[Senate Hearing 107-440]
[From the U.S. Government Printing Office]



                                                        S. Hrg. 107-440
 
           EFFECTIVE RESPONSES TO THE THREAT OF BIOTERRORISM
=======================================================================



                                HEARING

                               BEFORE THE

                     SUBCOMMITTEE ON PUBLIC HEALTH

                                 OF THE

                    COMMITTEE ON HEALTH, EDUCATION,
                          LABOR, AND PENSIONS
                          UNITED STATES SENATE

                      ONE HUNDRED SEVENTH CONGRESS

                             FIRST SESSION

                                   ON



 EXAMINING EFFECTIVE RESPONSES TO THE THREAT OF BIOTERRORISM, FOCUSING 
           ON DETECTION, TREATMENT, AND CONTAINMENT MEASURES

                               __________

                            OCTOBER 9, 2001
                               __________

 Printed for the use of the Committee on Health, Education, Labor, and 
                                Pensions






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          COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS

               EDWARD M. KENNEDY, Massachusetts, Chairman

CHRISTOPHER J. DODD, Connecticut     JUDD GREGG, New Hampshire
TOM HARKIN, Iowa                     BILL FRIST, Tennessee
BARBARA A. MIKULSKI, Maryland        MICHAEL B. ENZI, Wyoming
JAMES M. JEFFORDS (I), Vermont       TIM HUTCHINSON, Arkansas
JEFF BINGAMAN, New Mexico            JOHN W. WARNER, Virginia
PAUL D. WELLSTONE, Minnesota         CHRISTOPHER S. BOND, Missouri
PATTY MURRAY, Washington             PAT ROBERTS, Kansas
JACK REED, Rhode Island              SUSAN M. COLLINS, Maine
JOHN EDWARDS, North Carolina         JEFF SESSIONS, Alabama
HILLARY RODHAM CLINTON, New York     MIKE DeWINE, Ohio

           J. Michael Myers, Staff Director and Chief Counsel
             Townsend Lange McNitt, Minority Staff Director

                                 ______

                     Subcommittee on Public Health

                      EDWARD M. KENNEDY, Chairman

TOM HARKIN, Iowa                     BILL FRIST, Tennessee
BARBARA A. MIKULSKI, Maryland        JUDD GREGG, New Hampshire
JAMES M. JEFFORDS, Vermont           MICHAEL B. ENZI, Wyoming
JEFF BINGAMAN, New Mexico            TIM HUTCHINSON, Arkansas
PAUL D. WELLSTONE, Minnesota         PAT ROBERTS, Kansas
JACK REED, Rhode Island              SUSAN M. COLLINS, Maine
JOHN EDWARDS, North Carolina         JEFF SESSIONS, Alabama
HILLARY RODHAM CLINTON, New York     CHRISTOPHER S. BOND, Missouri

                      David Nexon, Staff Director
                 Dean A. Rosen, Minority Staff Director

                                  (ii)

  





                            C O N T E N T S

                               __________

                               STATEMENTS

                        Tuesday, October 9, 2001

                                                                   Page
Kennedy, Hon. Edward M., Chairman, Committee on Health, 
  Education, Labor and Pensions..................................     1
Frist, Hon. Bill, a U.S. Senator from the State of Tennessee.....     5
Cleland, Hon. Max, a U.S. Senator from the State of Georgia; Hon. 
  Chuck Hagel, a U.S. Senator from the State of Nebraska; Hon. 
  Evan Bayh, a U.S. Senator from the State of Indiana; Hon. Jon 
  Corzine, a U.S. Senator from the State of New Jersey...........
Edwards, Hon. John, a U.S. Senator from the State of North 
  Carolina.......................................................    12
Henderson, M.D., Donald A., Director, Johns Hopkins Center for 
  Civilian Biodefense Studies, Baltimore, MD; Janet Heinrich, 
  Director, Health Care and Public Health Issues, U.S. General 
  Accounting Office, Washington, DC, Mohammad N. Akhter, M.D., 
  Executive Director, American Public Health Association, 
  Washington, DC; and Michael T. Osterholm, Director, Center for 
  Infectious Disease Research and Policy, University of 
  Minnesota, Minneapolis, MN.....................................    17
    Prepared statements of:......................................
        Dr. Henderson............................................    20
        Ms. Heinrich.............................................    24
        Dr. Akhter...............................................    38
        Mr. Osterholm............................................    44

                          ADDITIONAL MATERIAL

Articles, publications, letters, etc.:
    The Center for Infectious Disease Research and Policy, 
      University of Minnesota, and the Workgroup on Bioterrorism 
      Preparedness...............................................    67

                                 (iii)

  


           EFFECTIVE RESPONSES TO THE THREAT OF BIOTERRORISM

                              ----------                              


                        TUESDAY, OCTOBER 9, 2001

                                       U.S. Senate,
Subcommittee on Public Health, of the Committee on Health, 
                            Education, Labor, and Pensions,
                                                    Washington, DC.
    The subcommittee met, pursuant to notice, at 10:02 a.m., in 
room SD-430, Dirksen Senate Office Building, Hon. Edward M. 
Kennedy (chairman of the subcommittee) presiding.
    Present: Senators Kennedy, Mikulski, Wellstone, Reed, 
Edwards, Clinton, Dodd, Murray, Frist, Hutchinson, Collins, and 
Sessions.

                  Opening Statement of Senator Kennedy

    The Chairman. We will start the hearing.
    We have two very important panels today. First, we welcome 
our colleagues to the committee. Then, we have a very important 
vote at 10:30.
    Three of my colleagues are here now. Senator Frist and I 
will make a statement, and I know Senator Edwards is a 
cosponsor of this bill with Senator Hagel. Under normal 
circumstances, six times five is 30, and that is when the bell 
is supposed to ring. It may ring a few moments before, but we 
will try to conclude the Senators' statements prior to the 
vote. Then we will commence with our second panel. We are 
enormously grateful to them for being here and for their help 
and assistance to this committee. They are old friends, and we 
have benefited and the country has benefited immensely as a 
result of their years of study and work on the matter of 
bioterrorism and drug-resistant bacteria. We are immensely, 
immensely appreciative of their willingness at this time to 
give us the benefit of their judgment and also to give us an 
idea about where we should be going and additional steps that 
should be taken.
    We will proceed in that order. I will make a brief opening 
statement and recognize Senator Frist, and then we will turn to 
our colleagues.
    It is a privilege to hold today's hearing on improving the 
Nation's preparedness for bioterrorism and to continue the work 
that this committee began 3 years ago on this issue of special 
importance. Yesterday, Tom Ridge was sworn in as director of 
the new Office of Homeland Security. One of the immediate tasks 
facing Governor Ridge is to close the gaps in our ability to 
deal with the possibility of bioterrorism on American soil. All 
of us in Congress stand ready to work with Governor Ridge and 
Secretary Thompson on this vital assignment.
    The response to the recent confirmed anthrax case in 
Florida and the suspected case in Virginia shows that there are 
many strengths in our public health and law enforcement 
systems. But as our witnesses today will attest, there is still 
much to be done. Every day we delay in expanding our 
capabilities exposes innocent Americans to needless dangers. We 
cannot afford to wait.
    Senator Frist and I began addressing this challenge 3 years 
ago. Last November, our initial legislation to strengthen the 
Nation's capacity to respond to bioterrorism was enacted into 
law. Last week, we proposed a fivefold increase in current 
Federal funding to deal with the consequences of a possible 
bioterrorist attack. Today's hearing will provide further 
evidence that our $1.4 billion plan is fully justified.
    Our first priority must be to prevent an attack. That means 
enhancing our intelligence capability and our ability to 
infiltrate terrorist cells. It also means using the renewed 
partnership between the United States and Russia to make sure 
that dangerous biological agents do not fall into the hands of 
terrorists. We have worked with Russia to prevent the spread of 
nuclear weapons, and we must work together now to prevent the 
spread of biological weapons.
    We must also improve America's preparedness for a 
bioterrorist attack. The keys to responding effectively to a 
bioterrorist attack lie in three key components--immediate 
detection, immediate treatment, and immediate containment.
    To improve detection, we should enhance the ability of 
health professionals to recognize the symptoms of a 
bioterrorist attack, identify biological weapons accurately, 
and communicate essential medical information rapidly and 
securely.
    To improve the treatment of victims of a bioterrorist 
attack, we must strengthen our hospitals and emergency medical 
plans.
    To improve containment, we must make certain that Federal 
supplies of vaccines and antibiotics are available quickly to 
assist local health officials in preventing the disease from 
spreading. Developing new medical resources for the future is 
also essential. We should use the remarkable skills of our 
universities and biotechnology companies to give us new and 
better treatments in the battle against bioterrorism.
    Senator Frist and I look forward to working with our 
colleagues on this committee and in Congress to achieve these 
extremely important goals. Senator Edwards and Senator Hagel 
have already put forward a number of significant proposals. We 
welcome the contributions and leadership of our colleagues, 
Senator Corzine, Senator Bayh, and Senator Cleland, a member of 
our Armed Services Committee who has taken a particular 
leadership position on this issue, as they testify before us 
today.
    September 11 was a turning point in American history. Our 
challenge now is to do everything we can to learn from that 
tragic day and prepare effectively for the future.
    [The prepared statement of Senator Kennedy follows:]

            Prepared Statement of Senator Edward M. Kennedy

    It's a privilege to hold today's hearing on improving the 
nation's preparedness for bioterrorism, and to continue the 
work that this committee began three years ago on this issue of 
special importance.
    Yesterday, Governor Tom Ridge was sworn in as President 
Bush's Director of the new Office of Homeland Security. As our 
forces continue their actions over Afghanistan, we can expect 
that our enemies will try to strike against our country again. 
One of the most immediate tasks facing Governor Ridge as he 
takes on this new extraordinary responsibility is to close the 
gaps in our ability to deal with the possibility of 
bioterrorism on American soil. All of us in Congress stand 
ready to work with Governor Ridge and Secretary Thompson on 
this vital assignment.
    The response of the Centers for Disease Control, the FBI, 
and local health authorities to the recent anthrax cases in 
Florida shows that there are many strengths in our public 
health and law enforcement system. But as our witnesses today 
will attest, there is still much to be done.
    Last week, Senator Frist and I proposed a five-fold 
increase in current federal funding to deal with the 
consequences of a possible bioterrorist attack. Today's hearing 
will provide further evidence that our $1.4 billion plan is 
fully justified, and that we should act now to provide this 
emergency funding.
    We want to reassure all Americans that much has already 
been done to assure their safety from such an attack, and to 
minimize the spread of biological agents if an attack does 
occur. The kind of heroism we witnessed from average Americans 
on September 11--with Americans caring for and protecting their 
fellow citizens--would take place once again in responding to a 
bioterrorist threat.
    But every day we delay in expanding our capabilities 
exposes innocent Americans to needless danger. We cannot afford 
to wait.
    That's why Senator Frist and I began addressing this 
challenge three years ago. Last November, our initial 
legislation to strengthen the nation's capacity to respond to 
bioterrorism was enacted into law. Now we look forward to 
working with the Administration and our colleagues in Congress 
to assure that the essential work of strengthening these 
defenses is accomplished as soon as possible.
    Our first priority must be to prevent an attack from ever 
occurring. That means moving quickly to enhance our 
intelligence capacity and our ability to infiltrate terrorist 
cells, wherever they may exist. It also means using the renewed 
partnership between the United States and Russia to make sure 
that dangerous biological agents do not fall into the hands of 
terrorists.
    Russia currently holds the largest supply of potential 
biological weapons. We have an opportunity now to make needed 
progress in securing these dangerous biological materials. 
We've worked with Russia to prevent the spread of nuclear 
weapons, and we must work together now to prevent the spread of 
biological weapons.
    We must also enhance America's preparedness for a 
bioterrorist attack. Our citizens need not live their lives in 
fear of a biological attack, but building strong defenses is 
the right thing to do.
    Unlike the assaults on New York and Washington, a 
biological attack would not be accompanied by explosions and 
police sirens. In the days that followed, victims of the attack 
would visit their family doctor or the local emergency room, 
complaining of fevers, aches in the joints or perhaps a sore 
throat. The actions taken in those first few days will do much 
to determine how severe the consequences of the attack will be.
    The keys to responding effectively to a bioterrorist attack 
lie in three key concepts: immediate detection, immediate 
treatment and immediate containment.
    To improve detection, we should improve the training of 
doctors to recognize the symptoms of a bioterrorist attack, so 
that precious hours will not be lost as doctors try to diagnose 
their patients. As we've seen in recent days, patients with 
anthrax and other rarely encountered diseases are often 
initially diagnosed incorrectly. In addition, public health 
laboratories need the training, the equipment and the personnel 
to identify biological weapons as quickly as possible.
    In Boston, a recently installed electronic communication 
system will enable physicians to report unusual symptoms 
rapidly to local health officials, so that an attack could be 
identified quickly. Too often, however, as a CDC report has 
stated: ``Global travel and commerce can move microbes around 
the world at jet speed, yet our public health surveillance 
systems still rely on a `Pony Express' system of paper-based 
reporting and telephone calls.''
    To improve the treatment of victims of a bioterrorist 
attack, we must strengthen our hospitals and emergency medical 
plans. Boston, New York and a few other communities have plans 
to convert National Guard armories and other public buildings 
into temporary medical facilities, and other communities need 
to be well prepared too. Even cities with extensive plans need 
more resources to ensure that those plans will be effective 
when they are needed.
    To improve containment, we must make certain that federal 
supplies of vaccines and antibiotics are available quickly to 
assist local public health officials in preventing the disease 
from spreading.
    Developing new medical resources for the future is also 
essential. Scientists recently reported that they had 
determined the complete DNA sequence of the microbe that causes 
plague. This breakthrough may allow new treatments and vaccines 
to be developed against this ancient disease scourge. We should 
use the remarkable skills of our universities and biotechnology 
companies to give us new and better treatments in the battle 
against bioterrorism.
    Much has already been done to improve the nation's 
readiness, but we need to be even more prepared. Senator Frist 
and I look forward to working with our colleagues on this 
committee and in Congress to achieve these extremely important 
goals. Senator Edwards and Senator Hagel have already put 
forward a number of significant proposals. And we welcome the 
contributions and leadership of our colleagues, Senator 
Corzine, Senator Bayh, and Senator Cleland, as they testify 
before us today.
    September 11th was a turning point in America's history. 
Our challenge now is to do everything we can to learn from that 
tragic day, and prepare effectively for the future.
    Senator Frist?

