Mr. Shays [continuing]. And then we'll finish up.
    Mr. Shays. Call this hearing to order and apologize. We had 
two votes, not one.
    What I would like to do is first state--I would like to 
acknowledge that there appears to be very good will between GAO 
and DOD and cooperation between both. And also to express 
appreciation that there wasn't an attempt to try to smother 
this report or, if there was, that it wasn't something that was 
    Because we're in new territory here. This is, I think, a 
very, very significant report but one that needs to be 
addressed. I think, frankly, by making sure that this is 
public, we have an added incentive to have people understand 
why resources need to be spent for DOD. I mean, we are clearly 
in a race with the terrorists to shut them down before they 
have a better system for chemical and biological weapons, 
nuclear waste or nuclear weapons. We're at war, and I think a 
lot of people in our country don't fully appreciate it.
    We all have to kind of think distinctly. We have to 
reorient our military differently. We need to reorient how we 
think about foreign aid. We need to do a lot of things. I mean, 
I've had some in the military tell me if we had put more 
resources into the State Department we might have prevented 
some of our military from having to be in some places risking 
their lives.
    When President Lincoln addressed Congress when--it's 
unbelievable to me, but we lost 10,000 men a month for 4 years 
in the Civil War. He addressed Congress, and he said, the 
dogmas of the quiet past are inadequate to the stormy present. 
The occasion is piled high with difficulty, and we must rise 
with the occasion. As our case is new, so we must think anew 
and act anew. We must disenthrall ourselves, and then we shall 
save our country.
    My view is that we're all being asked to think anew. And 
obviously the military is part of that. So I just want to put 
that on the table and say that I don't have a lot of judgment 
as to why we're here, but I am interested in what we can do to 
see us think anew and act anew.
    What I wanted to do was I wanted to go down, Dr. Kingsbury, 
the recommendations that you made and understand what each one 
was and understand what you think DOD's response was. I'm 
referring to page 47 in your report. Specific comments on 
recommendations made by DOD. It appears that they basically 
concurred with every one.
    Ms. Kingsbury. Yes, sir.
    Mr. Shays. Is your mic on?
    Ms. Kingsbury. It is now, yes, sir.
    Mr. Shays. Let me say that so, in your judgment, they 
concurred with every one. Is there any one recommendation or 
more than one in which you feel they qualified their response 
to it?
    Ms. Kingsbury. I don't think I would feel that they 
qualified their response. At the time they made their response 
they said they are taking certain actions, and the actions they 
described I would say were the first step necessary to actually 
make something happen differently. So, being GAO, we always 
maintain a certain healthy skepticism that this is actually 
going to move forward in the way it needs to, but it was 
certainly a positive first step.
    Mr. Shays. What I'm going to do is do 5 minutes, then roll 
over for the next 5.
    I missed that last sentence, I'm sorry, that last part.
    Ms. Kingsbury. The point I'm making, sir, is that they did 
concur explicitly with each of our recommendations. Then they 
described the steps that they were going to take. The first 
step that they were going to take, referring it to the Joint 
Planning Council or whatever. As I say, we will be happy to 
watch and make sure that something comes from that first step.
    Mr. Shays. What I get a sense of is there's an obvious 
concern--I had one. I had a concern that they agreed with the 
criticisms, but there wasn't a sense of time line or when 
certain things would actually take place.
    Ms. Kingsbury. That's correct, sir.
    Mr. Shays. You had--basically, the GAO recommended the 
SECDEF, which is--what is that?
    Ms. Ward-Zukerman. Secretary of Defense.
    Mr. Shays. For EF? Oh, Secretary of Defense--``address the 
gap between the stated CB threat and the current level of 
medical readiness by clarifying the Department's expectations 
regarding medical preparation for CB contingencies and, as 
appropriate, by directing the Joint Staff to integrate 
biological medical readiness in DPG.''
    And again DPG is----
    Ms. Kingsbury. Defense Planning Guidance.
    Mr. Shays. That's the key document.
    Ms. Kingsbury. Yes.
    Mr. Shays. DOD responds, concur. It says, ``As the 
coordinating body with the services and the CINCs on issues of 
this nature, the Joint Staff will be requested to conduct a 
reexamining of CB medical training issues and provide suggested 
adjustments to enhance the DOD's medical readiness posture.''
    What does that say to you?
    Ms. Kingsbury. That says they're going to look at the issue 
again. It does not say what solutions they expect to come out 
of it.
    Mr. Shays. OK. The second recommendation--if you just look 
at DOD's response and tell me what you think that's saying and 
if you're satisfied with that.
    Ms. Kingsbury. Well, again they're going to--they've asked 
the Joint Staff to address the issue of what the steps are that 
are going to be taken to actually get a Common User Data base 
established. It is not evident from this response.
    Mr. Shays. So on the second DOD response you would want to 
know what steps they're going to take.
    Ms. Kingsbury. Yes, sir.
    Mr. Shays. OK. The third one.
    Ms. Kingsbury. Oh, let's see----
    Mr. Shays. They basically are agreeing, and we just need to 
know now what ``agree'' means.
    Ms. Kingsbury. Well, in this response they do cite certain 
NATO standardization agreements which are certainly steps in 
the right direction of this effort. But there's a great deal 
that needs--I would say there's a great deal that needs to be 
done here in terms of the planning models and so forth that 
don't at the moment explicitly account for chemical and 
biological needs except very roughly.
    Mr. Shays. Let me just read on the next page. It says, 
``However, if the GAO recommendation pertains to the 
evacuation, EVAC, policy, DOD non-concurs.''
    So here we have a non-concurs. So what does it relate to?
    Ms. Ward-Zukerman. I think that the response that DOD gave 
made reference to evacuation policy, but it was our sense that 
the real disagreement was about evacuation capability. The Army 
officials specifically indicated to us that they had developed 
a medical force structure adjusting for the fact that they were 
skeptical about the actual evacuation capabilities that would 
be available when needed. Their response basically talks about 
evacuation policy which there is a policy that's written on 
paper that, you know, that is agreed. But the issue is more----
    Ms. Kingsbury. Implementation.
    Mr. Shays. On recommendation 4, ``the GAO recommended that 
the services develop CB medical training requirements and 
assess the effectiveness of training with rigorous proficiency 
metrics and standards.''
    What do you feel their response is there? And what's----
    Ms. Kingsbury. Well, again, it's been referred for further 
development, and the proof is in the pudding. The 
implementation of these--the actual existence of proficiency 
tests is what we would ultimately look for to see whether that 
recommendation was carried out. We would not conclude that it 
was until we began to see some of that----
    Mr. Shays. OK.
    Ms. Kingsbury [continuing]. In practice.
    Mr. Shays. When you get a concurrence, do you then in your 
documents respond to the concurrence? In other words, I'm kind 
of puzzled why we wouldn't go the next step and say the things 
that specifically they need to do some kind of time line to do 
    Ms. Kingsbury. Well, we certainly continue to follow what 
they do. I think as a general matter, unless we have done 
specific work that points to a particular solution to a problem 
of this sort, we would not substitute our judgment for the 
agency's or the service's about how best to do it. We believe 
that's their responsibility. We would look to see what they did 
and whether it met either the spirit or the literal meaning of 
our recommendation, and we do track these over time.
    Mr. Shays. The GAO recommendation 5, ``The GAO recommended 
that the services develop and maintain information management 
systems to monitor completion of required CB training and track 
the proficiency of medical personnel, at least for the first 
responders and key personnel in high risk areas of 
    Then they say they concur. How did you respond to their 
    Ms. Kingsbury. Well, they concur with the suggestion which 
in principle I would not disagree with which is that it might 
be better to actually track proficiency itself, rather than 
tracking training. Training is, at best, a surrogate for 
proficiency. If they could develop a system to actually track 
the proficiency of medical personnel, that would be, in fact, a 
better solution. That is, in our experience, probably harder to 
    Mr. Shays. Let me just say, for DOD's benefit here, I would 
love when they--and would expect that they will expound on the 
DOD response and give us some kind of sense of what's required 
and time lines of some kind, not obviously by month but give us 
a sense of what it's going to take to do these things.
    The last one, ``The GAO recommended that the Joint Staff, 
CINCs and services increase the realistic exercise of medical 
support to a level commensurate with current CB threat 
assessments. To the extent there is a threat of mass 
casualties, exercises should explore the limits of medical 
capabilities and the full consequences of the scenarios that 
overwhelm them.''
    What about this one?
    Ms. Kingsbury. Well, as I said earlier, we are concerned 
that, as we look at the conduct of exercises, that the exercise 
of the medical piece, particularly in the chemical and 
biological scenario, is rarely, if ever, addressed. And when we 
ask why we are often told it's because it's such a big piece of 
it and would get in the way of achieving the other objectives 
of the training.
    I certainly can be sympathetic to that, but that implies 
that if it actually happens you couldn't deal with it, and I 
think if we are going to be truly prepared we would have to 
have some knowledge of at what point is this manageable with 
great effort and at what point is it not and is there anything 
we can do about that. Recognizing that this may be a low 
probability event in the overall scheme of things, it is a very 
high consequence of that. It seems to us that some real 
exercises need to be done.
    Mr. Shays. I want your definition of low probability. Not 
that there would be chemical and biological attacks but they'll 
be massive, that they're low probability. It's not low 
probability that there will be an attack.
    Ms. Kingsbury. Relative to being shot at I expect it's a 
lower possibility, but it's perceived as higher now than 
    Mr. Shays. Is there--you've done an assessment----
    Ms. Kingsbury. I don't know what the actual probability is. 
