[Senate Hearing 107-142]
[From the U.S. Government Publishing Office]
S. Hrg. 107-142
FEMA'S ROLE IN MANAGING BIOTERRORIST ATTACKS AND THE IMPACT OF PUBLIC
HEALTH CONCERNS ON BIOTERRORISM PREPAREDNESS
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HEARING
before the
INTERNATIONAL SECURITY, PROLIFERATION AND FEDERAL SERVICES SUBCOMMITTEE
of the
COMMITTEE ON
GOVERNMENTAL AFFAIRS
UNITED STATES SENATE
ONE HUNDRED SEVENTH CONGRESS
FIRST SESSION
__________
JULY 23, 2001
__________
Printed for the use of the Committee on Governmental Affairs
U.S. GOVERNMENT PRINTING OFFICE
75-441 WASHINGTON : 2001
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COMMITTEE ON GOVERNMENTAL AFFAIRS
JOSEPH I. LIEBERMAN, Connecticut, Chairman
CARL LEVIN, Michigan FRED THOMPSON, Tennessee
DANIEL K. AKAKA, Hawaii TED STEVENS, Alaska
RICHARD J. DURBIN, Illinois SUSAN M. COLLINS, Maine
ROBERT G. TORRICELLI, New Jersey GEORGE V. VOINOVICH, Ohio
MAX CLELAND, Georgia PETE V. DOMENICI, New Mexico
THOMAS R. CARPER, Delaware THAD COCHRAN, Mississippi
JEAN CARNAHAN, Missouri ROBERT F. BENNETT, Utah
MARK DAYTON, Minnesota JIM BUNNING, Kentucky
Joyce A. Rechtschaffen, Staff Director and Counsel
Hannah S. Sistare, Minority Staff Director and Counsel
Darla D. Cassell, Chief Clerk
------
INTERNATIONAL SECURITY, PROLIFERATION AND FEDERAL SERVICES SUBCOMMITTEE
DANIEL K. AKAKA, Hawaii, Chairman
CARL LEVIN, Michigan THAD COCHRAN, Mississippi
ROBERT G. TORRICELLI, New Jersey TED STEVENS, Alaska
MAX CLELAND, Georgia SUSAN M. COLLINS, Maine
THOMAS R. CARPER, Delaware GEORGE V. VOINOVICH, Ohio
JEAN CARNAHAN, Missouri PETE V. DOMENICI, New Mexico
MARK DAYTON, Minnesota ROBERT F. BENNETT, Utah
Richard J. Kessler, Staff Director
Mitchel B. Kugler, Minority Staff Director
Brian D. Rubens, Chief Clerk
C O N T E N T S
------
Opening statement:
Page
Senator Akaka................................................ 1
Senator Cochran.............................................. 20
Prepared statement:
Senator Cleland.............................................. 3
WITNESSES
Monday, July 23, 2001
Bruce Baughman, Director, Planning and Readiness, Federal
Emergency Management Agency (FEMA)............................. 3
Scott R. Lillibridge, M.D., Special Assistant to the Secretary,
Department of Health and Human Services for National Security
and Emergency Management, Washington, DC....................... 5
Tara J. O'Toole, M.D., M.P.H., Johns Hopkins Center for Civilian
Biodefense Studies............................................. 10
Dan Hanfling, M.D., FACEP, Chairman, Disaster Preparedness
Committee, Inova Fairfax Hospital, Falls Church, Virginia...... 15
Alphabetical List of Witnesses
Baughman, Bruce:
Testimony.................................................... 3
Prepared statement........................................... 25
Hanfling, Dan, M.D., FACEP:
Testimony.................................................... 15
Prepared statement........................................... 52
Lillibridge, Scott R., M.D.:
Testimony.................................................... 5
Prepared statement........................................... 33
O'Toole, Tara J., M.D., M.P.H.:
Testimony.................................................... 10
Prepared statement........................................... 43
Appendix
Questions and responses for the record from:
Mr. Baughman................................................. 59
Dr. Lillibridge.............................................. 63
Dr. OToole................................................... 66
Dr. Hanfling................................................. 70
FEMA'S ROLE IN MANAGING BIOTERRORIST ATTACKS AND THE IMPACT OF PUBLIC
HEALTH CONCERNS ON BIOTERRORISM PREPAREDNESS
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MONDAY, JULY 23, 2001
U.S. Senate,
Subcommittee on International Security,
Proliferation, and Federal Services,
of the Committee on Governmental Affairs,
Washington, DC.
The Subcommittee met, pursuant to notice, at 2 p.m., in
room SD-342, Dirksen Senate Office Building, Hon. Daniel K.
Akaka, Chairman of the Subcommittee, presiding.
Present: Senators Akaka and Cochran.
OPENING STATEMENT OF SENATOR AKAKA
Senator Akaka. The Committee will please come to order. I
want to thank our witnesses--will you please be seated--Bruce
Baughman of the Federal Emergency Management Agency and Dr.
Scott Lillibridge of the Department of Health and Human
Services, for being with us today. I want to also welcome Dr.
Tara O'Toole of the Johns Hopkins Center for Civilian
Biodefense Studies, and Dr. Dan Hanfling from Inova Fairfax
Hospital.
According to Committee rules, it is required that all
witnesses be under oath while testifying. So, at this time, I
would like the witnesses to please stand and remain standing.
Raise your right hand. Do you solemnly swear to tell the truth,
the whole truth, and nothing but the truth, so help you, God?
Mr. Baughman. I do.
Dr. Lillibridge. I do .
Dr. O'Toole. I do.
Dr. Hanfling. I do .
Senator Akaka. Thank you. You may be seated. I look forward
to this hearing and to hear from FEMA and HHS describe what the
Federal Government is doing to prepare our local communities
for bioterrorism.
I am also eager to hear from our other witnesses, who will
tell us what their concerns are and how effective our Federal
programs have been. We have two agencies represented here, but
there are many Federal stakeholders and many programs that
address unconventional terrorism. For example, we have national
medical response teams, the Metropolitan Medical Response
System, FEMA urban search and rescue task forces, National
Guard RAID teams, and domestic preparedness training through
the Department of Justice. I want to commend these and all
terrorism-response efforts.
Across the country, States and communities are also working
to develop terrorism-response plans. I offer the statewide
terrorism preparedness efforts in Hawaii, which have been
hailed by HHS as, ``exemplary,'' as a national model of
Federal, State and local coordination and cooperation.
President Bush directed FEMA to create an Office of National
Preparedness, to coordinate anti-terrorism programs among all
these stakeholders. HHS and its Centers for Disease Control and
Prevention, with their expertise and experience, are the lead
implementing agencies for bioterrorism response programs.
Bioterrorism is different from other forms of terrorism. A
bioterrorist attack will not be preceded by a large explosion.
First responders will be the physicians and nurses in our local
hospitals and emergency rooms, who may not realize that there
has been an attack for days or weeks. Preparing for biological
events should not be limited to worst-case scenarios, where
thousands of Americans die from an intentional release of
anthrax or smallpox. A simple and perhaps more likely hostile
act of infecting a population with food poisoning would also
overwhelm most area hospitals. Naturally-occurring emergency
infectious diseases can do just as much damage.
We must ensure that hospitals and medical professionals are
equipped to deal with these threats. As former Secretary of
Health and Human Services Donna Shalala once said,
``Bioterrorism is perhaps the first time in American history in
which the public health system is integrated directly into the
national security system.'' Therefore, problems and concerns
within the public health system directly affect our ability to
plan and respond to acts of bioterrorism. Similarly, efforts to
improve our preparedness for bioterrorism also improve our
health and medical communities.
There are three things we must do to deal with a biological
event: (1) continuous surveillance so that an unusual event can
be recognized, (2) active investigation for a quick and
decisive diagnosis, and (3) an emergency response. These are
the areas that local and State planners concentrate on while
preparing their own response plans. These are also the areas
where the Federal Government can help. But how much are Federal
programs that are designed to help local communities prepare
for biological events, in fact, helping? Are they addressing
local planners primary concerns and needs?
Last year, the TOPOFF exercise simulated an outbreak of
plague in Colorado. Another exercise, Dark Winter, was
performed to simulate a possible U.S. reaction to the
deliberate introduction of smallpox in three States. Have we
begun to apply the lessons learned from TOPOFF and Dark Winter?