                   Opening Statement of Senator Frist

    Senator Frist. Thank you, Mr. Chairman.
    As America begins to strike back against Osama bin Laden, 
his terrorist cohorts, and the Taliban regime for the brutal 
assaults of September 11, today we face the possibility that a 
new front in the war on terrorism has opened at home--a second 
potentially deadly case of anthrax discovered in Florida just 
yesterday.
    Just as many of us never imagined that America's commercial 
airliners would be converted into weapons of mass destruction, 
it is perhaps beyond the grasp of many that the weapons of 
choice in the war of the 21st century may well be tularemia, 
smallpox, and anthrax. But this should come as no surprise. As 
we will hear today, the threats from biological and chemical 
agents are real. Terrorist groups have the resources and the 
motivation to use germ warfare.
    Osama bin Laden has said publicly that it is his religious 
duty to acquire weapons of mass destruction, including 
biological and chemical weapons. We all know that rapid 
advances in agent delivery technology have made the 
weaponization of germs much, much easier.
    Finally, with the fall of the Soviet Union, the expertise 
of thousands and thousands of scientists knowledgeable, trained 
professionally in germ warfare, may be available to the highest 
bidder. It can be bought.
    Unfortunately, as we will also hear today, America is not 
yet fully prepared to meet the threat of biological warfare. 
Great strides have been made in the past 3 years, but there is 
much more to be done. There are gaps to be filled.
    Today some of the Nation's leading experts on bioterrorism 
will help provide us further guidance as we prepare to meet 
this remote yet very real and growing threat. A biological or 
chemical attack on our soil could be even more deadly and more 
destructive than the recent attacks on the World Trade Center 
and the Pentagon.
    Without a substantial new Federal investment in our public 
health infrastructure, increased intelligence and preventive 
measures, expedited development and production of vaccines and 
treatments, and constant vigilance on the part of our Nation's 
health care workers, a terrorist attack using a deadly 
infectious agent, whether delivered through air, through food, 
or by any other means, could kill or sicken millions of 
Americans.
    Senator Kennedy has already mentioned the Public Health 
Threats and Emergencies Act of 2000 which originated in this 
committee and was ultimately passed. It provides a coherent and 
I believe relatively comprehensive framework for responding to 
health threats resulting from bioterrorism.
    Last week, Senator Kennedy and I asked the administration 
and the Senate Committee on Appropriations to provide an 
additional $1.4 billion for these activities. The vast majority 
of these funds would go toward a one-time investment in 
strengthening the response capabilities of our hospitals, our 
health care professionals, and local public health agencies 
that would indeed form the front line response team in the 
aftermath of a bioweapons attack.
    I look forward to working with our colleagues in the U.S. 
Senate and with the administration toward this goal.
    I too would like to recognize those Senators before us for 
their leadership on this particular issue. I believe their 
presence here is a heartening signal of the growing focus and 
commitment on the part of the United States Congress to take 
those steps necessary this year to make sure that our Nation is 
fully prepared to respond to any threat to the American people.
    The Chairman. Thank you very much.
    The Chairman. Senator Cleland, we welcome you to our 
committee. We enjoy serving with you on the Armed Services 
Committee where you have made this a particular area of your 
expertise.
    Welcome.

 STATEMENTS OF HON. MAX CLELAND, A U.S. SENATOR FROM GEORGIA; 
HON. CHUCK HAGEL, A U.S. SENATOR FROM NEBRASKA; HON. EVAN BAYH, 
   A U.S. SENATOR FROM INDIANA; AND HON. JON CORZINE, A U.S. 
                    SENATOR FROM NEW JERSEY

    Senator Cleland. Thank you very much, Mr. Chairman. I am 
honored to be here with my distinguished colleagues and with 
all of you.
    Mr. Chairman, we have long known that the threat of 
bioterrorism has existed. In the mid-1990's, intelligence 
sources believed that Iraq had a sophisticated bioweapons 
program, and during the cold war, the Soviet Union produced 
unknown quantities of the smallpox virus.
    In the wake of the September 11 attack on America, our 
intelligence agencies now State that there is a 100 percent 
chance of another domestic attack. What form of terror this 
attack will take is unknown, but we have seen bin Laden and his 
followers become more brutal and complex in their planning.
    Are we fully prepared to deal with such bioterrorism 
events? The answer at the moment is clearly no.
    Look at the results of the Johns Hopkins-sponsored ``Dark 
Winter'' smallpox bioterrorism exercise, which my former 
colleague and friend Sam Nunn participated in. There was 
another exercise, ``TOPOFF,'' regarding top officials regarding 
a nuclear and bioterrorism drill conducted this year to test 
the capabilities of the Centers for Disease Control and 
Prevention, the Federal Emergency Management Agency, the FBI 
and DOD. Both of these tests dramatically illustrate that our 
response to date is woefully inadequate to deal with a domestic 
bioterrorist event and that a reconsideration of both strategy 
and organizational structure is needed.
    I would like to call the committee's attention this morning 
to restructuring and improving dramatically the CDC in Atlanta, 
GA, which is an international resource for fighting 
bioterrorism.
    In 1999, I joined with Senators Kennedy, Mikulski, Murray, 
and my late friend Paul Coverdell to address the critically 
needed repairs and upgrade of the CDC's buildings and 
facilities. This has been an ongoing effort. The CDC is 
universally recognized as the lead Federal agency for 
protecting the health and safety of people at home and abroad, 
as well as the response and readiness for bioterrorist threats 
against the United States.
    However, Mr. Chairman, before last year, the CDC had been 
insufficiently funded to maintain the security of its perimeter 
and the safety of its laboratories. The CDC, which is based in 
Atlanta, was still using World War II-era buildings from a 
reclaimed army base. Scientists and laboratory staff were 
patching holes in the ceilings to protect their research 
studies. I have seen this kind of thing.
    In fiscal year 2001, we started the first year of 
compressing a 10-year CDC renovation plan into 5 years. That is 
the massive upgrade that we are talking about. This faster 
upgrade is more critical now than ever before.
    I would like to acknowledge three of Georgia's outstanding 
business leaders--Bernie Marcus, former head of Home Depot; Oz 
Nelson, former head of UPS; and Phil Jacobs, head of Bell 
South--known as friends of the CDC. They called these horrible 
situations to my attention.
    I would like to commend Senators Kennedy and Frist for your 
insights in developing and getting the Public Health Threats 
and Emergencies Act passed last year. This measure is critical 
in helping us to develop the needed infrastructure.
    I also commend key provisions in the measure which would 
enable CDC to maximize its bioterrorism response capabilities 
and to improve the preparedness of communities and hospitals.
    The level of preparedness for homeland defense that we will 
need to protect Americans will require money and resources and 
will take time. We can and must take the additionally needed 
steps and dramatically improve what we have in place, 
especially the CDC. This is one reason, Mr. Chairman, why I am 
seeking some $100 million extra beyond the $150 million that 
the President has requested for this fiscal year 2002 budget, 
and which will be going after three-quarters of a billion 
dollars of your $1.4 billion bioterrorism budget.
    I believe the President has taken an important step with 
the creation of a Cabinet-level position for homeland defense, 
but one of the key defenders in this homeland of ours is the 
CDC, and I urge my colleagues to pay special attention to that 
agency.
    Thank you very much, Mr. Chairman.
    The Chairman. I would just point out for the record, 
Senator, that you were tireless in pursuing the importance of 
upgrading the physical aspects of the CDC. None of us needs to 
be told how important that is in terms of its contribution to 
safety and public health. We were able to get that authorized 
and funded last year because of your intervention, and that has 
played an indispensable role both in New York and Florida.
    Senator Cleland. And with the anthrax scare, Mr. Chairman, 
the CDC has been able to be on top of that with 100 vials of 
antibiotics there to deal with that situation. But what we are 
talking about here is a bioterrorist attack where you have mass 
casualties, and we are patently unprepared to deal with that.
    The Chairman. Thank you very much.
    Senator Cleland. I thank the chairman.
    The Chairman. Senator Hagel.
    Senator Hagel. Mr. Chairman, thank you.
    I wish to extend my thanks to you and Senator Frist for 
your leadership. It has been very much a part of this issue 
over a rather sustained period of time; so to each of you, we 
appreciate that leadership and the very fast action that you 
are putting into place, especially with this hearing this 
morning, and the actions and consequences that will result from 
the hearing.
    My colleague and your committee colleague, Senator Edwards, 
and I collaborated last week on a bill that you mentioned, 
Chairman Kennedy, that we have introduced. I would like to take 
the time to address some of the general areas of what Senator 
Edwards' and my bill will do to hopefully contribute to this 
very real threat that our country and the world face, and to 
also thank the professionals who will be coming behind this 
panel of Senators. They are the real professionals who 
understand the issue and who will be charged with some very 
significant responsibilities as we set some perimeters for them 
and provide them with the new resources that we must.
    With that, the bill that Senator Edwards and I have 
introduced is a bill that addresses some very general areas of 
local, State, and Federal responders, and in particular the 
State and local first responders who are the ones who need, it 
is our belief, the resources because they are the ones who, as 
we have seen in New York and at the Pentagon, must deal with 
this on a real case basis and in real time.
    So the $1.6 billion bill that Senator Edwards and I have 
introduced focuses on some of the following key areas--
developing and stockpiling vaccines and antibiotics at the 
Centers for Disease Control, Department of Energy, National 
Institutes of Health, and Department of Agriculture; it 
provides additional training and equipment to State and local 
first responders; it enhances disease surveillance through 
coordinated efforts between the CDC and State and local public 
health services to provide sophisticated electronic nationwide 
access to medical treatment, data, guidelines, and health 
alerts.
    This bill also strengthens the local public health 
networks, including increased training, coordination, and 
Federal assistance. It assists local hospital emergency rooms 
with response training for personnel, biocontainment, and 
decontamination capabilities. It protects food safety and the 
agricultural economy from biological and chemical threats. This 
is a very significant part, Mr. Chairman, of our bill to focus 
on. It is one that I suspect, especially in light of the 
conversation that you and I had last week when we testified 
before the Senate Appropriations Committee, needs some 
attention.
    We provide in this bill assistance to States and local 
governments and health facilities through a series of block 
grants. We believe it is the best approach, the most 
accountable and responsible approach, to let these State and 
local first responders deal with these resources and frame them 
as they believe they need them.
    And our bill adds additional funding for Federal Government 
programs, much of what we are already doing, but we go further 
in some of these areas, and a number of agencies are connected 
to our efforts.
    Mr. Chairman, Senator Frist, we are all grateful again for 
your leadership and for an opportunity for me to represent my 
colleague, Senator Edwards, and myself here this morning to 
address some of the specifics of our bill and would be pleased 
to respond to any questions.
    Thank you.
    The Chairman. Thank you very much.
    Senator Bayh?
    Senator Bayh. Thank you very much, Mr. Chairman.
    I would like to echo the words of my colleague, Senator 
Hagel, in thanking you and Senator Frist for having this 
hearing today and for your legislation. It is reassuring to the 
country to have two individuals who have dedicated their lives 
to the cause of public health leading us in this effort.
    Senator Frist, I listened to your comments, and I whole-
heartedly concur. I believe that biological weapons have been 
characterized as ``the poor man's nuclear weapon,'' and they 
pose a much greater risk to our country today than ever before. 
So to both you and Chairman Kennedy, I give my thanks for 
focusing on this very timely threat to our national security.
    I want to acknowledge the good work of our colleague, 
Senator Hagel and my friend and colleague Senator Edwards. My 
proposal, Mr. Chairman, builds upon your work and Senator 
Frist's work and their work and seeks to refine and perhaps 
improve upon the area of State preparedness, which is vitally 
important to a successful response to an attack of this kind.
    To Senator Cleland, my good friend, I would say, Max, that 
my proposal will be squarely within the context of the CDC, 
under its umbrella and its good leadership, so I thank you for 
your work in this regard as well.
    Finally, Mr. Chairman, I am here today not only testifying 
in behalf of my own proposal but on behalf of seven of our 
colleagues, six of whom also served as former Governors and are 
well aware of the important role that State and local 
communities play in responding to any attack of this kind.
    Mr. Chairman, I would like to build upon your 
recommendations, your legislation, and Senator Frist's and also 
Senator Hagel's and Senator Edwards', particularly in the area 
of State preparedness, because one of the things that we have 
learned, as you mentioned in your very eloquent opening 
remarks, is that State and local communities are on the front 
lines of responding to any threat to our country of this 
nature.
    Yet, Mr. Chairman, it should be deeply concerning to all of 
us that a recent report indicated that too many States are not 
as prepared as they need to be to respond to a biological or 
chemical attack. As a matter of fact, the GAO just a few months 
ago determined that many States lacked the planning, the basic 
public health infrastructure, and the ability to respond to 
mass casualties or a surge of casualties that would be 
occasioned by a biological or chemical attack. And this, Mr. 
Chairman, in spite of the $124 million that has been spent over 
the last 2 years assisting States and local communities to beef 
up their capacity. Clearly, more work needs to be done.
    This is vitally important, as both of you have mentioned, 
because particularly in the area of a biological attack, it is 
quite possible that for the first several days while the 
diseases are communicable, cases could go undiagnosed or 
misdiagnosed because many of the symptoms, as I am sure Senator 
Frist would concur, replicate those of influenza or other 
diseases. So it is vitally important, Mr. Chairman, that we 
have trained health responders on the scene at the State and 
local level to make sure that we respond as comprehensively and 
quickly as possible.
    Specifically, Mr. Chairman, I propose the following--that 
we allocate $5 million per year to each individual State and an 
additional $200 million to be allocated on the basis of 
population. I believe that this is an improvement, Mr. 
Chairman, over the competitive grant approach. Competitive 
grants work very well in many circumstances, but here, Mr. 
Chairman, I think we simply do not want to leave any State 
behind in its preparedness to respond to a biological or 
chemical attack.
    It would be ironic, Mr. Chairman, if we left some States 
out. That would have the unintended consequence perhaps of 
identifying them as softer targets for anyone who would wish to 
do our country ill. So I would respectfully request that we 
allow every State to improve its planning to prepare for this 
eventuality.
    Our proposal is somewhat more flexible than some others 
that have been suggested because it is impossible for those of 
us sitting in Washington here today to identify each State's 
needs and the myriad possibilities that need to be addressed. 
Therefore, we require a plan to be submitted to the Secretary 
of Health and Human Services detailing the State's proposal and 
describing in depth its training and other initiatives but 
giving greater latitude to Governors and local officials to 
allocate the resources as needed and as dictated by the 
requirements of each individual State.
    Finally, Mr. Chairman, we would fund a simulation for each 
State so that each State could literally do a run-through of 
its plan to see where its strengths and weaknesses are and 
obviously improve those areas in need of additional attention. 
We require that they be part of the CDC's national 
communication network that has been underway for 2 years. We 
clearly need to have improved communication.
    And finally, Mr. Chairman, we would provide some additional 
funding as necessary for the best practices program currently 
funded through the CDC so that States and local communities can 
learn from one another about what works and what does not work.
    Again, Mr. Chairman, I would like to thank you, Senator 
Frist, and your colleagues on the committee for your courtesy 
today. State Governors and local officials are clearly on the 
front lines, and Mr. Chairman, I would like to work with you to 
ensure that those who will respond first to a disaster of this 
kind are prepared to do so in the most timely and effective 
manner.
    I thank you for holding the hearing.
    The Chairman. Thank you very much. We look forward to 
working with all of our panelists.
    We are glad to welcome Senator Corzine. His State and its 
people have suffered immensely. We can understand why, having 
gone through the horrific experience on September 11, Senator 
Corzine wants to make sure that we as a country are prepared to 
deal with other potential challenges of bioterrorism.
    We welcome you.
    Senator Corzine. Mr. Chairman, Senator Frist, and members 
of the committee, I am truly appreciative of the opportunity to 
talk to you about the preparedness issue with regard to 
biological and chemical weapons. It is a real issue.
    Just this last Friday, I sat with 34 hospital 
administrators in New Jersey and discussed this issue, and 
quite frankly, I came away chilled and sobered by the lack of 
coordinated planning with regard particularly to biological 
attacks. It is of very serious concern; I agree with many of 
the comments of my colleagues and do believe very much that it 
needs to be a very coordinated approach that works with the 
States and local governments.
    I think there is a growing consensus not only in New Jersey 
but across the country that we are unprepared for a serious 
biological and chemical attack, and I compliment you and 
Senator Frist for your efforts and leadership in this area. I 
think it is terrific what you have proposed.
    I would like to take it a step further, particularly with 
regard to the planning and coordination, and to that end, I 
introduced legislation, the Biological and Chemical Attack 
Preparedness Act, which happens to be S. 1508, really designed 
to build on your efforts, but it deals with improving 
coordination and planning of hospitals, State, local, and 
Federal governments in responding to these kinds of attacks.
    This bill is in concert with Senators Torricelli and Jack 
Reed, and the fundamental goal is to ensure that every American 
has access to public health resources in the event of such an 
attack through pre-prescribed comprehensive and coordinated 
planning.
    Our Nation's response, Mr. Chairman, to chemical and 
biological attacks will depend on a system that, frankly, is 
patchwork at best, and the disparities in planning and capacity 
of the various States and individual hospitals is really quite 
serious. It is in my own State and I suspect across the Nation.
    Improving our preparedness will require, first, resources. 
My legislation, as the others have suggested, provides for a 
grant program that would help hospitals, States, and 
municipalities purchase the items, services, and training that 
would be needed in the event we need to meet this kind of 
disaster.
    But simply distributing money is not sufficient in my view. 
We also need to ensure that every part of the country is 
covered and that they fully take up their responsibility in 
this area. We need a systematic, complete, comprehensive 
approach to the problem, with more coordination among the many 
parties involved.
    In an effort to promote such coordination, I would require 
each State to promptly develop and implement a public health 
disaster plan that addresses biological and chemical weapon 
attacks. Each disaster plan would be created in consultation 
with the many stakeholders in the State health care 
infrastructure, but it would be complete.
    The fact is they need to be developed for each individual 
State. The needs of New Jersey are more than a little bit 
different than those of Wyoming.
    The legislation I propose has an accountability feature in 
it. It requires certification of the Department of Health and 
Human Services that we are meeting that comprehensive coverage 
element, and it has a condition that if those plans are not in 
place and do not meet the compliance requirements of Health and 
Human Services, then Medicaid funding would be held in 
abeyance.
    As part of the disaster plan, each State would designate 
specific hospitals to assume responsibility for meeting related 
medical needs. One of the things that is very clear is that 
while this patchwork exists, everybody seems to be trying to 
meet the same problem, and there is a real need for a 
coordinated approach so that we do not overspend in this 
effort. We want to have a coordinated and comprehensive 
approach.
    Mr. Chairman, I thank you for all the efforts that you and 
Senator Frist are making. I think we need to have an 
accountable system, one that takes into account the ideas of 
all those at the local level; but I think we need to move very 
quickly. This is a danger, and it is probably not whether, but 
when we will have to deal with these issues, as we are seeing 
in Florida now.
    I appreciate this chance to comment, and I would like to 
work with my colleagues to make sure that we have that 
comprehensive approach for every American.
    Thank you.
    The Chairman. Thank you.
    Senator Edwards is a cosponsor and is also a member of the 
committee. As a matter of courtesy, if you want to make a brief 
comment, Senator, in addition to what Senator Hagel has said 
about your bill, we would welcome it at this time. Then it 
would be our intention to recess and vote and return with the 
second panel.
    Senator Edwards?