The current threat assessments tend to describe it as a low 
probability, low consequence attack. That's the only place we 
would draw that conclusion. We're not making an independent 
assessment of that.
    Mr. Shays. You didn't really look at the probability.
    Ms. Kingsbury. No, sir. We just looked at what the threat 
assessment said.
    Mr. Shays. Because I just want to make sure that you're not 
kind of giving credibility to something I think is not true.
    Ms. Kingsbury. I would not want to do that, sir. Thank you.
    Mr. Shays. The bottom line is you made an assumption, if 
there was an attack, how could we respond to it. You did not 
look at the threat assessment.
    Ms. Kingsbury. Well, we looked at it. We did not make an 
assessment of it. But I am reflecting what we were told by the 
people who were responsible for conducting exercises about why 
they did not include these scenarios in the exercises. Those 
descriptions were a part of those discussions.
    Mr. Shays. Mr. Kucinich.
    Mr. Kucinich. I want to go back to something you said a 
moment ago that implies if it happened we wouldn't be able to 
deal with it. What do you mean? If what happened?
    Ms. Kingsbury. If we actually had an attack that resulted 
in mass casualties in the battlefield.
    Mr. Kucinich. What do you mean we wouldn't?
    Ms. Kingsbury. At this point we don't know whether we would 
be able to deal with it, because it has not been exercised. The 
people who do the exercise believe it can't be dealt with. I'm 
talking mass casualties here.
    Mr. Kucinich. I understand that. And today in the front 
page of the L.A. Times President Bush is quoted as saying the 
threat is that terrorists also want chemical and germ weapons, 
President warns, as he tries to rally support from abroad. And 
in the article it says that the President had not previously 
raised such a concern in public, that the terrorist network is 
seeking weapons of mass destruction.
    Now, in this context which we're in, maybe not when you 
first started your report, we've got to look at this current 
    Ms. Kingsbury. I completely agree with that, sir.
    Mr. Kucinich. We are in a conflict now.
    Ms. Kingsbury. Yes, sir, we are. And those weapons are 
probably out there.
    Mr. Kucinich. For the first time we have a President saying 
publicly that terrorists are trying to obtain nuclear, 
biological, chemical weapons; and we have the GAO saying that 
the Department of Defense does not have a structure in place to 
protect the health of the troops essentially, if I read your 
report correctly.
    And I see from other reports, Mr. Chairman, that there's 
questions about whether enough vaccines are available from the 
private sector. There is even discussion in the government 
going on right now about the government itself being involved 
in the production of vaccines.
    Now, this isn't the question you have to answer, but it's a 
question I want our friends from the military to get ready for, 
and that is, under these circumstances, how could the military 
possibly recommend a ground assault in Afghanistan where our 
men and women could be exposed to a biological or chemical 
weapons attack and not have structures in place to make sure 
that they have some protection?
    This is a very serious issue here. The context has changed 
from when this report first began to be worked on. And, you 
know, I think that we have to remember back in World War I when 
soldiers were met with mustard gas, they had no idea of how to 
deal with it. You know, the gas mask came up but still there 
were people dying in the trenches.
    We need to be very--I think this issue that is brought to 
this committee of a low-probability, high-consequence effect 
needs to be looked at more carefully. Because if the 
probability increases, that means that the consequences have to 
increase commensurately.
    So I appreciate the Chair calling this hearing. But we need 
to look at the very severe implications of this for not only 
the health care infrastructure of the Department of Defense but 
the linkage to military strategic analysis, planning and 
initiation. Thank you.
    Mr. Shays. If the gentleman would let me followup before 
Mr. Putnam, you may want to followup because I may be 
qualifying your concern. But I want to make sure you looked 
force wide, correct?
    Ms. Kingsbury. Yes, sir.
    Mr. Shays. So, you know, my recollection when I have had 
the opportunity, as this committee has a great opportunity to 
do, to be out in the field with some of our special forces, 
they do have capabilities that would not be force wide; and I 
think that we'll be able to address that later.
    But your statement, if this were an all-out attack with 
lots of people, we'd have some real challenges. But I think, 
frankly, that if the numbers are small, we have that limited 
capability to do it.
    Mr. Kucinich. If I may, Mr. Chairman, I'm just making my 
statement and analysis from what's presented on the record, not 
from any secret information I have.
    Mr. Shays. It's not that this report--and that's what I 
want to clarify. This report was a report done based on looking 
at the entire services. You didn't look at any specific, 
specific unit or did you?
    Ms. Kingsbury. No, in this work we did not. We've had other 
work in the past where we have.
    I think it's also important to recognize in this report we 
only looked at how they do planning for medical resources and 
how they train for responding to these kinds of events. We did 
not look at equipment and things of that sort as a part of this 
    Mr. Kucinich. If the Chair would just permit me to make 
this observation, and that is it has been broadly stated and 
reported in the media that the use of ground troops in 
Afghanistan has not been ruled out. So that's why I raise the 
issue. I thank the Chair.
    Mr. Shays. I think it's very important to make that point.
    Is it your intention to stay while we have the testimony of 
our second panel?
    Ms. Kingsbury. I'm at your disposal, sir.
    Mr. Shays. I would welcome that. It may be that we would 
want you to just respond or add some clarification.
    In your statement which, as I said, was short and to the 
point, you attribute the lack of systematic evidence to several 
factors, including failure to establish chemical and biological 
readiness as a medical priority to defense planning guidance. 
There's no dispute about that. That hasn't been done. Data 
methodology constraints that complicate the task. Just 
elaborate what you mean by that.
    Ms. Kingsbury. Well, the whole question--I mean, there are 
models that are used and we haven't looked at them in depth to 
make a determination about what kinds of medical resources are 
needed in the various services and in the various scenarios. 
And the data to support those with respect to--certainly to 
biological and chemical areas has never been developed because 
they haven't actually had any experience on which to develop 
them. So it's a very rough kind of order of magnitude kind of 
analysis that goes into adding and factoring in chemical and 
    Mr. Shays. Disagreements among the services about capacity 
to implement evacuation policy. If you could just elaborate, 
give it some color, so we know how to ask the--our three 
branches what that means. I mean, can you give me some example?
    Ms. Kingsbury. One service, if they're on the ground like 
the Army, needs to make certain assumptions about how many 
people who are casualties can be evacuated by forces provided 
by another service, for example, the Air Force. And those 
assumptions, when written in planning guidance, the officials 
that we met with told us that they did not believe that 
capacity would actually be delivered when it was implemented. 
So the guidance says that it will be there, but there is 
differences of opinion among the warfighters and the medical 
folks about whether that would actually happen.
    Mr. Shays. Pessimism that medical personnel could 
effectively treat substantial numbers of chemical and 
biological casualties. In other words, even if they had a plan 
or because they don't? In other words----
    Ms. Kingsbury. Certainly because they don't. And, again, 
the way you work these things out is in planning for exercises 
and the like. And if you look at the possibility of an exercise 
and mass casualties, I think the people involved in it reach 
conclusions that they can't do it and it would stop the 
exercise. My own reaction to that is, yes, and it would stop 
the battle, so you really ought to think about it. But I think 
that's why we raised the issue in that way. It's such a big 
problem and everybody understands it to be a very big problem, 
almost so big that there haven't been the resources to try to 
understand it well enough.
    Mr. Shays. And probably the thought that it wouldn't have 
to because people wouldn't cross that red line.
    Ms. Kingsbury. Right.
    Mr. Shays. Which we know after September 11th there is no 
red line.
    Ms. Kingsbury. Doesn't appear to be.
    Mr. Shays. No, there is no red line.
    On page 3, you said, even medical personnel who had been 
trained could not be readily identified in the event of an 
emergency because tracking systems either do not exist or are 
not currently functioning. Thus the availability of trained 
personnel in a given situation is uncertain.
    What we learned with the Gulf war is there were very few 
people in the Department of Veterans Affairs and DOD that dealt 
with hazards--dealt with what toxic material that you would 
deal with in the workplace, and so there weren't a lot of 
people who had specialties. In fact, there were only--out of 
over 2,000 there were only like 3. And it was so stunning that 
it was almost incomprehensible. You couldn't comprehend it. But 
what you're saying is, if you have medical personnel who are 
trained, we don't really know where they are right now.
    Ms. Kingsbury. That's correct.
    Mr. Shays. OK. Within the system.
    Ms. Kingsbury. That's correct.
    Mr. Shays. Let me do this--do you have another question?
    Mr. Kucinich. No.
    Mr. Shays. I think that your recommendations are on the 
record. We know what their response was. Your comment would be 
that they agree with the recommendations. It's really a 
question of what agree means. In other words, how they go about 
implementing the recommendations, what kind of time line 
they're on and so on.
    Ms. Kingsbury. And what kind of priority it has, yes, sir.
    Mr. Shays. Well, we're going to try to give it a high 
priority. But I honestly don't think we need to. I think it was 
a real wake-up call from hell on September 11th. So thank you 
very much, and we'll look forward to maybe calling you back 
and, if we do, you have still been sworn in so we'll just 
remember that. Thank you.
    We'll go to panel No. 2. We have one testimony from Dr. 
William Winkenwerder, Assistant Secretary of Defense for Health 
Affairs, Department of Defense; accompanied by General Paul K. 
Carlton, Jr., Surgeon General, U.S. Air Force; General James B. 
Peake, Surgeon General, U.S. Army; and Admiral Donald C. 