Are we in better position to handle a bioterrorist attack
today, a year after TOPOFF or 6 years after the world learned
of the Aum Shinrikyo cult and their attempts to master
biological agents?
Once again, I welcome our witnesses and look forward to an
interesting and educational discussion. I am glad you are here
as our witnesses. I thank you very much, and Senator Cleland
regrets that he is unable to be here today. He has asked that
his comments be submitted for the record.
[The prepared statement of Senator Cleland follows:]
PREPARED STATEMENT OF SENATOR CLELAND
Thank you, Senator Akaka and Subcommittee members, for conducting
today's hearing on managing and preparing for acts of bioterrorism. One
of today's most serious potential threats to U.S. national security is
bioterrorism. I want to commend Sam Nunn and the Johns Hopkins'
sponsored Dark Winter small pox bioterrorism exercise conducted at
Andrews Air Force Base on June 22-23, 2001. This exercise dramatically
illustrates that our response to date is woefully inadequate to deal
with a domestic bioterrorist event and that a reconsideration both of
strategy and organizational structure are needed. There is, as yet, no
agreed upon comprehensive national strategy or plan to deal with
bioterrorism. The United States has just begun to act on many of the
needed biodefense programs.
During the last session of Congress, we passed P.L. 106-505. This
law authorizes crucial provisions for protection against public health
threats and to build a national biodefense plan. There is widespread
agreement that we face a significant potential for a domestic
bioterrorist attack, yet for fiscal year 2001, we appropriated only $1
million instead of the $99 million needed. Fully funding P.L. 106-505
is vital because it also recognizes the role of private industry
partnerships with Federal agencies and State and local public health
programs as the foundation of an effective national strategy for
bioterrorism preparedness and response.
I am very proud to have the Centers for Disease Control and
Prevention (CDC) in my State of Georgia. The CDC is and must be a major
and integral part of homeland defense, because of its ability to
expeditiously identify, classify, and recommend courses of action in
dealing with biological and chemical threats. Since January 1999, CDC
has been tasked by the Secretary of Health and Human Services to
develop national, State, and local public health capacities to
effectively respond to acts of biological and chemical terrorism. Yet
it was just this past year that Congress began to appropriate funds to
assist leading Federal agencies, including the CDC, in meeting this
challenge. The CDC also has a critical supportive role to the
Department of Defense Rapid Assessment and Initial Detection (RAID) in
preventing and preparing for the possibility of bioterrorism.
Additionally, CDC's research and development in areas of Gulf War
Syndrome and the current anthrax threats are of critical importance to
our military.
The problems with vaccine production and distribution encountered
during the Dark Winter exercise parallel the current difficulties with
Anthrax and adenovirus vaccines. My question is, ``do we have clear
procedures defining State and Federal responsibilities and on the use
and distribution of the national stockpile of vaccines?'' If the answer
is no, then why not?
For all of the attention that missile defense has received in
Congress and the Executive Branch, it is undeniably true that the use
of weapons of mass destruction, in the form of biological or chemical
agents delivered by terrorists, is a far more immediate and real threat
to the people of the United States. We must, I repeat must, set our
priorities accordingly. I thank you, Mr. Chairman and the Members of
the Subcommittee, for the opportunity to offer my comments on this
crucial issue.
Senator Akaka. I am expecting Senator Cochran soon.
Mr. Baughman, we welcome any opening statement or comments
you may have, so you may begin.
TESTIMONY OF BRUCE BAUGHMAN,\1\ DIRECTOR, PLANNING AND
READINESS, FEDERAL EMERGENCY MANAGEMENT AGENCY (FEMA)
Mr. Baughman. Thank you, Mr. Chairman. I am Bruce Baughman,
Director of Planning and Readiness Division at the Federal
Emergency Management Agency. Director Joe Allbaugh regrets that
he is unable to attend this session today. It is my pleasure to
represent him at this important hearing on bioterrorism. I will
briefly describe today how FEMA works with other agencies, what
our approach is to bioterrorism, and the role of the new Office
of National Preparedness. FEMA's mission is to reduce the loss
of life and property and to protect our Nation's critical
infrastructure from all types of hazards. As staffing goes,
FEMA is a small agency. Our success depends upon our ability to
organize and lead a community of local, State and Federal
agencies and volunteer organizations.
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\1\ The prepared statement of Mr. Baughman appears in the Appendix
on page 00.
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We provide a management framework, a funding source. The
Federal response plan is the heart of that framework. It
reflects the labors of interagency groups that meet in
Washington and all 10 of our FEMA regions to develop the
Federal capability to respond to any emergency as a team. That
team is made up of 26 departments and agencies, along with the
American Red Cross. Since 1992, the Federal response plan has
been the proven framework for managing major disasters and
emergencies, regardless of cost. It works. The reason is it is
simple. The plan organizes agencies into functions based upon
their existing authorities and expertise.
Now, we recognize that a biological scenario presents
unique challenges. The worst-case scenarios begin undetected
and play out as epidemics. That means that response begins in
the public health and medical community. Initial requests for
Federal assistance will probably come through the health and
medical channels to the Centers for Disease Control and
prevention, or CDC. At some point, the situation would escalate
into a national emergency. As an element of HHS, the CDC is a
critical link between the health and medical community and the
larger Federal response.
HHS leads the efforts of the health and medical community
to plan and prepare for a national response to a public health
emergency. FEMA works closely with HHS as the primary agency
for the health and medical function under the Federal response
plan. We rely on HHS to bring the experts to the table when the
Federal response plan agencies need to meet to discuss a
biological scenario. As a result of these efforts, we are
learning more about the threat, how it spreads, and the
resources and techniques that will be needed to control it. We
are making progress. Exercise TOPOFF in May 2000 involves two
concurrent terrorism scenarios in two metropolitan areas of the
United States. One of these scenarios was bioterrorism. We are
still working on the lessons learned from that exercise. It
takes time and resources to identify, develop and incorporate
changes into the system.
Exercises, when conducted properly and in moderation, are
critical to helping us prepare for the various scenarios we may
be confronted with by a weapon of mass destruction. In January
2001, the FBI and FEMA published the U.S. Government's
Interagency Domestic Terrorism Concept of Operations, or CON
plan. With the coordination of HHS and other key departments
and agencies, we pledged to continue the planning process to
develop specific procedures for different scenarios, including
bioterrorism. The Federal response plan and the framework it
can provide for managing disasters can also be used to manage a
bioterrorism event.
Now, let me take a few minutes to talk about our Office of
National Preparedness. On May 8, 2001, President Bush asked the
director of FEMA, Joe Allbaugh, to create an Office of National
Preparedness. This office will do the following: One,
coordinate all Federal programs dealing with weapons of mass
destruction consequence management; this office is not intended
to take over any individual agency program or function; two,
solicit input from first responders at the State and local and
emergency management organizations, and how to continue to
build and sustain a national capability; three, support the
collective effort to design a balanced national program that
involves planning, training, exercises, equipment, and other
elements as required; and, fourth, identify shortfalls and
duplications existing in Federal programs and make
recommendations on how to address these areas.
FEMA established this office earlier this month with an
initial staffing element. As the structure and activities of
the office evolve, staffing will be augmented with personnel
from other departments and agencies, State and local
organizations. Mr. Chairman, you convened this hearing to ask
about our approach to bioterrorism. It is FEMA's responsibility
to ensure that the Federal response plan is adequate to respond
to the consequences of catastrophic emergencies and disasters,
regardless of cause. Bioterrorism presents tremendous
challenges. We rely on HHS to lead the health and medical
community in addressing the health and medical aspects of this
problem. They need support to strengthen their detection and
reporting supporting capabilities, and their operating capacity
in emergency medicine. We need support to ensure that the
national system has the tools to gather information, set
priorities, and deploy resources in a biological scenario.
FEMA and the Federal response plan have a successful
history of coordinating Federal, State and local consequence
management efforts before, during and after emergencies. This
track record provides a strong foundation for the new Office of
National Preparedness. Thank you Mr. Chairman. I would be happy
to answer any questions.
Senator Akaka. Thank you very much, Mr. Baughman.
At this time, I would like to tell the witnesses that we
will include all of your statements, full statements, in the
record. Dr. Lillibridge, we invite you to make an opening
statement now.