                  Opening Statement of Senator Edwards

    Senator Edwards. Thank you, Mr. Chairman. I will be very 
brief because I know we need to get to the second panel.
    Senator Hagel covered very well the legislation that he and 
I have introduced. I also want to thank the chairman and 
Senator Frist for all the work you have done, the leadership 
you have shown, and all the members of the panel. We need the 
contributions of everyone on this very important issue to our 
country.
    The focus of Senator Hagel's and my legislation is on the 
people who will have to identify that a biological attack has 
occurred--your local emergency room, your local public health 
department, your family physician. These are the people who 
have to be trained and equipped to recognize and identify what 
is happening; and once they identify it, they have got to know 
what to do with that information.
    In effect, what we need to do is provide education and 
training for local first responders, and put a disease 
surveillance system in place so they can transfer the 
information to the place it needs to go.
    The second thing we need to do is make to sure that we have 
adequate antibiotics and vaccine available to treat whatever 
the biological agent is.
    And the third priority is to deal with the issue of agri-
terrorism, which I know all of us have had a great concern 
about. Senator Frist, Senator Kennedy, and I have discussed 
this. We need to protect our food supply, including our crops 
and farms.
    And I might add that I think a very important component of 
our bill is that, in the past, a lot of the funding that has 
been appropriated bioterrorism has stayed in Washington, DC. I 
think that misallocation is an enormous mistake which our bill 
seeks to remedy. We can equip all the expert response teams in 
the world here in Washington, but the people who need help are 
the people out there on the front lines--the doctors, the 
emergency rooms, the nurses, and the public health officials. 
Our bill gets the money out of Washington to the place where I 
believe that it is most needed--the people on the front lines.
    Mr. Chairman, I thank you for allowing me to make a 
statement.
    Senator Hagel, I thank you for your cosponsorship, and I 
thank all my colleagues for their very important contribution 
to this issue of national security.
    The Chairman. I want to thank all of you very much.
    A number of points caught my attention. One was Senator 
Bayh's mention of the difference in the grants approach. We 
have a competitive grant program because we have limited 
resources. Senator Frist can speak to this as well, but we 
would support the broader amounts for block grants with 
additional resources; we would be glad to work with you. It may 
be worthwhile to start that way in order to get this program 
started, but we do want to make sure that every State gets 
resources--but that moves the total amount up. I certainly feel 
that it would be justified, but it is basically a question of 
resources. We would be glad to work with you to take that into 
account.
    Senator Bayh. Thank you, Mr. Chairman.
    The Chairman. We thank all of the members. There are a lot 
of good ideas and a lot of areas covered that were not included 
in our proposal, so we value all of these suggestions. There 
will be others of our colleagues who have thought about this 
issue and have been meeting with experts back in their own 
communities. I think what is important for the American people 
to understand is that we have a way to go. But we have members 
of the administration and of Congress who are serious about 
trying to work through a process to do everything that we 
possibly can. We are committed to getting the resources out 
there, and we are going to go about our business in getting 
this job done.
    We look forward to the next panel. They are the real 
experts. I think they can give the American people some very 
important insights about where we are in addition to what we 
should be doing.
    We will recess now for 10 minutes.
    [Recess.]
    The Chairman. The committee will come to order.
    We have a very distinguished panel of experts in 
bioterrorism. Janet Heinrich led the team that prepared the 
recent GAO report on bioterrorism. As we developed legislation 
last year, Senator Frist and I were struck by how difficult it 
was to get a clear accounting of Federal activities in 
bioterrorism. We are grateful to her for the comprehensive and 
insightful report on this issue.
    We welcome any comments that Senator Mikulski would like to 
make by way of introduction of Dr. Donald Henderson.
    Senator Mikulski. Thank you very much, Mr. Chairman. Again, 
I want to thank you and Senator Frist for organizing this 
hearing. What I am so proud of is that both of you have taken 
the leadership well before this gruesome attack on the United 
States of America. Your leadership in other hearings on 
bioterrorism as well as your leadership in improving the public 
health infrastructure I think has laid the groundwork for us to 
be able to be ready, prepared, and able to respond. So I wish 
to thank you.
    Mr. Chairman, many of us have been working on this issue 
for some time, and I am proud to introduce to you one of the 
outstanding people in the United States of America in the field 
of epidemiology, eradicating disease, and helping America be 
prepared now.
    Dr. Donald Henderson comes to the table having recently 
been appointed by Secretary Thompson to head his Bioterrorism 
Advisory Panel. You could not have picked a better witness, and 
Secretary Thompson could not have picked a better person. Dr. 
Henderson is known globally for his leadership in eliminating 
smallpox around the world and also was dean of the Johns 
Hopkins School of Public Health.
    After leaving that post, he assembled the Center for 
Civilian Biodefense Studies, a small group operating out of 
Johns Hopkins that, quite frankly, I have going through 
earmarks--those little congressional mandates--because nobody 
else thought it was an important issue. Those little earmarks 
enabled Dr. Henderson to assemble the staff to do a good job.
    I really encourage us to listen to him because yes, we do 
need to do prevention and work through our law enforcement and 
national security, and yes, we need to be prepared, and we are 
going to have questions of Dr. Henderson and the panel, and we 
need to be able to respond. I am concerned that, after all the 
early surveillance and after all the detection, we will not be 
ready to respond because our first responders themselves will 
be wounded warriors.
    So we look forward to listening to our experts, and Mr. 
Chairman, I really think we need to move with a great sense of 
urgency both here, with our authorizing, as well as with the 
appropriations, because we need to be able to manage the 
attacks, and we also need to manage the panic around those 
attacks.
    So I am very honored to introduce Dr. Henderson to you.
    [The prepared statement of Senator Mikulski follows:]

                 Prepared Statement of Senator Mikulski

    Mr. Chairman, thank you for holding this important hearing 
today on bioterrorism. I want to applaud you and Senator Frist 
for your leadership on this issue. I extend a special welcome 
to Dr. D. A. Henderson, Director of the Center for Civilian 
Biodefense Studies at Johns Hopkins, a real hero and an expert 
in his field.
    What happened on September 11th was not only an attack 
against America. It was a crime against democracy, and decency. 
It was a crime against humanity. American citizens, American 
aircraft, American buildings were brought down by these 
barbaric terrorist attacks. Yet the American people--and our 
free and open society--stand unbowed and united.
    Now Americans are more determined than ever to protect the 
safety and security of this great nation. Bioterrorism is one 
of the gravest threats and greatest challenges we face. 
Preparing our federal, state, and local governments to detect 
and respond to a bioterrorist attack will require an enormous 
commitment of resources and the coordination of nearly every 
federal agency. It's a daunting task, but the United States 
Congress--and the American people--are up to the challenge.
    Efforts are underway. I was proud to be an early cosponsor 
of Senator Frist and Senator Kennedy's Public Health Threats 
and Emergencies Act that became law last year. Strengthening 
our nation's public health infrastructure is essential to our 
preparedness for and response to a bioterrorist attack. I have 
been working with my colleagues on the Subcommittee and on the 
Appropriations Committee over the last couple of years to make 
sure we have the infrastructure and resources to prepare 
ourselves for this threat. Now it's time to step up these 
efforts.
    Many federal agencies and departments have been involved--
from the Centers for Disease Control and Prevention to Ft. 
Detrick in Maryland that is on the frontline of bioweapons 
research to develop our best defense against these weapons. As 
Chairman of the Appropriations Subcommittee that funds the 
Federal Emergency Management Agency (FEMA), I am working with 
Ranking Member Bond and Director Allbaugh to ensure that FEMA 
is ready to handle its role of consequence management in the 
event of a bioterrorist attack.
    An explosion of doctors' visits--not the explosion of a 
building--may be the first sign of a bioterrorist attack. 
That's why we need a strong public health infrastructure--to 
detect a bioterrorist attack; to make sure federal, state, and 
local agencies have the resources, tools, and technology to 
combat bioterrorism; and to ensure that health professionals 
are trained to recognize the symptoms of potential biologic 
agents. We must encourage research into new drugs and vaccines 
to prevent against the effects of a bioterrorist attack. And we 
must give FDA the tools and resources it needs to protect the 
safety of our food supply. Investments in the fight against 
bioterrorism will pay off in other public health arenas such as 
antimicrobial resistance and infectious disease detection. 
Public health departments are on the front lines of this new 
kind of war. Let's make sure they are combat ready and fit-for-
duty.
    Lines of communication and accountability among our federal 
agencies, as well as at all levels, must be clear. Cowardly 
terrorists don't respect borders or boundaries. I want to make 
sure that our government agencies aren't letting jurisdictional 
boundaries or smokestack mentalities prevent the type of 
critical planning and training our country needs.
    I look forward to the testimony of all our witnesses today. 
We have much to learn and much to do. This is a national 
problem that requires a national solution and national 
leadership from the federal government. It requires the best 
and the brightest at all levels of government and industry. We 
must not wait for another disaster to occur. We must be ready 
with a plan of defense and a plan of offense. I look forward to 
working with my colleagues to make sure that we are combat 
ready for a bioterrorist attack. Thank you.
    The Chairman. Thank you so much.
    Dr. Henderson, Senator Frist and I both want to thank you 
so much for your help in drafting our own legislation. You were 
good enough to give up part of your vacation to come back. You 
have a longstanding commitment in this area, and we look 
forward to your testimony.
    I see my colleague Senator Wellstone here, who would like 
to introduce a very special witness, and we are glad to hear 
from him.
    Senator Wellstone. Thank you, Mr. Chairman. I will be very 
brief.
    Mr. Chairman, it is interesting that Michael Osterholm, of 
whom we are very proud in Minnesota, dedicated his book, 
``Living Terrors: What America Needs to Know to Survive the 
Coming Bioterrorist Catastrophe''--which is unfortunately 
prophetic--to ``Donald Henderson who, more than 20 years ago, 
led mankind's greatest public health and medical 
accomplishment, the eradication of smallpox, and who has 
courageously entered the fight again to prevent its horrible 
return.''
    I also want to honor you, Dr. Henderson. If Dr. Osterholm 
does, then I certainly as a Senator from Minnesota will do so 
as well.
    Michael Osterholm was the former Minnesota State 
Epidemiologist, and he has been internationally recognized. I 
think Senator Frist and Senator Kennedy have both met with 
Michael, and I thank both of you for your very fine work. He 
has been an internationally recognized leader in the area of 
infectious disease for the past two decades. He is a recipient 
of numerous honors and awards, and he served as personal 
advisor on bioterrorism to the late King Hussein of Jordan. He 
has led numerous successful investigations into infectious 
disease outbreaks of global importance. He has lectured around 
the world, and he is now director of the Center for Infectious 
Disease Research and Policy and professor at the School of 
Public Health at the University of Minnesota.
    He is a very strong, steady, intelligent, experienced 
voice, and we thank him for being with us.
    The Chairman. Thank you very much.
    We are also fortunate to have Dr. Mohammad Akhter, who has 
been a leader in public health, director of the American Public 
Health Association. He has been a dedicated and skilled 
advocate for better health for all, and through his clinical 
practice around the world, he has encountered some of the 
infectious diseases that might be used in a biological attack. 
So our committee looks forward to hearing from him.
    And finally, Janet Heinrich led the team that prepared the 
recent GAO report on bioterrorism. I mentioned earlier, Dr. 
Heinrich, how helpful it was to get your report and how much we 
appreciate your assistance in finding out where the gaps are 
and the areas we should be addressing. We are looking forward 
to continuing to work with you to try to address those 
observations. So, in the great tradition of the GAO, it is very 
constructive and helpful work, and we are looking forward to 
your testimony.
    Dr. Henderson, please.