Arthur, Jr., Deputy Surgeon General, U.S. Navy.
    We would welcome you to stand and swear you in. Then we'll 
take testimony.
    [Witnesses sworn.]
    Mr. Shays. Note for the record all four of our witnesses 
have responded in the affirmative.
    I want to say again from the outset that what we're 
ultimately all interested in is how we deal with the 
recommendations given, that you concur with them. And we want 
to understand the implications. We want to know what kind of 
task this represents for the military and how we can be helpful 
in getting you to a position I know you all would like to be 
in. And also, candidly, the implication of what Mr. Kucinich 
raised as well.
    So what we're going to do, Doctor, is take your testimony, 
and we'll roll over the clock, and invite all of you to respond 
to the questions. So thank you for being here.


    Mr. Winkenwerder. Chairman Shays and distinguished----
    Mr. Shays. Is the mic on?
    Mr. Winkenwerder. OK. Chairman Shays and distinguished 
committee members, thank you for inviting me to appear today 
before your committee.
    I'm Dr. William Winkenwerder, Assistant Secretary of 
Defense for Health Affairs. Today I'm going accompanied by the 
Surgeons General from the Air Force and the Army and the Deputy 
Surgeon General of the Navy.
    I have already submitted a written statement, but with your 
permission I would like to make a brief opening statement.
    As we all know, the perception of threats posed by 
nonconventional weapons has changed dramatically----
    Mr. Shays. If you tilt this, bend this up. Like this. So 
you don't talk straight in.
    Mr. Winkenwerder. Is that OK--has changed dramatically in 
the last 8 weeks. As our Nation addresses this threat, DOD 
plays a supporting role to civilian authorities where we have 
the capability to do so. The Department is working closely with 
Federal partners for homeland and defense matters.
    DOD is the primary Federal agency responsible for 
administering the national disaster medical system and sharing 
responsibilities with the Department of Health and Human 
Services, FEMA and the VA. We have many capabilities that can 
be used in support of civilian agencies to assist in both the 
prevention and the management of chemical and biological 
attacks, and these DOD assets have been used extensively in the 
current response to the domestic anthrax attacks.
    Our focus, however, has been and continues to be our men 
and women in uniform, not only because their medical readiness 
is a critical aspect of the success of any military operation 
but also because they are the most important asset. I can tell 
you without equivocation that this is my No. 1 priority as 
Assistant Secretary of Defense for Health Affairs.
    Since coming to this office just 2 weeks ago, I have begun 
to review our medical readiness training programs. It is clear 
to me that a solid foundation has been laid, much good work has 
been done in the past few years, but clearly we can do better. 
And I want to emphasize this, the threat is no longer 
theoretical. The events in the past 2 months have shifted 
priorities. Indeed, my mandate from Secretary Rumsfeld and 
Under Secretary Chu is clear, we will focus on a deliberate but 
accelerated process for improving our medical readiness 
training programs across the board to meet chemical and 
biological threats. Secretary Rumsfeld identified this 
requirement and this issue of asymmetric threats in his 
Quadrennial Defense Review as he has moved the Department from 
a threat-based planning model to a capabilities-based model.
    I will work closely with the Surgeons General to identify 
areas of concern and address those issues directly now.
    I will outline some of the actions we plan to undertake in 
the Department, but first I want to identify those areas in 
which we already have made significant progress.
    In recent years the military health system has placed 
increased emphasis on chemical and biological readiness. 
Training has increased at all levels, from individual training 
to the unit level. The military services have developed 
numerous training courses and other resources focused on the 
medical response to chemical and biological events.
    The courses that the Department has conducted on training 
materials that have been distributed have been broad and 
substantive. We have provided educational opportunities at 
every skill level within the range of our medical personnel, 
from junior enlisted to speciality physicians. These training 
methods vary from in-house, multi-day courses, abbreviated 
exportable courses, live and rebroadcast satellite courses, 
Web-based courses, printed manuals, newly printed manuals and 
handbooks that outline chemical or biological casualty 
management. With the added emphasis on domestic response, both 
military and civilian health providers have also attended these 
courses, I might note.
    Additionally, the Uniform Services University at the Health 
Sciences has robust and longstanding educational programs in 
the medical aspects of chemical and biological terrorism 
developed for our military medical students and graduate 
students. The university is now actively involved in adapting 
these programs to the civilian medical education community in 
both traditional and interactive Web-based formats. In this 
regard, I believe the value of our military medical educational 
institution is a national asset and a national leader in the 
development of education in the area of biological and chemical 
    It's very appropriate that this committee ask where we are 
in the Department with respect to medical readiness training in 
the areas of responding to chemical, biological or nuclear 
threats. In my view, the goal of the military health system 
should be to ensure all medical personnel receive appropriate 
training commensurate with their medical skill level and that 
all necessary medical planning and exercises have occurred that 
will ensure our personnel are ready.
    Since my swearing in 9 days ago, I have begun reviewing the 
basis upon which our military medical readiness plans have been 
constructed, the medical infrastructure needed to accomplish 
our mission, training requirements of the total medical force, 
active and reserve officer and enlisted, and the means by which 
we monitor and evaluate the training we provide.
    The General Accounting Office's report is helpful. I 
believe it provides a road map of many actions that I and the 
Surgeons General and others will undertake expediently to 
improve our ability to respond to these acts of terrorism.
    From my perspective, there are three main prongs related to 
medical preparedness for chemical and biological attacks: 
prevention, detection and response to the attack.
    Prevention of disease remains the preferred course in any 
aspect of health care delivery. It's especially true in 
considering the consequences of chemical and biological 
warfare. With anthrax as the current biological threat and 
cause of disease in our citizens, DOD and the services have 
taken precautions for the men and women in uniform. We have 
ensured that both adequate supplies of antibiotics and proper 
guidance are available to the deployment forces.
    Additionally, the Department also initiated an anthrax 
vaccine immunization program, as you know, to provide our 
service members with protection against this particular type of 
attack. I will be reviewing this program to ensure that it is 
effective for its stated goal.
    The detection of a chemical and biological attack requires 
the logistical element of equipment and emerging technology 
that the Department has aggressively pursued. Detection also 
encompasses the medical expertise required to identify signs 
and symptoms at an early stage of an attack, particularly a 
biological event in which the awareness of the attack could be 
delayed for days or week.
    Finally, proper medical response to an attack is essential 
for minimizing casualties and for sustaining our ability to 
fight the war. We must ensure that we have the right people to 
perform these missions, that these people are trained and that 
we know specifically who is trained at what level. To address 
this matter, my office and the Offices of the Surgeon General 
and the Joint Chiefs of Staff have already undertaken a number 
of initiatives.
    First, let me outline that we will be conducting a 
comprehensive review of current chemical biomedical training, 
and I'm here to tell you that we will be making some level of 
training mandatory at all levels. If we can make mandatory 
training on sexual harassment, we can make this kind of 
training mandatory which, obviously, is of high importance.
    Second, we will be standardizing medical response protocols 
across the services.
    Third, we will be enhancing medical planning tools to 
include development of a Common User Data base to enable the 
services to conduct medical planning for contingencies 
involving weapons of mass destruction.
    Fourth, we will be ensuring that future training and 
exercises include greater medical play and providing 
challenging and realistic scenarios that adequately assess the 
capabilities of our medical units to function in a chem/bio 
    Additionally, DOD will be developing a tracking system to 
monitor the training and the proficiency of health personnel to 
function in a chem/bio environment.
    Taken together, I'm confident that these actions will 
result in a military health system better prepared to support 
our military men and women in the coming months and years 
    I want to thank you for the opportunity to appear today. I 
appreciate the committee's commitment to our service members 
and look forward to working together to keep their safety and 
protection our first priority. I look forward to answering any 
questions you might have at this time.
    Mr. Shays. Thank you.
    [The prepared statement of Mr. Winkenwerder follows:]
    [GRAPHIC] [TIFF OMITTED] 82172.010
    [GRAPHIC] [TIFF OMITTED] 82172.011
    [GRAPHIC] [TIFF OMITTED] 82172.012
    [GRAPHIC] [TIFF OMITTED] 82172.013
    [GRAPHIC] [TIFF OMITTED] 82172.014
    [GRAPHIC] [TIFF OMITTED] 82172.015
    [GRAPHIC] [TIFF OMITTED] 82172.016
    Mr. Shays. We'll start with Mr. Putnam.
    Mr. Putnam. Thank you, Mr. Chairman.
    Dr. Winkenwerder--did I say that correctly?
    Mr. Winkenwerder. Winkenwerder, that's correct.
    Mr. Putnam. This is a whale of a 2 weeks for to you have 
started out in this position.
    Mr. Winkenwerder. An incredible time to arrive.
    Mr. Putnam. We appreciate your presence here and your 
commitment to improving the level of quality of care in the 
health services.
    According to the GAO report, between 1996 and 2000, you had 
over 1,300 service medical personnel take your 6\1/2\ day 
course. Your testimony says that, since 1997, 7,800 personnel 
have taken that course. Is there--how do you explain that 
    Mr. Winkenwerder. Well, I would say that, due to the short 
notice that we had, that certainly is nobody's fault. In 
preparing for this hearing, the written remarks that were 
provided to the committee did omit a number of important 
preparedness activities and programs that have been undertaken 
by all three services in the past few years and some in just 
the past few months and weeks. That's why I was very much 
pleased that you've allowed me to have my colleagues here, the 
Surgeons General, to talk about some of those, that there have 
been more people trained than was----
    Mr. Shays. Can you move your mic a little further away? 
