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



 
        RISK COMMUNICATION: NATIONAL SECURITY AND PUBLIC HEALTH
=======================================================================

                                HEARING

                               before the

                   SUBCOMMITTEE ON NATIONAL SECURITY,
                   VETERANS AFFAIRS AND INTERNATIONAL
                               RELATIONS

                                 of the

                              COMMITTEE ON
                           GOVERNMENT REFORM

                        HOUSE OF REPRESENTATIVES

                      ONE HUNDRED SEVENTH CONGRESS

                             FIRST SESSION

                               __________

                           NOVEMBER 29, 2001

                               __________

                           Serial No. 107-122

                               __________

       Printed for the use of the Committee on Government Reform





  Available via the World Wide Web: http://www.gpo.gov/congress/house
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                     COMMITTEE ON GOVERNMENT REFORM

                     DAN BURTON, Indiana, Chairman
BENJAMIN A. GILMAN, New York         HENRY A. WAXMAN, California
CONSTANCE A. MORELLA, Maryland       TOM LANTOS, California
CHRISTOPHER SHAYS, Connecticut       MAJOR R. OWENS, New York
ILEANA ROS-LEHTINEN, Florida         EDOLPHUS TOWNS, 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
STEVEN C. LaTOURETTE, Ohio           ELIJAH E. CUMMINGS, Maryland
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
TODD RUSSELL PLATTS, Pennsylvania    THOMAS H. ALLEN, Maine
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 
                               Relations

                CHRISTOPHER SHAYS, Connecticut, Chairman
ADAM H. PUTNAM, Florida              DENNIS J. KUCINICH, Ohio
BENJAMIN A. GILMAN, New York         BERNARD SANDERS, Vermont
ILEANA ROS-LEHTINEN, Florida         THOMAS H. ALLEN, Maine
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
EDWARD L. SCHROCK, Virginia

                               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

                              ----------                              
                                                                   Page
Hearing held on November 29, 2001................................     1
Statement of:
    Koop, Dr. C. Everett, former U.S. Surgeon General; Dr. 
      Kenneth I. Shine, president, Institute of Medicine, 
      representing the National Academy of Sciences; Dr. Mohammad 
      Akhter, executive director, American Public Health 
      Association; Dr. Joseph Waeckerle, editor and chief, Annals 
      of Emergency Medicine, representing the American College of 
      Emergency Physicians.......................................    34
    Satcher, David, U.S. Surgeon General.........................     3
Letters, statements, etc., submitted for the record by:
    Akhter, Dr. Mohammad, executive director, American Public 
      Health Association, prepared statement of..................    57
    Koop, Dr. C. Everett, former U.S. Surgeon General, prepared 
      statement of...............................................    38
    Satcher, David, U.S. Surgeon General, prepared statement of..     8
    Shine, Dr. Kenneth I., president, Institute of Medicine, 
      representing the National Academy of Sciences, prepared 
      statement of...............................................    44
    Waeckerle, Dr. Joseph, editor and chief, Annals of Emergency 
      Medicine, representing the American College of Emergency 
      Physicians, prepared statement of..........................    64


        RISK COMMUNICATION: NATIONAL SECURITY AND PUBLIC HEALTH

                              ----------                              


                      THURSDAY, NOVEMBER 29, 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 10:17 a.m., in 
room 2154, Rayburn House Office Building, Hon. Christopher 
Shays (chairman of the subcommittee) presiding.
    Present: Representatives Shays, Putnam, Gilman, Schakowsky, 
Tierney and Lynch.
    Staff present: Lawrence J. Halloran, staff director and 
counsel; Kristine McElroy and Thomas Costa, professional staff 
members; Michael Bloomrose, intern; David Rapallo, minority 
counsel; and Earley Green, minority assistant clerk.
    Mr. Shays. We call this Subcommittee on National Security, 
Veterans Affairs and International Relations of the Government 
Reform Committee hearing to order.
    The title of the hearing is ``Risk Communication: National 
Security and Public Health.''
    I welcome our witnesses. I welcome our guests to this 
hearing.
    Anthrax is not contagious. Fear is.
    In the battle against bioterrorism, fear is one of the most 
infectious diseases we face. For the terrorist, it is a potent 
force multiplier, capable of amplifying a minor, manageable 
outbreak into a major public health crisis. Driven by fear 
alone, hordes of the ``worried well'' could overwhelm emergency 
rooms and clinics, impeding diagnosis and treatment of the 
genuinely ill. Many would needlessly expose themselves to the 
risks of antibiotic treatments, incurring individual side 
effects and increasing the general threat of antibiotic-
resistant criteria. Fear-based worst-case scenarios can draw 
scarce medical supplies and vaccines to the wrong places at the 
wrong times, diluting response capabilities to meet the real 
threat.
    The only antidote to terrorism's toxin of fear is the 
truth.
    When something as unthinkable as a biological attack 
occurs, the public and the media need to hear one authoritative 
voice conveying the unvarnished truth about the extent of risk 
and the public health response. During a disease outbreak, the 
right information at the right time can save lives. Rumor, 
speculation, implausible optimism and mixed messages fuel panic 
and endanger public health and safety.
    In the Dark Winter exercise earlier this year, a lack of 
information about the extent and pace of three simultaneous 
smallpox outbreaks paralyzed national leadership 
decisionmaking. Opportunities to contain the epidemic were 
missed, irreplaceable vaccine stocks were wasted, public order 
decayed, State borders were closed, and communications were 
disrupted. National security was compromised, and for want of 
the facts our very sovereignty as a Nation dissolved.
    The recent anthrax attacks also taught some hard lessons 
about effective communication of critical public health 
information. In the hours and days after the first case was 
discovered, Federal, State and local officials struggled to 
rebut inaccurate, sometimes sensational, reports about the 
risks of a rare, little-understood disease, inhalational 
anthrax.
    We heard inconsistent assessments of the virulence of the 
pathogen and the sophistication of its manufacture. An 
epidemiological tool, nasal swab culture, was widely 
mischaracterized as a diagnostic test. It took some time for 
the voices of public health and medical experts to be heard as 
law enforcement and political officials gathered and 
disseminated information on rapidly unfolding events.
    To be prepared for the next biological attack, frank and 
frequent communication of medical information, risk parameters, 
treatment options and response plans should begin now, while 
the information can be heard and deliberated calmly.
    The draft response protocol for smallpox recently released 
by the Centers for Disease control and Prevention [CDC], 
recognizes the significance of public health education and pre-
emptive communication as integral parts of an effective 
outbreak control effort. But in the event of a widespread 
biological attack, one that threatens agriculture, food 
supplies, water and human health, who will collect, synthesize 
and reliably convey complex but critical information to a 
nervous public?
    One voice well suited to address public concerns about 
bioterrorism is that of the Surgeon General, Dr. David Satcher. 
As a former head of CDC, Dr. Satcher brings unique experience 
and unquestioned credibility to our discussion of public health 
information, public health infrastructure and medical data 
technologies. In past oversight efforts on blood safety and 
hepatitis-C, he was an indispensable partner to the Human 
Resource Subcommittee. We appreciate his expertise and his 
candor then, and we look forward to his testimony today.
    All our witnesses this morning bring important information 
and expertise to our discussion of better ways to fight 
terrorism with the simple truth. We welcome them.
    At this time we would recognize Dr. David Satcher, U.S. 
Surgeon General, and invite him to stand. I'll administer the 
oath, and then we'll take his testimony.
    [Witness sworn.]
    Mr. Shays. Thank you. Dr. Satcher, it is very nice to have 
you here.