TESTIMONY OF SCOTT R. LILLIBRIDGE,\1\ M.D., SPECIAL ASSISTANT
TO THE SECRETARY, DEPARTMENT OF HEALTH AND HUMAN SERVICES FOR
NATIONAL SECURITY AND EMERGENCY MANAGEMENT, WASHINGTON, DC
Dr. Lillibridge. Thank you, Mr. Chairman and Members of the
Subcommittee. Thank you for inviting me here today to discuss
the activities of the Department of Health and Human Services
in responding to bioterrorism, other emergencies and acts of
terrorism. I am Scott Lillibridge, Special Assistant to the
Secretary of HHS for National Security and Emergency
Management. On July 10, Secretary Tommy Thompson appointed me
to this position and directed me to develop a unified HHS
preparedness and response system to deal with these important
issues. I would like to discuss that effort with you,
highlighting some of the areas in which HHS works with the
Federal Emergency Management Agency.
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\1\ The prepared statement of Dr. Lillibridge appears in the
Appendix on page 00.
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Bioterrorism has unique characteristics, as you mentioned
in your opening statement, that set it apart from other acts of
terrorism. Biologic agents are easy to conceal, potentially
contagious in nature, and, in the most worrisome scenario, the
first responders are likely to be health professionals in
emergency rooms, outpatient clinics and public health settings.
HHS is the primary agency responsible for health and medical
response under FEMA's Federal response plan. HHS also
coordinates and provides health leadership to the National
Disaster Medical System, NDMS. This is a partnership that
brings together HHS, the Department of Defense, FEMA, the
Department of Veterans Affairs, and the private sector.
NDMS was developed to provide medical response, patient
evacuation, and definitive medical care for mass-casualty
events. This system addresses both disaster situations and
military contingencies. I would like to talk a little bit about
bioterrorism preparedness and response--and begin with how HHS
provides technical assistance to the FBI during bioterrorism
threats and then discuss other issues associated with crisis
management. FEMA is the lead agency in charge of consequence
management. The broad goals of a national response to
bioterrorism or any epidemic involving a large population will
simply be to detect the problem, control the epidemic spread in
the population, and to treat the victims. The Department's
approach to this challenge has been to strengthen the public
health infrastructure and to hone our emergency health and
medical response capacities at the Federal, State and local
level.
In an emergency, HHS is able to mobilize NDMS resources,
CDC disease experts and the national pharmaceutical stockpile.
In addition, disaster teams of the Office of Emergency
Preparedness, the Public Health Services Commissioned Corps
Readiness Force, and the support of other Federal agencies can
be mobilized. Since fiscal year 1995, HHS, through the Office
of Emergency Preparedness, has been developing Metropolitan
Medical Response Systems, MMRS. This initiative enhances the
existing local and city system's capability to respond to a
chemical or biologic incident, and provides for triage and
medical treatment. These city systems have been developed to
help address the medical needs of victims of terrorism and to
facilitate the transport of patients to hospitals.
In the area of training, HHS has used classroom training,
distance learning and hands-on training activities to prepare
the health and medical community for contingencies such as
bioterrorism. Expansion of the bioterrorism training component
of Nobel Training Center and Hospital at Fort McClellan,
Alabama, is a high priority for HHS. We will continue our
strong linkage with the adjacent Department of Justice Office
of Justice Programs training facility for first responders and
its National Domestic Preparedness Consortium.
The recent FEMA-CDC initiative to expand the scope of
FEMA's integrated emergency management course will serve as a
vehicle to integrate emergency management and the health
community response efforts in a way that has not been possible
in the past. It is clear that these communities can best
respond together if they are able to train together. Our
priorities for HHS? Well, through CDC, we need to expand our
cooperative agreements to health departments and to enhance
State and local preparedness for bioterrorism.
In the near future, as part of its responsibility
associated with the National Disaster Medical System, HHS must
begin to broaden its perspectives to address issues related to
health facility preparedness in civilian communities. It is
also time to review the roles and responsibilities between NDMS
partners, to see how they match against the new threats facing
our Nation. In conclusion, the Department of Health and Human
Services is committed to ensuring the health and medical care
of our citizens. We are prepared to quickly mobilize the
professionals required to respond to a disaster anywhere in the
United States and its territories, and we are actively
preparing for the challenge posed by acts of bioterrorism.
At the end of my second week at this new post, it is clear
that close ties between HHS, FEMA, and the Department of
Justice will be paramount in addressing the consequences of
bioterrorism and other terrorist incidents. Mr. Chairman, that
concludes my prepared remarks and I would be pleased to answer
your questions at this time.
Thank you.
Senator Akaka. Thank you very much, Dr. Lillibridge. I find
the amount of work being done within both your agencies in
response to this threat to be very impressive. I do have a few
questions for both of you. Mr. Baughman, an Office of National
Preparedness section is being created at FEMA headquarters and
in each of the 10 regional offices. Will these offices be
staffed by new personnel or by existing staff who will have
additional responsibilities?
Mr. Baughman. They are going to be staffed really by three
sets of individuals: There will be existing FEMA personnel,
there will be personnel from other agencies, and then there
will be State and local personnel also staffing these offices.
Senator Akaka. These personnel from other agencies, are
they going to be just coordinating with you from their
agencies?
Mr. Baughman. I think initially that they will be resident
at our agency until we can map out the strategy that we have
been asked to work with the White House on, and then after that
we will have to see how things play out. If things are well-
coordinated, then I think that perhaps they could go back to
their home agencies. But I think initially our intent is to
have those personnel at our agency.
Senator Akaka. You mentioned in your written testimony the
Emergency Management Institute Comprehensive Course on Public
Health Concerns. This sounds like just the sort of program that
is needed to foster cooperation and heighten awareness to the
issues surrounding bioterrorism. My question is how do
communities and participants become involved? Do you find
interest in these courses uniform across the country or are
some States and regions very active, while others are less so?
Mr. Baughman. Senator, our Office of Training could answer
that better than I could. I can provide you a response to that
for the record.
Senator Akaka. Please do. Please provide it.
Dr. Lillibridge, the key to minimizing the consequences of
a biological event, whether a naturally-occurring epidemic or
an overt terrorist attack, is to notice that it is an event as
soon as possible. My question is what is your office doing to
help communities know if an unusual event is occurring? For
example, can you tell them what an abnormal number of cases
would be for a certain disease or illness?
Dr. Lillibridge. Fair enough. Mr. Chairman, we are working
on a number of avenues, primarily through the Centers for
Disease Control, to develop and enhance local surveillance
systems at the State and local level. These systems help cross
over early clues of awareness--like 911 calls and health
service utilization--and help build that public service
infrastructure to give us that early warning. There is more
that we could be doing in this area, and we are working through
training and several other grant mechanisms to develop this
activity in virtually all States.
Senator Akaka. Dr. Lillibridge, the Emergency Medical
Treatment and Labor Act of 1986 establishes the general
requirements for emergency rooms. For example, a hospital that
operates an emergency department must comply to any medical
examination request. Also, if an individual comes to the
hospital with an emergency medical condition, the hospital must
provide treatment. The question is, this act requires emergency
care to be provided to anyone who needs treatment, regardless
of their insurance status or ability to pay. Does this law have
an impact on planning bioterrorism response?
Dr. Lillibridge. Mr. Chairman, I think that law relates to
several of our planning efforts. One way the law relates is
that we look at our preparedness and response activities to
involve planning at the most local level. This includes the
regulation or movement of patients, the collective act of
moving certain patients to certain hospitals, and involves most
facets or nearly all facets of planning at the local level. We
have also given consideration to this in terms of our planning
grants through CDC and through our MMRS activity at the local
level.
It is something that we have to consider as an extremely
important part of our planning process, but does not stop us
from doing the essential things in epidemic control.
Senator Akaka. Dr. Baughman, we have heard from Dr.
Lillibridge about the National Disaster Medical System, which
was designed for responding to natural disasters. In it, member
hospitals are required to accept patients from other hospitals
in the event of a crisis. Tell me, how will this work during a
bioterrorist attack? Would a remote hospital whose
participation in a system is voluntary be willing to accept
contagious patients suffering from plague? Could FEMA require
them to do so?