Move it back away from you a little bit.
    Mr. Winkenwerder. There have been more people trained than 
has been indicated. I don't want to suggest that in my response 
that enough people or all the people that we want to be trained 
have been trained. But the numbers are something better than 
has been provided, and we would--thank you--and we would be 
glad to provide those numbers to you.
    Mr. Putnam. OK. I would certainly appreciate that. But 
you're standing by at least 7,800.
    Mr. Winkenwerder. Yes.
    Mr. Putnam. OK. You also said that 19 percent of the 
uniformed health service personnel have completed the specific 
chem/bio training and not more than a little over 2 percent of 
medical officers have completed the full 6\1/2\ day course and 
then those who have been through it we don't really have any 
way to track where they are to get them in a hurry. How are we 
addressing that issue? Why aren't the uniformed health service 
personnel required to take a specialized course and what steps 
do you have in mind as you embark on this to bump that up and 
increase the number who will be exposed--excuse me--who will be 
trained for a chem/bio event?
    Mr. Winkenwerder. Well, just in a matter of the past few 
days I have requested the surgeons to develop a plan that would 
include the level of training and courses that we believe would 
be mandatory for all personnel. Obviously, one size doesn't fit 
all here. Our goal would not be to have everybody who's a 
military health care provider attend a 3 or 6-day course. We 
need to target the level of training to the particular kind of 
provider or professional. But, whatever that level is, we want 
to make sure that everybody has the training that they need to 
    Mr. Putnam. I guess the part about the raw numbers of this 
that is a little bit disturbing is that all of us on the 
civilian first response side probably slept pretty well at 
night prior to the 11th knowing that somebody out there on the 
military side had a large team of people equipped to deal with 
these types of scenarios. I think that we're finding that there 
weren't quite as many people out there as we may have 
previously thought. So to the degree what we can help you turn 
that around and share some of that knowledge and training with 
the civilian first responders would be very helpful.
    And I see that my time is up.
    Mr. Winkenwerder. We would very much like to do that.
    Mr. Putnam. I yield back the balance, Mr. Chairman.
    Mr. Shays. Thank you.
    Mr. Kucinich.
    Mr. Kucinich. Thank you.
    Mr. Secretary, it was encouraging to hear your response to 
the GAO report in saying that you will train, you will help 
personnel to become more ready. At no time in your testimony 
have I heard you say that the Department of Defense is ready to 
protect its troops in the event of a biological or chemical 
weapons attack. Is that correct? You did not say that, did you?
    Mr. Winkenwerder. I believe that we are prepared to protect 
our troops.
    Mr. Kucinich. At this very moment you're saying that we're 
prepared to protect our troops. And how are we prepared to 
protect our troops?
    Mr. Winkenwerder. Well, Congressman, protection of the 
troops really is a multifaceted set of activities.
    Mr. Kucinich. I understand that.
    Mr. Winkenwerder. Let me just for everyone's information 
talk about that for just a moment. There's issues of 
intelligence and intelligence on the ground. There's issues of 
chemical and biological detectors, early detectors in the field 
where we can detect agents prior to their dispersal or at the 
time they might be dispersed. There is the issue of protective 
clothing and equipment. Training, obviously, we've talked about 
of troops and medical personnel, antibiotics, vaccinations. So 
there's a whole host of things.
    I don't want to minimize some of the deficiencies that have 
been pointed out in the area of training and planning.
    Mr. Kucinich. I understand. It's good to hear that you're 
trying to address this, and I understand you've only been on 
the job for 9 days. This report questions the readiness of the 
Department of Defense, the medical readiness. You know, not 
whether you have intelligence on the ground, not whether you 
have chemical or biological detectors, but whether or not there 
is a medical readiness. As this report says, as a consequence 
of their study, they're saying medical readiness for CB 
scenarios cannot be insured.
    And the reason why I'm focusing on this, you know, we have 
to get our time tense straight. We are ready, which means we're 
ready today, or we will be ready, which means some time in the 
future, that we're planning on this, we're thinking about it. 
But the difference is, if you have men and women in the field 
and they're subjected to an attack, you can't tell them we will 
be ready. They need to know they are ready.
    So, based on that, Mr. Secretary, would you at this moment, 
understanding the work that needs to be done, be ready to 
recommend that or even be asked whether circumstances exist 
which would be conducive to sending troops into the field in 
Afghanistan without the proper medical structure in place? 
Would you comment on that?
    Mr. Winkenwerder. Well, in the final analysis, we rely on 
our commanders in the field and on the Joint Staff, I think 
that has been pointed out, to make the determination of overall 
readiness. And that includes medical readiness. I think the 
events of recent weeks and the perception that possibly an 
enemy would be willing to use certain agents may have changed 
the threat assessment.
    Mr. Kucinich. We're on the same team here. We're working 
together. Because you want to make sure that the men and women 
who serve are going to be protected. I know that's true of all 
the officers who are here. That's your life's work. I 
understand that. It's our life's work, too.
    I just want to make sure, though, that the political 
imperatives which may exist somehow mesh with the realities of 
the medical readiness. And I'm hopeful that the Generals and 
the Admiral here, that somebody in the command level at the 
Department of Defense is going to talk to you and then that 
somebody is going to go over this report before we start 
committing troops to an invasion of a country that, given the 
geography is tough enough, but the medical readiness, that's 
what I'm concerned about. I just want to make sure that if we 
send our sons and daughters over to Afghanistan in order to 
fight terrorists that they're not going to be injured and not 
have a structure in place to be able to help them. That's all.
    And General----
    General Carlton. I just returned from down range and looked 
at the medical preparedness. I believe that we are in perfect 
harmony with your concerns. We've addressed every known factor 
that we will face. We've made our point. We have hardened 
facilities that are in the evacuation chain.
    Again, raw numbers are confusing. When we say 2 percent of 
the medical providers have been trained, this is a 7-day train, 
the trainer course; and that's about right for the people that 
will train ours that deploy in harms way. We have a readiness 
skill verification program where we certify that people are 
prepared to go do what they will encounter in that environment. 
So all of these things have stood up.
    Mr. Kucinich. General, again we all understand what a 
different environment you're in. And again we're working 
together here. This isn't an adversary proceeding at all. 
Because we need to make sure that our men and women are going 
to be safe.
    Now in this report here, Mr. Chairman, staff, just on page 
10 of the report, I would ask the gentlemen at the table if you 
would refer to page 10 of the report, paragraph 2, the middle 
of the paragraph. It says, ``Army Medical Department officials 
indicated both that they were not authorized to structure 
medical care for biological contingencies and that battlefield 
CB scenarios causing mass casualties would overwhelm current 
medical capabilities.''
    So, you know, that's the purpose of this meeting, to 
discuss this report.
    Again, as a Member of Congress, as a fellow American, I 
just want to express my concern that this discussion take place 
in the upper echelons of the Department of Defense before any 
decision is made to commit to ground troops. And the reason I'm 
saying that is that, if that decision is made, we want to make 
sure that all of the areas that are covered in this report are 
given careful consideration so we're not in a situation after 
the fact where somebody comes back to any one of you and says, 
now what do we do. And that's why we're all here listening to 
this right now.
    But, you know, in a few weeks from now we could be learning 
of mobilization of troops to Afghanistan, and I just want to 
make sure that our men and women, that they and their families 
are assured that this government is going to do everything it 
can to make sure that those enlisted people would be protected 
as best as possible under the circumstances.
    So I thank the Chair for giving me this opportunity. I want 
to thank the witnesses for the service that each of you gives 
to our country.
    Mr. Winkenwerder. I can assure you that it is and will be a 
top priority, that these matters that are in this report and 
the concerns will be reviewed at the highest levels.
    Mr. Shays. Mr. Secretary, it's pretty amazing to come into 
a job in 2 weeks and have to present a response to a report 
before Congress; and I appreciate you being here.
    I would welcome the participation of the rest of your panel 
as well in any of these questions. Because you all have been 
involved in this obviously a lot longer.
    On page 9 of the report it talks about, under the 
subheading, that DOD and the services have not systematically 
reviewed the adequacies of the medical specialist mix for the 
treatment of CB casualties. And then it says, service methods 
for personnel planning do not specify the personnel required to 
manage CB casualties.
    And, page 12, I want to read to you a long paragraph. I'd 
like all four of you to respond, if you will.
    On page 12 it says, ``While maintaining that the current 
specialty mix is generally appropriate to these emerging 
threats, service planners did identify additional skills that 
would be key to successful medical management of CB warfare 
    So, in addition to this whole issue of training people for 
6 days, ``some Army officials expected that chemical warfare 
readiness would require an increase in respiratory therapy, 
ward nursing, and internal medicine. Others noted that the Army 
did not have a lot of infectious disease experts in deployed 
hospitals for surveillance and prevention. Similarly, Air Force 
officials expected that chemical warfare scenarios would 
require more respiratory technicians, pulmonologists, critical 
care nurses and intensive care beds. They stated that the 
threat of biological warfare would increase the need for 
infectious disease and preventive medical personnel as well as 
personnel to collect baseline, predeployment data. Air Force 
and Navy medical planners both anticipated that chemical 
scenarios would require more emergency personnel who could 
recognize and respond to symptoms quickly.''