STATEMENTS OF DR. DONALD A. HENDERSON, DIRECTOR, JOHNS HOPKINS 
 CENTER FOR CIVILIAN BIODEFENSE STUDIES, BALTIMORE, MD; JANET 
HEINRICH, DIRECTOR, HEALTH CARE AND PUBLIC HEALTH ISSUES, U.S. 
  GENERAL ACCOUNTING OFFICE, WASHINGTON, DC; DR. MOHAMMAD N. 
AKHTER, EXECUTIVE DIRECTOR, AMERICAN PUBLIC HEALTH ASSOCIATION, 
WASHINGTON, DC; AND MICHAEL T. OSTERHOLM, DIRECTOR, CENTER FOR 
     INFECTIOUS DISEASE RESEARCH AND POLICY, UNIVERSITY OF 
                   MINNESOTA, MINNEAPOLIS, MN

    Dr. Henderson. Thank you, Mr. Chairman and distinguished 
members of the committee, for this hearing and for your 
leadership in this field, and my appreciation to Senator 
Mikulski for her very generous introduction.
    Tragically, we find ourselves contemplating the possibility 
of a bioterrorist attack on U.S. civilians. As we consider 
these grave matters, it is important that we recognize that 
that attack is by no means a foregone conclusion; but the risk 
of this is not zero.
    Some of the distinguished experts in this field have 
pointed out that it is difficult to identify a pathogenic 
organism, to grow it properly, to put it in the proper form, 
and then to disperse it. I think we need to remind some of our 
distinguished experts in the field that those who flew the 
airplanes into the trade towers did not know how to make 
airplanes. They have money, they have access, and they can 
coopt that which they do not have.
    There is much that can be done if we take some prudent 
action beforehand. It has been emphasized by several that the 
first responders are health care workers and public health 
officials. There are many who still do not appreciate this and 
who still seem to think that we would be dealing with fire, 
police, and emergency rescue people. They will be needed for 
explosive and chemical events, but a bioterrorist attack on the 
United States would be completely different from the events of 
September 11. It would in all likelihood be a covert attack. 
There would be no discrete event, no explosion, no immediately 
obvious disaster to which the firefighters and the police and 
the ambulances would rush. We would know we had been attacked 
only when people began appearing in emergency rooms and 
doctors' offices.
    Our ability to effectively deal with such an event depends 
directly on the capacity of our medical care institutions and 
our public health system to quickly recognize that an attack 
has occurred, to promptly identify those who might be at risk, 
and to deliver effective medical care, possibly on a massive 
scale.
    A number of steps have been taken to prepare the Nation to 
respond, and clearly, I would say from my position that we are 
better positioned to do this now than we were several months 
ago, indeed, several weeks ago. But there is an awfully great 
deal that needs to be done yet.
    On October 4, Secretary of Health and Human Services Tommy 
Thompson named me to chair an advisory council which is to work 
with him in furthering efforts to prepare the Nation to 
respond. I am honored to accept this post. The council is 
intended to draw on expertise and persons from across the 
country with varied experience at local, State, and Federal 
levels. The membership of the council and its precise functions 
will be established within the next few days.
    There is particular concern on the part of your committee 
and certainly at this time in the executive office as to needs 
in the immediate and near term--really, within the next 30 to 
90 days--to better prepare the Nation to respond to possible 
acts of bioterrorism, and that is what I will tend to focus on.
    In doing so, however, it is important that we bear in mind 
that there are no simple actions that we can take or one-time 
infusions of funding that will rebuild a deteriorated public 
health system quickly and provide the needed surge capacity in 
our hospitals to be able to cope on an emergency basis with 
large numbers of casualties. We do need a longer-term strategy.
    The Department of Health and Human Services over the past 
several years, and especially in recent months, has taken a 
number of important steps to improve our readiness to respond 
to bioterrorism. There are many capable people working on a 
number of different projects. The efforts, however, still lack 
coherence. The diverse and disconnected efforts have to be 
brought together into a single unified program, and that is, I 
know, high on the Secretary's agenda. We need a single, 
centralized medical and public health strategy for preparing 
the Nation to respond.
    State and local public health departments across the 
country are the real backbone for detection and response to 
biological weapons attack, and that has been noted earlier this 
morning. They need resources, and they need them urgently if 
they are to effectively carry out even the rudimentary actions 
which are absolutely essential for dealing with a major 
infectious disease outbreak.
    It is difficult for me to exaggerate the deficiencies of 
our present public health capabilities. Assuming that Federal 
funds could expeditiously be made available, there will be need 
for an expedited process to get those funds to State and local 
levels. Reference has been made to block grants as perhaps 
being an approach to do that.
    Such funds cannot be overly constrained, because certainly, 
priorities and needs do differ from Newark to Phoenix to 
Montgomery County, AL.
    There are specific public health functions in need of 
immediate improvement. If we are to detect and rapidly identify 
a new health problem, health officials must be available 24 
hours a day, 7 days a week, to take calls from clinicians 
reporting cases which may be suggestive of a bioweapons-related 
disease. In many areas of the country today, this is not done, 
and indeed it is not possible because of lack of personnel to 
take those calls.
    Support in terms of training and equipment is being 
provided to a national network of 80 laboratories capable of 
diagnosing the principal threat agents. One of these 
laboratories in Florida is the one responsible for the early 
diagnosis of the anthrax case. That process needs to be 
substantially speeded up--that is, their capacity to 
differentiate a number of different organisms which ordinarily 
laboratories would not see--so that the full range of potential 
agents could be rapidly and accurately identified.
    The Department of Health and Human Service began some years 
ago to require a national stockpile of drugs and equipment that 
could be called upon in case of need for a mass casualty 
situation. Because of recent events, the nature and quantity of 
materials available will need to be reviewed, and I have been 
asked to meet with an expert advisory group later this month to 
do exactly that.
    Secretary Thompson has initiated a number of steps to 
ensure that the supplies of smallpox vaccine are immediately 
ready for distribution if needed and has taken steps to expand 
the amount of smallpox vaccine available at an early time.
    But perhaps the most uncertain part of the equation that 
has not really been addressed is how to get those drugs and 
vaccines to the population involved in a very short period of 
time. Distribution is not easy. Health departments have had 
very little experience in the large-scale, rapid distribution 
of either drugs or vaccines. Here again is where resources are 
needed for the State and local health departments to undertaken 
contingency planning for distribution and to prepare 
themselves.
    However much we try to provide from the Federal level, we 
will be highly dependent on the knowledgeable people at the 
local level who know the area, as they say, know the territory, 
and know the buttons to push to get something done.
    For our public health officials, emergency room health 
personnel, and infectious disease physicians, educational 
materials are urgently in need. At this time, many of these 
diseases are totally unknown to those who would be likely to 
see cases. To date, few good materials have yet to be provided.
    Obviously, it does little good to have a public health 
system that can detect disease outbreaks and manage epidemics 
if we cannot take care of the sick people. Over the past 
decade, our hospitals and the medical care system have labored 
under intense financial pressures. One reaction to these 
pressures has been the elimination of excess capacity from the 
health care system. Today, few hospitals could respond 
effectively to a sudden, significant surge in patient demand. 
Indeed, based on our contacts with hospitals and hospital 
associations, we believe that 500 patients would overwhelm the 
health care systems of most cities.
    The first step is to recognize that the problem exists and 
to encourage hospitals to join forces in the search for 
solutions. We would advocate an effort to establish regional 
consortia of hospitals, groups of institutions collocated in 
cities or counties around the Nation, to begin planning. Here, 
they need to plan with the State and local health departments.
    But even simple steps will require money, and financial 
relief or incentives to enable hospitals to carry out these 
initial steps should be considered.
    Finally, just a word on research and development. A well-
conceived and integrated plan for research and development is 
clearly needed. We have a number of challenges. In the near 
term, we could use an improved anthrax vaccine, and a great 
deal has been done. With an intensive effort, that vaccine 
should be able to be available within a matter of a couple of 
years. There are new therapies to treat anthrax. We need drugs 
to deal with the complications of smallpox vaccine.
    Beyond this, one could envisage an array of solutions that 
might prevent the use of biological weapons or at least 
mitigate the likelihood of their use and so make bioterrorism 
and its consequences less likely or less severe. The science 
section of The New York Times today provides an interesting 
array to display some of the initiatives that might be taken.
    But years and not months will be required for the 
development. Regrettably, I am afraid that biological weapons 
and biological terrorism will be with us for the foreseeable 
future.
    Thank you, Mr. Chairman.
    The Chairman. Thank you, Dr. Henderson.
    [The prepared statement of Dr. Henderson follows:]
 Prepared Statement of Donald A. Henderson, M.D., MPH, Director, Johns 
             Hopkins Center for Civilian Biodefense Studies
    Mr. Chairman, distinguished members of the Committee, tragically, 
we find ourselves contemplating the possibility of a bioterrorist 
attack on US civilians. As we consider these grave matters, it is 
important that we recognize that such an attack is by no means a 
foregone conclusion although the risk is not zero. However, there is 
much that can be done--if we take prudent actions beforehand--to 
mitigate the consequences of an epidemic deliberately initiated by 
terrorists.
    A bioterrorist attack on the US would be completely different from 
the events of 11 September. It would in all likelihood be a covert 
attack. There would be no discrete ``event''; no explosion, no 
immediately obvious disaster to which firefighters and police and 
ambulances would rush. We would know we had been attacked only when 
people began appearing in emergency rooms and doctors' offices with 
inexplicable illnesses or with seemingly common illnesses of unusual 
severity.
    The ``first responders'' to bioterrorism would be health care 
workers and public health officials. Our ability to effectively deal 
with such an event depends directly on the capacity of our medical care 
institutions and our public health system to quickly recognize that an 
attack has occurred; to promptly identify those who might be a risk; to 
deliver effective medical care--possibly on a massive scale; and, 
should the bioweapon prove to be transmitted from person to person, to 
rapidly track and contain the spread of disease. A number of steps have 
been taken to fully prepare the nation to respond and, clearly, we are 
better positioned than we were several months ago, indeed several weeks 
ago, but much remains to be done.
    On October 4, Secretary of Health and Human Services Tommy Thompson 
named me Chair of an Advisory body which is to work with the Secretary 
in furthering efforts to prepare the nation to respond to acts of 
bioterrorism or other attacks which could place large numbers of US 
civilian victims needing medical attention. I am honored to accept this 
post, but as I am sure you will understand, it is premature to discuss 
either the functions or composition of the Advisory Council other than 
to say that it will operate in accordance with the Federal Advisory 
Committee Act (FACA). It will draw on expertise and persons from across 
the country and with varied experience at local, state and federal 
level. The membership of the Council and its precise functions will be 
established within the next few weeks.
    There is concern on the part of your Committee as to needs in the 
immediate and near-term--that is, the next 30-60 days--to better 
prepare the nation to respond to possible acts of bioterrorism and that 
I am happy to address. In doing so, however, it is important that we 
bear in mind that there are no simple actions or one-time infusions of 
funding that will rebuild a deteriorated public health system and 
provide the needed surge capacity in our hospitals to be able to cope, 
on an emergency basis, with large numbers of casualties. A longer-term 
strategy is critical. We must also, at the same time, embark on a 
search for better ways to prevent and treat infectious disease, 
especially those diseases likely to be used as biological weapons. We 
must find ways to use our significant assets in biomedical research to 
make bioweapons effectively obsolete as weapons of mass destruction.
    HHS, over the past several years but especially in recent months, 
has taken a number of important steps to improve our readiness to 
respond to bioterrorism. There have been many laudable new initiatives, 
and existing programs that have relevance to bioterrorism response that 
have been promoted. Many capable people are working hard on a number of 
projects. The efforts, however, lack needed coherence. The task now is 
to combine these diverse and disconnected efforts into a unified 
program of action. We need a single, centralized medical and public 
health strategy for preparing the nation to detect and respond to 
bioterrorist attacks. It is an effort that appropriately should be 
managed by HHS, integrated across the Department, coordinated with 
state and local authorities, and able to interface efficiently with 
other federal agencies.
    The difficulty of understanding and managing the complex 
interactions among the different agencies, levels of government and 
private sector organizations that have roles to play in bioterrorism 
response is profound. New partnerships must be forged. Policy makers 
must be educated to understand the operational realities faced by 
hospitals and public health agencies. They must recognize that 
protecting national security will demand investments in sectors not 
typically considered integral to defense strategy.
    State and local public health departments across the country are 
the backbone for detection and response to a biological weapons attack. 
They need resources and they need them urgently if they are to 
effectively carry out even the rudimentary actions that are absolutely 
essential for dealing with a major infectious disease outbreak. It is 
difficult to exaggerate the deficiencies of our present public health 
capacities. Indeed, it is inaccurate to even call the varied public 
health structures at state, city and county level a public health 
``system'', since many of these units are not connected or coordinated 
in any meaningful way. In the near term, it is important that we 
identify and support the essential steps needed to make this motley 
arrangement functional.
    Assuming that federal funds can expeditiously be made available, 
there will be a need for an expedited process to get these funds to 
state and local level. The leisurely and tortuous administrative 
channels will need to be foreshortened so that funds become available 
in weeks, not months. Moreover, such funds should not be overly 
constrained by restrictive definitions of how they are to be spent. The 
variety of needs in the 50 state and 3000 local public health 
departments around the country are such that, for a program of this 
urgency and complexity, it would not be sensible for the federal 
government to dictate what the most urgent spending priorities should 
be in Newark or Phoenix or Montgomery County, Maryland.