Mr. Baughman. Mr. Chairman, we cannot require them to do
so, and it is voluntary, so it may be problematic, and maybe
Dr. Lillibridge can maybe lend a little bit more to that.
Senator Akaka. Would you?
Dr. Lillibridge. Mr. Chairman, in our recent exercises with
TOPOFF last year and recently with Dark Winter, it was clear
that even, over and above the Federal Government, that
governors have extraordinary powers during emergencies, during
State emergencies, that would include epidemics or an act of
bioterrorism. There may be issues where they will restrict the
movement of people in their State. They may close businesses.
They may even order the movement of patients or closure of
certain facilities.
Many of these issues are being considered at that level of
planning with the governors. At the recent Governors
Association Meeting, issues of bioterrorism were the focus of
nearly 2 days of discussions.
Senator Akaka. Dr. Lillibridge, many veterinarians are
familiar with diseases that affect both animals and humans.
Several of these diseases are potential bioterrorism agents,
such as anthrax and plague. Some diseases, such as the West
Nile virus, generally affect animals before humans. These
factors make communication between veterinarians, medical
doctors and public health officials very important. How does
the CDC communicate with local and State veterinarians? Do you
have a senior level official who is in regular contact with the
animal health community?
Dr. Lillibridge. Yes, sir. We have communication with the
veterinary community through a number of fora. As a matter of
fact, in the bioterrorism program at CDC, essentially half of
the staff in our surveillance office are veterinarians--for
that very reason, for the crossover. It became clear during
West Nile and other activities related to preparedness for
bioterrorism that consideration for crossing over the human
health and the veterinary health link was extremely important.
We have embodied that concept in the surveillance activities
that we are working on--and in some of our partnerships with
the Department of Justice and the Department of Defense--as we
work on bioterrorism preparedness research and response
activities.
Senator Akaka. Dr. Lillibridge, I agree with your plans to
strengthen surveillance networks beyond public health
departments. You mentioned how detailed information on
emergency department visits, 911 calls, health service usage,
and pharmacy sales would be useful for timely and effective
detecting and reporting of disease outbreaks. Do you think that
also including veterinarians in this network would be useful?
What resources would a community require to get all of this
information?
Dr. Lillibridge. Mr. Chairman, we think that would be
extremely useful. We have embarked on a pilot project to begin
looking at linking animal and human health through
surveillance, and it is clear that there is going to be--if
there is a bioterrorism attack in the human population--some
intrusion perhaps into the animal population. That is going to
be extremely important from the veterinary side. The West Nile
virus showed us that early attention to cases in animals could
precede cases in humans, and those will expand over time.
Through linkage with the veterinary associations, our
colleagues in the research and veterinary communities, we are
beginning to forge those links.
In the Office of Bioterrorism Activities at the Centers for
Disease Control, there is deliberate consideration for active
engagement and expansion of those kinds of networks.
Senator Akaka. I am sure my colleagues will have questions
for you, so I will keep the record open, of this Subcommittee
so that other questions may be placed into the record.
Dr. Baughman and Dr. Lillibridge, I want to thank you again
being here this afternoon and for your cooperation. This, I
think, will be the beginning of some interesting planning for
the future, but there is no question that we must take the time
to do critical planning in case something like this happens to
our communities. Thank you very much.
Mr. Baughman. Thank you, sir.
Senator Akaka. So you may be excused.
Dr. Lillibridge. Thank you, Mr. Chairman.
Senator Akaka. Thank you. And now, we invite Dr. Tara
O'Toole of the Johns Hopkins Center for Civilian Biodefense
Studies and Dr. Dan Hanfling of Department of Emergency
Medicine at Inova Fairfax Hospital. I invite you to come to the
witness table, and as soon as you are ready, we will proceed
with the hearing.
Dr. O'Toole, I know both of you have taken the oath
already, so we will continue. Dr. O'Toole, we welcome any
opening statement or comments that you may have, and as I said,
your full statement will be placed in the record.
TESTIMONY OF TARA O'TOOLE,\1\ M.D., M.P.H., JOHNS HOPKINS
CENTER FOR CIVILIAN BIODEFENSE STUDIES
Dr. O'Toole. Thank you, Mr. Chairman. Thank you for the
opportunity to be here today and to make remarks on this very
important topic. I want to emphasize at the beginning that in
my view and that of my colleagues at Johns Hopkins, FEMA is a
government organization success story and has brought vital
help and comfort to millions of Americans through a whole array
of disasters over the past decade and more. Likewise, CDC is
world-renowned as an expert in epidemic management and in
public health, and there is no doubt about either its
reputation or its expertise.
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\1\ The prepared statement of Dr. O'Toole appears in the Appendix
on page 00.
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That said, it is my belief that in the context of
responding to a biological weapons attack on U.S. civilians,
FEMA and CDC are likely to find themselves called upon to
facilitate decisions and actions which are unfamiliar,
unpracticed and highly controversial within the decision making
circles. They are also going to be asked to coordinate a
medical and public health response, which is not only complex,
and time sensitive, but will depend critically on institutions
and infrastructures which we believe are very fragile and may
well become dysfunctional or collapse altogether in the face of
a sudden surge in patient demand. I am talking here
particularly about the medical service infrastructure.
Hospitals, in particular, have very little elasticity or
ability to respond to sudden surges in patient demand. Second,
the public health infrastructure, which has been neglected
financially and, in terms of political attention, for decades
cannot handle the demands an epidemic would impose.
It is clear that Secretary Thompson has put bioterrorism
very high on his agenda. I think the appointment of Dr.
Lillibridge to be his special assistant is an extremely
positive move. I also think that Director Allbaugh's
designation of a new Office of National Preparedness is very
encouraging. There is no question that the Federal Government--
Congress and the administration together--have made progress in
bioterrorism response in the past several years. But I am going
to focus today on your question, Mr. Chairman, are the current
Federal programs really meeting local needs, and what could we
do to meet those needs more effectively?
I am going to take a glass-half-empty approach here, with
the appropriate caveat beforehand that I think we have made
progress. I am going to suggest four recommendations which I
will run through right now. First of all, I think we have to
get hospitals and hospital leadership much more engaged in
bioterrorism response planning. That is going to take attention
from the appropriate Federal agencies, but also money from
Congress, and I will come back to that.
Second, I think we have to really assess by means of
independent studies that are beyond reproach, the actual
capacity of the National Disaster Medical System, the VA
hospital system, and other institutions that the Federal
response plan now says, are going to be there if we need them
to treat sick people in the midst of epidemic.
Third, I think we need to do a lot more to design, assess
and encourage drills, exercises such as TOPOFF, that would
include not only the usual responder communities, including
hospitals and public health officials, but would also include
decisionmakers themselves, members of Congress, members of the
cabinet and the National Security Council, and so forth, so
that the issues that they are going to be confronting if--God
forbid, there is a bioterrorist attack--are more familiar and
the options are also perhaps more lucidly understood.
So that is where I am going to end up. Let me go back to my
analysis of why those recommendations are, in my view,
necessary. You have already outlined, Mr. Chairman, how a
bioterrorist attack would differ from natural disasters or even
other kinds of catastrophic terrorism. It is going to cause an
epidemic. The awareness of the epidemic will likely build
slowly as people die inexplicably or large numbers of people
become ill and report to the medical care system. Hopefully,
early on, physicians and clinicians will alert the public
health system that something strange is happening. That does
not now happen, as a matter of course.
When the first two cases of West Nile virus were called in
to the New York City Department of Health, there were already a
dozen cases of encephalitis in hospitals in New York City.
Encephalitis is a legally-reportable disease, but none of the
physicians caring for those patients had called them in. There
is a lot of data to support that this is usually the case. It
is also the case that most health departments do not have the
resources to man phone lines 24 hours a day, 7 days a week. So
in many States, even if the physician were to call some
suspicions in, he or she may not get an answer on the other end
of the line for a day or more.
The U.S. medical care system has been under tremendous
financial stress for at least a decade, and one of its
responses to these financial pressures has been to cut out
excess capacity. Hospitals in virtually every town in this
country, whether it is the Johns Hopkins Medical Center or a
small rural hospital, are basically now functioning on ``just-
in-time'' models. The number of nurses that are going to be
working at Hopkins tomorrow are based upon the number of
patients in the hospital today; likewise for supplies, for
antibiotics, for what have you. It is very difficult for any
hospital to ramp up quickly in response to a sudden surge in
demand, as we find out every flu season.