    Although these informal assessments vary, they imply that 
the current speciality mix needed revision. I'd love you to 
respond to that, and then I'd like each of the branches to 
    Mr. Winkenwerder. Let me make two general points and then 
would like very much my colleagues to respond as well. I think 
with respect to chemical and biological weapons there are two 
areas that come to mind that we will need to review and look at 
with respect to the medical personnel mix and the numbers. One 
is infectious disease, and the second is in the area of 
pulmonary medicine and the support personnel because of the way 
the agents work, and those would be the areas that I would 
expect we will be looking at and reviewing to ensure that we've 
got adequate numbers and adequate mix deployed in proper 
locations, etc. And so with that, I'll turn it over to General 
    General Peake. Sir, we have a modular structure--all of us 
basically have a modular structure that can be added to or 
taken from. The bases in our hospital situation is a combat 
support hospital. We have the ability to bring modules, 
infectious disease, laboratory and so forth to add where we see 
that threat, where that threat exists and as the threat 
changes. We have what we call smart teams, special medical 
augmentation response teams that reside in our medical 
treatment facilities that include intensive care as an example. 
It includes epidemiologic expertise such as that we have loaned 
to HHS as they look at the Capitol Hill, as a matter of fact. 
Those teams are available to be moved into theatre if that were 
    We rely on the commander in chief of that theater who looks 
at the threat, who makes those assessments, and then our Title 
X responsibility is to provide him trained and ready folks to 
deal with that. Many of those folks get their training and 
experience in our military treatment facilities. There was a 
comment by Dr. Kingsbury about the dichotomy, sir, if you 
would, of the peacetime health care and the go-to-war health 
care. Well, those infectious disease folks are--they need to be 
at the top of their game in their field as an example.
    So I think there is a translation there and we have quality 
people because of our ability to have that infrastructure that 
takes care of patients every day, and then added to that is 
their expertise that they get as military physicians. We are 
actually kind of proud of that 2-week course. We are proud of 
the fact that we push those courses out.
    Mr. Shays. There is a big difference, though, between a 2-
week course for your medics and your nurses and so on, and your 
doctors versus someone who has an actual specialty.
    General Peake. Yes, sir. But the infectious disease folks 
that--I mean, we have folks that are infectious disease 
specialists just as--that work in our teaching programs, that 
work in our hospitals and they're the same folks that come out 
of that and deploy as part of these specialized teams or as an 
internist in one of our combat support hospitals. So we have--
it's a leavening of the force of quality people of their solid 
basis of clinical medicine, and then in addition to that, as 
they go through the developmental process of an Army physician 
as an example, come into the Army basic course and they have 
training in MBC. Come back to the officer advanced course, and 
there's hours of training associated with that.
    Mr. Shays. You attempted to answer my question or may have. 
I'm not sure I fully understand why some of what of you're 
saying relates to this specific issue, and that's probably my 
fault, not yours. But the bottom line, there seems to be 
disagreement among the different branches from this statement 
and it would be--first, I will come back.
    Admiral, if you would just respond to the statement and 
let's see what we get, and then I will make my point.
    Admiral. Arthur. Yes. Good morning. Thank you.
    Mr. Shays. Good morning.
    Admiral. Arthur. I agree with much of what General Peake 
has said. We have our operational forces, which are----
    Mr. Shays. Move the mic a little closer, but not as close 
as the doctor had it.
    Admiral. Arthur. Have we got it calibrated now? Great. 
Thank you. We're staffed to provide forces in response to our 
lines projected operational requirements, and we have just 
about as many people as we need to do that and not very much in 
excess. We have many operational courses that we use to train 
people who go with our operational forces. We have people who 
go with the surface ships and they get a 6-week course. The 
flight surgeons get a 6-month course. The undersea medical 
officers who do the diving and submarines go to a 6-month 
course, and the Marines have their own course of 4 weeks, and 
in each of these courses there are didactic segments which deal 
with chemical and biological, and there are varying lengths. 
These are mainly physicians that I'm talking about.
    Mr. Shays. Yes. But with all due respect, what we are 
learning is that you really haven't--none of the branches have 
seemed to adjust to this new world environment. So you're 
telling me the courses that you have, but are we really focused 
on chemical and biological? And it appears that we're not. I 
don't see how we can say you are when you agree with every one 
of the points being made in the report, and then you're telling 
me we're doing it, and that's why I'm confused.
    Admiral. Arthur. Well, we're not as prepared as we now know 
we should be, and I think that was one of the points that Dr. 
Winkenwerder made. We have been awakened by the September 11th 
incidents in that we have an area of vulnerability that we had 
not recognized was of such magnitude. I would say, though, that 
we have to perhaps temper the discussions with enormous 
difficulty in retraining the staff and equipment that would be 
required for an all-out response to this when they're basically 
unused for the majority of the time and in peacetime, with the 
tremendous pressure we've had to deliver the health benefit in 
an austere funding environment.
    So it's very difficult to say let's have 100 more 
pulmonologists that we might need, and have the health benefit 
in some area go wanting.
    Mr. Shays. See, the problem is a whole host of problems 
exist. Our committee has had all three commissions come before 
us and said no one is known, we have not made a proper 
assessment of the terrorist threat. They said we don't have a 
strategy to deal with the terrorist threat, and they say we're 
not organized as a government to maximize our ability to be as 
successful as we could with our resources.
    So that's what they said to your government. We saw, sadly, 
the military mix, the terrorist threat and the military threat, 
and we're kind of confusing the two, it seems to me. I mean one 
of the things which still have some certainty is that you're 
more likely to have a chemical and biological attack if the 
person can disguise that they actually delivered it and not 
have to have retribution.
    So now what we've done is we've said if a terrorist is 
moving forward and doing these acts, we're going to hold 
somebody we can identify, a country, accountable; so we are 
going to hold countries accountable. But we don't know because 
we haven't done the proper threat assessment, both in the 
military, frankly, and the civilian threat, the terrorist 
threat, but it's probably less likely that you would encounter 
chemical or biological from a military force unless they 
decided to commit suicide, which obviously is a possibility as 
    I guess where I'm coming down to, though, is that as a 
committee, we saw the military say everybody in the military 
had to have anthrax vaccine and we used it all up, and we only 
have less than 20,000 left, and then we have 5 million that's 
unapproved at BioPort, some of it before they did their plan, 
some of it after they'd done it; so that's kind of this mess we 
find ourselves in and what we're trying to sort out is--what 
I'm trying to first sort out is, I understand now that you are 
doing programs you didn't do in the past, your 5-day, your 6-
day, your 7-day, I'm trying to understand the quote from the 
GAO's report where it says either medical personnel who have 
been trained cannot be readily identified in the event of an 
emergency, because tracking systems either do not exist or are 
not currently functioning, lest the availability of trained 
personnel given the situation is uncertain. I would like just 
the GAO to affirm, was that basically on identifying those in 
the 6-day courses, in the 7-day courses, or is it also meaning 
doctors with specialties?
    Ms. Ward-Zukerman. That was with respect to training 
    Mr. Shays. I want you to just get to the mic. If she could 
do that.
    Ms. Kingsbury. That was just with respect to tracking the 
people who had attended the training.
    Mr. Shays. OK. Just the training. So it's not an issue of 
being able to track those with specialties. Because 
unfortunately at the VA, they're unable to track people very 
easily with specialties, the Department of Veterans Affairs. We 
don't have that problem in our three branches as it relates to 
people with specialties?
    General Peake. We can track people with specialties. Let me 
just comment on in terms of tracking the training. We would 
like to be able to do better with tracking training. Looking at 
that 6-day course as an example, this morning I said pull it 
up, I can identify 1,747 people, 672 docs, 112 general core 
officers, 508 nurses that have had that training. I can pull 
them out of the data base by name. So I don't think I have 
captured all of them. I can tell you that. There are some data 
issues that----
    Mr. Shays. The question is, though, can you get that out to 
the field?
    General Peake. Yes, sir. We can pull them off of mods. 
There was----
    Mr. Shays. OK. Let me just go to--but the specialty issue 
that, wasn't a claim from GAO. General Carlton, you wanted to 
make--you were doing a lot of writing. Either you wanted to 
make a comment or you wanted to just----
    General Carlton. Yes, sir. I'd like to make a couple 
comments. We have been focused for the last 6 years on 
terrorists, specifically biological and chemical, and we've 
invested heavily in them. Regarding page 12, we have something 
called the critical care transport team that can be a ground 
asset or an air asset. We have more than 200 such teams that 
we've identified more than 150 trained to be able to fill this 
specific requirement. We've thought it through. We can building 
block those in, as General Peake indicated to you, very early. 
We recently certified a level 4, which the most highly 
infectious disease problem for air vac use, a joint Air Force/
Army discussion.
    Before we send people to the field, we have a readiness 
skills verification program that is a check, and we certify 
that they are certified to deploy depending on their skill 
level. We've been working on that for several years now. Every 
one of our GME institutions gives us military unique training. 
To answer that second piece that we'd require more emergency 
personnel, we train the personnel to be able to do that. One or 
two infectious disease people cover a medical center currently. 
We have been training through those infectious disease people 
extensively, and actually have our premier course, which starts 
next week, which is called a hospital-focused approach to 
biological weapons and toxins. It's filled up immediately and 
has been for 6 months.
    We've really been focused on these for a long time, and I 
believe that as you look at these, it raises a level of concern 
and our approach was, yes, we can do better, which is the 
reason that we concurred, but I don't want you all to leave 
with an impression that we have not focused on this, and we are 
ready at this time for the expected illnesses in the bright 
percentages. If somebody threw me 2,000 casualties at one of my 
deployed locations and all need ventilators, I have a problem, 
but that's not the current threat.