Public Health Functions in Need of Immediate Improvement

Systems Linking the Medical Community to Public Health
    If we are to detect and rapidly identify a new health problem, 
public health officials must be available 24 hours a day seven days a 
week to take calls from clinicians reporting cases which may be 
suggestive of such as a bioweapons-related disease. This is not 
possible in most areas of the country. Creating this vital link between 
the medical system--which is likely to be where the first evidence of a 
bioterrorist attack arises--and public health will in some cases 
require hiring more health department staff. In some locales, it may 
require purchasing beepers or an answering service. It need not--
indeed, should not be--a high-tech operation, but it is vital to the 
early discovery of an intentional epidemic. And early discovery is 
vital to saving lives.
Improved Communications and ``Connectivity'' among Public Health 
        Agencies
    There is a need to augment communications at local, state and 
federal level to assure the possibility for rapid communications 24 
hours per day, 7 days per week between agencies.
Improved Laboratory Diagnostic Capacity
    Support in terms of training and equipment is being provided to a 
national network of more than 60 laboratories capable of diagnosing the 
principal threat agents. This process needs to be substantially speeded 
up so that the full range of potential agents can be rapidly and 
accurately identified.
Ensuring the Adequacy, Availability of the National Pharmaceutical 
        Stockpile (NPS)
    HHS began some years ago to acquire a national stockpile of drugs 
and equipment that could be called upon in time of need for mass 
casualty situations. Today, the NPS consists of caches of such 
supplies, located in strategic locations around the country. CDC has 
reported that these supplies can be delivered within 12 hours to any 
point in the nation. Because of recent events, the nature and 
quantities of materials available will be reviewed by an expert 
advisory group later this month.
    In addition, Secretary Thompson has initiated a number of steps to 
ensure that the supplies of smallpox vaccine held by the federal 
Centers for Disease Control and Prevention (CDC) are immediately ready 
for distribution if needed. The Secretary has recently directed that 
the amount of smallpox vaccine produced under the HHS contract with 
Acambis be significantly increased, and has taken steps to move up the 
date of delivery.
    Perhaps the most uncertain part of the equation in getting drugs 
and vaccine to the population relates to the question of distribution. 
Health departments have had little experience in the large scale, rapid 
distribution of either drugs or vaccines. Should such be needed, there 
predictably would be staggering logistical problems. Here again is 
where resources are needed for state and local health departments to 
undertake contingency planning for distribution.
Improved Training of Public Health Officials, Emergency Room Health 
        Personnel and Infectious Disease Physicians
    These three groups of professionals along with the laboratory 
personnel represent the foundation for early detection, diagnosis, 
definition of the epidemic and application of preventive and 
therapeutic measures. Educational materials are urgently in need. 
Resources are required for training programs, drills, tabletop 
exercises, etc. In the longer term there is a need for rigorous 
curricula and training programs to prepare public health professionals 
to manage deliberate epidemics, and to incorporate public health 
practice-related curricula into academic training programs.

Medical Care Functions In Need of Improvement

    Obviously, it does little good to have a public health system that 
can detect disease outbreaks and manage epidemics if we cannot 
effectively take care of sick people. Over the past decade, hospitals 
and the medical care system generally, have labored under intense 
financial pressures. One reaction to these pressures has been the 
elimination of excess capacity from the health care system.
    Today, few hospitals could respond effectively to a sudden, 
significant surge in patient demand. Research done by the Hopkins 
Biodefense Center indicates that no hospital, or geographically 
contiguous group of hospitals, could effectively manage even 500 
patients demanding sophisticated medical care such as would be required 
in an outbreak of anthrax, for example. In the event of a contagious 
disease outbreak--such as smallpox--far fewer patients could be 
handled. There isn't enough staff, enough supplies, enough drugs on 
hand to cope with such an emergency. This problem of lack of surge 
capacity has no simple solutions.
    The first step is to recognize that the problem exists and to 
encourage hospitals to join forces in the search for solutions. We 
advocate an immediate effort to establish regional consortia of 
hospitals--groups of institutions co-located in cities or counties 
around the nation--to begin planning how best to use available 
resources most efficiently. Hospitals should immediately review their 
existing disaster plans, paying particular attention to management of 
mass casualties and to how they would handle large numbers of patients 
with potentially contagious disease. Even these simple steps will 
require money. Congress should immediately investigate how they might 
provide financial relief or incentives to enable hospitals to carry out 
these initial steps. Secondly, medical professionals must be made aware 
of the possibility of bioterrorist attacks and learn to recognize the 
symptoms of the six or so pathogens thought most likely to be used as 
bioweapons. It is imperative that clinicians not only be able to 
recognize the symptoms of anthrax, smallpox, etc., but that they be 
aware of the responsibility to report suspicions of such diseases to 
the public health authorities--and that they know exactly who to call 
and how to reach them.

Research and Development

    A well-conceived and integrated plan for research and development 
is needed to deal with a number of challenges--in the near term: an 
improved anthrax vaccine, new therapies to treat anthrax, and drugs to 
deal with the complications of smallpox vaccine. But beyond this, one 
could envisage an array of solutions that might prevent the use of 
biological weapons or at least mitigate the likelihood of their use and 
so make bioterrorism and its consequences less likely or less severe--
new vaccines and treatments for currently untreatable viral and toxin 
diseases; rapid diagnostic tests; sensor systems; and immune 
enhancement mechanisms. Years, not months, will be required for their 
development but, regrettably, biological weapons and biological 
terrorism will be with us for the foreseeable future.

    The Chairman. Dr. Heinrich?
    Ms. Heinrich. Mr. Chairman and members of the subcommittee, 
I appreciate the opportunity to be here today to discuss our 
ongoing work on public health preparedness for a domestic 
bioterrorist attack.
    We recently released a report which you referred to on 
Federal research and preparedness activities related to public 
health and medical consequences of a bioterrorist attack on the 
civilian population. I would like to begin by giving a brief 
overview of the findings in our report and then address 
weaknesses in the public health infrastructure that we believe 
warrant special attention.
    We identified more than 20 Federal departments and agencies 
as having a role in preparing for or responding to the public 
health or medical consequences of a bioterrorist attack. These 
agencies are participating in a variety of activities, from 
improving the detection of a biological agent and developing 
new vaccines to managing a national stockpile of 
pharmaceuticals.
    Coordination of these activities across departments and 
agencies is fragmented. The chart that we have prepared gives 
examples of efforts to coordinate these activities at the 
Federal level as they existed before the creation of the Office 
of Homeland Security. I will not walk you through the whole 
chart, but as you can see, a multitude of agencies have 
overlapping responsibilities for various aspects of 
bioterrorism preparedness. Bringing order to this picture will 
be challenging, and as Dr. Henderson said, we are in great need 
of coherence.
    Federal spending on domestic preparedness for bioterrorist 
attacks involving all types of weapons of mass destruction has 
risen 310 percent since fiscal year 1998 to approximately $1.7 
billion in fiscal year 2001.
    Funding information and research in preparedness of a 
bioterrorist attack as reported to us by the Federal agencies 
involved shows increases year by year from generally low or 
zero levels in 1998. For example, within HHS, CDC's 
Bioterrorism Preparedness and Response Program first received 
funding in fiscal year 1999. Its funding has increased from 
approximately $121 million at that time to approximately $194 
million in fiscal year 2001.
    While many of the Federal activities are designed to 
provide support for local responders, inadequacies in the 
public health infrastructure at the State and local levels may 
reduce the effectiveness of the overall response effort. Our 
work has pointed to weaknesses in three key areas--training of 
health care providers, communication among responsible parties, 
and capacity of hospitals and laboratories.
    As we have heard, physicians and nurses in emergency rooms 
and private offices will most likely be the first health care 
workers to see patients following a bioterrorist attack. They 
need training to ensure their ability to make astute 
observations of unusual symptoms and patterns and report them 
appropriately. Most physicians and nurses have never seen 
diseases such as smallpox or plague, and some biological agents 
initially produce symptoms that can be easily confused with 
influenza or other common illnesses, leading to a delay in 
diagnosis.
    In addition, physicians and other providers are currently 
underreporting identified cases of diseases to the infectious 
disease surveillance system.
    Because the pathogen used in a biological attack could take 
days or weeks to identify, good channels of communication among 
the parties involved in the response are essential to ensure as 
timely a response as possible. Once the disease outbreak has 
been recognized, local health departments will need to 
collaborate closely with personnel across a variety of agencies 
to bring in the needed expertise and resources.
    Past experiences with infectious disease outbreaks have 
revealed a lack of sufficient secure channels in sharing such 
information.
    Adequate laboratory and hospital capacity is also in 
question. Even though the West Nile virus outbreak was 
relatively small, it strained laboratory resources for several 
months. Further, Federal and local officials told us that there 
is little or no excess capacity in the health care system in 
most communities for accepting and treating mass casualty 
patients.
    In conclusion, although numerous bioterrorist-related 
research and preparedness activities are underway in Federal 
agencies, we remain concerned about weaknesses in public health 
and medical preparedness at the State and local levels.
    Mr. Chairman, this concludes my prepared remarks. I would 
be happy to answer questions.
    The Chairman. Thank you very much.
    [The prepared statement of Ms. Heinrich follows:]
  Prepared Statement of Janet Heinrich, Director, Health Care--Public 
                             Health Issues
    Mr. Chairman and Members of the Subcommittee: I appreciate the 
opportunity to be here today to discuss our work on the activities of 
federal agencies to prepare the nation to respond to the public health 
and medical consequences of a bioterrorist attack.\1\ Preparing to 
respond to the public health and medical consequences of a bioterrorist 
attack poses some challenges that are different from those in other 
types of terrorist attacks, such as bombings. On September 28, 2001, we 
released a report \2\ that describes (1) the research and preparedness 
activities being undertaken by federal departments and agencies to 
manage the consequences of a bioterrorist attack,\3\ (2) the 
coordination of these activities, and (3) the findings of reports on 
the preparedness of state and local jurisdictions to respond to a 
bioterrorist attack. My testimony will summarize the detailed findings 
included in our report, highlighting weaknesses in the public health 
infrastructure that we have identified in our ongoing work and which we 
believe warrant special attention.
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    \1\ Bioterrorism is the threat or intentional release of biological 
agents (viruses, bacteria, or their toxins) for the purposes of 
influencing the conduct of government or intimidating or coercing a 
civilian population.
    \2\ See Bioterrorism: Federal Research and Preparedness Activities 
(GAO-01-915, Sept. 28, 2001). This report was mandated by the Public 
Health Improvement Act of 2000 (P.L. 106505, sec. 102). Also, see the 
list of related GAO products at the end of this statement.
    \3\ We conducted interviews with and obtained information from the 
Departments of Agriculture, Commerce, Defense, Energy, Health and Human 
Services, Justice, Transportation, the Treasury, and Veterans Affairs-, 
the Environmental Protection Agency-, and the Federal Emergency 
Management Agency.
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    In summary, we identified more than 20 federal departments and 
agencies as having a role in preparing for or responding to the public 
health and medical consequences of a bioterrorist attack. These 
agencies are participating in a variety of activities, from improving 
the detection of biological agents to developing a national stockpile 
of pharmaceuticals to treat victims of disasters. Federal departments 
and agencies have engaged in a number of efforts to coordinate these 
activities on a formal and informal basis, such as interagency work 
groups. Despite these efforts, we found evidence that coordination 
between departments and agencies is fragmented. We did, however, find 
recent actions to improve coordination across federal departments and 
agencies. In addition, we found emerging concerns about the 
preparedness of state and local jurisdictions, including insufficient 
state and local planning for response to terrorist events, a lack of 
hospital participation in training on terrorism and emergency response 
planning, the timely availability of medical teams and resources in an 
emergency, and inadequacies in the public health infrastructure. The 
last includes weaknesses in the training of health care providers, 
communication among responsible parties, and capacity of laboratories 
and hospitals, including the ability to treat mass casualties.

Background

    A domestic bioterrorist attack is considered to be a low-
probability event, in part because of the various difficulties involved 
in successfully delivering biological agents to achieve large-scale 
casualties.\4\ However, a number of cases involving biological agents, 
including at least one completed bioterrorist act and numerous threats 
and hoaxes, \5\ have occurred domestically. In 1984, a group 
intentionally contaminated salad bars in restaurants in Oregon with 
salmonella bacteria. Although no one died, 751 people were diagnosed 
with foodborne illness. Some experts predict that more domestic 
bioterrorist attacks are likely to occur.
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    \4\ See Combating Terrorism: Need for Comprehensive Threat and Risk 
Assessments of Chemical and Biological Attacks (GAO/NSIAD-99-163, Sept. 
14, 1999), pp. 10-15, for a discussion of the ease or difficulty for a 
terrorist to create mass casualties by making or using chemical or 
biological agents without the assistance of a state-sponsored program.
    \5\ For example, in January 2000, threatening letters were sent to 
a variety of recipients, including the Planned Parenthood office in 
Naples, Florida, warning of the release of anthrax. Federal authorities 
found no signs of anthrax or any other traces of harmful substances and 
determined these incidences to be hoaxes.
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    The burden of responding to such an attack would fall initially on 
personnel in state and local emergency response agencies. These ``first 
responders'' include firefighters, emergency medical service personnel, 
law enforcement officers, public health officials, health care workers 
(including doctors, nurses, and other medical professionals), and 
public works personnel. If the emergency were to require federal 
disaster assistance, federal departments and agencies would respond 
according to responsibilities outlined in the Federal Response Plan. 
\6\ Several groups, including the Advisory Panel to Assess Domestic 
Response Capabilities for Terrorism Involving Weapons of Mass 
Destruction (known as the Gilmore Panel), have assessed the 
capabilities at the federal, state, and local levels to respond to a 
domestic terrorist incident involving a weapon of mass destruction 
(WMD), that is, a chemical, biological, radiological, or nuclear agent 
or weapon.\7\
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    \6\ The Federal Response Plan, originally drafted in 1992 and 
updated in 1999, is authorized under the Robert T. Stafford Disaster 
Relief and Emergency Assistance Act (Stafford Act; P.L. 93-288, as 
amended). The plan outlines the planning assumptions, policies, concept 
of operations, organizational structures, and specific assignment of 
responsibilities to lead departments and agencies in providing federal 
assistance once the President has declared an emergency requiring 
federal assistance.
    \7\ Some agencies define WMDs to include large conventional 
explosives as well.
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    While many aspects of an effective response to bioterrorism are the 
same as those for any disaster, there are some unique features. For 
example, if a biological agent is released covertly, it may not be 
recognized for a week or more because symptoms may not appear for 
several days after the initial exposure and may be misdiagnosed at 
first. In addition, some biological agents, such as smallpox, are 
communicable and can spread to others who were not initially exposed. 
These differences require a type of response that is unique to 
bioterrorism, including infectious disease surveillance, \8\ 
epidemiologic investigation, \9\ laboratory identification of 
biological agents, and distribution of antibiotics to large segments of 
the population to prevent the spread of an infectious disease. However, 
some aspects of an effective response to bioterrorism are also 
important in responding to any type of large-scale disaster, such as 
providing emergency medical services, continuing health care services 
delivery, and managing mass fatalities.
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    \8\ Disease surveillance systems provide for the ongoing 
collection, analysis, and dissemination of data to prevent and control 
disease.
    \9\ Epidemiological investigation is the study of patterns of 
health or disease and the factors that influence these patterns.
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Federal Departments and Agencies Reported a Variety of Research and 
                    Preparedness Activities