        STATEMENT OF DAVID SATCHER, U.S. SURGEON GENERAL

    Dr. Satcher. Thank you very much, Congressman Shays and 
members of the Subcommittee on National Security, Veterans 
Affairs and Intergovernmental Relations, the Committee on 
Government Reform. I'm delighted to be able to join you and 
certainly the outstanding members of panel two in discussing 
this very important issue.
    As you know, I'm David Satcher, the U.S. Surgeon General, 
and I'm speaking to you about the public health response to 
bioterrorism and the threats of bioterrorism, and specifically 
the role which the Department of Health and Human Services 
plays in information dissemination and risk communication.
    The terrorist events on and since September 11th have been 
defining moments for all of us. Both as a Nation and as public 
health officials we have been taken to a place where we have 
not been before. It sometimes was uncertain what we were 
dealing with and to what extent. We had very little science of 
past experience to draw upon, and we literally learned more 
every day. The Nation's focus on issues related to public 
health has been greatly sharpened. There has been fear, shock, 
confusion and, in some cases, even panic; and panic when it 
occurs, as you said, supports the aim of the terrorists.
    We have certainly encountered some bumps in the road, but 
it is somewhat remarkable how well-coordinated our efforts have 
been overall. The challenge was great. We were faced with the 
task of coordinating communications among local governments, 
State governments and the Federal Government. Each level came 
with its own set of elected officials and public health 
officials, all with their own concerns. The Department of 
Health and Human Services tried to deal with it by being 
forthcoming. We tried to inform the public quickly. We let them 
know what we knew and when we knew it. When the information 
changed because we learned something new, we tried to let them 
know that. Through it all, vital public health information has 
been disseminated promptly and we have delivered medicine and 
expertise where needed.
    I believe it is fair to say that, as a result, while we 
have lost five people too many to this bioterrorist attack, we 
have saved countless lives. Casualties were kept far below 
expectations, in that the fatality rate for inhalation anthrax 
has been thought to be around 80 to 100 percent.
    Mr. Shays. Now, if you had been courteous, you would have 
stumbled over inhalation to make me try to feel----
    Dr. Satcher. Let me try it again. No, you did great.
    The fatality rate to date in our experience has been only 
40 percent. All of this demonstrates why effective 
communication based on a strong and flexible public health 
infrastructure is so critical.
    I think under the leadership of Secretary Thompson, HHS has 
been working to strengthen the overall public health 
infrastructure so that we're prepared to respond to a range of 
disasters and emergencies, including bioterrorism. Since 
September 11th, we have intensified our efforts, resulting in a 
heightened level of preparedness. We are committed to 
increasing our preparedness based on lessons learned in recent 
months.
    Now, because I believe that the public health 
infrastructure is a critical issue here and communication 
before, during and after such an attack is so critical, I want 
to discuss the public health infrastructure as it exists and 
its role.
    Our public health infrastructure consists of several 
interrelated components at many different levels. Communication 
within and among each level is critical, as is the need for 
mutual support.
    At the government level, the Public Health Service, the 
Department of Health and Human Services, works closely with 
State and local health departments. Our philosophy is to help 
support local officials, rather than to try to replace them.
    Throughout the recent crises, the CDC's Health Alert 
Network and Laboratory Alert Network immediately notified State 
and local health departments of the latest developments on 
anthrax and the possibilities of other bioterrorism attacks. In 
fact, the Health Alert Network was used September 11th to 
immediately put State health departments on alert for anything 
suspicious following the attack on the World Trade Center.
    Now, the role of the Surgeon General in all of this, of 
course is, No. 1, to command the Commissioned Corps, and the 
Commissioned Corps consists of about 5,600 health 
professionals--physicians, nurses, dentists, veterinarians, 
environmental health specialists. That Commissioned Corps was 
activated on September 11th and has been activated since. These 
are people who are on call 24 hours a day, 7 days a week. We 
have deployed hundreds of them to New York City and to other 
places as needed.
    The second role of the Surgeon General is to communicate 
directly with the American people based on the best available 
public health science. Usually this results in a report from 
the Surgeon General after months and years of study of a 
particular topic, such as smoking and health, mental health, 
suicide prevention. But in the case of a bioterrorist attack, 
the role of the Surgeon General in this communication has never 
been clearly defined, and that is one of the things that we 
have been struggling with.
    The anthrax cases in Florida provided a good example of how 
CDC works with State and local health officials. After the 
first case there resulted in death, the CDC moved quickly to 
confirm the case of the second victim early on the evening of 
October 7th. The Centers for Disease Control and Prevention and 
other components of HHS, the Federal Bureau of Investigation, 
the Department of Justice, the Florida Governor's Office, the 
Florida Public Health Department and local public health 
departments quickly formulated a plan that got word out 
overnight to the AMI employees that they needed to come to the 
clinic for medicine and testing the very next morning. The CDC 
shipped medicine to Florida overnight and immediately deployed 
epidemiologists to Florida; and CDC and Florida officials 
issued a joint release at 11 p.m. on October 7th notifying the 
media and the public of the second case. So it was a good 
example of local, State and Federal officials working together 
to get the message out to send medicine and to mobilize people 
to come to get treatment--literally overnight on a Sunday 
evening.
    In a Federalist system, there are going to be communication 
challenges between Federal, State and local government. In all 
of the anthrax situations, for example, once the CDC receives 
initial test results, it promptly begins doing more accurate 
confirmatory tests. But a mayor or Governor may decide to go 
out and talk to the media before the confirmatory tests are 
concluded. Those officials make the decision whether to do that 
based on their perception of the needs of the community, and we 
respect those decisions. At the same time, when you try to 
communicate that tests are merely preliminary, you hope that 
the public and the media will hear that and appreciate what 
that means.
    That is the first layer of the public health 
infrastructure.
    The second layer of the public health infrastructure is the 
health care delivery system, and it consists of not just the 
private sector but also there are public components like 
community health centers, community mental health centers and 
others. It is a very critical front-line part of the public 
health infrastructure.
    The Department of Health and Human Services and especially 
the CDC worked extensively to reach out to various groups 
within the delivery system to inform them of what we knew. The 
Secretary met early on with the medical associations, the 
biotech industry, the pharmaceutical industry, the food 
industry to address bioterrorism concerns. Together with the 
CDC, a conference call with the State and territorial health 
departments took place immediately.
    We also realize that there are tremendous opportunities to 
strengthen our lines of communication at this level through the 
use of conference calls and through satellite and video 
technologies, and we should not wait until there is a 
bioterrorist attack. CDC and HHS have done two major satellite 
conferences with physicians and hospitals on anthrax, smallpox 
and bioterrorism. We must continue to look for new ways to 
reach out aggressively.
    The third layer of the public health infrastructure is 
really the general public. The third level is by no means any 
less important than the other two, especially since it actually 
serves as the real front line: the public. Bioterrorism attacks 
first impact the public, either individually or in groups. We 
rely on the public to seek treatment or advice regarding 
unusual occurrences and to assist health care providers in the 
efforts to detect disease early.
    The public must also be informed and educated about good 
public health habits, such as handwashing after handling 
foreign objects, safe handling and washing of foods, thoroughly 
cooking meats, for example, and the careful handling of 
suspicious mail and other packages. Good public health habits 
are individual and community in nature.
    After October 4, we immediately made available to the media 
an array of medical/scientific spokespersons, in addition to 
myself and Secretary Thompson, and that included CDC Director 
Jeffrey Koplan, Tony Fauci at NIH, the Secretary's recently 
named special adviser D.A. Henderson, and other officials at 
CDC, NIH and the FDA. The CDC also made officials available to 
the local media during the news conferences conducted by local 
officials, whether that was in Florida, New York or in 
Washington.
    One challenge that we faced in these situations was the 
volume of demand--and I want to really make that point. There 
were so many news shows and networks who wanted to interview, 
there was no way that one person could have met the media 
demands. By making several people available with expertise, we 
could more readily service this demand and at the same time 
draw upon the diversity of expertise that we had available, and 
there were times when the media requested specific people based 
on what they saw as a specific area of interest or expertise.
    Now, the second week in October, the Secretary and senior 
members of the HHS team began holding daily teleconferences 
with the media. The CDC began doing daily press calls with the 
media about a week later.
    Now, the interesting thing about bioterrorism, of course, 
and the way it differs from the public health response to other 
problems and infectious diseases, is that it requires a 
partnership with the criminal justice system. In instances of 
naturally occurring disease outbreak, those three levels would 
be sufficient. But because the disease outbreak is 
bioterrorism, it is intentionally triggered, a public health 
emergency response must include the criminal justice system as 
part of this infrastructure, while striving to maintain the 
appropriate independence of the public health system. That has 
been an ongoing challenge, but I think, for the most part, 
communication with the Department of Justice has been good.
    I would make four types of recommendations for 
strengthening risk communication before, during and after a 
bioterrorist attack.
    First, it is critical that we continue to strengthen the 
public health infrastructure, and we must ensure that all 
components of that infrastructure are strengthened. And this is 
not just about treating diseases or emergency. This is about 
promoting health and preventing diseases. That is right now, in 
my opinion, the Achilles heel of the American health system. We 
have not adequately invested in the public health 
infrastructure, especially as it relates to health promotion 
and disease prevention, and that is why we have trouble with 
antibiotics and antibiotic resistance and people understanding 
why it is not appropriate to take antibiotics when not 
prescribed--or not as prescribed.
    We must continue to improve educational opportunities and 
information sharing between the Public Health Service and 
front-line health providers. This is critical. Many doctors at 
the local level still fail to report disease diagnosis to 
Federal officials, and this has been a long struggle to get any 
reportable diseases, unusual cases reported to the Public 
Health Service. By the same token, Federal officials sometime 
fail to provide local providers with a national picture on a 
timely basis that they can use in terms of their index of 
suspicion. This can be strengthened, and it must. The mechanism 
must be put in place to ensure that we have an ongoing dialog 
that will make it easier for providers to access information.
    In the minds of some people, and it is an old saying, that 
all public health is ultimately local, and there is a lot of 
truth to that saying, so there must be local efforts as well as 
Federal and State efforts to educate the community as well as 
health care providers.
    We have a tremendous opportunity to improve our system of 
risk communication and to be much better prepared for the next 
major bioterrorist attack, which hopefully will not come, but, 
in order to do that, we must work together, and we must begin 
by making a commitment to strengthen the public health 
infrastructure.
    Thank you, Mr. Chairman. I will be happy to respond to any 
questions. As you know, I have submitted a more extensive 
written statement for the record, but the Department would also 
be happy to respond to any questions that you would like to 
submit.
    Mr. Shays. Thank you very much.
    [The prepared statement of Dr. Satcher follows:]
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    Mr. Shays. I want to just first get some housekeeping out 
of the way. I appreciate your statement. It was thorough and 
very helpful.
    I ask unanimous consent that all members of the 
subcommittee 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 statement in the record. 
Without objection, so ordered.
    And I would note the presence of Ms. Schakowsky from 
Chicago and Mr. Tierney from Massachusetts.
    I'd be happy to start with questions, but I'd be happy--if 
you're all set, we could start with you. I recognize Ms. 
Schakowsky.
    Ms. Schakowsky. Thank you, Mr. Chairman; and thank you very 
much, Dr. Satcher, for being here.
    I have to tell you that I was somewhat surprised by your 
description of the administration's handling of the anthrax 
crisis, that it was so glowing, frankly, especially considering 
some of the major missteps that we have all seen. You call 
these mere bumps in the road, and you said that actually you 
thought coordination was remarkable in your statement. But I 
was surprised because the administration has, in fact, been 
highly criticized by many highly qualified experts, especially 
in the arena of risk communication, which we're mainly focusing 
on today, and especially in light of several deaths, which at 
least some people say might have been averted.
    I'd like to direct your attention to some of the statements 
that were made--and some of the individuals are going to be on 
our second panel with--well, there are four--remarks were made 
on the record, so you'll excuse me if you're being quoted here.
    But Dr. C. Everett Koop, former U.S. Surgeon General, said 
that, ``I'm communicating information to the public on 
bioterrorism. I would not give the administration a high 
mark.''
    Dr. Mohammad Akhter, executive director of the American 
Public Health Association, said, ``health departments have 
obtained information from CNN more rapidly than they have from 
each other or from the CDC.'' It went on to say that law 
enforcement, intelligence agency and public health officials, 
``stumbled over each other in responding to the anthrax 
outbreak.''
    Dr. Kenneth Shine, President of the Institute of Medicine, 
believes, ``the effectiveness of communications to the public 
and to health professionals about the anthrax terrorism were 
found wanting.''
    And, finally, Dr. Joseph Waeckerle, editor of the Annals of 
Emergency Medicine, found that, ``crisis communication was 
often inaccurate and misleading or too scanty. No centralized 
leadership, no voice of authority and inconsistent information 
resulted in the American public remaining in an informational 
vacuum.''
    My concern, therefore, in terms of your remarks is that I 
think it's important that we take a very cool eye as we look 
back and take a studied look at what exactly happened in order 
to put in place what needs to be done, and so I'm wondering 
really, in light of those comments, how your interpretation of 
the events could be so different from those that I just quoted 
to you.
    Dr. Satcher. Well, let me first say, as you know, I have 
tremendous respect for the four people you've quoted. I've 
worked very closely with them over the years, and even since 
this outbreak. And clearly, as I said in my statement, there 
were problems in our response to this outbreak, and it is true 
that, since I knew that they were going to emphasize the 
negatives, I thought it was important to also point out that 
there were many positives. And we don't point that out. We do a 
great injustice to the people at the local, State and Federal 
level who have been working so well together. There have been 
problems, but they have saved a lot of lives.
    I could go into that in more detail, about what could have 
happened and what the terrorists intended to do and what 
anybody would have projected would have happened if we had 
discussed this 6 months ago, what would have happened when you 
had the first anthrax attack. Most people would have projected 
that we would have lost many more lives, especially dealing 
with aerosolized anthrax.
    So the rapid response of getting medication to anyplace in 
the country within a few hours, the rapid response of getting 
epidemiologists on the scene within a few hours and acting in 
such a way as to determine who was exposed and therefore who 
needs to be--receive prophylactic antibiotics--over 30,000 
people, perhaps 35,000 to 40,000, have been started on 
antibiotics, and at least 5,000 continued it for 60 days. Many 
of those people could have gotten inhalation anthrax.
    We deeply regret the five deaths that have occurred, and 
obviously we keep retracing what could have been done 
differently to save those lives. But I think the point of the 
matter is we have to also build on our strengths. We have to 
know what they are.
    And we have to also know what our weaknesses are. I've 
tried to point out what I think those weaknesses are.
    It is going to be very difficult to satisfy the media with 
one person being the spokesperson, for, No. 1, there are--I 
have done 40 interviews on television and radio within the last 
few weeks, and that doesn't begin to tell you how many requests 
there have been. What about all the other people--Tony Fauci, 
Dr. Fauci from NIH, who has done many interviews, Dr. 
Henderson, the Secretary? There have been many people.
    The problem--and I think you're right, and I would agree--
we have to figure out a way to better coordinate the message 
that we send out. But the difficulty is, this is a dynamic 
situation. I mean, it's changing every minute, and we don't 
actually know what the terrorist is going to do next, and we 
don't necessarily know how he or she is going to do it. And in 
that environment to try to communicate a message----
    The public wants to hear from you on a very timely basis, 
but they also want your statements to be definitive. They don't 
want you to say, our preliminary information is the following. 
The CDC is continuing to do tests. And then tomorrow you come 