    Mr. Kucinich. Excuse me. If I may, General, you're with the 
Air Force; right?
    General Carlton. Yes, sir.
    Mr. Kucinich. What does the Army say?
    General Peake. I would say exactly the same thing. That is, 
we structured our force to where would see the risk. We 
understand the environment that our soldiers are in. We 
understand what their force protection capabilities are and you 
work with them--the maximum, you know, a credible event, and 
you try to structure your forces to cover that. I believe we 
have good--as General Carlton said, we would--there's always 
more things to do, but in terms of having a level of comfort of 
being able to care for our soldiers and being proactive about 
it, recently we just pumped antibiotics as part of our DRB, or 
defense division ready brigade support packages, so that, you 
know, we plussed them out looking at the new threat. We've done 
that since September 11th.
    So as everybody sort of alluded to, this has been an, OK, 
now let's pay attention to this one a little bit more, but 
it's--I sort of feel a little that we probably sound a bit 
defensive, sir----
    Mr. Kucinich. You don't have to be because you're not under 
attack here. We're together.
    General Peake. But the fact is there have been a number of 
things gone on. The issue of the planning tool that was 
mentioned, it's true, there is not one in the map, but since 
the early mid 1990's, we have been working with NATO to work up 
planning scenarios and casualty models we now have that we are 
investing in a tool to be able to go ahead and use the patient 
time test TRTA files that have been developed that was alluded 
to in the report. We expect we will work with the other 
services to move that into the medical planning tool, but we do 
have a desktop model that I was looking at this morning.
    So there are a lot of positive things that are a part of 
this journey to getting better and we're along that journey, as 
Dr. Winkenwerder has indicated, and we will accelerate along 
that highway.
    Mr. Winkenwerder. Let me also add in here if I might, just 
in terms of the exercises, and I don't want to sound as if I'm 
quibbling here too much, but based on the information that 
these men have given me, we have had more exercises of some 
sort than is indicated in the report, and I'm told roughly in 
the range of 20, 21 in the last couple of years, many of them 
with civilian, we also have to look at the home front issue of 
how to support them. So we have an area that the military 
supports its civilian authorities, and so there have been 
exercises, tabletop. You've heard of some of them. Dark Winter 
    Mr. Kucinich. I actually read your testimony, and I'm 
impressed with what you're trying to do on a domestic front, 
and all Americans are concerned with that. But with all due 
respect, you've got a lot of work to do, I would think, and 
hope before you get to a point of saying send the troops in, 
and you know, that's not a decision you're going to make, but 
you're going to be called upon for an evaluation of the medical 
    Now, Mr. Chairman I just want to ask one other question 
here of Admiral Arthur, and that is, you raised this report, 
actually touched on, and that is the question of available 
resources, because that's something that none of us can escape. 
There are financial budget issues and, as you said, whether or 
not you can have--you may have used a figure 100 pulmonologists 
and have them waiting and seeing if anything develops. I think 
that's one of the discussions considering this constantly 
changing picture. I think that's one of the discussions that 
you're going to have to have, and then if there is a need for 
additional funding, I'm hopeful that you'll come back to this 
Congress and inform the Members of Congress that in order to 
assure medical readiness that you need to--that this is what 
you need. We cannot hold you accountable if you don't have the 
resources and feel that you can't have access to the resources. 
So I would just say that as surgeons general, that we need to 
know from you just exactly what you need in order to do the job 
and have a high level of medical readiness in the event that we 
find ourselves on the ground with a full-scale effort in 
Afghanistan. So that----
    Admiral Arthur. Sure.
    Mr. Kucinich. And I just want you to know I heard you, 
    Admiral Arthur. Yes, sir. I'd like to amplify one point, 
and General Carlton brought this up. They have two, for 
example, infectious disease specialists at a medical center. We 
can't have 100 like we would like. But what we do, as General 
Carlton said, is we cross-train a lot of people. We have a lot 
of people familiar with the basics. So I think we are capable, 
and we could never interest 100 pulmonologists in staying if 
they weren't truly busy. But we also train our Reserves. We 
train a lot of people to come in and fill in when the 
requirements exist, and it's different than the civilian sector 
where people just do their one thing because they're 
compensation driven. We have a system that is very much more 
flexible than anything in the civilian sector, and I think 
that's our No. 1 strength.
    The No. 2 strength is this is where the expertise is for 
chemical and biological issues, and I think one of the ways 
that we can help as a service, and you can help us, is to 
assist us in getting out the information to our civilian sector 
to allow them to be more flexible when some of these issues are 
raised in the domestic front.
    Mr. Kucinich. I would like to ask one final question. In 
the report at the conclusions and recommendations on page 36, 
it says that the DOD has not developed comprehensive meaningful 
training requirements, adequate tracking system, or rigorous 
proficiency testing. The available evidence indicates that 
proficiency is low from training only a fraction of personnel 
to failing to conduct realistic challenging combat field 
exercises that include CB medical treatment, DOD has not fully 
responded to the threat as stated, and what you're saying 
today, gentlemen, is that you're moving in that direction of 
addressing that; is that correct?
    Mr. Winkenwerder. Yes.
    Mr. Kucinich. I want to thank the witnesses and thank all 
of you for your commitment and service to the country.
    Mr. Winkenwerder. Let me, if I might, just say one other 
thing with respect to the funding. We have put in requests that 
are related to the additional emergency funds that have been 
distributed out to the Federal Government and to DOD to lay 
claim to part of that for these very issues. And as we develop 
our plans here over the next days and weeks, we'll be coming 
forward inside the Department to identify the requirements that 
we think need to be met, and any funding or resources that are 
associated with that.
    Mr. Kucinich. I want to thank the Chair for allowing this 
opportunity to ask questions. I want to thank Mr. Putnam for 
his participation as well. I think this has been a productive 
    Mr. Shays. Thank the gentleman. Mr. Putnam, if you don't 
mind, if I could just finish. I think I'm figuring out that 
we're probably not going to get some answers at a hearing that 
we need to get because of some of it is a time line issue, and 
we don't have a sense of what it's going to take, but where I'm 
getting a little concerned is I feel like we're mixing 
different things together. For instance, Dr. Winkenwerder, when 
the military is telling you that they have had training, I 
believe it's training on the civilian side. In other words, 
we're coming in and there's a challenge in the United States. 
My understanding is we're not going through exercises on the 
field with, you know, a massive chemical attack or not even a 
massive, or a biological attack. I don't think that's happening 
yet, and so I just want to be clear as to what we're saying is 
    General, you kind of wanted to finish and I'm happy to have 
you finish your point, and I'd love you to address the point I 
just asked.
    General Carlton. Yes, sir. We added them up to find out is 
the criticism true.
    Mr. Shays. I just need to know adding what up? What are you 
really adding up? What exercises?
    General Carlton. Military-specific exercise that included 
chem-bio activities in the last 2 years number 12. Civilian-
specific exercises where we did things military and civilian 
together involving chem-bio exercises, No. 9.
    Mr. Shays. Right. But there is a difference, there truly is 
a difference between the two.
    General Carlton. Yes, sir. The presentations to senior 
meetings in international presentations by just the Air Force 
staff number 1,000 in the last 2 years.
    Mr. Shays. What does that mean? Slow down, I want to 
understand. In other words, there is dialog with people about--
    General Carlton. No, sir. Delivering a key note speech as I 
will do tomorrow in Detroit, as one of my brigadiers will do at 
the Southern Medical Association on Thursday.
    Mr. Shays. And so that means that you're thinking about the 
    General Carlton. That means that we've addressed their 
civilian folks--on the military side I'm very comfortable. 
We've thought these through. We even planned the attack on the 
Pentagon and we exercised it in May. We're prospectively 
thinking this ahead. We planned the attack on New York City and 
D.C., invested in the equipment to diagnose it 3 years ago, and 
we have all the teams trained now. So we're thinking ahead and 
we're trying to get to our civilian colleague to help them 
understand the world's changed, and all of a sudden they're 
listening, and it's delightful.
    Mr. Shays. OK. Let me just tell you now why I'm confused. 
You can't concur with all of the criticisms that GAO made and 
then say that the report isn't--doesn't reflect what is 
happening. That's my disconnect. I feel like I should take a 
lunch break and read the report again and see if I have read 
this report properly and your concurrences. It's not----
    Mr. Winkenwerder. Let me try to clarify it because----
    Mr. Shays. You can do that with 2 weeks on the job----
    Mr. Winkenwerder [continuing]. I do need to speak for all 
of us. We concur and we agree, and agree means agree.
    Mr. Shays. Yes.
    Mr. Winkenwerder. OK? It's very simple. We agree. That 
said, I think the difference of the discrepancy may be that we 
want to leave you with the impression that some more things 
have been done, are being done than maybe the report was able 
to recognize because of the timing.
    Mr. Shays. If the glass is one third full, you want me to 
know at least it's one third full and not empty.
    Mr. Winkenwerder. It may be a little more than one third 
    Mr. Shays. OK. I didn't want to use one half. Something 
below half. OK. You're smiling, General. Is that----
    General Carlton. No, sir. I think it's a very valid 
concern. I'm very comfortable with the overseas piece. I'm 
scared to death for homeland defense, and medically we have 
some work to do but we've been engaged for 6 years----
    Mr. Shays. But you're talking as it relates to the 
    General Carlton. As it relates to the military for our 
overseas pieces.
    Mr. Shays. Right. But are you saying--are you scared here 
for your military or are you scared here for the civilians?