    Federal spending on domestic preparedness for terrorist attacks 
involving WMD's has risen 310 percent since fiscal year 1998, to 
approximately $1.7 billion in fiscal year 2001, and may increase 
significantly after the events of September 11, 2001. However, only a 
portion of these funds were used to conduct a variety of activities 
related to research on and preparedness for the public health and 
medical consequences of a bioterrorist attack. We cannot measure the 
total investment in such activities because departments and agencies 
provided funding information in various forms--as appropriations, 
obligations, or expenditures. Because the funding information provided 
is not equivalent,\10\ we summarized funding by department or agency, 
but not across the federal government (see apps. I and II).\11\ 
Reported funding generally shows increases from fiscal year 1998 to 
fiscal year 2001. Several agencies received little or no funding in 
fiscal year 1998. For example, within the Department of Health and 
Human Services (HHS), the Centers for Disease Control and Prevention's 
(CDC) Bioterrorism Preparedness and Response Program was established 
and first received funding in fiscal year 1999 (see app. I and app. 
II). Its funding has increased from approximately $121 million at that 
time to approximately $194 million in fiscal year 2001.
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    \10\ For example, an agency providing appropriations is not 
necessarily indicating the level of its commitments (that is, 
obligations) or expenditures for that year--only the amount of budget 
authority made available to it by the Congress, some of which may be 
unspent. Similarly, an agency that provided expenditure information for 
fiscal year 2000 may have obligated the funds in fiscal year 1999 based 
on an appropriation for fiscal year 1998. To simplify presentation, we 
generally refer to all the budget data we received from agencies as 
``reported funding.''
    \11\ Although there are generally no specific appropriations for 
activities on bioterrorism, some departments and agencies did provide 
estimates of the funds they were devoting to activities on 
bioterrorism. Other departments and agencies provided estimates for 
overall terrorism activities, but were unable to provide funding 
amounts for activities on bioterrorism specifically. Still others 
stated that their activities were relevant for bioterrorism, but they 
were unable to specify the funding amounts. Funding levels for 
activities on terrorism, including bioterrorism, were reported for 
activities prior to the 2001 Emergency Supplemental Appropriations Act 
for Recovery From and Response to Terrorist Attacks on the United 
States (P.L. 107-38).
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Research Activities Focus on Detection, Treatment, Vaccination, and 
                    Equipment

    Research is currently being done to enable the rapid identification 
of biological agents in a variety of settings; develop new or improved 
vaccines, antibiotics, and antivirals to improve treatment and 
vaccination for infectious diseases caused by biological agents; and 
develop and test emergency response equipment such as respiratory and 
other personal protective equipment. Appendix I provides information on 
the total reported funding for all the departments and agencies 
carrying out research, along with examples of this research.
    The Department of Agriculture (USDA), Department of Defense (DOD), 
Department of Energy, HHS, Department of Justice (DOJ), Department of 
the Treasury, and the Environmental Protection Agency (EPA) have all 
sponsored or conducted projects to improve the detection and 
characterization of biological agents in a variety of different 
settings, from water to clinical samples (such as blood). For example, 
EPA is sponsoring research to improve its ability to detect biological 
agents in the water supply. Some of these projects, such as those 
conducted or sponsored by DOD and DOJ, are not primarily for the public 
health and medical consequences of a bioterrorist attack against the 
civilian population, but could eventually benefit research for those 
purposes.
    Departments and agencies are also conducting or sponsoring studies 
to improve treatment and vaccination for diseases caused by biological 
agents. For example, HHS' projects include basic research sponsored by 
the National Institutes of Health to develop drugs and diagnostics and 
applied research sponsored by the Agency for Healthcare Research and 
Quality to improve health care delivery systems by studying the use of 
information systems and decision support systems to enhance 
preparedness for the delivery of medical care in an emergency.
    In addition, several agencies, including the Department of 
Commerce's National Institute of Standards and Technology and DOJ's 
National Institute of Justice are conducting research that focuses on 
developing performance standards and methods for testing the 
performance of emergency response equipment, such as respirators and 
personal protective equipment.

Preparedness Efforts Include Multiple Actions

    Federal departments' and agencies' preparedness efforts have 
included efforts to increase federal, state, and local response 
capabilities, develop response teams of medical professionals, increase 
availability of medical treatments, participate in and sponsor 
terrorism response exercises, plan to aid victims, and provide support 
during special events such as presidential inaugurations, major 
political party conventions, and the Superbowl.\12\ Appendix H contains 
information on total reported funding for all the departments and 
agencies with bioterrorism preparedness activities, along with examples 
of these activities.
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    \12\ Presidential Decision Directive 62, issued May 22, 1998, 
created a category of special events called National Security Special 
Events, which are events of such significance that they warrant greater 
federal planning and protection than other special events.
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    Several federal departments and agencies, such as the Federal 
Emergency Management Agency (FEMA) and CDC, have programs to increase 
the ability of state and local authorities to successfully respond to 
an emergency, including a bioterrorist attack. These departments and 
agencies contribute to state and local jurisdictions by helping them 
pay for equipment and develop emergency response plans, providing 
technical assistance, increasing communications capabilities, and 
conducting training courses.
    Federal departments and agencies have also been increasing their 
own capacity to identify and deal with a bioterrorist incident. For 
example, CDC, USDA, and the Food and Drug Administration (FDA) are 
improving surveillance methods for detecting disease outbreaks in 
humans and animals. They have also established laboratory response 
networks to maintain state-of-the-art capabilities for biological agent 
identification and the characterization of human clinical samples.
    Some federal departments and agencies have developed teams to 
directly respond to terrorist events and other emergencies. For 
example, HHS' Office of Emergency Preparedness (OEP) created Disaster 
Medical Assistance Teams to provide medical treatment and assistance in 
the event of an emergency. Four of these teams, known as National 
Medical Response Team, are specially trained and equipped to provide 
medical care to victims of WMD events, such as bioterrorist attacks.
    Several agencies are involved in increasing the availability of 
medical supplies that could be used in an emergency, including a 
bioterrorist attack. CDC's National Pharmaceutical Stockpile contains 
pharmaceuticals, antidotes, and medical supplies that can be delivered 
anywhere in the United States within 12 hours of the decision to 
deploy. The stockpile was deployed for the first time on September 11, 
2001, in response to the terrorist attacks on New York City.
    Federally initiated bioterrorism response exercises have been 
conducted across the country. For example, in May 2000, many 
departments and agencies took part in the Top Officials 2000 exercise 
(TOPOFF 2000) in Denver, Colorado, which featured the simulated release 
of a biological agent. \13\ Participants included local fire 
departments, police, hospitals, the Colorado Department of Public 
Health and the Environment, the Colorado Office of Emergency 
Management, the Colorado National Guard, the American Red Cross, the 
Salvation Army, HHS, DOD, FEMA, the Federal Bureau of Investigation 
(FBI), and EPA.
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    \13\ 1n addition to simulating a bioterrorism attack in Denver, the 
exercise also simulated a chemical weapons incident in Portsmouth, New 
Hampshire. A concurrent exercise, referred to as National Capital 
Region 2000, simulated a radiological event in the greater Washington, 
D.C. area.
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    Several agencies also provide assistance to victims of terrorism. 
FEMA can provide supplemental funds to state and local mental health 
agencies for crisis counseling to eligible survivors of presidentially 
declared emergencies. In the aftermath of the recent terrorist attacks, 
HHS released $1 million in funding to New York State to support mental 
health services and strategic planning for comprehensive and long-term 
support to address the mental health needs of the community. DOJ's 
Office of Justice Programs (OJP) also manages a program that provides 
funds for victims of terrorist attacks that can be used to provide a 
variety of services, including mental health treatment and financial 
assistance to attend related criminal proceedings.
    Federal departments and agencies also provide support at special 
events to improve response in case of an emergency. For example, CDC 
has deployed a system to provide increased surveillance and 
epidemiological capacity before, during, and after special events. 
Besides improving emergency response at the events, participation by 
departments and agencies gives them valuable experience working 
together to develop and practice plans to combat terrorism.

Fragmentation Remains Despite Efforts to Coordinate Federal Programs

    Federal departments and agencies are using a variety of interagency 
plans, work groups, and agreements to coordinate their activities to 
combat terrorism. However, we found evidence that coordination remains 
fragmented. For example, several different agencies are responsible for 
various coordination functions, which limits accountability and hinders 
unity of effort; several key agencies have not been included in 
bioterrorism-related policy and response planning; and the programs 
that agencies have developed to provide assistance to state and local 
governments are similar and potentially duplicative. The President 
recently took steps to improve oversight and coordination, including 
the creation of the Office of Homeland Security.

Departments and Agencies Use a Variety of Methods to Coordinate 
                    Activities

    Over 40 federal departments and agencies have some role in 
combating terrorism, and coordinating their activities is a significant 
challenge. We identified over 20 departments and agencies as having a 
role in preparing for or responding to the public health and medical 
consequences of a bioterrorist attack. Appendix III, which is based on 
the framework given in the Terrorism Incident Annex of the Federal 
Response Plan, shows a sample of the coordination efforts by federal 
departments and agencies with responsibilities for the public health 
and medical consequences of a bioterrorist attack, as they existed 
prior to the recent creation of the Office of Homeland Security. This 
figure illustrates the complex relationships among the many federal 
departments and agencies involved.
    Departments and agencies use several approaches to coordinate their 
activities on terrorism, including interagency response plans, work 
groups, and formal agreements. Interagency plans for responding to a 
terrorist incident help outline agency responsibilities and identify 
resources that could be used during a response. For example, the 
Federal Response Plan provides a broad framework for coordinating the 
delivery of federal disaster assistance to state and local governments 
when an emergency overwhelms their ability to respond effectively. The 
Federal Response Plan also designates primary and supporting federal 
agencies for a variety of emergency support operations. For example, 
HHS is the primary agency for coordinating federal assistance in 
response to public health and medical care needs in an emergency. HHS 
could receive support from other agencies and organizations, such as 
DOD, USDA, and FEMA, to assist state and local jurisdictions.
    Interagency work groups are being used to minimize duplication of 
funding and effort in federal activities to combat terrorism. For 
example, the Technical Support Working Group is chartered to coordinate 
interagency research and development requirements across the federal 
government in order to prevent duplication of effort between agencies. 
The Technical Support Working Group, among other projects, helped to 
identify research needs and fund a project to detect biological agents 
in food that can be used by both DOD and USDA.
    Formal agreements between departments and agencies are being used 
to share resources and knowledge. For example, CDC contracts with the 
Department of Veterans Affairs (VA) to purchase drugs and medical 
supplies for the National Pharmaceutical Stockpile because of VA's 
purchasing power and ability to negotiate large discounts.

Coordination Remains Fragmented Within the Federal Government

    Overall coordination of federal programs to combat terrorism is 
fragmented.\14\ For example, several agencies have coordination 
functions, including DOJ, the FBI, FEMA, and the Office of Management 
and Budget. Officials from a number of the agencies that combat 
terrorism told us that the coordination roles of these various agencies 
are not always clear and sometimes overlap, leading to a fragmented 
approach. We have found that the overall coordination of federal 
research and development efforts to combat terrorism is still limited 
by several factors, including the compartmentalization or security 
classification of some research efforts.\15\ The Gilmore Panel also 
concluded that the current coordination structure does not provide for 
the requisite authority or accountability to impose the discipline 
necessary among the federal agencies involved.\16\
---------------------------------------------------------------------------
    \14\ See also Combating Terrorism: Comments on Counterterrorism 
Leadership and National Strategy (GAO-01-556T, Mar. 27,2001), p. 1.
    \15\ See Combating Terrorism: Selected Challenges and Related 
Recommendations (GAO-01-822, Sept. 20, 2001), pp. 79, 84.
    \16\ Advisory Panel to Assess Domestic Response Capabilities for 
Terrorism Involving Weapons of Mass Destruction (Gilmore Panel), Toward 
a National Strategy for Combating Terrorism, Second Annual Report 
(Arlington, Va.: RAND, Dec. 15, 2000), p. 7.
---------------------------------------------------------------------------
    The multiplicity of federal assistance programs requires focus and 
attention to minimize redundancy of effort.\17\ Table 1 shows some of 
the federal programs providing assistance to state and local 
governments for emergency planning that would be relevant to responding 
to a bioterrorist attack. While the programs vary somewhat in their 
target audiences, the potential redundancy of these federal efforts 
highlights the need for scrutiny. In our report on combating terrorism, 
issued on September 20, 2001, we recommended that the President, 
working closely with the Congress, consolidate some of the activities 
of DOJ's OJP under FEMA. \18\
---------------------------------------------------------------------------
    \17\ See also Combating Terrorism: Issues in Managing 
Counterterrorist Programs (GAO/T-NSIAD-00-145, Apr. 6, 2000), p. 8.
    \18\ See GAO-01-822, Sept. 20, 2001, pp. 104-106.

 Table 1: Selected Federal Activities Providing Assistance to State and
   Local Governments for Emergency Planning Relevant to a Bioterrorist
                                 Attack
------------------------------------------------------------------------
 Department
  or agency                Activities                 Target audience
------------------------------------------------------------------------
HHS-CDC       Provides grants, technical support,  State and local
               and performance standards to         health agencies.
               support bioterrorism preparedness
               and response planning.
------------------------------------------------------------------------
HHS-OEP       Enters into contracts to enhance     Local jurisdictions
               medical response capability. The     (for fire, police,
               program includes a focus on          and emergency
               response to bioterrorism,            medical services;
               including early recognition, mass    hospitals; public
               postexposure treatment, mass         health agencies; and
               casualty care, and mass fatality     other services).
               management.
------------------------------------------------------------------------
DOJ-OJP       Assists states in developing         States (for fire, law
               strategic plans. Includes funding    enforcement,
               for training, equipment              emergency medical,
               acquisition, technical assistance,   and hazardous
               and exercise planning and            materials response
               execution to enhance state and       services; hospitals;
               local capabilities to respond to     public health
               terrorist incidents.                 departments; and
                                                    other services).
------------------------------------------------------------------------
FEMA          Provides grant assistance to         State emergency
               support state and local              management agencies.
               consequence management planning,
               training, and exercises for all
               types of terrorism, including
               bioterrorism.
------------------------------------------------------------------------
Source: Information obtained from departments and agencies.

    We have also recommended that the federal government conduct 
multidisciplinary and analytically sound threat and risk assessments to 
define and prioritize requirements and properly focus programs and 
investments in combating terrorism.\19\ Such assessments would be 
useful in addressing the fragmentation that is evident in the different 
threat lists of biological agents developed by federal departments and 
agencies.
---------------------------------------------------------------------------
    \19\ See Combating Terrorism: Threat and Risk Assessments Can Help 
Prioritize and Target Program Investments (GAO/NSIAD-98-74, Apr. 9, 
1998) and GAO/NSIAD-99-163, Sept. 14, 1999.
---------------------------------------------------------------------------
    Understanding which biological agents are considered most likely to 
be used in an act of domestic terrorism is necessary to focus the 
investment in new technologies, equipment, training, and planning. 
Several different agencies have or are in the process of developing 
biological agent threat lists, which differ based on the agencies' 
focus. For example, CDC collaborated with law enforcement, 
intelligence, and defense agencies to develop a critical agent list 
that focuses on the biological agents that would have the greatest 
impact on public health. The FBI, the National Institute of Justice, 
and the Technical Support Working Group are completing a report that 
lists biological agents that may be more likely to be used by a 
terrorist group working in the United States that is not sponsored by a 
foreign government. In addition, an official at USDA's Animal and Plant 
Health Inspection Service told us that it uses two lists of agents of 
concern for a potential bioterrorist attack. These lists of agents, 
only some of which are capable of making both animals and humans sick, 
were developed through an international process. According to agency 
officials, separate threat lists are appropriate because of the 
different focuses of these agencies. In our view, the existence of 
competing lists makes the assignment of priorities difficult for state 
and local officials.
    Fragmentation is also apparent in the composition of groups of 
federal agencies involved in bioterrorism-related planning and policy. 
Officials at the Department of Transportation (DOT) told us that even 
though the nation's transportation centers account for a significant 
percentage of the nation's potential terrorist targets, the department 
was not part of the founding group of agencies that worked on 
bioterrorism issues and has not been included in bioterrorism response 
plans. DOT officials also told us that the department is supposed to 
deliver supplies for FEMA under the Federal Response Plan, but it was 
not brought into the planning early enough to understand the extent of 
its responsibilities in the transportation process. The department 
learned what its responsibilities would be during the TOPOFF 2000 
exercise, which simulated a release of a biological agent.