back and say, well, on further testing, that sample was not 
negative. It was positive. Well, that, in fact, is accurate, 
that is true, but the fact of the matter is it's a dynamic 
situation, so if you're going to keep the public informed----
    And there is a lot to be said for that in terms of dealing 
with the kind of panic that Congressman Shays described. You 
try to give up-to-date information.
    But the question is, do people really appreciate that a 
test may be preliminary, that using nasal swabs to screen 
people at the outset was not necessarily a bad idea in terms of 
determining who might have been exposed in a given situation?
    The problem was that the public misunderstood that nasal 
swabs were not definitive tests. And so when people came back 
and said, even though your test was positive, when we did 
further tests at CDC it was negative, so you don't have to 
continue Cipro--or, in other cases, even though you had a 
negative nasal swab, because we have determined that you could 
have been exposed, we're going to put you on Ciprofloxacin or 
Doxycycline for the next 60 days.
    Those are not easy messages to communicate to the general 
public, and I think anyone could be justified at selecting the 
negative things that have happened and weaknesses and focusing 
on those. And I think there is something to be said for that, 
and I think it makes a contribution to the whole distribution, 
but I also think somebody needs to stop and say, some things 
went right here, and we've got to build on those things that 
went right and to make sure that in the future more things go 
right.
    That is the perspective that I'm taking. Because it is very 
clear to me that you have the experts here to criticize what 
happened.
    Mr. Shays. What I'll do is I'll ask questions. Then we'll 
go to Mr. Tierney, and then we'll go to Mr. Putnam.
    I think it's very clear that it's been a pretty dramatic 
few months, and I think it's pretty clear that we had some 
people who were not only having to deal with this issue but 
they were new to the job as well. But you have been around for 
a while, and I consider you a pretty steady hand. I'd like to 
have you give me an assessment of whether you felt you were 
playing the role you should have played as the Surgeon General. 
I view you as, you know, the chief health care spokesperson for 
the government.
    Dr. Satcher. Well, let me say a couple of things.
    I think I could have played a more impactful role. The 
Surgeon General functions best--and there is a lot of history, 
Dr. Cooper and others--when the Surgeon General has the ability 
to base his or her statements on the best available science. 
Throughout history, Surgeon General's reports have been based 
on extensive examination of the research that has been done in 
an area. The American people have come to trust those reports 
because they are so solidly based in public health science, not 
politics, not personal opinion.
    We have not been here before where you have to respond to 
an ongoing bioterrorist attack. You really don't have time to 
assemble all of the science, and the science is also changing, 
and therefore there are a lot of questions that people want to 
ask. Some of them relate directly to the science. Some of them 
relate to organization and management. And so there have been 
interviews done in all of those areas.
    I think Secretary Thompson saw himself as responsible for a 
department that included the Centers for Disease Control and 
Prevention, the National Institutes of Health that is 
responsible for the research to produce better drugs and 
vaccines and supplies----
    Mr. Shays. You can move the mic a little away because----
    Dr. Satcher. I'm sorry.
    Mr. Shays. No, you don't need to apologize that you have 
such a nice voice. It carries well.
    Dr. Satcher. Thank you--the Food and Drug Administration. 
So he is responsible for all of these agencies, and I think he 
felt there was a responsibility to communicate about the 
overall picture within a department.
    Now, has the Secretary--has the Surgeon General in the past 
been in a position to speak for the entire Public Health 
Service? Yeah, many years ago before the structure was changed. 
But the structure is completely different today than it was 
when the Surgeon General was the head of the Public Health 
Service, and so the situation in terms of day-to-day 
communication about what is happening in a department is not a 
role that the Surgeon General has played in recent years.
    The Surgeon General has reported on specific issues based 
on the best available science. Surgeon General Koop reported on 
HIV/AIDS in 1986. The AIDS epidemic started in 1981. We learned 
a lot about AIDS in those years before the report went out. I 
could say the same thing about my report on mental health.
    So I think one of the problems we have here is we have not 
done the job that we need to do at redefining the role of the 
Surgeon General, communication about a dynamic bioterrorist 
attack, that are ongoing, where the science is evolving on a 
day-to-day basis. We think we need to do that because I think 
there is a critical role.
    Mr. Shays. I'm going to have you turn the mic a little 
closer but not too much closer. That's perfect.
    You basically said that we've learned a lot. Just about 
say, anthrax, just walk me through some of the things. One of 
the things we learned was that inhalation anthrax was something 
we thought could kill somebody. I mean, when we had hearings on 
the anthrax vaccine in the military, it was, you know, if you 
inhaled it, you were dead, and we learned that is not so, where 
also it's conceivable that--we're learning that--some of the 
people that died were people who were dealing with some--who 
were either older or were dealing with some physical 
challenges, that they become more susceptible to the inhalation 
anthrax, killing them, as opposed to being healed through 
antibiotics.
    Just walk me through some of the things we've learned.
    Dr. Satcher. Well, let me just say I think one of the most 
painful lessons that we have learned involved the deaths of the 
two postal workers at the Brentwood facility, because I think, 
up until that occurrence, the assumption and the public health 
line was that people exposed to an envelope in an office that 
had been opened were susceptible to anthrax and needed to be 
treated prophylactically. But many statements of the CDC up 
until that time had said we have no reason to believe that a 
closed envelope passing through a post office could expose 
people. We know better than that now, and it would have been 
greater if we had known that before.
    We know more about, for example, how mail can be handled 
and how envelopes can be ripped apart, but there was no 
evidence in this case that had happened. So let me just say we 
still don't have the full answer to what happened in the 
Brentwood post office, but we do know that somehow at least two 
postal workers were exposed.
    You would have to assume, Congressman Shays, that many more 
workers were exposed; and the question is, why haven't they 
come down? Because, obviously, we got to them early enough. If 
we had known beforehand of the potential of the spores to 
escape in a post office setting and infect people in that 
environment, we could have perhaps saved those two people.
    By the same token, getting back to the second level, if 
people on the front lines who take care of patients had been 
more acutely aware and had the appropriate level of suspicion, 
it might well be that we could have saved those two postal 
workers. But all of that is in retrospect. I think that is the 
most painful lesson we've learned, is how critical it is to 
really have the kind of working relationship with the front 
line that leads people on the front line to have the 
appropriate level of suspicion at a time like this and to make 
sure that everybody is asked about their work environment. If 
they show up with an upper respiratory infection--but, 
remember, there were hundreds of thousands of people who showed 
up with upper respiratory infections during those 2 days.
    I think we've also learned that the American public needs 
much more information about the use of antibiotics and 
vaccines, the appropriate use. I know CDC has had a strategy 
going to try to reduce drug resistance in recent years, and 
part of that has been to make sure that people understood that 
if you take antibiotics inappropriately you do great damage not 
only to yourself potentially but other people. I can tell you 
that the American people are going to a doctor's office today 
asking for antibiotics for the common cold, as we speak. There 
are people going saying, I want a penicillin shot or I want 
this antibiotic, because I believe that will help me get over 
this cold that I have. So we have a lot of education to do so 
that the American people really understand and appreciate the 
dangers, and we take that responsibility----
    Mr. Shays. Just a second--and I appreciate Mr. Tierney's 
patience here, but it is absolutely imperative in that 
circumstance that the physician tell the patient it would be a 
terrible mistake to have an antibiotic. Correct? I mean, it's--
--
    Dr. Satcher. That brings you to the second level. You know, 
I've trained primary care physicians in my career; and I 
remember in an area like Watts training them and counseling 
them about when you go out there to take care of patients make 
sure that you do this and that. And they come back and say, 
well, if we don't do it, the patient goes to find another 
physician who will.
    So we're caught up in a situation here where many 
physicians on the front line--and we've talked about this 
with--the American Academy of Pediatrics and the American 
Academy of Family Physicians feel an unusual pressure to 
prescribe antibiotics for patients, and they've done it within 
recent weeks, patients who have requested antibiotics and even 
other things that they wanted.
    So it is a team, it is a partnership, and I think everybody 
in that partnership has to be empowered and better informed.
    Mr. Shays. I look forward to asking some more questions of 
you, but let me recognize Mr. Tierney for a good 7 minutes.
    Mr. Tierney. I don't need all that time. Thank you.
    I have a question to followup on----
    Mr. Shays. Could I just interrupt? I apologize. I didn't 
acknowledge the presence of Mr. Putnam or Mr. Lynch and 
appreciate both of them being here. I'm sorry. Thank you. Thank 
you.
    Mr. Tierney. Thank you.
    I want to followup on what you have just spoken about in a 
minute, but first let me ask you, there was a Dark Winter--it 
was the name of a program or the exercise I guess that was gone 
through by a number of people. During the course of that, 
former Senator Nunn made a comment that there is an inherent 
conflict between health and law enforcement when you have a 
situation like we have with anthrax, and then there were 
reports in the newspaper in Florida that the FBI had actually 
told public health officials that they couldn't speak publicly 
about what was going on. Would you talk about what happened in 
Florida and what happened and a little about that conflict and 
how you would remedy that?
    Dr. Satcher. Well, let me just say that I'm not going to 
give details about what happened that you might want, but let 
me just say there is a difficult situation when you have a 
bioterrorist attack. Everybody wants to find out who is doing 
this. And I think whether you're in public health or law 
enforcement your first priority is how do we stop this from 
happening. So if the Department of Justice or the FBI say to 
us, we really want to treat this information carefully so that 
we don't tip off the terrorists as to what we have, we have to 
cooperate with that.
    I mean, when there's a natural occurrence of influenza or 
something, we can control the prevention. We can't when it's a 
bioterrorist attack until we find the person or persons who is 
doing it. Our hands are tied, and we don't know what they're 
going to do next.
    So I would say those of us in the Public Health Service 
appreciate the role of the criminal justice system in dealing 
with a bioterrorist attack, and when they need cooperation that 
is critical to carrying out their responsibilities we believe 
that it's our responsibility to cooperate.
    Mr. Tierney. Do you see that conflicting sometimes with the 
need to get information to the public?
    Dr. Satcher. Most definitely.
    Mr. Tierney. And how do you reconcile that?
    Dr. Satcher. Well, we've tried to do that, and you've seen 
several interviews done even with the White House and Governor 
Ridge where people have asked questions and we've just said we 
can't respond to that right now. That's in the hands of the FBI 
and Department of Justice, if they were not there to respond 
themselves. So we have tried to explain that in some cases we 
were not able to give information because we felt that it might 
endanger the investigation. That is what we've tried to do. 
It's not easy, and it is a very difficult conflict to deal 
with, as Senator Nunn pointed out in that exercise.
    Mr. Tierney. Do you think that we're properly using 
technology that is available to us to get the public health 
message in a crisis situation down to doctors at the local 
level and hospitals at the local level community centers?
    Dr. Satcher. I think we are now, but I think we should have 
done it before there was an attack. I think we educated and 
communicated with hundreds of thousands of physicians since the 
attack. But what it says to me is that, whereas in the past we 
have relied on physicians to go to meetings and conferences to 
become educated about bioterrorism, we could have used the 
satellite system for ongoing communication with providers, and 
hopefully in the future that is what we will do. I think it's 
an area where we can make a lot of improvement, and I made that 
as a recommendation.
    Mr. Tierney. You have.
    Dr. Satcher. Yes, and included it in the testimony.
    Mr. Tierney. Last, let me just ask you this. The end of 
your answer responding to the Chairman Shay's question, you 
talked about doctors going out and saying that they've got a 
great deal of pressure from patients to give antibiotics to 
others. How much of that do you attribute to this phenomenon of 
advertising by the manufacturers and placing their seed in the 
mind of patients?
    Dr. Satcher. Yeah. I think in recent years, with the 
Internet especially but with advertising in general, I think 
many patients come to physicians asking for drugs that they've 
heard about through the newspaper or through the Internet. So 
it is a major part of the problem. I don't think it's a problem 
that we can't solve, because I think there are a lot of 
positive things about a better-informed patient and patient 
community, but somehow we've got to get to the point where we 
have everybody on the same wave length as to how we protect the 
health of the public.
    Again, my opinion is--and I had this opinion for many years 
and I've stated it for many years--there's no place in the 
world better than this country when it comes to treating 
diseases and crises. The problem is, how do we protect the 
health of the public? How do we promote health and prevent 
disease? I think that's the Achilles heal of our health system, 
and it's reflected in that interaction.
    Mr. Tierney. Thank you.
    Dr. Satcher. Uh-huh.
    Mr. Tierney. Yield back.
    Mr. Shays. I recognize--thank the gentleman and recognize 
Mr. Putnam.
    Mr. Putnam. Thank you, Mr. Chairman.
    Dr. Satcher, to followup somewhat on the previous line of 
questioning, there have been a number of complaints from local 
law enforcement officials about the FBI's refusal to share 
information with them that were critical to their mission. Have 
you found the FBI unwilling to share information, even if it 
may be of--information you don't share publicly, but have you 
found them to be willing to share with you the information you 
need to accomplish your mission as a public health officer?
    Dr. Satcher. Well, because that's handled at a departmental 
level, I can only say to you that Secretary Thompson's position 
has been that he's had good communication with the Department 
of Justice and the FBI, and that communication would take place 
at his level. And that is--you know, his official position is 
that he's had good communication with the Department of Justice 
and the FBI.
    Mr. Putnam. I've just been handed something that indicated 
that the Secretary has admitted to being frustrated at times in 
attempting to acquire and pass on information to the public on 
anthrax due to the classifications or other FBI restrictions.
    Dr. Satcher. Well, I think that is a different issue. I 
think clearly, as I said in answer to Mr. Tierney's question, 
it's frustrating when the public wants you to pass on 
information that you can't pass on because it's a part of the 
investigation. But I thought your question was, are we getting 
information that we need from the FBI, as opposed to can we 
pass on information that we'd like to pass on to the public? In 
the latter case, it has been very frustrating, as Senator Nunn 
defined it. But I thought you were asking me, is the 
communication between the Secretary and Attorney General and 
the FBI satisfactory? I have not heard him complain about that. 
I've heard him complain about being limited in his ability to 
then pass on this information to a public that expects him to 
pass it on.
    Mr. Putnam. You're correct. The first question you did 
answer adequately.
    With regard to sharing of the information with your local 
health officials, State and local health departments, how many 
of them have access to your Health Alert Network and Lab Alert 
Network?
    Dr. Satcher. The Health Alert Network is actually now 
available to all State health departments. As you know, the 
State and local health departments vary tremendously in their 
capability. That is one of the weaknesses of the public health 
infrastructure, the tremendous vulnerabilities among State and 
local health departments. There has been a program in place now 
for over 5 years and Congress has provided funds through the 
CDC to strengthen State public health laboratories. We still 
have a long ways to go, as you know.
    There are States in this country that don't have a trained 
epidemiologist. There are local health department--there are 
local communities that don't have a local board of health. And 
so the problem in the country today as I see it is a great 
heterogeneity among the various States and local communities.
    I think the Health Alert Network needs a lot of support. It 
needs more funding. We also need the Laboratory Alert Network 
to be continually developed and strengthened.
    So the official statement I think from the CDC is that 50 
States are receiving funding under the Health Alert Network 
grant program, in addition to Guam, the District of Columbia, 
New York City, Los Angeles and Chicago. You know, we fund some 
localities as if they were States because they are so big.
    Thirteen States are connected to all of the local health--
all of their local health jurisdiction, only 13. Thirty-seven 
States have begun connecting to local providers.
    So it is true that 50 States are receiving funds, but 
there's a lot of difference--there is a lot of heterogeneity in 
terms of what happened within those States and their ability to 
use the information.
    Mr. Putnam. It's essentially--in terms of disseminating 
information quickly, it's little more than an e-mail or a fax, 
isn't it? I mean, please----
    Dr. Satcher. Well, the Health Alert Network is based on the 
best technology.