    General Carlton. I'm scared for our civilian population, 
that we have a lot to share with our civilian friends on what 
we have done in the last several years on the BWCW discussion.
    Mr. Shays. OK. Well, you know what? I'm going to come back, 
but I still want this paragraph identified as to where you 
agree and disagree with the various points. You're basically 
saying respiratory and infectious diseases is your greatest 
need. I'm going to make an assumption, unless you correct me, 
that you feel you have the limited numbers of people in these 
specialties and you're looking to get more, I'm making an 
assumption if you have a limited number, that means that if you 
were having to defend your forces around the world, you 
wouldn't have enough, but if we're in Afghanistan, you can 
bring these resources to the field, and I make an assumption, 
and I would like to have a ``yes'' on this one, that you have 
the medical personnel and will have the medical personnel in 
the field of contention to deal with whatever bio or chemical 
challenge you're faced with. Is that accurate, General?
    General Carlton. Yes, sir, it is.
    Mr. Shays. Is that accurate?
    General Peake. Yes, sir, it is.
    Mr. Shays. OK. Mr. Putnam. Don't even give him a clock.
    Mr. Putnam. Thank you, Mr. Chairman. I have been listening 
with great interest in this, and I find myself a little bit 
confused about the different training portions that have been 
taking place.
    General Carlton, you said that what keeps you up at night 
is fear for the civilian population, and I think that what you 
had implied in some earlier comments was that you have been 
trying to prepare some civilian health care professionals for 
some time, and only since the 11th, have they been particularly 
interested in listening to the progress that you've made? And I 
certainly understand that. How prepared is the civilian 
population and how prepared is the military for a situation 
that it's very conceivable 6 or 8 months from now where you 
have a chemical or biological attack on ground troops engaged 
in combat and a massive civilian incident in an urban area that 
would require substantial expertise from the health care 
community? So if you could take those couple of bites of the 
apple first before I go further.
    Mr. Winkenwerder. I'm going to try to speak for us as one 
voice here on this. I think it's not fair for us to speak for 
civilian preparedness across the board. I think that's really 
the domain of Secretary Thompson and the leadership at the 
Department of Health and Human Services to speak to that issue. 
I think we all know there's a tremendous amount of interest and 
training and activity going on across the civilian sector as we 
speak, many cities and towns across the country, people trying 
to learn and get up to speed on these issues, and we're here to 
help and support, but I think it wouldn't be fair to try to 
quantify or qualify how, you know, where that degraded.
    Mr. Putnam. Is it fair to say that the military is further 
along in preparedness than civilian?
    Mr. Winkenwerder. I think it would be fair to say that, 
yeah, and everyone should hope so. I think we are.
    Mr. Putnam. And that in many situations, these Governors 
and mayors are returning to their own military to help prepare 
their own city and State for these types of incidents?
    Mr. Winkenwerder. Well, I think they're turning to wherever 
the knowledge is, and that to the point that earlier brought 
General Peake and General Arthur is that we can be a real 
source of support that we want to be. We feel like one of our 
greatest capabilities is to train and educate and--on the 
civilian side and to--and we are in active discussions with the 
Department of Health and Human Services around concepts of, you 
know, protecting people, protecting populations of people, how 
to ensure good command and control and biological event 
situations and all of that.
    Mr. Putnam. I'm not trying to box you into a position of 
making any comments about the preparedness or the lack thereof 
of civilian health care population, professional population. 
What I'm trying to point out is that there is a symbiotic 
relationship between civilian health care professionals and 
military health care professionals.
    Mr. Winkenwerder. Absolutely.
    Mr. Putnam. It's been 10 years since you were engaged in a 
major combat situation; so you've put a number of your medical 
professionals in emergency rooms and trauma centers in urban 
areas to see what gunshot wounds are like. The civilians depend 
on your expertise to prepare for chem-bio-type situations and 
in a major incident that would occur while we are engaged in 
ground combat, we would have a limited number of people spread 
around the world and so that was really the direction I was 
interested in taking us which was, you know, how are we going 
to deal with that type of situation? How quickly can we 
standardize just the services much less spread it out to the 
civilians being able to be prepared. You have a shortage of 
specialists, pulmonologists and ear, nose and throat, and 
there's a number of others identified in the footnotes. To keep 
those folks sharp when we're not engaged in war they've got to 
be doing something else----
    Mr. Winkenwerder. That's right.
    Mr. Putnam. So there is a very connected----
    Mr. Winkenwerder. There is.
    Mr. Putnam [continuing]. Relationship between you and 
civilian population. So that was only the purpose of my 
    Mr. Winkenwerder. Thank you.
    Mr. Putnam. There is a recent Washington Times article that 
highlights your board surgical teams, the Army's board--General 
Peake's surgical teams, and indicates that they--attached to 
every brigade, the closest thing yet to battle field surgery, 
the article points out significant medical treatment literally 
is right over the hill. Are those folks prepared for a chem-bio 
attack? And simultaneously, let me also ask, do the benefits of 
having them close for conventional type of warfare put your 
first responders in jeopardy for this new type of asymmetric 
threat, General Peake?
    General Peake. Sir, they are at--when you're putting them 
that close, they're at jeopardy for even conventional warfare, 
depending on how far forward you have to go, depending on the 
tactical scenario, and they are--therefore have the period 
defensive medical protective--chem-bio protective posture as 
the rest of the troops that they're supporting in terms of 
masks and so forth.
    And so they basically share the hazards. You try to employ 
them so you protect them reasonably, but that's the 
organization's design to go far forward with the brigade. In 
terms of their ability to take care of chem-bio casualties, 
those folks, like our division surgeons as well, are folks that 
go get targeted to go to that course that we were speaking 
about before; so they have that kind of experience. We have 
within that unit ventilator support, a limited amount, but the 
idea is to stabilize folks and then transfer them further back 
to a more definitive facility.
    Mr. Putnam. Mr. Secretary, you have made very clear that 
one of your top priorities is to eliminate any disparities 
between the services and the standardization of readiness.
    Mr. Winkenwerder. Absolutely.
    Mr. Putnam. Do you feel that you are there?
    Mr. Winkenwerder. We're not all the way there, but I can 
assure you that we're going to be trained on to this entire 
issue, including that aspect of it as we speak and in the days 
and weeks ahead. It's my top priority.
    Mr. Putnam. What sense of time line have you established as 
an objective?
    Mr. Winkenwerder. I haven't set a time line other than to 
set the idea in motion that it's now, we're moving, we're 
acting, we're doing, and I would be glad to get back to the 
committee at a later date in terms of if that's of interest to 
you with respect to what might be realistically accomplished 
over what period of time. We're glad to try to, you know, 
properly set expectations, but we're working on this. It's our 
top priority.
    General Peake. Sir, there are things that are still coming 
about. I will give you an example. I'm going tomorrow to look 
at chem-bio protective shelters that are part of a Humvie that 
we have had in the pipeline as developmental. Our intent is to 
be able to put one of those board surgical teams within a chem-
bio protective shelter, because we do understand the 
environment that changed on September 11th. That's the kind of 
thing that we will put on the fast track to field, and quickly 
put into place where we see that threat.
    So we're willing to change our structure on the fly. We're 
required to try to meet the threat that we see evolving.
    Mr. Winkenwerder. There is one other thing that I'd like to 
leave the committee with, and that is the notion that much of 
the discussion here is focused on managing an attack once it 
occurs, and assuming there's casualties. I know that's not all 
of the discussion, but there has been a fair amount of that. It 
would be my plan coming into this role that we focus a great 
deal of effort on how to detect events at an early stage, and 
how we can prevent certain things from happening and how we can 
address things during that early phase where there's the 
opportunity to treat people, whether it's biological with 
antibiotics or even a chemical situation with antidotes and so 
forth, so that the whole matter of detection, the kind of 
equipment we have to detect and how it works, that's part of 
all of this and that's important and just sort of our readiness 
in terms of intelligence and thinking, both in the deployed 
situation as well as on the home front.
    And let me add to that the whole area of vaccination. I 
think that's another issue that we've got to look at and relook 
at in the context of the situation that we now find ourselves 
    Mr. Putnam. Thank you. Thank you, Mr. Chairman.
    Mr. Shays. We're going to get you out of here pretty soon. 
I'd like the counsel to ask a few questions and then I would 
like to ask a few and then we will be done.
    Mr. Halloran. Thank you. With regard to proficiency 
testing, which is a matter the GAO raised, the training 
numbers, as she said, are a surrogate for how capable people 
actually are, what might your near-term plans be in terms of 
determining the proficiency of medical units in CB casualty 
    Mr. Winkenwerder. I'm not steeped into the details of our 
current proficiency testing capabilities or programs, but what 
I'm--would plan to do is to work with the surgeons with respect 
to determining what levels of proficiency we ought to have for 
different levels of personnel and that we get rapid agreement 
on that and that we, sort of going along with that, have the 
capabilities in place to track the proficiency.
    Mr. Halloran. You might just solve two problems at once in 
terms--are proficiency determinations made as a result of 
    Mr. Winkenwerder. That's a good question.
    General Peake. It is one measure of proficiency. You have--
you sort of have to break it down. Individual proficiency with 
technical expertise, hands-on expertise, cognitive expertise, 
those are all elements of proficiency. And then there is unit 
proficiency, how that unit works together internally, and then 
in the larger, it's the systems proficiency, the evacuation 
system feeding the medical system and then the further 
evacuations. So each of those are looked at in a little bit 
different way, some from the larger exercise perspective, some 
from the CPX nonfield training perspective to see how well you 
do with that. And then others are sort of the hands-on skill 
testing that, for instance, we are initiating as we change the 
military occupational specialty to 91 Whiskey in the Army, 
where twice a year they want to do the specific hands-on skills 
to prove that they can start that IV, to maintain that airway, 
can assess that patient. It's not a single question, sir, it's 
an expanded question.