Staff shortages are chronic. They are not just in nursing,
which is the most famous source of shortages right now, but
they cover virtually all of the functions of the hospital:
Respiratory technicians, lab technicians, pharmacists and so
on, and these staff shortages are expected to worsen. If we are
in the midst of an epidemic, particularly a lethal epidemic or
one that is contagious, one has to wonder if health care staff
are going to report to work. Some are going to have to be home
caring for their own families. Others may be sick. Others may
be fearful of bringing contagion home. So these staff shortages
may worsen, just at the time we have great need for people
working in hospitals in dealing with patients.
Few, if any, hospitals in America today could handle 100
patients suddenly demanding care. The Secretary of Health in
Maryland did a study a year ago, after a fire in a high-rise
building which luckily caused no serious injuries, to see if
Baltimore or, indeed, Maryland, home to two medical schools,
could handle 100 patients suddenly needing ventilator
assistance. We could not. There is no way, and this is a State
with over 50 hospitals in it. There is no metropolitan area, no
geographically-contiguous area, that could handle 1,000 people
suddenly needing advanced medical care in this country right
now.
There is no surge capacity in the medical care system. This
is most serious in the hospital sector, but it also pertains to
doctors' officers and clinics. That is a big problem. We need
to deal with that fact. It is also the case that hospitals are
not now engaged in bioterrorism planning. The Office of
Emergency Preparedness at HHS has tried to get hospitals
engaged, as has FEMA, to a lesser extent. Hospitals are not
interested. We had a meeting with over 30 CEOs of hospitals of
all shapes and sizes last year, and they told us the following:
We are so busy trying to keep our heads above water on a day-
to-day basis that we are not going to put aside any resources
for bioterrorism planning unless two things happen: (1) the
highest levels of government have got to tell us that this is a
priority and that we are expected to play a vital role, and (2)
they have got to send money. Hospitals today do not feel that
they can divert any of their precious resources, even to what
it takes to plan for a bioterrorism response. That lack of
engagement of the hospital sector in planning is a big problem
for us.
Moving on to the public health infrastructure, Dr.
Lillibridge talked about the vital work that CDC is doing to
try and improve the public health infrastructure at the State
and local level. When Secretary Thompson testified in May
before the combined Senate committees, he affirmed that
improving the public health infrastructure is possibly the most
important task ahead of HHS, in improving bioterrorism
response. I would agree, but we are spending less than $50
million a year on what the Secretary of HHS--two Secretaries of
HHS--have now said is the most vital component of bioterrorism
response. This is a piddling amount for so crucial a feature of
our capacity to protect people from epidemic disease.
I think we have to spend less attention asking the question
who is in charge and more time and attention thinking about
what are we going to do and what information decisionmakers are
going to need to make informed decisions. During the Dark
Winter exercise, which was a fictional smallpox scenario that
asked a panel of former high-level government officials to act
as members of the National Security Council, the participants
were continually asking for more information, more data: What
about this? What is the story here? How many people are sick
here? How many more can we expect to get ill?
We could not answer those questions, and, in fact, these
participants had more information than they would in the real
world. Once we know we are under attack, once we know we have
an epidemic underway, it is the public health officials who
have to answer the question: How many people are sick? Where
are they? What do they have in common? How many other people
are likely to become ill? Where are the supplies that we need
in order to protect people or to give them effective treatment
and so forth. If the State health departments are not able to
answer those questions, there will be very little that FEMA or
CDC can do.
CDC itself is quite small. There are fewer than 150 people
in the Epidemic Intelligence Service, which is, in the normal
course of small natural outbreaks, who you would call upon to
augment State and local health departments. Now, CDC could
probably, in a dire emergency, put in the field 1,000 or so
people who have some background in epidemic control, but CDC
itself has a very small office of bioterrorism. Most of the
people working in it are matrixed to other responsibilities,
and they could use some more resources in this important
endeavor.
I mentioned that there are vulnerabilities in
decisionmaking structures. This is reflected, I think, in
Congress' continuing worries about who is in charge of
bioterrorism response, and also showed up in many different
guises in the TOPOFF exercise. We found, in our analysis of
TOPOFF, which we agree was an enormously valuable drill that we
ought to consider repeating in many different ways--we found
that there were several different joint operation centers. We
found that hospital leaders had no idea who was in charge or
who to call for information or to get more supplies. It
appeared that the law-enforcement operations and the health-
care operations were running on separate tracks. The public
health and the medical people were meeting in one place and
making their own sets of decisions, and the law-enforcement
folks were going about their business. There was not actual
conflict between these two hubs, but there did not seem to be a
lot of collaboration or crosstalk. I think that would be an
unrealistic way to go in the midst of an actual attack on the
United States.
We also found that key participants could not really tell
you what decisions had been made. For example, people who were
in the throes of things had very different ideas about whether
or not it had been decided to actually quarantine Denver and
Colorado. That is a key decision, and yet there was dispute
about whether it had been made or not. We found in Dark Winter
and also in the course of conversations with many different
officials at both the State and Federal level that there is a
preoccupation with imposing quarantines, particularly if the
disease is contagious. There is an array of public health
measures beyond quarantine, before quarantine, that are likely
to be much more beneficial, that are much easier to employ, and
that ought to be considered long before anybody starts talking
about closing down Baltimore, Washington, DC, or New York City.
Yet these different public health measures, I think because
they are unfamiliar to governors and to Senators and to
national security officials, have gotten very little discussion
or attention. Also, for these measures to be put in place,
certain preparatory actions have to be considered.
So all of these vulnerabilities in the decisionmaking
structures, in addition to the ones Congress has already
noted--46 different agencies, the national security crowd and
the law-enforcement crowd and the public health crowd all
trying to be coordinated and collaborative--I think deserve
intense attention and discussion.
Finally, we need more effective vaccines and medicines.
Some of the most effective and important bioterrorism response
tools are not going to be there unless they are gotten ready
long before an attack occurs. We now have drugs or effective
vaccines for only about a dozen of the 50 pathogens thought to
be most likely used as biological weapons.
We are going to be asking FEMA and CDC to lead a response
to an epidemic without having sufficient supplies of effective
medicines and vaccines. This is like asking firefighters to
respond to a 12-alarm blaze without water or foam. It is crazy.
We really need to give serious consideration in this country to
a major biomedical R&D program that would, first of all, target
the likely bioweapons pathogens and create effective medicines
and vaccines for those organisms, and second that would delve
into the causes and means of preventing and treating infectious
diseases, generally. I do not see any way around this.
As biology progresses, which it is doing at a prodigious
pace, both the power and the diversity of biological weapons is
going to increase. That is where the trajectory of science is
going. We have to keep up with it. We can do this, and we can
shift the advantage from the offense to the defense, if we
invest the tremendous talent in R&D and biomedical areas that
exist in this country appropriately, but we have to get going
on this.
So, to end, Mr. Chairman, my recommendations again are:
First, engage hospitals and their leadership and get them
involved in planning and responding to bioterrorism. Congress
must lead in this. They must signal to hospitals that they have
an important role to play, and also spend money so that
hospitals can show up. Second, we should assess the real
capacity of the National Disaster Medical System and the VA
hospital system via independent analyses of our current
institutional capabilities and plans to care for the sick, and
find out if that really is a solid pillar of the Federal
response plan. Third, we should mount a substantial research
and development program that involves biomedical talent in the
private sector and the universities. Fourth, I would encourage
FEMA, in particular, to design, assess and use drills that
might reveal the vulnerabilities and inspire coordination and
improve awareness of the issues and options that a biological
weapons attack would present to decisionmakers.
Thank you.
Senator Akaka. Thank you very much, Dr. O'Toole.We will now
hear from Dr. Hanfling.