    Mr. Putnam. So, I mean, surely the technology and the price 
pressures for cheap technology would be such that there 
shouldn't be any States or any health department or any 
hospital or any doctor's office out there that not have access 
to----
    Dr. Satcher. Well, I would like to refer you to Senator 
Frist's statement when he and Senator Kennedy introduced 
legislation to provide $3.5 billion for strengthening health--
the public health infrastructure. He pointed out how many 
health departments did not have a computer in this country. So, 
as strange and shocking as it may seem, there is tremendous 
heterogeneity among--especially among health departments but 
also State health departments. But I would refer you to his 
testimony about the major problem that we have in terms of the 
technology that is available in many different situations.
    Mr. Putnam. And very quickly, as my time has expired, 
because of the crossover of anthrax, for example, being 
essentially an animal disease and some of the--how much 
coordination is there between the HHS and USDA and between the 
medical professionals and veterinarians to coordinate 
information as the entry points for some of these may actually 
be through animal or agricultural products?
    Dr. Satcher. Yeah. I think there's room for improvement in 
this area, but I do want to say that the Commissioned Corps, 
which I oversee, which has 5,600 health professionals, has over 
100 veterinarians; and we have sent people from our department 
to areas where there were outbreaks that involved animals, 
including outbreaks recently in England and in places in Europe 
in terms of mad cow disease. So we do have veterinarians in the 
Public Health Service, and we do have a working relationship 
with the USDA. I think everyone would agree that we can do much 
to strengthen that working relationship.
    Mr. Putnam. Thank you, Dr. Satcher.
    Mr. Shays. I thank the gentleman.
    At this time, I would recognize our newest member. It's 
wonderful to have you here, Mr. Lynch. Do you have questions?
    OK. Thank you.
    Mr. Gilman, do you have any questions you would like to 
ask? Or I have some that I could quickly ask and give you some 
time.
    Mr. Gilman. Well, thank you, Mr. Chairman. I want to thank 
you for holding today's hearing to examine the overall level of 
communications between the Federal Government and the public 
health system regarding bioterrorism risks, and I want to thank 
our panelists who are here today.
    For many years discussions about the possibility of a 
biological terrorist attack occurring in our Nation was 
relegated to the academic and policy discussions. Regrettably, 
the terrible events of September 11th and the subsequent 
anthrax incidents in New York and Washington sharply focused on 
our national attention on terrorism and underscored our 
vulnerability.
    You and I attended a hearing earlier today with our arms 
Secretary in the State Department, and he noted how many 
nations there were who have been developing biological weapons. 
It's certainly an important element for us to take a good, hard 
look at, both in terms of where the threat originates and what 
specific agents pose the greatest danger. So far, the media has 
focused its attention only on anthrax and smallpox, yet those 
represent only two out of the many agents which could 
conceivably be utilized. Still, those two agents are the ones 
that have garnered the most attention.
    In the case of anthrax, the events following the 
contaminated mail incidents in October have shown that there is 
much room for improvement on the part of our own government and 
the communication process, and while officials at CDC and HHS 
have demonstrated improvement in their communication strategy 
over time, their early missteps, particularly in downplaying 
the initial risk of exposure, has led to additional 
complications as the situation--it's vital, therefore, that 
these Federal health officials have learned from those past 
mistakes and are able to ensure the public that they will not 
be repeated in the future.
    So I want to just ask one question. Have the various 
Federal and public health services considered adopting a daily 
briefing program similar to those conducted by the White House, 
the Department of Defense with regard to the bioterrorism 
situation?
    Dr. Satcher. Yes. Congressman, I mention in my testimony 
that both the Secretary of Health and Human Services and the 
CDC have initiated daily briefings for the press since the 
second week in October. So there have been ongoing 
interactions. I think that is the part of the strength of the 
communication, but it is also a part of the things that people 
are going to be able to criticize. Because by having daily 
briefings, you're also going to give information that is 
evolving, which means that some of it is preliminary, and 
therefore how do you deal with preliminary information where 
the results are going to change.
    But I think the daily briefings are important and think 
they have been very helpful to members of the media and, 
therefore, to the general public.
    Mr. Gilman. Dr. Satcher, who has the overall responsibility 
of conducting our Nation's defense against bioterrorism? Is 
there any one person or any one agency?
    Dr. Satcher. Well, it's really the Justice Department that 
has the overall responsibility for defense against 
bioterrorism----
    Mr. Gilman. And is----
    Dr. Satcher. And all of the bioterrorists, including the 
exercise that was discussed earlier with Senator Nunn. It is 
understood that the first responsibility in terms of protecting 
the American people and guarding against criminal behavior, 
which we're talking about here--we're talking about criminal 
behavior, where there is a criminal somewhere attacking----
    Mr. Gilman. But, Dr. Satcher, what I'm trying to pinpoint 
is where is the overall responsibility for coordination and to 
make certain all of the agencies are working together on this.
    Dr. Satcher. Oh, right now, of course, it's the new Office 
of Homeland Security in the White House, but that's a new 
office.
    Mr. Gilman. And does that Homeland Security Director have 
the responsibility then of coordinating----
    Dr. Satcher. Coordinating, yes.
    Mr. Gilman [continuing]. All of our efforts on 
bioterrorism?
    Dr. Satcher. Governor Ridge, the head of homeland security 
today, has the overall responsibility for coordinating all of 
the efforts.
    Mr. Gilman. And do you report to him with regard--or do you 
work with him with regard to----
    Dr. Satcher. I report to Secretary Thompson in the 
Department of Health and Human Services, and he deals directly 
with Governor Ridge.
    Now, Governor Ridge has often asked me as Surgeon General 
to join him at the White House for conferences with the media. 
But, in our department, that relationship is with the 
Secretary, as it is with--you know, with other departments, 
Department of Justice, Attorney General.
    Mr. Gilman. Dr. Satcher, do you sit in with other agencies 
to explore what has to be done on bioterrorism?
    Dr. Satcher. Agencies within the Department of Health and 
Human Services?
    Mr. Gilman. All of the agencies.
    Dr. Satcher. No. Again, that interaction would be at the 
level of Secretary Thompson.
    Mr. Gilman. And do you sit in with Secretary Thompson on 
that kind of direction?
    Dr. Satcher. There are times, but that is really not the 
major role of the Surgeon General. If the Surgeon General did 
that----
    Mr. Gilman. I realize that.
    Dr. Satcher. If the Surgeon General did that, it would be 
very difficult then to be responsible for the Commissioned 
Corps and deploying people under an emergency basis and 
continuing to speak with the American people all over the 
country. So it is not a day-to-day responsibility of the 
Surgeon General.
    Mr. Gilman. So the Surgeon General then doesn't have any 
responsibility on planning with regard to bioterrorism or----
    Dr. Satcher. Well, the Surgeon General has input to 
planning, yes, definitely, but not to be involved in meetings 
with departments. Because when you say--you're talking about 
meetings with the Department of Justice and----
    Mr. Gilman. Well, I want to ask you, if you had some 
thoughts, constructive thoughts on what should be done on 
bioterrorism, who would you pass that on to?
    Dr. Satcher. Secretary Thompson of the Department of Health 
and Human Services.
    Mr. Gilman. Thank you.
    Thank you, Mr. Chairman.
    Mr. Shays. I thank the gentleman.
    Dr. Satcher, we could ask you a lot more questions. We have 
another panel we want to get to. I want to ask you just a few, 
though.
    I want to ask you how you would define the role of the 
Surgeon General in terms of you and anyone who follows you as 
it relates to bioterrorism.
    Dr. Satcher. The Surgeon General has two major areas of 
responsibility as I see them today. The first area is the 
responsibility for the Commissioned Corps, the 5,600 health 
professionals who are on call 24 hours a day, 7 days a week to 
respond to any threat to the health of the American people, 
whether it's a bioterrorist attack or whether it's a natural 
outbreak. And we often deploy people when there are floods, 
tornados, an epidemic in this country or even in another 
country if it's a threat to the health of the American people.
    So September 11th, while on the way to the airport, I 
stopped and activated the Commissioned Corps readiness force, 
and we have sent many of those people to New York City and 
other places to respond. That's a very important day-to-day 
responsibility of the Surgeon General; and, as you know, we 
deployed the Deputy Surgeon General to Capitol Hill, Dr. Ken 
Moritsugu, who has been intimately involved with briefings on 
Capitol Hill since the letter to Senator Daschle.
    The second and perhaps in some ways most important 
responsibility of the Surgeon General when you really think 
about it is the direct communication with the American people 
based on the best available public health science. The context 
of that communication historically for the most part has been 
to look at an area of concern to the American people, does 
smoking cause lung cancer? So Dr. Luther Terry's report was the 
first ever Surgeon General's report on smoking and health.
    There have been many reports on that topic since, and 
during my tenure, of course, I have released reports in areas 
of mental health, suicide prevention, youth violence 
prevention, oral health. I released three reports on smoking 
and health, including women and smoking. Those reports were all 
based on thorough public health science examination of those 
areas.
    So when we speak to the American people, we speak with the 
kind of authority based on a lot of the investigation.
    But I believe that we have to define a clearer role for the 
Surgeon General in terms of bioterrorist attack. I think that's 
one of the things that we've learned that the American people 
do, in fact, want to be able to rely on the voice of authority 
and credibility in public health science. And so I think that 
as we look at how to improve the system of communication, I 
think the role of the Surgeon General is critical in this. But 
it's got to be very clear that there are political issues 
involved in responding to an outbreak, there are organizational 
issues. And the question is, which of those issues are we going 
to look to the Surgeon General to speak on? And I think the 
Surgeon General has to speak on the public health science.
    Mr. Shays. It strikes me that the Surgeon General has 
consistently over the years, you and those who preceded you, as 
basically being the voice where the science takes you and not 
an office that can be manipulated by political considerations. 
Obviously, political considerations can come in terms of typing 
of a report and so on, but in the end, what you issue is viewed 
to be the truth untainted by political considerations, and I 
mean, you and those who preceded you.
    In other words, I consider you, kind of your position, an 
honest broker, an honest voice, and is that a view that I 
should consider or should I consider you basically under a 
secretary, and if the secretary says change your report, you 
have to change your report?
    Dr. Satcher. Well, I think the first description is the one 
that is accurate for a Surgeon General. But I also want to add 
something to that.
    Mr. Shays. Sure.
    Dr. Satcher. As you know, there are times when there are 
disagreements. I've issued a report on promoting sexual health 
and responsibility for sexual behavior, which was not supported 
by the Secretary or the White House, but they did allow the 
report for the public health science, but it was not 
necessarily politically a report that was supported.
    I do want to make it very clear, Congressman Shays, that 
the Surgeon General's office is, in fact, impacted by politics. 
The budget of the Surgeon General's office has been virtually 
depleted since 1994. So there is virtually no budget. The 
Surgeon General relies upon NIH, CDC, other agencies when we do 
a report even. Because there is no--the funding is not there. A 
lot of the changes that have taken place have resulted from 
disagreements with things that came out of the office of 
Surgeon General.
    I have been very fortunate, I think it has something to do 
with the fact that I was director of CDC before, and I've had 
an ongoing working relationship with people in these various 
agencies now for several years, so I have not had difficulty 
getting support to do a report on mental health, for example. I 
didn't have the money in the Surgeon General's office to do 
that. I didn't have the money to do the youth violence 
prevention report. I had some.
    So in every one of these areas, I've had to rely upon other 
agencies within our department. So while on the one hand I say 
to you that it is the responsibility of the Surgeon General to 
issue reports that are based on the best available public 
health science and not politics and not personal opinion, I 
would not be honest if I said those things don't impact upon 
the strength of the Office of the Surgeon General. As you 
imply, clearly, organizationally, the Surgeon General reports 
through the Secretary.
    That's the way the organization is. That affects budget, 
that affects everything. And that's the reality. I would like 
to see it--to be honest with you, I would like to see it 
different. I would like to see the Surgeon General able to have 
a strong office and able to report on based on the best 
available public health science, even when there is 
disagreement about that. I'm talking about the future, not 
talking about myself.
    Mr. Shays. I appreciate your candor. I know you're talking 
about the future. I apologize that I haven't been as aware that 
since 1994, this office has gotten less and less resources.
    Dr. Satcher. You might want to look at the budget of the 
Office of Surgeon General.
    Mr. Shays. There's a lot we should look at. I would ask 
this one last question. You have to respond to the FBI. But do 
they ever have to respond to you? Can you ever trump the FBI? 
They trump you, they trump the health care side. Can the health 
care side trump the FBI? You go from detection and prevention 
of a terrorist attack, you have crisis management, 
investigating the crime, you got the consequence of the act. 
But isn't there times when the consequence of the act should 
trump the crisis management?
    Dr. Satcher. Yeah. I don't know if I would use that term 
because it implies expedition when I think it ought to be 
looked at as a partnership. The FBI is very dependent upon the 
public health service for information. Whether it's the CDC 
and, of course, there is the U.S. Army Medical Research 
Institute for Infectious Diseases [USAMRIID], that does a lot 
of the analysis. But the FBI is often dependent upon the public 
health service for information that they will use in their 
work. And that's certainly been true with the anthrax outbreak. 
They have looked to the CDC for information about the nature of 
the strain, for example.
    It is very important that in all of the four letters that 
have been sent with anthrax, they have all been of the same 
strain. It's upon, it seems as if to date, the letter sent to 
Chile may well be a different strain. All of this is 
information that comes out in a laboratory. It is all 
information that the FBI uses in its investigation.
    Mr. Shays. But would it be wrong for me to make the 
assumption that if someone's life is in danger, that trumps 
their trying to protect evidence? In other words, if an 
envelope is there that could be dangerous, and if we could have 
that envelope and we could begin to see what's in it, should I 
believe that because they may want to protect the evidence 
that----
    Dr. Satcher. Oh, I see your point, yeah. I don't think that 
the decision would ever be made. You know, at least I don't 
think so. I can't think of an instance where someone's lives 
have been put at danger because the information was protected 
for the investigation. I think the overall goal here is to save 
lives. And we believe that in the case of a bioterrorist 
outbreak, finding the person who is behind it is very critical 
to saving lives. But I can't think of an instance where we have 
endangered lives of people because, you know, we don't get 
information where it was suppose to. We didn't take action. We 
may not have explained to the public why we took a particular 
action.
    Mr. Shays. As always, I appreciate you coming before our 
committee. Appreciate your candor. I appreciate your good work. 
I would just invite you to make any closing comment if there is 
anything you wanted to say or question you wish we had asked, I 
invite you to make a comment before we go to our next panel.
    Dr. Satcher. One of the things that we've talked about is 
the dynamic nature of this situation. And when the exercise 
that Congressman Tierney mentioned with Senator Nunn took 
place, we were actually in a different place in this country 
than we are now. The FBI had the lead for crisis management 
with bioterrorism. FEMA had the lead for consequence management 
and the department reported through them. There was no homeland 
security office. So even since the bioterrorist operation took 
place, we have seen changes even in how we're organized and how 
people report. This is a dynamic situation and hopefully moving 
in the right direction. I think this hearing is so important in 
that regard.
    Mr. Shays. Thank you very much. Appreciate you being here. 
We'll call our final panel and obviously thank them for their 
patience. All of them are busy people and I know have other 
places to be. I invite Dr. C. Everett Koop, former U.S. Surgeon 
General; Dr. Kenneth I. Shine, president, Institute of Medicine 
representing the National Academy of Sciences; Dr. Mohammad 
Akhter, executive director, American Public Health Association; 
Dr. Joseph Waeckerle, editor and chief, Annals of Emergency 
Medicine, representing the American College of Emergency 
Physicians. I will invite you gentlemen to stand. I will catch 
you before you all sit down and administer the oath.
    [Witnesses sworn.]
    Mr. Shays. Note for the record that our witnesses have 
responded in the affirmative. I would invite you to give your 
testimony as I called you. We'll start with you, Dr. Koop, and 
go to Dr. Shine, Dr. Akhter and Dr. Waeckerle. What I'll do is 
I'll--we'll have a 5-minute clock. We'll roll it over, but hope 
that you could stay within the 5 minutes, but if you roll over, 
you have another 5 minutes if it's necessary.
    Dr. Koop, it's always wonderful to have you here. Thank 
you. We'll start with you. Let's make sure that mic is on.