Recent Actions Seek to Improve Coordination Across Federal Departments 
                    and Agencies

    In May 2001, the President asked the Vice President to oversee the 
development of a coordinated national effort dealing with WMDs.\20\ At 
the same time, the President asked the Director of FEMA to establish an 
Office of National Preparedness to implement the results of the Vice 
President's effort that relate to programs within federal agencies that 
address consequence management resulting from the use of WMDs. The 
purpose of this effort is to better focus policies and ensure that 
programs and activities are fully coordinated in support of building 
the needed preparedness and response capabilities. In addition, on 
September 20, 2001, the President announced the creation of the Office 
of Homeland Security to lead, oversee, and coordinate a comprehensive 
national strategy to protect the country from terrorism and respond to 
any attacks that may occur. These actions represent potentially 
significant steps toward improved coordination of federal activities. 
Our recent report highlighted a number of important characteristics and 
responsibilities necessary for a single focal point, such as the 
proposed Office of Homeland Security, to improve coordination and 
accountability. \21\
---------------------------------------------------------------------------
    \20\ According to the Office of the Vice President, as of June 
2001, details on the Vice President's efforts had not yet been 
determined.
    \21\ See GAO-01-822, Sept. 20, 2001, pp. 41-42.
---------------------------------------------------------------------------

Despite Federal Efforts, Concerns Exist Regarding Preparedness at State 
                    and Local Levels

    Nonprofit research organizations, congressionally chartered 
advisory panels, government documents, and articles in peer-reviewed 
literature have identified concerns about the preparedness of states 
and local areas to respond to a bioterrorist attack. These concerns 
include insufficient state and local planning for response to terrorist 
events, a lack of hospital participation in training on terrorism and 
emergency response planning, questions regarding the timely 
availability of medical teams and resources in an emergency, and 
inadequacies in the public health infrastructure. In our view, there 
are weaknesses in three key areas of the public health infrastructure: 
training of health care providers, communication among responsible 
parties, and capacity of laboratories and hospitals, including the 
ability to treat mass casualties.
    Questions exist regarding how effectively federal programs have 
prepared state and local governments to respond to terrorism. All 50 
states and approximately 255 local jurisdictions have received or are 
scheduled to receive at least some federal assistance, including 
training and equipment grants, to help them prepare for a terrorist WMD 
incident. In 1997, FEMA identified planning and equipment for response 
to nuclear, biological, and chemical incidents as areas in need of 
significant improvement at the state level. However, an October 2000 
research report concluded that even those cities receiving federal aid 
are still not adequately prepared to respond to a bioterrorist attack. 
\22\
---------------------------------------------------------------------------
    \22\ A.E. Smithson and L.-A. Levy, Ataxia: The Chemical and 
Biological Terrorism Threat and the U.S. Response (Washington, D.C.: 
The Henry L. Stimson Center, Oct. 2000), p. 271.
---------------------------------------------------------------------------
    Inadequate training and planning for bioterrorism response by 
hospitals is a major problem. The Gilmore Panel concluded that the 
level of expertise in recognizing and dealing with a terrorist attack 
involving a biological or chemical agent is problematic in many 
hospitals. \23\ A recent research report concluded that hospitals need 
to improve their preparedness for mass casualty incidents. \24\ Local 
officials told us that it has been difficult to get hospitals and 
medical personnel to participate in local training, planning, and 
exercises to improve their preparedness.
---------------------------------------------------------------------------
    \23\ Advisory Panel to Assess Domestic Response Capabilities for 
Terrorism Involving Weapons of Mass Destruction, p. 32.
    \24\ D.C. Wetter, W.E. Daniell, and C.D. Treser, ``Hospital 
Preparedness for Victims of Chemical or Biological Terrorism,'' 
American Journal of Public Health, Vol. 91, No. 5 (May 2001), pp. 710-
16.
---------------------------------------------------------------------------
    Local officials are also concerned about whether the federal 
government could quickly deliver enough medical teams and resources to 
help after a biological attack. \25\ Agency officials say that federal 
response teams, such as Disaster Medical Assistance Teams, could be on 
site within 12 to 24 hours. However, local officials who have deployed 
with such teams say that the federal assistance probably would not 
arrive for 24 to 72 hours. Local officials also told us that they were 
concerned about the time and resources required to prepare and 
distribute drugs from the National Pharmaceutical Stockpile during an 
emergency. Partially in response to these concerns, CDC has developed 
training for state and local officials in using the stockpile and will 
deploy a small staff with the supplies to assist the local jurisdiction 
with distribution.
---------------------------------------------------------------------------
    \25\ Smithson and Levy, p. 227.
---------------------------------------------------------------------------
    Components of the nation's public health system are also not well 
prepared to detect or respond to a bioterrorist attack. In particular, 
weaknesses exist in the key areas of training, communication, and 
hospital and laboratory capacity. It has been reported that physicians 
and nurses in emergency rooms and private offices, who will most likely 
be the first health care workers to see patients following a 
bioterrorist attack, lack the needed training to ensure their ability 
to make observations of unusual symptoms and patterns. \26\ Most 
physicians and nurses have never seen cases of certain diseases, such 
as smallpox or plague, and some biological agents initially produce 
symptoms that can be easily confused with influenza or other, less 
virulent illnesses, leading to a delay in diagnosis or identification. 
Medical laboratory personnel require training because they also lack 
experience in identifying biological agents such as anthrax.
---------------------------------------------------------------------------
    \26\ Smithson and Levy, p. 248.
---------------------------------------------------------------------------
    Because it could take days to weeks to identify the pathogen used 
in a biological attack, good channels of communication among the 
parties involved in the response are essential to ensure that the 
response proceeds as rapidly as possible. Physicians will need to 
report their observations to the infectious disease surveillance 
system. Once the disease outbreak has been recognized, local health 
departments will need to collaborate closely with personnel across a 
variety of agencies to bring in the needed expertise and resources. 
They will need to obtain the information necessary to conduct 
epidemiological investigations to establish the likely site and time of 
exposure, the size and location of the exposed population, and the 
prospects for secondary transmission. However, past experiences with 
infectious disease response have revealed a lack of sufficient and 
secure channels for sharing information. Our report last year on the 
initial West Nile virus outbreak in New York City found that as the 
public health investigation grew, lines of communication were often 
unclear, and efforts to keep everyone informed were awkward, such as 
conference calls that lasted for hours and involved dozens of people. 
\27\
---------------------------------------------------------------------------
    \27\ See West Nile Virus Outbreak: Lessons for Public Health 
Preparedness (GAO/HEHS-00-180, Sept. 11, 2000), pp. 21-22.
---------------------------------------------------------------------------
    Adequate laboratory and hospital capacity is also a concern. 
Reductions in public health laboratory staffing and training have 
affected the ability of state and local authorities to identify 
biological agents. Even the initial West Nile virus outbreak in 1999, 
which was relatively small and occurred in an area with one of the 
nation's largest local public health agencies, taxed the federal, 
state, and local laboratory resources. Both the New York State and the 
CDC laboratories were inundated with requests for tests, and the CDC 
laboratory handled the bulk of the testing because of the limited 
capacity at the New York laboratories. Officials indicated that the CDC 
laboratory would have been unable to respond to another outbreak, had 
one occurred at the same time. In fiscal year 2000, CDC awarded 
approximately $11 million to 48 states and four major urban health 
departments to improve and upgrade their surveillance and 
epidemiological capabilities. With regard to hospitals, several federal 
and local officials reported that there is little excess capacity in 
the health care system in most communities for accepting and treating 
mass casualty patients. Research reports have concluded that the 
patient load of a regular influenza season in the late 1990s overtaxed 
primary care facilities and that emergency rooms in major metropolitan 
areas are routinely filled and unable to accept patients in need of 
urgent care. \28\
---------------------------------------------------------------------------
    \28\ J.R. Richards, M.L. Navarro, and R.W. Derlet, ``Survey of 
Directors of Emergency Departments in California on Overcrowding,'' 
Western Journal of Medicine, Vol. 172 (June 2000), pp. 385-88. R. 
Derlet, J. Richards, and R. Kravitz, ``Frequent Overcrowding in U.S. 
Emergency Departments,'' Academic Emergency Medicine, Vol. 8, No. 2 
(2001), pp. 151-55. Smithson and Levy, p. 262.
---------------------------------------------------------------------------

Concluding Observations

    We found that federal departments and agencies are participating in 
a variety of research and preparedness activities that are important 
steps in improving our readiness. Although federal departments and 
agencies have engaged in a number of efforts to coordinate these 
activities on a formal and informal basis, we found that coordination 
between departments and agencies is fragmented. In addition, we remain 
concerned about weaknesses in public health preparedness at the state 
and local levels, a lack of hospital participation in training on 
terrorism and emergency response planning, the timely availability of 
medical teams and resources in an emergency, and, in particular, 
inadequacies in the public health infrastructure. The latter include 
weaknesses in the training of health care providers, communication 
among responsible parties, and capacity of laboratories and hospitals, 
including the ability to treat mass casualties.
    Mr. Chairman, this completes my prepared statement. I would be 
happy to respond to any questions you or other Members of the 
Subcommittee may have at this time.

Contact and Acknowledgments

    For further information about this testimony, please contact me at 
(202) 512-7118. Barbara Chapman, Robert Copeland, Marcia Crosse, Greg 
Ferrante, Deborah Miller, and Roseanne Price also made key 
contributions to this statement.

Appendix 1: Funding for Research

  Total Reported Funding for Research on Bioterrorism and Terrorism by Federal Departments and Agencies, Fiscal
                                         Year 2000 and Fiscal Year 2001
----------------------------------------------------------------------------------------------------------------
                                                Dollars in millions
-----------------------------------------------------------------------------------------------------------------
                                                 Fiscal year  Fiscal year
              Department or agency                   2000         2001               Sample activities
                                                   funding      funding
----------------------------------------------------------------------------------------------------------------
U.S. Department of Agriculture (USDA)--                    0         $0.5  Improving detection of biological
 Agricultural Research Service                                              agents.
----------------------------------------------------------------------------------------------------------------
Department of Energy                                   $35.5        $39.6  Developing technologies for detecting
                                                                            and responding to a bioterrorist
                                                                            attack.
                                                                           Developing models of the spread of
                                                                            and exposure to a biological agent
                                                                            after release.
----------------------------------------------------------------------------------------------------------------
Department of Health and Human Services (HHS)--         $5.0            0  Examining clinical training and
 Agency for Healthcare Research and Quality                                 ability of frontline medical staff
                                                                            to detect and respond to a
                                                                            bioterrorist threat.
                                                                           Studying use of information systems
                                                                            and decision support systems to
                                                                            enhance preparedness for medical
                                                                            care in the event of a bioterrorist
                                                                            event.
----------------------------------------------------------------------------------------------------------------
HHS--Centers for Disease Control and Prevention        $48.2        $46.6  Developing equipment performance
 (CDC)                                                                      standards.
                                                                           Conducting research on smallpox and
                                                                            anthrax viruses and therapeutics.
----------------------------------------------------------------------------------------------------------------
HHS--Food and Drug Administration (FDA)                 $8.8         $9.1  Licensing of vaccines for anthrax and
                                                                            smallpox.
                                                                           Determining procedures for allowing
                                                                            use of not-yet-approved drugs and
                                                                            specifying data needed for approval
                                                                            and labeling.
----------------------------------------------------------------------------------------------------------------
HHS--National Institutes of Health                     $43.0        $49.7  Developing new therapies for smallpox
                                                                            virus.
                                                                           Developing smallpox and bacterial
                                                                            antigen detection system.
----------------------------------------------------------------------------------------------------------------
HHS--Office of Emergency Preparedness (OEP)                0         $4.6  Overseeing a study on response
                                                                            systems.
----------------------------------------------------------------------------------------------------------------
Department of Justice (DOJ)--                           $0.7         $4.6  Developing a biological agent
Office of Justice Programs (OJP)                                            detector.
----------------------------------------------------------------------------------------------------------------
DOJ--Federal Bureau of Investigation                       0         $1.1  Conducting work on detection and
                                                                            characterization of biological
                                                                            materials.
----------------------------------------------------------------------------------------------------------------
Department of the Treasury--Secret Service                 0         $0.5  Developing a biological agent
                                                                            detector.
----------------------------------------------------------------------------------------------------------------
Environmental Protection Agency (EPA)                      0         $0.5  Improving detection of biological
                                                                            agents.
----------------------------------------------------------------------------------------------------------------
Note: Total reported funding refers to budget data we received from agencies. Agencies reported appropriations,
  actual or estimated obligations, or actual or estimated expenditures. An agency providing appropriations is
  not necessarily indicating the level of its obligations or expenditures for that year--only the amount of
  budget authority made available to it by the Congress. Similarly, an agency that provided expenditure
  information for fiscal year 2000 may have obligated the funds in fiscal year 1999 based on an appropriation
  for fiscal year 1998.
Source: Information obtained from departments and agencies.