TESTIMONY OF DAN HANFLING,\1\ M.D., FACEP, CHAIRMAN, DISASTER
PREPAREDNESS COMMITTEE, INOVA FAIRFAX HOSPITAL, FALLS CHURCH,
VIRGINIA
Dr. Hanfling. Mr. Chairman, thank you very much for
inviting me here this afternoon to discuss issues that I think
are of great importance to the well-being of our Nation. I am
Dan Hanfling, a board-certified emergency physician with
extensive experience in the practice of out-of-hospital
emergency care. As an ``ER doc'' working in the trenches of
Inova Fairfax Hospital, a teeming, bustling emergency
department and trauma center located just across the river in
northern Virginia, as medical director of one of the best-
respected fire and rescue services in the country, and as a
veteran of the urban search-and-rescue disaster environment, I
can tell you that I have seen pain, suffering and devastation
that is, at times, unimaginable. But the consequences of a
surreptitious release of a biological agent in our midst, or
the effects of an as-yet unconsidered, newly-emerging,
infectious pathogen would make what I see daily pale by
comparison.
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\1\ The prepared statement of Dr. Hanfling appears in the Appendix
on page 00.
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I would like to discuss briefly the ability of emergency
departments to handle the aftermath of a bioterrorist attack.
Conventional pre-hospital and hospital disaster plans prepare
for events that may result in the transport of tens or possibly
hundreds of patients to local community emergency departments
and trauma centers. Even these extenuating circumstances would
place a significant burden on most local communities, as Dr.
O'Toole just mentioned. Emergency department overcrowding,
nursing staff shortages, hospital financial burdens and other
constraints on our existing health care system make rendering
such care difficult. These conditions contribute to impediments
that hamper local disaster planning and preparedness.
Across the country, hospitals are so full that ambulance
crews are often rerouted or diverted from where they usually
deliver their patients. In northern Virginia, this is what we
call circling the beltway. Facing the difficulties that we face
now, how are we to manage the number of patients that will
require care in the aftermath of a bioterrorist attack?
Emergency departments and in-hospital patient bed availability
will be a major issue, so, too, the ability to encourage
trained personnel to remain to treat patients. Razor-thin
inventories of pharmaceutical and medical equipment will be
quickly exhausted. Effective communication links will be
crucial, and yet only a handful of communities have invested
the money to creating a system that works in a crisis. And all
these become issues only after the deluge has struck.
I would now like to discuss the local impact of Federal
agencies. We have come a long way towards improving the role of
Federal agencies in community-oriented disaster mitigation, and
it is in large part due to the tremendous efforts of the
agencies that were represented here before us today. However,
disaster mitigation must be accomplished using local resources
and by the local community. Successful local disaster-planning
efforts must be predicated on the fact that the calvary is not
coming, at least not right away. I must emphasize that the
issue of bioterrorism is not exclusively a large, urban,
traditional first-responder event, as you have heard mentioned
many times already this afternoon.
This will affect all types of communities, urban, suburban
and rural, and it will be the medical and public health
communities that are up to bat first. So this is where we must
focus our efforts. Federal support of local and regional
planning efforts, taking an all-hazards approach, but geared
towards bioterrorism preparedness, is what is greatly needed.
How can this be effected? First, invest in restoring our
medical infrastructure to be the strongest possible. We must
focus attention on the issue of hospital and emergency
department overcrowding. Second, support the development of a
meaningful partnership between the medical and public health
communities. Even without shooting for pie-in-the-sky
information system capabilities, funding must be made available
now to pay for the time required to conduct drop-in
surveillance, such as was performed in the metro Washington, DC
area during the past Presidential inauguration. Finally,
promote disaster preparedness at the local level specifically
by funding educational, training and planning initiatives.
This process has already begun. The Department of Health
and Human Services and the American College of Emergency
Physicians recently released a report, that was funded by the
HHS Office of Emergency Preparedness, on the current state of
training for civilian emergency medical responders. That
includes paramedics, firefighters, emergency physicians and
nurses. This report evaluated current training programs,
analyzed barriers to implementing training, and established
objectives, content and competencies for the training of these
individuals. This represents a very important first step in the
right direction, because it is clear that we must begin by
creating a cadre of knowledgeable health care responders.
I want to be more specific. Federal funding for
bioterrorism preparedness must be made available to hospitals,
and a framework for hospital and community-wide planning, in
fact, already exists. Guidelines of the Joint Commission on the
Accreditation of Hospital Organizations are carefully followed
by hospitals that wish to achieve and maintain coveted
accreditation status. However, they receive no funding to
implement such guidelines, and these guidelines specify the
following: Establishing community and hospital linkage by
integrating the hospital with community-wide response agencies;
identifying alternative care treatment facilities; establishing
backup external and internal communication systems; providing
an ongoing orientation and education program; and conducting
drills each year. Please, Mr. Chairman, help us fund these
important steps.
In March 1992, patients from the first documented anthrax
hoax were treated in Inova Fairfax Hospital. Three years prior
to that, Ebola virus decimated a stock of laboratory rhesus
monkeys in Reston, Virginia, and again it was Inova Fairfax
Hospital in the eye of the storm. Each episode involved few
patients and the lethality of each infectious agent was not an
issue, so we breathed a sigh of relief. But now, almost 10
years later, emergency departments, hospitals and the health
care community are not organized to treat victims of a
bioterrorist attack. Meaningful discussion on the issue of
domestic preparedness must focus on the development of
community-wide endeavors to meet this tremendous challenge. In
order to be truly effective, the planned Federal efforts to
improve domestic preparedness will require substantial
additional resources and funding at the local level.
With 20/20 hindsight, one can say that ``duck-and-cover''
represented a somewhat ludicrous civil preparedness stance in
the face of nuclear attack. I hope that as emergency planners
of the future look back on our discussions of today, they do
not chuckle the way that some of us do now.
Mr. Chairman, I truly appreciate the opportunity to be here
and, of course, I am willing to take any questions.
Senator Akaka. Thank you very much, Dr. Hanfling. I
appreciate your statements. You have certainly identified the
huge problem that this will bring, as well as to mention some
of the resources and maybe how we can bring it together,
including resources and money, possibly, from Congress. But,
Dr. O'Toole, the Department of Justice is the lead agency and
in sole command of an incident while in the crisis management
phase. FEMA, as we have heard, is responsible for all
consequence-management activities.
The question is do you find this division between crisis
and consequence management useful in combatting and responding
to biological terrorism?
Dr. O'Toole. No.
Senator Akaka. Can you expand on that?
Dr. O'Toole. Well, there will be no crisis in a
bioterrorist event, as it is traditionally understood. If it is
an announced attack, then perhaps there will be some prelude
during which people try to figure out how to mobilize a
response. But it is likely going to creep up on us, and it will
be the medical and public health community, not the
intelligence community, not the law-enforcement community, that
gets the first inkling that something is up. So there will not
be that initial crisis response, as there was, for example, in
the Oklahoma City bombing. It is going to have very different
flavor. It is going to have a very different pace than other
sorts of disasters.
I do not think the distinction between crisis and
consequence management is helpful. I am not sure it is a
problem. I think the FBI obviously would be involved very early
on, at the first suspicion that this was a deliberate epidemic,
and I think they will have their job to do. I do think it would
be very useful to deepen the coordination and collaboration
between the FBI and public health at the local level. One FBI
agent in New York told me that they would have at least 200 to
500 people on the ground within 24 hours after a major
bioterrorist attack. As a public health professional, I was
very envious of that operational capability. Public health
cannot do that. Even if we had the full force of CDC behind us
I do not think we could do that in 24 hours.
Early on, the FBI and the public health officials are going
to want answers to virtually the same questions: Where were
you? What were you doing? Who have you been in contact with? If
everybody is holding the same set of questions on palm pilots
that get coordinated, maybe the FBI and the public health could
share their expertise and resources in very constructive ways.
So this crisis consequence management division, I think, is not
very helpful. It is basically not going to exist as even an
imaginary line in a bioterrorism event.
Senator Akaka. Dr. O'Toole, you stated that the medical and
hospital communities need to be included in bioterrorism
preparedness and response planning. Are there other groups that
are routinely left out of the biological terrorism discussion,
and if you know, if so, why?
Dr. O'Toole. Well, I think you touched on the
veterinarians, who are also very important. You could envelop
the entire world in bioterrorism response and were, Lord
forbid, there to be an epidemic, we will envelop the entire
world very quickly, because it will affect transportation. It
will affect trade. It will affect virtually every aspect of
human activity. But if we are setting priorities in terms of
increasing awareness and fostering engagement, my list right
now is, (1) the hospital community, because they are the core
of the medical community, institutionally speaking; and (2)
would be the governors, who I think have an enormous amount at
stake and are in a position similar to hospital CEOs. They say,
``Look, I have an enormous amount going on. I have daily fires
I have to take care. I have major priorities for my State that
I want to accomplish.'' National security is not usually within
the purview of governors, and they do not consider it to be
their business. I think it would be very helpful if the
governors were awakened to the implications of bioterrorism and
started applying their own insights, as well as their political
muscle and influence, to the problem.