STATEMENTS OF DR. C. EVERETT KOOP, FORMER U.S. SURGEON GENERAL; 
    DR. KENNETH I. SHINE, PRESIDENT, INSTITUTE OF MEDICINE, 
  REPRESENTING THE NATIONAL ACADEMY OF SCIENCES; DR. MOHAMMAD 
AKHTER, EXECUTIVE DIRECTOR, AMERICAN PUBLIC HEALTH ASSOCIATION; 
  DR. JOSEPH WAECKERLE, EDITOR AND CHIEF, ANNALS OF EMERGENCY 
   MEDICINE, REPRESENTING THE AMERICAN COLLEGE OF EMERGENCY 
                           PHYSICIANS

    Dr. Koop. Good morning, Mr. Chairman and members of the 
committee.
    Mr. Shays. It's not on yet, Dr. Koop.
    Dr. Koop. Now?
    Mr. Shays. Yeah.
    Dr. Koop. Sorry. I am C. Everett Koop, a pediatric surgeon 
by training and the Surgeon General of the United States for 
two 4-year terms, from 1981 to 1989. I appreciate much your 
invitation to testify before you.
    Our public health care system has been weakened in the past 
8 years and the recent bioattacks have stressed its ability to 
protect the American public. We were not prepared for the 
anthrax bioattack, regardless of its source, and the fear 
generated by it far outweighed the health threat.
    Morally, I think we really never thought anyone would do 
it, but they did and the public is still uncertain, that they 
would deliver a catastrophic attack by some other bioterror. 
Think of the distraction and chaos involved with fewer than 50 
anthrax victims, real or uncertain, in the anthrax scare, how 
would our resources handle not 50 but 5,000? How about 50,000? 
How about 5 million?
    The public health service has a long and distinguished 
history of protecting America in the past from many threats 
that have reached our border or have originated domestically. 
However today's threats are unique in a world without borders, 
and therefore require new strategies and policies coupled with 
operational plans to combat the threats to our Nation's health 
care and to our people.
    Our domestic defense system has not been able to protect 
the American people or their economy from the present small 
bioterrorism attacks. What will we do with weapons of mass 
destruction or weapons designed to maximize panic and mistrust 
in our health care system?
    Mr. Chairman, your staff asked me to answer a few questions 
on communicating information to the public on terrorism. And I 
would not give the government high marks in this recent 
episode. The spokesperson in such situations is usually the 
Surgeon General, and usually in the setting of a press 
conference and not a talk show. And yet I have heard almost 
nothing from him and those who were his surrogates, except Drs. 
Fauci and Koplan, who have not been accurate.
    I don't mean Fauci and Koplan, I mean the others. That is 
particularly egregious because as you know, the current Surgeon 
General was, for some time, director of the Centers for Disease 
Control and is eminently qualified in this area.
    Communicating threats to the public are based, I think, on 
common sense. And I have a few rules that I don't really think 
about when I talk, but I made them up in response to the 
question. First of all don't make statements especially 
predictions that are not based on fact. Deliver warnings with 
enough information to prepare and protect without causing 
panic. Choose words understandable to a 10th or 12th grader, 
and go over the draft again and again so there is no ambiguity. 
Make certain that the public understands the difference between 
an immediate threat versus a long-term outcome, and between 
fatal and a nonfatal threat. Inform the public frequently and 
in increasing depth. Squelch rumors that are untrue, such as 
AIDS can be transmitted by contact with door knobs and toilet 
seats. Translate science for the non scientific public and 
never speculate or indulge in opinions. And finally, and 
perhaps most important, keep the press on your side through 
honesty and forthrightness.
    There will likely be a series of biothreats, chemical 
threats, agro threats and cyberthreats, nuclear threats and 
threats to our food supply and our water supply over the next 
months and years until we win our international war against 
terrorism. While recent actions were designed to cause maximum 
panic and economic harm, future threats may indeed be aimed at 
causing catastrophic numbers of casualties.
    This likelihood needs a new strategy where all of America 
is linked together using our strengths of command communication 
and control technologies to defeat future attacks. We need to 
be able to rapidly mobilize all of our health care resources to 
be concentrated on wherever the threat appears, even if it 
appears in multiple sites simultaneously. The defense against 
bioterrorism is not to be found in the military, their 
responsibility is primarily strategic offense. Anticipated 
threats against civilians cannot be prevented unless we destroy 
the source or have extraordinary and credible intelligence for 
a specific site at a specific time. But we can mount multiple 
plans tailored to the threat aimed at managing the assault, 
containing its spread, treating victims and controlling the 
ensuing panic.
    A new biodefense system needs to address the possibility of 
weapons of mass destruction such as contagious weapon that will 
overwhelm the limited surge capacity of our health care system, 
our pharmaceutical industry, and the public health service. 
These weapons can be unleashed from abroad and move silently 
within individuals traveling throughout our country, 
undetected, until the first sentinel case is found.
    At a similar time in history, Winston Churchill, deeply 
troubled by England's lack of preparation for World War II said 
this, ``the responsibility of ministers (that is, government 
officials) for the public safety is absolute and requires no 
mandate. It is, in fact, the prime object for which governments 
come into existence.''
    A new biodefense system must be created based on a net 
centric command information and control technology, based on 
advances in biotechnology, telemedicine and robotics that can 
reduce the effect of bioattacks on us with weapons of mass 
destruction. A terrorist attack designed to cause catastrophic 
levels of casualties by spreading a contagious disease or a 
chemical or radiation illness across America needs to be met 
with a health care system that increases dramatically that 
surge capacity to respond within hours and not days. This will 
protect the health of America and provide security to our 
people, our economy, and ultimately to our freedom-based way of 
life.
    Fortunately, most of the bioterrorist agents are treatable 
with antibiotics, with the exception of smallpox, a deadly 
disease without treatment with a latency of incubation period 
of 12 days. Again, fortunately, the victim of smallpox is 
usually rendered sedentary by the severity of the illness by 
the 14th to 16th day after exposure. Smallpox, as you know, has 
been eliminated from the globe since 1977. And few people have 
been vaccinated since that time.
    The doses of vaccine on hand are minuscule compared to the 
number needed to immunize the public. We have no experience at 
all that says our vaccine is efficient against modern smallpox, 
which may have mutated or have been bioengineered. There is, 
indeed, frightening evidence published this year suggesting it 
is possible to make people more susceptible to a pox virus, 
while at the same time, turning off the victim's own natural 
immune protection.
    After a dirty nuclear bomb or radioactive material in 
conventional explosives goes off in some major city, or we have 
a smallpox epidemic, the country will settle down in disarray 
to establish a widespread protection plan. And if we will do it 
then, why not now. I don't know if CDC's plans announced in the 
Washington Post 2 days ago are inclusive of this knowledge.
    The creation of this new system should be done as a large-
scale project. It will be expensive, but not nearly as 
expensive as doing nothing. It would take advantage of the 
strengths of America and can be accomplished rapidly if we 
start now to build it. If we commit to this plan, this 
administration can assure the American public that we can 
protect them from any biothreat. We cannot not stop all 
threats, but we can help to reduce the harm to both our people 
and our economy.
    Without such a plan in place, I don't think we can reduce 
the present panic which many of our people feel. We need to 
uphold the trust in our health care system and the ability of 
our government to provide security to the American people. To 
win the war, we need both a successful offensive strategy that 
will work in time, and a defensive strategy that will protect 
America while we wait for this win in the war against 
terrorism.
    Mr. Chairman, I would be pleased to, as you and your 
members of the committee choose, to elaborate further.
    Mr. Shays. Thank you very much, Dr. Koop.
    [The prepared statement of Dr. Koop follows:]
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    Mr. Shays. Dr. Shine.
    Dr. Shine. It's a privilege to meet with you. I'm Ken 
Shine. I'm president of the Institute of Medicine. For the last 
3 years, I've also served on the Commission of--congressionally 
mandated Commission on Weapons of Mass Destruction, chaired by 
Governor Gilmore of Virginia.
    I should preface my comments based on the discussion with 
Dr. Satcher that 2 years ago, we recommended the creation in 
the Executive Office of the President of an entity which 
provided overview of threats of weapons of mass destruction 
including bioterrorism. That office as a consequence of 
September 11th has been created with Governor Ridge in charge.
    One of the recommendations we made was that there ought to 
be an associate director of that office for health. And that's 
not happened. We believe that it's extremely important that 
there be such an individual because that's the site at which 
the interface between HHS, the criminal justice system, the 
Department of Agriculture, a lot of other places would come 
together and that's the place where relationships between the 
medical professions, the public health community also could 
come together in an overall approach to bioterrorism.
    As the chairman pointed out, terrorism is about creating 
fear, rumors, anxiety, misinformation and chaos. I would argue, 
sir, that credible information is critically important as 
medicine for that terrorism. We did not do well in the anthrax 
outbreak. There were multiple talking heads on television, 
including a number of pseudo experts, one identified himself as 
an expert on the anthrax virus, anthrax is not a virus, it's a 
bacteria. We had situations in which the Web was covered with 
all kinds of information about anthrax which was incorrect. We 
had all kinds of promoters promoting all kinds of variety of 
materials that you should purchase or promoting antibiotics and 
so forth.
    We were so concerned about this that the Presidents of the 
National Academy of Science Engineering and myself issued a 
statement early in October identifying what we thought were 
reliable Web sites, those at the National Library of Medicine, 
the CDC and, at that time, Johns Hopkins. But we believe that 
we did not do a good job with regard to communication with the 
American people.
    There are four issues that I would like to just briefly 
touch upon. First, within the government, within the Department 
of Health and Human Services there needs to be a single 
credible medical public health expert who is the spokesperson 
for the Department. That doesn't mean that other people can't 
speak on the subject, but it means that that individual should 
be responsible for communicating with the public about these 
issues, that individual is credible because he or she has 
professional knowledge, has current information, and in 
coordination with law enforcement, is articulate, knows, like 
Dr. Koop has shown over and over again, how to translate 
information to the public, and doesn't talk down to the public.
    That individual ought to be able to stand next to political 
leaders and administrators and be available so that when a 
question is asked by the media, that the political leader to 
turn to that individual and get an immediate answer. That 
individual has to be so credible that when he or she doesn't 
know, she can say he or she doesn't know. And in a report we 
did in 1996 on understanding risk, our evidence is that if the 
person is credible, if the person provides information, saying 
I don't know in fact increases the credibility. Does not 
diminish it.
    Tony Fauci performed that function extremely well when he 
was put into use in this area. But that didn't happen until 
well into the outbreak. And the fact that there was no 
individual doing that was a clear deficit. The Associate 
Director of the Office of Homeland Security, if that individual 
were a health person, could serve a similar function. But if 
that's the case, they ought to coordinate their activities so 
the same information is provided that does not confuse the 
public.
    Second, we need much more attention to the Internet, the 
Web sites within government, in this case, the CDC. The CDC 
does have a Web site. We identified it as one of the more 
reliable ones. But, in fact, there were times when you couldn't 
get into it. It was not always easy if you were a health 
professional to get the information you needed. And I should 
emphasize that we heard at our commission hearings from people 
in local public health departments about the number of calls 
they got from health professionals about what to do. And they 
were not informed during the early stages of the outbreak.
    The role of the Internet in this regard needs to be 
enhanced. And Mr. Chairman, that would require resources 
because it is necessary that all public health departments have 
computers, that you can have the use of the Internet as a way 
of getting them information. I would emphasize that the people 
working in this area work 24 hours a day, 7 days a week during 
this outbreak. In fact, that was the testimony to how poorly 
staffed they were and how poorly prepared we were. But we need 
to invest in the Internet the Web site communications.
    Mr. Chairman, I would emphasize we need to learn from the 
lesson in anthrax so that if there's a problem with 
agriculture, the Department of Agriculture is prepared with a 
spokesperson and a Web site. If there's a problem with the 
radiologic episode, that the Department of Energy is. We don't 
know who the spokesperson would be if there was a chem 
outbreak. It seems to me that we need to think about that.
    Third, we need to do a better job in both understanding and 
doing risk communication with the public. What is the risk, 
what is the benefit, how do you measure those. Dr. Satcher has 
made reference to some of the problems with antibiotic use. I 
would use the smallpox debate as an excellent example. Here we 
have an agent where once we have stores of vaccines, we got to 
decide how to use them. The public needs to understand, if we 
vaccinate the entire population, we will kill several hundred 
people by the act of vaccinating. In fact, we're going to 
probably kill and make sick a lot more than that because of the 
large number of immuno-compromised people that were not around 
at the time that smallpox was being protected against.
    And I would remind you that choosing not to vaccinate such 
individuals may not protect them from the virus of vaccinia if 
we did mass vaccination. On the other hand, we know how to use 
the vaccine to surround cases of smallpox. That was how it was 
eradicated from the globe. So if you have adequate stores, you 
can follow the cases, you have several days after exposure in 
which you can vaccinate. There is probably some residual 
immunity in our population. And so if you look at the risk 
benefit, you can come up with some logical ways to develop a 
policy that the public can understand. I'm very worried about 
the potential in agricultural terrorism of hoof and mouth 