    Mr. Halloran. Understood. Thank you. Sir.
    Admiral Arthur. I'd like to add that the insulting agent 
may be different than what we're commonly seeing. For instance, 
it may be a chemical agent or may be a biologic agent, but the 
underlying pathology, the actual disease process, is common to 
many of the diseases and injuries and illnesses that we see 
every day, and I think the pathology and the skills that are 
existent in our health care professionals today once recognized 
will be able to adequately treat those same symptoms and signs 
that would be from chemical or naturally occurring disease.
    Mr. Halloran. But that's good news and bad news. I mean, 
we're all learning everything looks like the flu in the first 
48 hours.
    Admiral Arthur. And many of them are treated 
symptomatically or with specific agents. Now, we have to have 
an awareness that we've been infected perhaps with anthrax to 
treat appropriately, but we have specialists who do this, and 
once recognized, the treatment is fairly standardized and think 
we're well equipped to do that.
    Mr. Halloran. Finally, let me just change the subject. And 
it's not really a curve ball because I shared this with you 
before, but there is a report out today on the military blood 
tracking system that the Inspector General has found it lacking 
in some significant respects, and just for the record if you 
could comment on that, please.
    Mr. Winkenwerder. I'm going to let General Peake do that 
because of his responsibility.
    General Peake. I just briefly saw the report and I haven't 
read it in detail, but I'd be more than happy to get back to 
you for the record on----
    Mr. Halloran. Please.
    General Peake [continuing]. On the details of it. It is an 
important issue to be able to track in an automated fashion the 
blood and that's why we put the DIB system in place. I know we 
have some investment that we are putting in to try to improve 
the product, but it's an important issue for all of us.
    Mr. Halloran. If you would get that to the committee, I'd 
appreciate it.
    General Peake. I will be happy to, sir.
    Mr. Halloran. Thank you.
    Mr. Shays. Dr. Winkenwerder, I appreciate the tone you set, 
one of, I think, just trying to be candid, and all of you. It 
tells me that we can work well with each other, and on that 
basis, what I would like is on all these--on the report which 
is your response where you concur, rather than just going 
through it in this public session, I think we will probably get 
a clearer response if you have time to think about it a little 
longer. But on page 47 and 48 of the report, it talks about the 
recommendation and DOD's response, and what I'd like is for you 
to work with the committee and give us a sense--I think it's 
fairly clear that GAO felt, and I would agree that the 
responses are somewhat general.
    In other words, it's kind of like we agree and we're going 
to look into it or we're going to--you know, as an example, it 
talks about how, just taking this as an example, with the first 
recommendation, concur as the coordinating body with the 
services in sync on issues of this nature. The joint staff will 
be requested to conduct a reexamination of CV medical training 
issues and provide suggested adjustments. You know, that's a 
pretty general response, and I would like to know when that's 
likely to happen and then what's the result of that. And so 
that would be--so if we----
    Mr. Winkenwerder. I will be glad to do that.
    Mr. Shays. If we could do that, it would give us a little 
clearer idea as to what some of your responses mean. The second 
thing I want to do is just I honestly believe that there has 
been a lot of good work obviously to deal with this issue, but 
I don't want to overstate where we're at. For instance the 12 
exercises, I don't--can't grasp your version of exercise versus 
mine or what I think of it. Can you give me an example of what 
kind of exercise we're talking about? Are we talking about an 
exercise where all of a sudden we've got, you know, 60 people 
who have got a chemical--been exposed to chemicals? Are we 
talking about 200 people who have smallpox? What are we talking 
about here?
    General Carlton. Yes, sir. I'm happy to do that. Alamo 
alert is the best example that we have. It was a mil/civ 
cooperation, a 3-day symposium that we put on. The first day 
was educational. The second day was a smallpox attack with our 
city leaders in place to include the mayor, the fire department 
chief, the police chief, etc., and they're the shot callers. 
And then we played the scenario based on what they responded. 
We had an outside company orchestrate this response. The third 
day, then, were the critiques of what happened on the second 
    Mr. Shays. This committee has participated in those kinds 
of exercises in what we called them, the rapid deployment--the 
ray teams. But how about civilians off--not the civilians. I 
thought the 12 was the civilians----
    General Carlton. That was a mil/civ. The example of a mil/
mil was at the joint training center where we practiced our new 
scenarios. The Shugart-Gordon is a training range that looks 
like a city to most of us. Two years ago they started doing 
chemical scenarios involved there. It was a force-on-force 
discussion. Chemicals are here, how do you detect, how do you 
protect, how do you take care of people?
    Mr. Shays. Was that a U.S. target?
    General Carlton. That's the U.S. Army. It is was a joint 
exercise down at Fort Polk, LA.
    Mr. Shays. Is that a field exercise?
    General Carlton. It's field exercise, yes, sir.
    Mr. Shays. And how many casualties?
    General Carlton. I'm sorry. I can't tell you. I didn't have 
enough time to prepare that.
    Mr. Shays. Would it be fair to say that there have been a 
minimal number given the need?
    General Carlton. I can't give you the number.
    Mr. Shays. No. I don't mean the casualties. I'm sorry. I 
didn't ask my question properly. We're talking--I guess I don't 
want to leave--I don't want to set a false impression that we 
aren't doing enough. I don't want to set an impression that 
we've been doing these exercises, and that they have really 
constituted a significant military exercise, and so----
    General Carlton. Yes, sir. Pacific Warrior in February of 
this year was a 2,000-person exercise that was the Korean 
scenario that we played in Hawaii, and it involved a chem 
    General Peake, I don't think it had a biological component 
to it.
    Mr. Shays. Because what we're hearing is that there really 
haven't been many bio in particular. In other words, even this 
number of 7,800 versus the 1,718, what I'm being told is that 
you have onsite and you have offsite exercises, and the offsite 
training exercises and that the offsite have not involved the 
bio exposure, it's just mostly chemical.
    General Carlton. In the military exercises that I have been 
involved with, only three have involved biological activities. 
None of them were in the field. They were think tank type 
    Mr. Shays. Right.
    General Carlton. So when you start adding 17----
    Mr. Shays. So that's really the tabletop kind of exercise?
    General Carlton. Yes, sir.
    Mr. Shays. I guess really when I'm thinking of an exercise, 
I'm really thinking what you're out in the field and you're 
trying to expose your troops to this kind of training exercise.
    General Carlton. Yes, sir. Without exercises--some of the 
things that have been very exciting are surveillance systems. 
We had a real world exercise last summer, the summer of 2000 
where we had a food borne illness break out in one of our 
forward deployed places. The year before we had a 60 percent 
casualty rate from that food borne illness. Because we had 
installed a new surveillance system, we had a 2.5 percent. When 
we could identify it quickly, it involved using the rapid 
pathogen identification, and so we've had some real world that 
we don't call exercises, but real world experiences with our 
equipment, with our toys that have worked beautifully.
    Mr. Winkenwerder. Mr. Chairman, if it would be helpful, 
we'd be glad to try to summarize these----
    Mr. Shays. Yeah. Why don't we do that. Because I'm really 
left with the feeling that some of these are civilian responses 
to terrorist activities and some of them----
    Mr. Winkenwerder. Yeah.
    Mr. Shays. But in other words, this isn't foreign to you, I 
agree, but my sense is that you do agree with this report, and 
the report says there is a lot that needs to happen and I'm 
going to kind of----
    Mr. Winkenwerder. And you deserve to know exactly what we 
have done here, and a little more clarification on the 
exercises that have taken place.
    Mr. Shays. And Admiral Arthur, have you had many exercises 
in the last--on the field, not over a desktop and not in a room 
on bio?
    Admiral Arthur. We've--not specifically on by bio or 
chemical, but we do incorporate that aspect into our training 
when we train specifically on the ground with the Marines, when 
we exercise the fleet hospitals in support of the Marines or 
the medical battalion in support of the Marines. We also have 
our shipboard casualty drills where we do drill for chemical 
and biological, when we lock down the ship and we wash the ship 
and we----
    Mr. Shays. That's mostly for chemical; right?
    Admiral Arthur. Chemical and biological.
    Mr. Shays. I'm sorry. I interrupted. So you wash down the 
ship and----
    Admiral Arthur. And we have the exercises where we isolate 
certain portions of the ship based on contamination. So we do 
these exercises. We don't do much with submarines. We figure 
they're pretty protected.
    Mr. Shays. All right. Is there a question that you want to 
ask yourself that you wished I had asked?
    Mr. Winkenwerder. I can't think of one.
    Mr. Shays. I'd like to know if GAO would just like to make 
any comment before we adjourn? OK.
    Well, in the spirit of the obvious need, we look forward to 
working with you and we'll all take a fresh start at this. We 
will think anew, we will act anew, and we'll disengage 
ourselves and try to break out of the box and in the spirit of 
what Mr. Kucinich said, we need to know where there are needs, 
and if you tell us the needs, then it's our fault if we don't 
respond. But if you don't tell us the needs, then it won't lie 
on our shoulders and we'd like to share in that responsibility. 
So we will adjourn this hearing and thank all four of you for 
    [Whereupon, at 12:49 p.m., the subcommittee was adjourned.]