Senator Akaka. You also mentioned that there are other
public health measures that can be used instead of quarantine.
Can you tell me what they are and how can we make these known
to policy makers and planners?
Dr. O'Toole. Well, there has been a lot of discussion about
this lately within public health circles and also at Dark
Winter. Quarantine is a concept that actually comes from the
Middle Ages, when they forced ships to lay off at one corner of
the harbor for 40 days, to try and prevent the introduction of
diseases into the port. Sometimes it worked, sometimes it did
not, but it became a historical fact. Quarantining a major
metropolitan city is all but impossible, as we discovered in
TOPOFF. They tried to impose a quarantine on Denver initially,
when they realized they had a contagious disease abroad and
they did not have enough antibiotics to protect everyone from
the disease. That is the first problem.
If you have the vaccines and you have the prophylactic
antibiotics, you do not have to worry about quarantine. You can
give people the protective medicines and they can go on about
their way. The second problem is that by the time you know you
have got an epidemic on your hands, people who are infected are
probably going to be all over the world, and calling them back
and gathering them together in one place is basically going to
be impossible.
Another method beyond appropriate medicines and vaccines is
to limit the interaction of people in ways that are less
Draconian than quarantine. So, for example, you can forbid
congregate gatherings. You can cancel sporting events and so
forth. You can limit, for example, the transportation of people
without completely forbidding the movement of cargo and food,
so you do not find the problem they did in TOPOFF. Three days
into the quarantine, they realized Denver was out of food.
Probably the most important thing one needs to do is enlist
the help of the public at-large. This is a constantly-neglected
priority. I neglected it in my testimony today, partly because
the notion of engaging the public in a cooperative enterprise
aimed at stopping the spread of disease or protecting whole
populations seems to be so hard.
But we do need to think through how we would communicate
effectively with people and tell them how best to protect
themselves and their families. People do not panic in
catastrophic situations, history shows. They actually do very
reasonable things, and if you give them reasonable options,
they will pursue them. If you tell them, on the other hand,
there is a deadly plague abroad in your city, your kids may
die, there are not enough medicines to go around, this city is
running out of medicines and we are about to close all exit
routes out of the city, they are probably going to pack up
their kids and try to get someplace where there are still
medicines or at least less of a danger.
So I think enlisting the public in cooperative measures
that are not coercive is probably one of the most important
things that we could do.
Senator Akaka. Dr. Hanfling, are the physicians and nurses
in your hospital trained to watch for unusual clusters of
symptoms or cases that are indicative of bioterrorist activity,
and would you explain the chain of command on such cases?
Dr. Hanfling. To answer the first question first, with
respect to the training and capabilities of our emergency
physicians, nurses and other health professionals, there has
been very limited formal training of these staffs on these
issues. A handful of physicians and a few nurses have had the
opportunity to attend some of the hospital preparedness
training that came about as a result of the Nunn-Lugar-Domenici
Domestic Preparedness Program. But, as you know and have
probably heard in testimony previously to this Subcommittee,
there was very little attention focused on the hospital portion
and inpatient treatment, diagnostic, and therapeutic modalities
during that curricula. Most of it was actually focused on the
traditional first-responder community.
During the Presidential inauguration this past January, we
actually implemented as part of a State of Virginia Department
of Health project, a ``drop-in'' surveillance program where,
for the 2 weeks preceding the inauguration and the 2 weeks
following the inauguration, we were looking at every emergency
department patient with respect to one of a number of symptoms
that they presented with. Unfortunately, because of the
constraints that I mentioned earlier in my testimony, this was
very difficult to effect and, in fact, we had to have the
health department supply their own personnel to review each and
every one of our charts. We see up to 250 patients in a 24-hour
period, and to do the paperwork that was required was onerous
and difficult, on top of all of the other requirements for
patient care.
To answer your second question, with respect to chain of
command, the chain of command is very loose within the hospital
organizations. There has been a lot of effort put forth--in
fact, this has been championed in the State of California, in
the Office of Emergency Preparedness, or whatever their title
is, in developing a hospital incident command system. This is a
formal application of a framework that addresses the issue of
chain of command, and this is beginning to catch on in the
hospital communities. But, again, without funding for support
of these endeavors, it is very hard to put these in place.
So when we talk about our current chain of command, it
involves the chairman of the emergency department, it involves
the chairman of the disaster preparedness committee, it
involves the chief administrator of the hospital, it will, at
some point, involve the fire chief or his designate and the
police chief and his designate, but I can tell you I do not
think any of us have ever sat down at a table together. So it
has never really been tested.
Senator Akaka. In his testimony, Dr. Hanfling, Dr.
Lillibridge stated that one of the lessons learned from the
TOPOFF exercise was the importance to link emergency management
services and health decision making at the State and local
level. He gave the example of training to help workers to
understand emergency management tools, like the incident
command system. In your opinion, how big a task is this? Do you
feel that health care workers will welcome this training?
Dr. Hanfling. Well, I would like to comment on some of what
Dr. Lillibridge mentioned in his response to that question of
yours. Primarily, the efforts of training that come from the
Federal level have been designated towards the traditional
first-responder community. So this really ends up falling in
the laps of our pre-hospital fire and rescue services
providers. There has been very little engagement of the folks
that I mentioned in my testimony from the hospital community
and, as Dr. O'Toole mentioned, in the public health community,
in these same sorts of emergency management curricula.
To get our emergency physicians and nurses, our paramedics
and firefighters, to do the sort of reporting that they are
required to do today as part of their day-to-day work is an
onerous and difficult task enough, and that is, I think, the
challenge of providing yet additional curricula and additional
requirements. We need to find a way to incentivize these
efforts, to make it worth their while and, at the same time,
not make it yet another additional requirement that might be
viewed as a burden for additional work.
Senator Akaka. Thank you, Dr. Hanfling.
Let me ask my friend and colleague, Senator Cochran, for
any statement that you may have and questions that you may
have.
OPENING STATEMENT OF SENATOR COCHRAN
Senator Cochran. Thank you very much, Mr. Chairman. I
appreciate the fact that you have organized this hearing. I
think it is a timely subject to discuss. I was pleased to see
the administration assume some responsibilities earlier this
year, and try to set up a framework for coordinating and
examining the capabilities we have to deal with these threats.
I am hopeful that that will focus attention, as obviously
attention is being focused by this Subcommittee today, on the
subject and how serious it can be and how it could stretch our
resources and also be a threat to the lives and health of our
American citizens.
So we want to be sure that we are getting it right, that we
understand the facts, and that we understand what the
improvements are that can be made to deal with this very
serious situation.
Thank you very much, Mr. Chairman. I have some questions,
but I do not want to interfere with your----
Senator Akaka. Well, you are welcome to----
Senator Cochran. Well, I will ask Dr. O'Toole--I see that
you are at the Johns Hopkins Center for Civilian Biodefense
Studies--what your impression is of these new suggestions that
we are hearing regarding coordination? There had been some
suggestion that the Department of Health and Human Services was
not very well-organized to handle this job, and this
administration has suggested that a new position of special
assistant to the secretary would help increase the coordination
of the department's anti-bioterrorism efforts. Do you agree
with that?
Dr. O'Toole. Yes, very strongly, Senator. I think Secretary
Thompson's appointment of Dr. Lillibridge to be his special
assistant on bioterrorism is a very good idea. As the Chairman
remarked earlier, HHS is not normally in the room when national
security issues are being discussed, and yet bioterrorism
preparedness requires a sustained, collaborative effort here in
Washington and around the country amongst many different
agencies, including HHS. So having someone who is in a position
to run to meetings, which the NSC often calls at the last-
minute, as you know, and to present the medical point of view,
I think, is an enormously important step forward. I think
Secretary Thompson's testimony at the May hearings also
evidences that he is very aware of bioterrorism as a high-
priority issue and intends to grab hold of it.