disease. But in contrast to the situation in Europe in which 
cattle were slaughtered by the tens of thousands, you can 
immunize animals against hoof and mouth. Do we have the vaccine 
and did the public understand that meat would be safe if, in 
fact, you stopped an epidemic using it?
    Finally you already heard the concerns about public health. 
I would emphasize in 1988, the Institute of Medicine issued a 
report called the ``Future of Public Health.'' In that report, 
we said that the public health system was in disarray. And 
everything has been downhill since. The reality is that we 
missed hantavirus for a significant period of time because 
reporting systems for hantavirus were inadequate. We know that 
West Nile virus got going because we laid down on the mosquito 
abatement programs and allowed mosquitos to proliferate, so 
when a bird got infected we now had an outbreak.
    You've heard about the problems with regard to resources. 
We need people, facilities, research and particularly 
communications. And may I emphasize that we need that for the 
entire system all the time. We had an outbreak of two cases of 
meningococcus meningitis in a town in the middle of the country 
earlier this year. Thousands of people took antibiotics and 
vaccines because of one uninformed statement by a doc on a 
television station. It was entirely inappropriate. The point is 
that the communications become absolutely critical.
    Finally, there are communications about risk which are 
based on science and are based on the need for the truth, as 
you put it. But remember, there are many irrational kinds of 
fear and anxiety. And we need to understand what those are. And 
it is entirely possible that we ought to have a mechanism by 
which the CDC either through focus groups or through networks 
similar to what Nielsen uses or others can test what the public 
is, in fact, frightened of and communicate information which 
will be addressed to their fears as well as addressed to the 
scientific truths. Thank you, Mr. Chairman.
    Mr. Shays. Thank you very much Dr. Shine.
    [The prepared statement of Dr. Shine follows:]
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    Mr. Shays. Dr. Akhter.
    Dr. Akhter. Thank you, Mr. Chairman, members of the 
committee. I really appreciate the opportunity to be here this 
morning. My name is Mohammad Akhter. I am the executive 
director of the American Public Health Association. We 
represent the public health workers in this country, both 
Federal, State, local level of protecting the health of the 
American people every single day. So what I'm going to say is 
not----
    Mr. Shays. You don't represent, say, the directors of the 
public health?
    Dr. Akhter. Many of them are our members, yes, sir. It's a 
professional organization. We are a professional organization, 
scientific organization, and as such, many of the members are 
professional directors. Like Dr. Satcher is, for example, one 
of the members of the American Public Health Association. So we 
speak on the basis of science and actual on the ground 
experience.
    So, Mr. Chairman, despite what my senior colleagues and 
some of the other folks in the government may have said before, 
I want to say one thing about the previous anthrax attack and 
that is, that a lot of people worked very hard, but the fact is 
we got lucky. We were very fortunate that there were handful of 
cases and that took place in an area where we have very good 
resources.
    And we were able to deal with it. If the same situation 
would have taken place in another part of our Nation, we 
wouldn't be so lucky. And so my comments are based upon what 
can we do for the future. And there are four areas of risk 
communication that I very quickly want to run by you for your 
consideration: The first is the communication between the front 
line workers in bioterrorist attack. It's not the fire chief 
who pulls the alarm. It's not the disaster preparedness 
director who pulls the alarm. It is the physician, a paramedic, 
a nurse, an EMT on the front line. If those people were not 
connected with the health department, there is no 
communication. Then we have difficulty.
    Handful of health departments right now have that 
capability. Where the cases are reported, as long as somebody 
sees a suspicion case, the case gets reported to the health 
department. So that this system could be activated, we could do 
the followup, do the tracking. So the capacity needs to be 
built at the local level, the local health department, 
particularly those health departments that are 50,000 or less 
population. They are the ones who really do not have that 
capacity.
    My second area of communication, risk communication deals 
with the communication between the Federal Government, State 
government and local government. Despite the grants that were 
given, despite the health alert network that's been in place, 
the reality on the ground as we speak, Mr. Chairman, today, is 
that 10 percent of the local health departments do not have e-
mail capability. 50 percent of the local health departments do 
not have high speed Internet connection. So you can give them 
the information. Even if they receive it, they cannot forward 
that information to their physicians in their area, to the 
hospitals in their area, to the ambulance providers in the 
area. So there is a bottleneck there. And we really don't have 
the full communication in place that could be very effective in 
saving lives and protecting against disease.
    The third area, Mr. Chairman, is the area of communication 
between the public health community, the Department of Defense, 
and the Intelligence Community. I had the great honor of 
serving for 30 years of public health positions, including 
being the director of health for the State of Missouri.
    Not until I became Health Commissioner in Washington, DC, 
did I ever have the opportunity to work with the Defense 
Department or the Intelligence Community. These communities 
have not worked very well together. We don't have the history, 
we don't have the tradition of working together. So when they 
come together, as is the case is imperative now that we all 
work together to deal with this new situation, we don't have 
any structure. We don't have any authority, any way to really 
do this thing together. And collaboration between different 
agencies at the State level, even within the agency, is a very 
difficult task. And it will not take place, Mr. Chairman, until 
and unless there is a directive from the very highest level of 
our government, perhaps from the President, to make sure that 
the Defense Department that has a wealth of information on 
these areas, Intelligence Community, law enforcement, and 
public health community, work together to share information. 
And if necessary, give several key health officials the FBI 
clearance so they can get the information on a need-to-know 
basis they can prepare and protect the health of the American 
people.
    And finally, Mr. Chairman, I come to the major issue of 
communication with the public. When it comes to bioterrorist 
attack, we aren't dealing with anthrax or smallpox virus, we 
are dealing with people who may have been exposed to anthrax, 
who may have been affected by the anthrax and who are afraid of 
anthrax. And what these people need is clear, concise, usable 
information from an authoritative source. And I'm sorry to say 
and I agree with my colleagues here that we were unable to 
provide that in the past. And I see no change as we speak 
today, Mr. Chairman, to be able to do that. All the things that 
I've learned in the communication is that you need to have a 
single, centralized person responsible who could provide that 
information to the American people.
    Dealing with bioterrorism is a public private partnership. 
All the doctors, the hospitals, the ambulance providers are 
private people. They work with the Health Department very 
closely to be able to protect the health of the American 
people. One of such entity out there is the American news 
media. Frankly, many of our people learned--got the information 
from the news media faster than they got through our own 
channels of communication in public health. And we should bring 
the news media in on the table so that we could have the news 
media sit down with the key folks.
    So here is what I recommend in my closing. That at each 
level of our government, Federal Government, State government, 
and the local government, a single source be identified for 
communication with the public and that the news media be 
brought in in communication, and we need to work out the 
protocols and the way how we're going to provide the 
information to the people so people get the right and accurate 
information so we can get the support and the confidence of the 
American people to deal with this new and emerging situation.
    Mr. Chairman, I thank you very much for this opportunity. 
Be glad to answer any questions you might have.
    Mr. Shays. Thank you, Dr. Akhter.
    [The prepared statement of Dr. Akhter follows:]
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    Mr. Shays. Dr. Waeckerle.
    Dr. Waeckerle. Chairman Shays, members of the subcommittee 
and fellow panelists, good morning. It's a privilege to be 
here.
    Mr. Shays. Privilege to have you.
    Dr. Waeckerle. I'm Joe Waeckerle. I'm a practicing 
emergency physician, board certified and residency trained. I 
live in Kansas City, MO. I currently serve as editor-in-chief 
of the Annals of Emergency Medicine of the American College of 
Emergency Physicians and have chaired the Task Force on Health 
Care and Emergency Services Professionals on Preparation for 
Nuclear Biologic and Chemical Attacks. I also have worked as a 
consultant to the Federal Bureau of Investigation. I have 
served on the task force of the Defense Science Board for the 
Department of Defense looking at biologic threats to the 
American people and the American continent and have worked 
closely with the CDC and the Office of Emergency Preparedness.
    I'm here today to testify on behalf of the American College 
of Emergency Physicians who currently has 23,000 members. We 
take of over 100 million patients per year, and hopefully I 
will represent them well.
    Emergency physicians as earlier stated are in the front 
line of biologic preparedness in this country. We are the new 
first responders along with our colleagues, the nurses and the 
EMT paramedics. And the new scene of terrorism in this country 
will be the emergency departments of America where the patients 
present for care.
    To that end, we must be clinically able to recognize and 
initiate a response because early detection will save lives and 
mitigate any biologic terrorism in this country. We have 
attempted to foster that in our membership and across the 
country by the task force educational programs and the 
development of curricula for the public and our patients as 
well as for our members.
    Today we're going to focus on a discussion of the 
challenges of crisis communication. This is appropriate since 
the September 11th incident has centered on a tragic and 
senseless loss of innocent lives. More importantly, however, we 
have witnessed what many of us have feared most for a long time 
and have discussed with you previously, including my visit here 
in September 1999 before you. And that's the use of biologic 
agents by terrorists. America has unfortunately learned that 
the consequences of a biologic attack are incredibly severe, 
even of the small isolated incidents that we have faced 
recently, much less a large scale attack. Biologic weapons are 
formidable weapons of uniqueness and complexity that a specific 
defense strategy is fundamental to our protection.
    As many of you know in the room, good communication is 
absolutely essential to any national strategy. That's what 
we're here for today. In times of crisis, the citizens of 
America look to you, other elected leaders and government 
officials, for information and direction. At no time in 
contemporary history was this more evident than after the 
recent tragic events that we've experienced. In the early 
stages of this event, it was apparent that crisis communication 
strategy was evolving. There was no obvious centralized 
leadership, no voice of authority, and inconsistent information 
that was soon outdated or required correction on a daily basis. 
This resulted in the American public remaining in an 
informational vacuum as stated earlier. The public did not have 
a steady flow of updated information, so seized any information 
from anyone, no matter how unproven, to reassure themselves. 
For example, many patients presented to our emergency 
departments across the country asking for diagnostic nasal 
swabs to determine if they had anthrax. Because they thought 
this was the right thing to do. They did not know and were not 
told by anybody that nasal swabs were not diagnostic entities 
but were, in fact--they did determinations of exposure and use 
for epidemiologic investigation. Therefore, they were 
erroneously informed. The appropriate treatment of anthrax 
caused an unnecessary public controversy as well. Initially, 
the public was appropriately told that cipro was the treatment 
of choice. Later the public was told that doxycycline was the 
preferred treatment.
    Many of those who were potentially exposed and therefore 
prophylactically treated, including many in this area in the 
United States, in the Washington, DC, area, became concerned 
that they did not receive the best treatment. This issue, in 
fact, became contentious at some point, but it could have been 
prevented with proper communication. Appropriate authorities, 
all they had to do was explain to the American people that 
ciprofloxacin was initially chosen because we didn't know if 
the bacteria had been genetically enhanced to be weaponized. 
Once tested, determined that it had not and was sensitive to 
standard therapy, standard therapy was appropriate and 
preferred.
    During difficult times, it is also natural for the general 
public, who is uneducated in these areas, to respond with 
unreasonable solutions. The preoccupation of the media with the 
question of gas mask use was likely provoked by the public's 
unanswered concerns for personal protection. Although the use 
of gas masks was repeatedly dismissed by many experts, the 
public look for a credible Federal authority to convince them 
that the use of gas masks and other protection devices was 
unnecessary.
    Finally, there was the dilemma of how to balance the 
release of sensitive information to inform and protect our 
American public versus when to keep it confidential to maintain 
national security or prevent public panic. This decision should 
have been carefully analyzed on a case-by-case basis. And 
despite the fact that it may have been, mistakes occurred. The 
controversy surrounding the release of potential threats to the 
Golden Gate Bridge in California was an example. The FBI and 
the governmental authorities were in a no-win situation, as was 
the Governor of California. If they released it and it did not 
occur, they were wrong. If they didn't release it and it did 
occur, we suffered a tragic event unnecessarily.
    Fortunately, many of these communication deficiencies can 
be corrected. Consistency is an absolute must. The American 
public expects leaders who are knowledgeable authorities, and 
more importantly, who can effectively communicate the knowledge 
to the public. A consistent message is usually best conveyed by 
a recognizable voice, regularly scheduled press conferences 
located at the same site and time to be considered. The media 
deadlines also conveys a message of reliable and responsible 
leadership. The message delivered should be clear, for all to 
understand, concise and to the point without much elaboration 
or any speculation and above all, credible and correct.
    The public can appreciate, in my opinion, that the 
situation may change if they are told it may change so that the 
message may vary from moment to moment. The partnership with 
the media established prior to any incident will promote the 
goals of crisis communication. I have not seen evidence of the 
partnership in our national strategy. Disseminating correct and 
helpful information will control rumors, limit the use of 
pseudo experts, foster cooperation and thereby enhance our 
ability to respond. The partnership with the media is 
critically important because they are the public's primary 
source of information. Go to any emergency department in 
America and we had on CNN so we could learn what was going on. 
We only have to remember the most trusted man in America during 
his tenure was Walter Cronkite, not a Federal, State or local 
official, and that's because he demonstrated those areas of 
crisis communication that we just discussed.
    These communication deficiencies are not limited to just 
the public. My colleagues have talked about it, we have 
discussed in the past, they include the Federal agencies' 
ability to deal among themselves to deal with the State and 
local officials, and to deal with the private sector as well as 
State and local officials have failed, in my opinion, to deal 
effectively with the Federal Government, with, or, and other 
State and local officials including, of course, the important 
private public health and medical sector.
    In conclusion, crisis communication using a partnership 
with the media to provide clear concise credible information 
consistently delivered by a recognizable authority, is, in my 
opinion, an absolute requirement. We must also develop 
principles for communication to the public that address the 
dilemma between the public's right to know and the Nation's 
national security.
    Congress must provide the leadership, financial investment 
and organizational and logistical support to develop not only a 
comprehensive national strategy with solid domestic 
preparedness and response plans, but also a comprehensive 
communications strategy. Good communication provides knowledge 
that results in an informed and cooperative America. Without 
information, fear prevails. And as President Roosevelt once 
said, the only thing we have to fear is fear itself. Thank you 
for the opportunity to be here. I look forward to answering any 
questions.
    [The prepared statement of Dr. Waeckerle follows:]
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    Mr. Shays. I thank you all very much. I'm going to start 
with the questions, and just it seems to me, make an 
observation, it seems to me that you pretty much all agree. I 
mean, your message is pretty consistent, but I'd like you to 
tell me where you would disagree with anyone else who have 
spoken on the panel, and you point that you might disagree. Or 
Dr. Satcher. Any comments that were made today that you would 
just take exception to or not as strongly but just disagree? 
Start with you, Dr. Koop.
    Dr. Koop. In general, we seem to be of one mind. We might 
have little different ways of dotting I's and crossing T's, but 
I think the thrust has been the same from all of us.
    Dr. Shine. Dr. Satcher talked about the notion that one 
person can't be everywhere and that you should have multiple--
there may need to be multiple spokespersons, that the media 
demand is very high and so forth. While he is quite correct 
about the media demand, the fact is that if there is a single 
source of information holding a daily press conference and 
coordinating his information or her information with other 
players, you can still have multiple exposures to the media. I 
don't see that the two are in conflict with each other. But I 
do believe that the notion that you can have multiple people 
talking is not credible.
    Mr. Shays. I'm going to come back, because I think I 
disagree with you. I would love to follow through.
    Dr. Akhter. I also generally agree with what my colleagues 
have said, but I do believe in a single credible spokesperson 
and that person be the Surgeon General of the United States. We 
were very distressed to see the General absent in the war 
against terrorism at home. What kind of army you want to see--
the public health community, we consider him to be our leader. 
The leader is not visible, then the people just got confused, 
looking to every direction, every which way. It was not the 
public who were confused but the public health people who were 
confused. I think, to clarify that, it ought to be the Surgeon 
General of the United States who should stand up and speak and 
be the leader.
    Mr. Shays. Which will lead me to a question, Dr. Koop, I 
will ask you about, because you had the AIDS epidemic to deal 
with and you were pretty much the spokesperson, it seemed to 
me. I'll come back to you on that one.
    Dr. Waeckerle.
    Dr. Waeckerle. Probably don't have a lot more intelligent 
remarks, but I do think that----
    Mr. Shays. You should have----
    Dr. Waeckerle [continuing]. I could give you one example of 
what I think was a very effective leader who did a very good 
job, and that was Mayor Giuliani. In fact, throughout the 
crisis in New York, he demonstrated all of the characteristics 
and all of the behaviors that we've all discussed before you 
today and reassured, informed and calmed New York City.
    I would also point out to you that maybe the most effective 
press conference I saw during this whole incident is when 
Governor Ridge took command and had Surgeon General Satcher and 
had Secretary Thompson and the Post Office Director and others 
involved. And while he was the main spokesperson he allowed 
each of those individuals to give us an update on information 
so that there was one credible person leading the news 
conference at that time or the President briefing but that we 
had a cadre of informed, intelligent, responsible authorities 
behind him.
    Mr. Shays. That's a good lead-in to tell you, Dr. Shine, 
where I get a little uneasy. I would begin to think if there 
was only one spokesperson for the government that the 
government was trying to hide something, that they weren't 
allowing so and so to speak or they won't allow so and so to 
speak. I would become very suspect and begin to question 
whether I was being told the full story.
    Dr. Shine. Congressman Shays, I am not suggesting that 
other people don't speak at all. What I'm saying is that when 
Secretary Thompson has a press conference, for example, the 
individual who is charged as the spokesperson is, just as Dr. 
Waeckerle described, a certain person standing next to him, and 
who is able to provide that information. Similarly, at a daily 
briefing that individual could provide those briefings.
    That doesn't mean that a lot of other people will not be 
communicating but does mean that some--one of the things that 
was striking, if you looked at the media during these episodes, 
was that there are all kinds of experts who, when on 
television, if you watched them carefully there were two kinds 
of experts. Most of them knew the history of anthrax 
previously. None of them had ever had any experience with 
inhalation anthrax because it hadn't existed to any significant 
extent except in Russia. And what would happen is the media 
would then say, after they gave this articulate description of 
anthrax, but what does it mean, though they just had a case in 
a postal worker or whatever, and there were two responses.
    The credible people said, well, I don't really know the 
details of that. I don't know what the organism is. The other 
response was--of the expert was to speculate based on what he 
or she----
    Mr. Shays. I know that, but you can have experts on TV all 
the time, including some of you will be on TV and you'll be 
debating somebody else who calls himself an expert. So that 
will happen on TV. But I mean truly it will.
    Dr. Shine. That's why there needs to be someone who has 
knowledge of the actual event who is in the department, who as 
a consequence was being briefed by what's going on in the CDC, 
was briefed by the FDA, whatever the problem is, who has access 
to all that information for purposes of being the spokesperson.
    Mr. Shays. Let me get to Dr. Koop.
    I'm struck by trying to process what you're saying, that 
you want someone to help coordinate, bring people forward. But, 
for instance, if I want to hear from the head of CDC, I may 
want to hear from the NIH, I may want to hear particularly from 
the Surgeon General.
    But just refresh me, Dr. Koop. There was and still is an 
AIDS epidemic, but I would guess the AIDS epidemic is more 
prevalent in places in Asia and Africa but still an epidemic 
everywhere, or am I being sensational?
    Dr. Koop. It's still an epidemic everywhere. And the 
African countries are being very hit very hard, and some of 
those are actually facing genocide. Our own problems here are 
specifically concentrated on Afro American women. So the 
country has its own problems.
    Mr. Shays. I just didn't want to not call it an epidemic if 
it wasn't to be correct.
    Dr. Koop. An epidemic means----
    Mr. Shays. I called anthrax a virus at one time before 
someone corrected me, like this person.
    Dr. Koop. Anthrax affected very few people, but it was more 
people that you would ever expect to have it, so that's an 
epidemic.
    Mr. Shays. I recall you became the spokesperson pretty 
early on when we were dealing with HIV/AIDS.
    Dr. Koop. No, I wasn't. I was given specific orders that 
AIDS did not come under my purview.
    Mr. Shays. No kidding.
    Dr. Koop. It wasn't until the end of Mr. Reagan's first 
term when the first-termers began to go back to their homes the 
Public Health Service was filled with innumerable vacuums. 
Filled as many of those as I could. That's how I became the 
spokesperson. I was really self-appointed.
    Mr. Shays. But good thing. Because there began to be some 
real knowledge about this disease. But walk me through it. So 
did we have the same kind of thing we have now, a lot of 
different people speaking or nobody speaking?
    Dr. Koop. In those days, nobody wanted to speak; and the 
people surrounding President Reagan thought those who had AIDS 
deserved it. It was a very tough time.
    Dr. Shine. But having that spokesperson did not mean that 
Tony Fauci couldn't speak about HIV, that people at CDC 
couldn't speak about it. In other words, I don't think having a 
spokesperson doesn't mean you don't have--but what it does 
mean, as Dave Satcher described, you have a telephone 
conference call of key players, you review where you are, you 
agree on what, in fact, you know and what you're able to say so 
that the message is consistent and not contradictory.
    Mr. Shays. Right. It begs another question, though. If the 
truth is sometimes contradictory, how----
    Dr. Shine. Then you have to acknowledge that. That's what 
the truth is about.
    Mr. Shays. Mr. Tierney, have as much time as you want.
    Mr. Tierney. Thank you. Thank all of you for your 
testimony.
    I guess, going back to an underlying theme that the 
chairman was talking about also, is there any way that we can 
get the media to be more responsible, or are we always going to 
be subject to the talking heads? I noticed this in legal 
matters. Everybody is all of a sudden a legal constitutional 
expert. It takes the whole gamut. Now it seems to be medical 
issues. Are we going to be subjected to whoever they decide to 
throw on the air and people are going to get innuendo and 
surmise and speculation and bad information? Or is there some 
way through what we do that we heighten the responsibility that 
there will be a responsible message and voice out there? 
Anybody that wants to respond.
    Dr. Koop. I hinted at this in my remarks, and that is that 
the thing that made it possible for me to do the job that I did 
during AIDS I think was largely because, in the beginning, I 
appeared in the press conference atmosphere and there those 
days the Surgeon General could get time on any network within 2 
hours if he had an emergency. I don't know whether that still 
exists or not.
    Mr. Tierney. Probably need to put it on a soap opera.
    Dr. Koop. But when you have all of the stations really 
turning health issues into entertainment on the talk shows, 
then you do get controversy because they don't always know how 
to pick the right people. And the second thing is they have 
very strict time constraints, and many times you can't on the 
Today Show or Good Morning America get out the whole message 
you have to get out because you only have a 90-second sound 
bite.
    Dr. Shine. In a free society it's going to be very 
difficult to manage that. On the other hand, I lived for 20-odd 
years in Los Angeles. Shirley Fannan was the spokesperson for 
the Department of Health in Los Angeles County. When a problem 
emerged, she was the first person who got interviewed. She gave 
information to health providers. She gave information to the 
public. She was a recognizable spokesperson. And it out 
balanced all of the other experts.
    I would argue if you look at what happened with the 
American Flight 587, the crash, the woman who was the Chair of 
the National Transportation Board--I don't remember her name--
but every day for the next 5 days she was giving very good 
information and she trumped--using the chairman's term, she 
trumped all the talking heads because she knew what was going 
on. She was prepared to say how long it was going to take to 
get the information, what they knew and so forth.
    And that's I think the way you deal with the media, is make 
sure that you've got some way of getting information across 
that--where they know where to go and get it. They knew to go 
and get Koop.
    Dr. Akhter. Two quick things. As the health commissioner in 
Washington, I had to order 2 million people to boil the water 
for about a week or so when I was health commissioner. And the 
first thing you do is to make the highest level possible in 
your government available to the news media according to their 
needs, their morning news and afternoon news. So that I was 
available to be available for them to talk to them and provide 
them the information.
    Once you provide that information every single day, day in 
and day out, then the need for the other side experts goes 
down.
    The second thing, you need to really sit down with the 
media, as I said earlier, in a partnership, sit down and 
develop a strategy. In case of a true national emergency, how 
are we going to assess the information and provide the 
information? And that plan has not been worked out as we speak.
    Mr. Tierney. I think we're talking about something that 
this current situation didn't have done, the administration 
didn't do, was single out somebody and put them in an 
authoritative position. Given what the Surgeon General said 
about not having any budget, his position almost being 
downgraded somewhat, amongst the four of you, who would that 
individual be in your estimation? Who should that individual be 
that takes the stand on health issues, public health issues in 
the Federal Government? Should it be the Surgeon General or 
should it be the Secretary or what's your opinion?
    Dr. Shine. Well, I've made it clear in my testimony I think 
that the Secretary, for example, may be communicating with the 
public, but I think a credible medical public health expert has 
to be the individual to play that role. Because only under 
those circumstances will the public believe that it's getting 
effective medical public health information.
    My colleagues have made reference to the Surgeon General. 
The Surgeon General would be an excellent choice, but I would 
argue that for certain kinds of problems it might be the 
Assistant Secretary of Health, who is a physician, if that 
position is filled. It could be the head of the CDC. It could 
be Anthony Fauci, whatever.
    Mr. Tierney. Professional as opposed to political.
    Dr. Shine. The critical issue is, what are the attributes 