Senator Cochran. I think the President has also asked the
Vice President to undertake a high-level review, to be sure
that we do what we can to focus and increase the Federal
Government's ability to respond government-wide to a biological
weapons attack. Do you agree that that is a step in the right
direction, as well?
Dr. O'Toole. I think the more light we shed on this, the
better off we are, and I think the President initiating those
kind of discussions at the highest levels is very important,
substantively and also as a signal that he intends that the
government take this matter very seriously.
Senator Cochran. Dr. Hanfling, I noticed that FEMA and CDC,
the Centers for Disease Control, have entered into an agreement
to conduct a course for emergency management and health
community personnel to improve their ability to respond to a
bioterrorism attack. Do you think that may be a step in the
right direction, too, to generate more interest in the health
community and awareness?
Dr. Hanfling. Yes, Senator. I think that these efforts to
improve education, especially focused on the State and, most
certainly, at the local level, will be steps in the right
direction. To put it in perspective, though, in order to get
those emergency managers and those personnel involved in the
day-to-day care of their communities away, to be able to attend
courses that might be a week in time, may require travel, etc.,
requires the sort of support that is not always available in
the local communities.
I would also make another point, which is that it is often
the best and the brightest who have the opportunity to attend
those sorts of courses and curricula, and I think that the
model that the Federal agencies have used in the past, which is
a train-the-trainer model, is a successful way to impart that
information. But those may not be the folks who are manning the
helm when the proverbial event happens. So we have got to allow
this information to trickle down to all levels of providers.
Senator Cochran. Thank you, Mr. Chairman.
Senator Akaka. Thank you for your questions. I have a few
more questions I would like to continue with.
Dr. Hanfling, I asked Dr. Lillibridge about the Emergency
Medical Treatment and Labor Act of 1986, which guarantees
emergency room care to anyone who seeks treatment. As someone
who works in an emergency room, how do you see this law
impacting bioterrorism response?
Dr. Hanfling. I commend you on asking that question,
because I do think that this is an important issue that needs
some attention. As an emergency physician, I view the EMTALA,
or Emergency Medical Treatment and Labor Act, as really
providing the legal framework that creates a safety net for
providing care across our country for those who have no other
place to turn. So I am very supportive of this act, in
supporting the efforts that I try to achieve each and every
day. But in the context of a bioterrorism attack, I think we
have to consider the utility of such a law, which requires
medical attention and more than just triage. It actually
requires a medical screening exam for each patient who comes to
the hospital, and I think Dr. O'Toole is more the expert in
terms of looking at some of the strategies that might be put
into place, to enact treatment in out-of-hospital environments,
but one such endeavor might be to sequester patients who are
sick or patients who have not been exposed in facilities far
away from the community that is impacted, and yet those
patients may initially present to the local community hospital
seeking care.
So I think we have to consider appropriate amendments of
acts such as EMTALA in the setting of a catastrophic event such
as bioterrorism, that would change the structure in which we
are practicing medicine and delivering all of our social
services day-to-day. Does that answer your question?
Senator Akaka. Yes. Thank you very much for that response.
You stated, Dr. Hanfling, that relationships between Federal
agencies and State officials have improved, but are still
limited on the local level. Are there steps that we can take to
improve these relationships?
Dr. Hanfling. I think that attention has been focused
appropriately here this afternoon on the role of governors and
the important power that the governors wield in such crisis
situations. It is clear that the Federal response plan is put
in place and designates lead agencies in crisis and consequence
management, but the fact is that these disasters occur at the
local level, and that in occurring in that manner, at least
initially, the State governors have some ownership and
authority of those efforts. So I think that there ought to be
some attention focused at the State level to really making the
sorts of meaningful relationships come into play, to allow
community preparedness to occur, as a part of regional
preparedness, and State preparedness, all fitting into the
national picture.
Senator Akaka. You also mentioned the barriers between
traditional first responders and hospital communities. Do you
think that long-term plans by FEMA and HHS, as described by Mr.
Baughman and Dr. Lillibridge, will help either of these
concerns?
Dr. Hanfling. I do believe that, in the long-term, these
gentlemen understand that this is a matter that is not going to
be solved at the Federal level, and that these are issues that
really require effective preparedness at the local level in
order to mitigate them properly. I think that FEMA has taken
tremendous steps in the last decade to prove that it is able to
do that, but bioterrorism is different than a hurricane or an
earthquake, and so we really have to focus, I think, at the
local level, enhancing the local infrastructure, and really
allowing the health-care community--that includes the medical
community and the public health community--to be able to stand
alone until those Federal assets are available, and we know
that might take some time.
Senator Akaka. A question to both of you: Some say one of
the barriers for training for bioterrorism first-responders,
mainly emergency room physician, nurses and emergency medical
technicians, is that existing medical and nursing school
training programs are so full, and time is limited. The
question is how can we persuade medical and nursing schools
that bioterrorism preparedness justifies dedicating resources
and time to course curricula? Would you substitute bioterrorism
training over other areas to ensure awareness?
Dr. O'Toole.
Dr. O'Toole. Well, health professionals learn all the time.
I mean, it is part of their job, and I would target first not
medical schools or nursing schools, because I think it is very
difficult to get new curriculum subjects introduced into
medical schools and nursing schools. I would target practicing
physicians, and provide enough seed money to create some
reliable continuing medical education credits for both
physicians and nurses through their professional societies,
which is how health professionals learn, and I think with that
seed money, the Infectious Disease Society of America and the
nursing associations and so forth will take it upon themselves
to proliferate the original curriculum.
We have been having discussions--I know CDC has been having
discussions--with professional groups. I know OEP has been
talking to the emergency physicians' professional societies,
and the problem with all of these groups is the initial seed
money to develop the first core curriculum, but then everybody
can go out and share, whether it is in San Francisco or
Mississippi. So I think monies for professional curriculums and
putting them in the hands of the appropriate professional
societies would be the way to go. I think that training
component is very important.
Dr. Hanfling. I think I would echo what Dr. O'Toole has
stated. In the context of the American College of Emergency
Physicians' evaluation of this very issue, they found that
funding and time constraints were the biggest barriers to
getting effective training curricula to the designated health-
care professionals. I think that certainly in the context of
the existing medical and nursing school curricula, which are
already so chock-full of absolute requirements, it might be
hard to carve additional time out of what is already a robust
schedule. But certainly those who begin to practice would be
the appropriate group of folks to target this information. One
additional means of making that information attractive and
imperative, would also be to focus on hospital CEOs and
administrators, who do have a certain impact on the medical
staffs of their respective institutions, and get them to
champion these as important issues for the safety, not only of
their hospitals and the well-being of their health systems, but
also of the communities in which they serve.
Senator Akaka. Thank you very much.
Senator Cochran, would you have any more questions or
comments to make?
Senator Cochran. Mr. Chairman, I do not, except to thank
you for convening the hearing. I think it is a very important
subject for us to consider, particularly in light of the new
initiatives the administration is pushing to try to get better
control over the way we are organized, to deal with and respond
to these problems, to understand them, and having the vaccines
in the quantities that we need to deal with some of these
emergency situations. I think we are moving in the right
direction.
Senator Akaka. Thank you. I think so, too. I would like to
thank our witnesses, Dr. O'Toole and Dr. Hanfling, and I want
to thank my friend and colleague, Senator Cochran, for being
here this afternoon and for your cooperation in this effort.
Today's testimony has given us much to think about and
consider. I have heard three underlying concerns that need to
be met to properly prepare for bioterrorism: First, the medical
and hospital community needs to be more engaged in bioterrorism
planning; second, the partnership between medical and public
health professionals needs to be strengthened; and, third,
hospitals must have the resources to develop surge
capabilities. The first two concerns can be addressed through a
coordinated national terrorism policy, as being developed by
FEMA. The last concern is more complicated and will require
substantial changes to our health care system. I look forward
to working with all the different stakeholders in their efforts
to prepare our communities for an act of bioterrorism.
I do not have any further questions. However, Members of
this Subcommittee may submit questions in writing for any of
the witnesses. We would appreciate a timely response to those
questions. The record will remain open for these questions and
for further statements by my colleagues. I would like to
express my sincere appreciation once again to all the witnesses
for their time and for sharing their insights with us this
afternoon. This hearing is adjourned.
[Whereupon, at 3:28 p.m., the Subcommittee was adjourned.]
A P P E N D I X
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