of that individual? What does that individual know? Can that 
person communicate? Can that person be credible?
    As I indicated to Congressman Shays, we've got lots of data 
from our studies that individual can say we don't know all the 
answers and people will feel better that there is such an 
individual. But the problem is, if you don't have someone who 
has medical public health credentials, then there is always a 
doubt on the part of the public as to whether somebody who is 
an administrator or political appointee is the right person.
    Dr. Koop. It depends on who the person is and how careful 
he wants to be. I can assure you that many of the things that I 
said as so-called spokesperson for the government on AIDS went 
through Tony Fauci's mind and Jim Mason's mind at CDC before I 
ever said them in public. We talked about those and frequently 
met with the Vice President on the same issues.
    Mr. Tierney. I just want to mention something aside on 
that. I first met you some years ago when you spoke at Salem 
State College up in Salem, MA, and you spoke on the subject of 
tobacco and the propensity of----
    Dr. Shine. That is unusual.
    Mr. Tierney [continuing]. And the propensity of this 
government to support the export of tobacco. Even though we 
might be doing a better job in trying to diminish smoking in 
this country, we have started to export it and allow the export 
of it or whatever, and I just want to thank you for speaking 
out on that issue and continuing to do the good work that you 
do there.
    Let me just conclude by asking one last question. You, Dr. 
Koop, said that we had no assurance that today's smallpox 
vaccine would be effective against the modern smallpox threat. 
Could you expand on that a little bit and tell us what we might 
do to counteract that problem?
    Dr. Koop. Well, the smallpox vaccine that we have was 
prepared against a smallpox virus that now has been frozen in 
Atlanta and supposedly Russia, but maybe many other places, for 
about 30 years, and there are two things that can happen. One 
is the virus can mutate, but the thing that is more likely to 
happen is that it can be tampered with biotechnology, so that 
maybe the vaccines we have would not be effective against the 
virus that we're going to meet.
    Mr. Tierney. Is there anything we can do about that?
    Dr. Koop. I don't think there's a thing you can do about it 
until you know that is the situation, but then you've got to 
make new vaccine to cover that thing.
    Mr. Tierney. So all of the vaccine that's being ordered up 
right now in today's papers indicate that there's enough 
vaccine to take care of the entire country, all of that may be 
ineffective?
    Dr. Koop. I don't know the details of that, but I don't 
know how they would get a terrorist version of a smallpox 
vaccine to work with.
    Mr. Tierney. So are we wasting money?
    Dr. Koop. No. I think in the protection against terrorism 
of any kind, when it is all over, you're going to say we wasted 
a lot of money, but I think you have to waste the money, 
because it is the only kind of precaution and prevention that 
you can undertake. And when you think about the money, it is a 
pretty small amount of----
    Mr. Tierney. Well, I guess I was thinking in terms of money 
and false sense of security for people, too.
    Dr. Koop. Yeah, well, the false sense of security might be 
secretly good for the panic that ensues, but I think you'd know 
pretty soon whether or not the vaccine worked, because if--as 
was explained to you today, you get one case, and you surround 
the patient and vaccinate the people that were in touch with 
them, and if they come down with it in 12 days, you know you 
haven't got an adequate vaccine.
    Mr. Shays. Would the gentleman yield?
    Mr. Tierney. Sure I'll yield.
    Mr. Shays. Because it ties into a point. That was the old 
method, you kind of circle your suspects.
    Dr. Koop. It worked.
    Mr. Shays. It worked, but it worked kind of in a rural--I 
don't know if it can work in Chicago.
    Dr. Shine. No. It was used in New York City in 1979 when 
there was a case of smallpox, and several million people were 
vaccinated.
    Mr. Shays. How do you do it in an airport, that they 
contracted it in the Atlanta airport, and they went to 100 
towns?
    Dr. Shine. Well, again, you have a--first of all, you don't 
become infectious until you've got the virus, that is until 
you've got pox, until you have the actual disease. So, I mean, 
somebody has to enter the country through Atlanta with a 
disease, and it has to be spread in some way.
    Mr. Shays. I don't want to take the gentleman's time, but 
you--on record, you believe that still the best method is 
identify the potential candidate and encircle it----
    Dr. Shine. Because this is a key issue for the Gilmore 
Commission. We consulted with D.A. Henderson and Bill Fagey, 
both of whom were responsible for eradicating smallpox in the 
world. We consulted with people in public health and so forth. 
So it is not just my own opinion. This is opinion based on 
people who have very active experience with smallpox that is a 
feasible way to approach it.
    The issue is--there are always ifs and ands about it, but 
the issue is balancing that against trying to immunize everyone 
where you know you're going to produce a certain amount of 
encephalitis, and you're going to produce a certain amount of 
death. So you're trying to balance what is the risk/benefit.
    Mr. Shays. Let me give the time back to----
    Dr. Shine. Could I just respond to you, Mr. Chairman? Two 
quick points I would make. One is in terms of the investment we 
make in the public health enterprise, we need a much better 
investment in vaccines and vaccine development that include--
the anthrax vaccine is a lousy vaccine. It takes you 18 months, 
6 shots at the present time to immunize somebody. You know, we 
can--there are reasons to believe that with a modest 
investment, we can genetically engineer P antigen, which is the 
effective antigen, and create vaccines, and then if we have the 
technology, if somebody comes up with an anthrax bacteria that 
has a different genetic makeup, which is what Dr. Koop was 
talking about, you've got a rapid ability to respond because 
you have the technology to make a new vaccine to a new antigen. 
And the same thing is true with smallpox.
    But the other point I would emphasize, and this is again 
part of the Gilmore deliberations through the years, if you 
want--if you're a terrorist and you want to produce terrorist 
effects, you don't have to go to the highest technology to do 
it. I mean, it was box cutters on September 11th. It was 
envelopes with anthrax. With regard to smallpox, if you can get 
ahold of any of the existing stores of smallpox someplace, that 
is a terrible threat in and of itself. While engineering--
bioengineering is important, and we need to prepare for it, we 
need to prepare for the greater probability, which is what if 
somebody gets it, it's the currently available pox, and 
therefore you want to be able to deal with it.
    Mr. Tierney. I actually don't have any more questions, and 
that is actually intensive, because the information you all 
gave was thorough and helpful, and I want to thank everybody.
    Dr. Shine. Could I emphasize again, because my colleagues 
have brought up the law enforcement issue, the agriculture 
issue and so forth, when the Gilmore Commission assessed our 
country's preparedness, it said there had to be a place where 
all these came together, and you heard from Dave Satcher that 
he doesn't meet with people in Agriculture or the Justice 
Department. There has to be a place to bring those together, 
and that is why we think the role of health in the Office of 
Homeland Security is so critical to bring those various 
interfaces together, including communication.
    Mr. Tierney. Well, I wish I could be more helpful with you 
there. I'll tell you, Chairman Shays has done a great job of 
bringing this to everybody's attention. We were having hearings 
on the need for a homeland security director and office long 
before others would pay any attention to this committee. The 
problem is that now that the President has appointed obviously 
a guy without a portfolio--and the real shame of this is that 
if you really look at what's going on, he has no direction, no 
legislative guidance, no portfolio at all, and a great 
reluctance that I still sense in this Congress to give that 
kind of authority and specificity and budget authority to cut 
across all those different agencies and be the one to draw them 
together with any authoritative basis. And I think we've got 
some work as this Congress to do and move in that direction. 
We've got several bills that are filed. We need to encourage 
this administration to stop saying that, oh, it can wait until 
next year or sometime down the line and move forward, and I 
know that Chairman Shays will keep moving on that issue.
    Mr. Shays. Do all of you agree that office would make 
sense? I mean, would you recommend--I know you do, Dr. Shine, 
but would you, Dr. Akhter, Dr. Koop or Dr. Waeckerle?
    Mr. Waeckerle. If you remember in September 1999, we 
discussed this for a long period of time, and it was the 
consensus of all the State and local authorities who Attorney 
General Reno convened that was the single foremost problem in 
America. There was no central oversight management, and as a 
result----
    Mr. Shays. As it relates to health care?
    Mr. Waeckerle. As it relates to all of the defense, to the 
strategy and specifically with public health and medical, as 
well as hospitals, because we were never able to have a 
coherent, collaborative plan that integrated those three 
important areas.
    Mr. Shays. Dr. Koop.
    Dr. Akhter. Mr. Chairman, it is absolutely necessary that 
it be Homeland Security Office. Not for today, tomorrow, but 
for years to come this threat is going to be with us. But it 
does need its own budget and its own authority, and without its 
own budget and its own authority, we just have window dressing.
    Mr. Shays. I'm talking more specifically about within that 
office, someone direct--we're trying to get the--the way they 
broke out the task, because I thought there was someone on--
within the office----
    Dr. Shine. But it's second level, Congressman Shays. 
There's an associate director for prevention and so forth, and 
then a health person reporting to that individual, and that is 
never going to get the health issue to the level that I think 
it needs to be--deserves.
    Mr. Shays. Dr. Koop, would you respond to this?
    Dr. Koop. I would agree with that entirely, and I think you 
have to--I don't like to run things by committee, but I named 
the most likely threats. I think there's got to be somebody 
representing agriculture, medicine, chemistry. We need probably 
eight people on a panel that--making this their own job.
    Mr. Shays. Right. OK.
    Dr. Koop. Could I raise one other quick question?
    Mr. Shays. Sure.
    Dr. Koop. A lot of people have said that the Surgeon 
General should be the person that we think about for the 
responsibility at hand. I would remind you that David Satcher 
will not be with us much longer, and the person who replaces 
him will be a very key person in the next administration. 
Having been through it myself, I can tell you that you don't 
walk into that job 1 day and know how to do it the next, and I 
would hope that somebody could influence the appointment of a 
person who knows something about what we've been talking about 
rather than be a political appointment.
    Mr. Shays. OK. That's very important. I think the same 
thing applies even to the Homeland Security Office themselves. 
I was not eager to see Governor Ridge be a spokesperson early 
on, because there's such a steep learning curve, which we all 
knew he had to have, anyone in that position, and so I was very 
concerned the press wanted to hear from him right away, forcing 
him to speak on health care issues, on defense issues and so 
on.
    Lots we could talk about. We have a vote, and I'm not going 
to keep you. Is there anything----
    Mr. Tierney. No. Thank you.
    Mr. Shays. You--this has been an excellent panel, and 
it's--we've learned a lot, a tremendous amount. Is there 
anything that any of you want to say in closing before we go?
    Dr. Shine. Just to reinforce the notion that when we 
recommended an office in the executive branch for home 
security--we didn't use that term--we said that individual 
should be confirmed by the Senate and should have budgetary 
authority, because we just don't see--and I think Mohammad has 
emphasized this. Getting the agencies to work together, you've 
got to have some kind of leverage, and I don't think you can 
give them the budget--the budget can't be that big that it 
covers all of the areas. Therefore, it has got to have 
authority to work with the OMB and say if you're not 
cooperating, if you're not collaborating, if you're not--
there's a stick; there's some penalty if you don't do that.
    Mr. Shays. I think Mr. Tierney and I disagree a bit on 
this, and so I'd be happy to have him respond, but my view 
right now is the President has combined the Gilmore and the 
Hart-Rudman Commissions. In one sense, he has given it a 
Cabinet level, but he hasn't made it a department. You don't 
have a homeland security. But he's given Ridge the opportunity 
to write his job eventually, and he's already said, you know, 
he's going to probably suggest there be a homeland area.
    And in terms of the budget, I just have to say, if anybody 
crosses Ridge, they're crossing the President of the United 
States. And so I know eventually the budget is going to matter, 
but right now, I mean, if you cross Ridge, it's going to get to 
the President right away. Their offices are next door, and 
you're mincemeat.
    Dr. Shine. That is absolutely true right now. The question 
is--Mohammad said it well--this is a long-term problem, and 
what is going to happen a year from now, 2 years from now.
    Mr. Shays. And I think he's going to get his way, which is 
also what I'd like to see happen. I think it's going to happen.
    Any other comment?
    Mr. Waeckerle. Yeah. I'd like to thank you for the 
opportunity to be here, and I'd like to close with the 
following remarks for you to consider. Biologic terrorism, in 
my opinion, has the potential to be the doom of mankind. Now 
and into the future, especially as we get into bioengineering 
genetically designer--designed bugs, because the State-
sponsored--the State-supported, the States and the local nuts 
and zealots of the world, because of the technology today and 
the information available today, will be able to carry out 
terrorism against us. And I think that it requires an 
appropriate strategy and response, as you all know and we've 
discussed today.
    And there's one major fault that I believe we need to focus 
on, and that is the critical human infrastructure and the 
response to biologic terrorism in this country will occur in 
the local community, and it's the triumvirate of health care 
professionals, public health and hospitals, and to date, 
despite numerous committee hearings and much writing and 
rhetoric, the local community and those key players have not 
been integrated or coordinated with any national programs, and 
they have no input. And I hope that when we talk about 
communication with the public and crisis communication, we 
remember that many of us believe that the communication between 
the Federal family and the local and State partners that we 
have in this war has been neglectful, and it needs to be 
greatly improved.
    Mr. Shays. I thank you for that. There's a minicrisis, a 
tiny crisis that we're going to have a vote in 4--5 minutes. 
So, I mean, it's in the process. We have 5 minutes left. Thank 
you all very much. Wonderful job. This hearing is closed.
    [Whereupon, at 12:29 p.m., the subcommittee was adjourned.]

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