Appendix II: Funding for Preparedness Activities

   Total Reported Funding for Preparedness Activities on Bioterrorism and Terrorism by Federal Departments and
                                 Agencies, Fiscal Year 2000 and Fiscal Year 2001
----------------------------------------------------------------------------------------------------------------
                                                Dollars in millions
-----------------------------------------------------------------------------------------------------------------
                                               Fiscal year  Fiscal year
             Department or agency                  2000         2001                Sample activities
                                                 funding      funding
----------------------------------------------------------------------------------------------------------------
USDA--Animal and Plant Health Inspection                 0         $0.2  Developing educational materials and
 Service                                                                  training programs specifically dealing
                                                                          with bioterrorism.
----------------------------------------------------------------------------------------------------------------
Department of Defense                                 $3.4         $8.7  Planning, and when directed, commanding
(DOD)--Joint Task Force for Civil Support                                 and controlling DOD's WMD and high-
                                                                          yield explosive consequence management
                                                                          capabilities in support of FEMA.
----------------------------------------------------------------------------------------------------------------
DOD--National Guard                                  $70.0        $93.3  Managing response teams that would
                                                                          enter a contaminated area to gather
                                                                          samples for on-site evaluation.
----------------------------------------------------------------------------------------------------------------
DOD--U.S. Army                                       $29.5        $11.7  Maintaining a repository of information
                                                                          about chemical and biological weapons
                                                                          and agents, detectors, and protection
                                                                          and decontamination equipment.
----------------------------------------------------------------------------------------------------------------
HHS--CDC                                            $124.9       $147.3  Awarding planning grants to state and
                                                                          local health departments to prepare
                                                                          bioterrorism response plans.
                                                                         Improving surveillance methods for
                                                                          detecting disease outbreaks.
                                                                         Increasing communication capabilities
                                                                          in order to improve the gathering and
                                                                          exchanging of information related to
                                                                          bioterrorist incidents.
----------------------------------------------------------------------------------------------------------------
HHS--FDA                                              $0.1         $2.1  Improving capabilities to identify and
                                                                          characterize foodborne pathogens.
                                                                         Identifying biological agents using
                                                                          animal studies and microbiological
                                                                          surveillance.
----------------------------------------------------------------------------------------------------------------
HHS--OEP                                             $35.3        $46.1  Providing contracts to increase local
                                                                          emergency response capabilities.
                                                                         Developing and managing response teams
                                                                          that can provide support at the site
                                                                          of a disaster.
----------------------------------------------------------------------------------------------------------------
DOJ--OJP                                              $7.6         $5.3  Helping prepare state and local
                                                                          emergency responders through training,
                                                                          exercises, technical assistance, and
                                                                          equipment programs.
                                                                         Developing a data collection tool to
                                                                          assist states in conducting their
                                                                          threat, risk, and needs assessments,
                                                                          and in developing their preparedness
                                                                          strategy for terrorism, including
                                                                          bioterrorism.
----------------------------------------------------------------------------------------------------------------
EPA                                                   $0.1         $2.0  Providing technical assistance in
                                                                          identifying biological agents and
                                                                          decontaminating affected areas.
                                                                         Conducting assessments of water supply
                                                                          vulnerability to terrorism, including
                                                                          contamination with biological agents.
----------------------------------------------------------------------------------------------------------------
Federal Emergency Management Agency                  $25.1        $30.3  Providing grant assistance and guidance
                                                                          to states for planning and training.
                                                                         Maintaining databases of safety
                                                                          precautions for biological, chemical,
                                                                          and nuclear agents.
----------------------------------------------------------------------------------------------------------------
Note: Total reported funding refers to budget data we received from agencies. Agencies reported appropriations,
  actual or estimated obligations, or actual or estimated expenditures. An agency providing appropriations is
  not necessarily indicating the level of its obligations or expenditures for that year--only the amount of
  budget authority made available to it by the Congress. Similarly, an agency that provided expenditure
  information for fiscal year 2000 may have obligated the funds in fiscal year 1999 based on an appropriation
  for fiscal year 1998.
Source: Information obtained from departments and agencies.

Appendix III: Examples of Coordination Activities on Bioterrorism Among 
                    Federal Departments and Agencies

    We identified the following federal departments and agencies as 
having responsibilities related to the public health and medical 
consequences of a bioterrorist attack:
 USDA--U.S. Department of Agriculture
     APHIS--Animal and Plant Health Inspection Service
     ARS--Agricultural Research Service
     FSIS--Food Safety Inspection Service
     OCPM--Office of Crisis Planning and Management
 DOC--Department of Commerce
     NIST--National Institute of Standards and Technology
 DOD--Department of Defense
     DARPA--Defense Advanced Research Projects Agency
     JTFCS--Joint Task Force for Civil Support
     National Guard
     U.S. Army
 DOE--Department of Energy
 HHS--Department of Health and Human Services
     AHRQ--Agency for Healthcare Research and Quality
     CDC--Centers for Disease Control and Prevention
     FDA--Food and Drug Administration
     NIH--National Institutes of Health
     OEP--Office of Emergency Preparedness
 DOJ--Department of Justice
     FBI--Federal Bureau of Investigation
     OJP--Office of Justice Programs
 DOT--Department of Transportation
     USCG--U.S. Coast Guard
 Treasury--Department of the Treasury
     USSS--U.S. Secret Service
 VA--Department of Veterans Affairs
 EPA--Environmental Protection Agency
 FEMA--Federal Emergency Management Agency

    Figure 1, which is based on the framework given in the Terrorism 
Incident Annex of the Federal Response Plan, shows a sample of the 
coordination activities by these federal departments and agencies, as 
they existed prior to the recent creation of the Office of Homeland 
Security. This figure illustrates the complex relationships among the 
many federal departments and agencies involved. (Note: This GAO chart 
is maintained in the Committee file.)
    The following coordination activities are represented on the 
figure:
     OMB Oversight of Terrorism Funding. The Office of 
Management and Budget established a reporting system on the budgeting 
and expenditure of funds to combat terrorism, with goals to reduce 
overlap and improve coordination as part of the annual budget cycle.
     Federal Response Plan--Health and Medical Services Annex. 
This annex to the Federal Response Plan states that HHS is the primary 
agency for coordinating federal assistance to supplement state and 
local resources in response to public health and medical care needs in 
an emergency, including a bioterrorist attack.
     Informal Working Group--Equipment Request Review. This 
group meets as necessary to review equipment requests of state and 
local jurisdictions to ensure that duplicative funding is not being 
given for the same activities.
     Agreement on Tracking Diseases in Animals That Can Be 
Transmitted to Humans. This group is negotiating an agreement to share 
information and expertise on tracking diseases that can be transmitted 
from animals to people and could be used in a bioterrorist attack.
     National Medical Response Team Caches. These caches form a 
stockpile of drugs for OEP's National Medical Response Teams.
     Domestic Preparedness Program. This program was formed in 
response to the National Defense Authorization Act of Fiscal Year 1997 
(P.L. 104-201) and required DOD to enhance the capability of federal, 
state, and local emergency responders regarding terrorist incidents 
involving WMDs and high-yield explosives. As of October 1, 2000, DOD 
and DOJ share responsibilities under this program.
     Office of National Preparedness--Consequence Management of 
WMD Attack. In May 2001, the President asked the Director of FEMA to 
establish this office to coordinate activities of the listed agencies 
that address consequence management resulting from the use of WMDs.
     Food Safety Surveillance Systems. These systems are 
FoodNet and PulseNet, two surveillance systems for identifying and 
characterizing contaminated food.
     National Disaster Medical System. This system, a 
partnership between federal agencies, state and local governments, and 
the private sector, is intended to ensure that resources are available 
to provide medical services following a disaster that overwhelms the 
local health care resources.
     Collaborative Funding of Smallpox Research. These agencies 
conduct research on vaccines for smallpox.
     National Pharmaceutical Stockpile Program. This program 
maintains repositories of life-saving pharmaceuticals, antidotes, and 
medical supplies that can be delivered to the site of a biological (or 
other) attack.
     National Response Teams. The teams constitute a national 
planning, policy, and coordinating body to provide guidance before and 
assistance during an incident.
     Interagency Group for Equipment Standards. This group 
develops and maintains a standardized equipment list of essential items 
for responding to a terrorist WMD attack. (The complete name for this 
group is the Interagency Board for Equipment Standardization and 
Interoperability.)
     Force Packages Response Team. This is a grouping of 
military units that are designated to respond to an incident.
     Cooperative Work on Rapid Detection of Biological Agents 
in Animals, Plants, and Food. This cooperative group is developing a 
system to improve on-site rapid detection of biological agents in 
animals, plants, and food.

Related GAO Products

Bioterroilsm: Coordination and Preparedness (GAO-02-129T, Oct. 5, 
    2001).
Bioterrorism: Federal Research and Preparedness Activities (GAO-01-915, 
    Sept. 28, 2001).
Combating Terrorism: Selected Challenges and Related Recommendations 
    (GAO-01-822, Sept. 20, 2001).
Combating Terrorism: Comments on H.R. 525 to Create a President's 
    Council on Domestic Terrorism Preparedness (GAO-01-555T, May 9, 
    2001).
Combating Terrorism: Accountability Over Medical Supplies Needs Further 
    Improvement (GAO-01-666T, May 1, 2001).
Combating Terrorism: Observations on Options to Improve the Federal 
    Response (GAO-01-660T, Apr. 24, 2001).
Combating Terrorism: Accountability Over Medical Supplies Needs Further 
    Improvement (GAO-01-463, Mar. 30, 2001).
Combating Terrorism: Comments on Counterterrorism Leadership and 
    National Strategy (GAO-01-556T, Mar. 27, 2001).
Combating Terrorism: FEMA Continues to Make Progress in Coordinating 
    Preparedness and Response (GAO-01-15, Mar. 20, 2001).
Combating Terrorism: Federal Response Teams Provide Varied 
    Capabilities; Opportunities Remain to Improve Coordination (GAO-01-
    14, Nov. 30, 2000).
West Nile Virus Outbreak: Lessons for Public Health Preparedness (GAO/
    HEHS-00-180, Sept. 11, 2000).
Combating Terrorism: Linking Threats to Strategies and Resources (GAO/
    T-NSIAD-00-218, July 26, 2000).
Chemical and Biological Defense. Observations on Nonmedical Chemical 
    and Biological R&D Programs (GAO/T-NSIAD-00-130, Mar. 22, 2000).
Combating Terrorism: Need to Eliminate Duplicate Federal Weapons of 
    Mass Destruction Training (GAO/NSIAD-00-64, Mar. 21, 2000).
Combating Terrorism: Chemical and Biological Medical Supplies Are 
    Poorly Managed (GAO/T-HEHS/AIMD-00-59, Mar. 8, 2000).
Combating Terrorism: Chemical and Biological Medical Supplies Are 
    Poorly Managed (GAO/HEHS/AIMD-00-36, Oct. 29,1999).
Food Safety: Agencies Should Further Test Plans for Responding to 
    Deliberate Contamination (GAO/RCED-00-3, Oct. 27, 1999).

    The Chairman. Dr. Akhter?
    Dr. Akhter. Thank you, Mr. Chairman, members of the 
committee. I really appreciate this opportunity to be here 
today to discuss with you our views.
    I represent the public health community. We are 55,000 
public health workers working at the State, local, and Federal 
levels to protect the health of the American people, and we are 
all very much ready to serve in any capacity to help deal with 
this new threat to America's security and the peace of our 
people.
    We are a scientific community. Our people are experts in 
the field. We wrote the book on ``Dealing with Communicable 
Diseases.'' We have been publishing this book since 1917. This 
is the book which is used worldwide to deal with infectious 
diseases. The United States Army buys 24,000 copies of this 
book to be distributed to its members to be able to protect 
against communicable diseases.
    So we have a significant amount of knowledge about how to 
proceed, and we also have knowledge as to what is the reality 
on the ground. So I want to present to you, Mr. Chairman and 
members of the committee, the reality on the ground on 
different arenas.
    First, prevention of bioterrorism is the key. There has not 
been any relationship between the public health community and 
the intelligence community. These two communities have never 
worked together in the past. There is very limited contact 
between these two communities. Good intelligence, not only 
looking at the foreign agents coming in but at our own labs, 
where these things could be manufactured, is very, very 
important. In fact, I would suggest that we make our State 
public health directors part of the intelligence community. Let 
us get them the clearance and get them hooked up, because the 
sooner there is free communication, the better work we as a 
public health community can do.
    The second part is the local health department capacity. 
There are 3,000 local health departments. Ten percent of them 
do not even have email or Internet connection. Most health 
departments are 9 to 5 operations. So if there is an outbreak 
on Friday afternoon, there will be nobody there to take care of 
them on Friday evening, Saturday, Sunday, or Monday. The window 
of opportunity to deal with these infectious agents is 24 to 48 
hours during which we need to either provide the vaccine or 
provide treatment to save the life of the individual and also 
to prevent the spread of disease. If nobody is there, how are 
we going to deal with this?
    What I suggest we do is to look at the regional approach, 
get these health departments together, and have someplace 
where, 24 hours a day, 7 days week, people are available whom 
the local health providers could talk to and could provide 
service.
    As we look at our local situation, we see the weakest link. 
I was State health director in Missouri and also health 
commissioner in our Nation's Capital, and I had the great 
pleasure of being the emergency medical services director for 
the States of Illinois and Michigan. The weakest link between 
the health department and health care providers just at the 
moment--there is no direct connection and no direct link in 
most places so that the emergency providers, EMTs, paramedics, 
could send in direct information immediately to the hospitals, 
clinics, and private providers. The information comes too late. 
We need to have that relationship and that link strengthened. 
Simply giving money and resources to the States to do things 
without asking them to do these specific things would not solve 
our situation.
    Finally, Mr. Chairman, there is a lack of epidemiological 
capacity at the State level--the people who are trained, the 
medical detectives, to go after such things day in and day 
out--almost half of our States do not have such people on board 
as we speak today. I think we need to build that capacity; we 
need to have these folks in there to carry out this 
responsibility.
    Now I come to our premier agency, the Centers for Disease 
Control and Prevention. This is the lead agency in the world. 
The quality of this agency is unmatched by any other 
institution in the world. But its capacity is very narrow. Its 
ability to fight on multiple fronts is very, very limited. We 
need to expand that capacity.
    In the natural history of disease, one case leads to 
another case; another case leads to another case. In a 
terrorist attack, large numbers of cases take place at the same 
time. And remember--the incubation period of a disease could be 
from one to 7 days; so by the time the first case appears, in 
our mobile society, people will have traveled many, many 
places. So that being available on multiple fronts is very 
important.
    I suggest the capacity of CDC be increased and also that 
its capacity be placed at strategic locations, most likely at 
the regional offices, so that in case of transportation 
failure, people can get to it, or in case of a terrorist attack 
in Atlanta. So we need to decentralize some of this capacity so 
that we can provide the trained personnel, provide the drugs, 
provide the vaccines to the people in a timely manner where 
they need it.
    Of course, there are many, many other issues dealing with 
the distribution of drugs. You all saw yesterday people in 
Florida standing outside, waiting for several hours to get 
their share of the medication. That is just a small group of 
people. Think about if you had to provide medication in New 
York City to all the population, or if you had to provide 
immunization to all the people in San Francisco. Do we have 
built up that kind of capacity, that kind of ability to be able 
to do this work?
    The reason I am telling you all of this is not to scare 
you, but to tell you that we are vigilant, we are looking at 
it, and we will do whatever we need to do, but that this 
requires a long-term, sustained commitment by the Federal 
Government, the State governments, and the local authorities to 
be able to deal with the situation.
    Finally, Mr. Chairman and members of the committee, I was 
born in India and grew up in Pakistan. As a child, I saw many 
of these diseases. There was an outbreak of smallpox when I was 
a child, and one-third of my classmates were infected. These 
are no ``walk in the garden'' kinds of diseases where you give 
medicine, and they get better. There are consequences besides 
death from these diseases which are lifelong.
    We cannot afford not to be fully prepared to deal with 
these diseases. The unthinkable has already happened, and I as 
a public health official cannot sit here and say yes, we are 
ready, we are prepared. I say to you that we are underprepared, 
and we had better get ourselves ready to do the best we can.
    Thirty years ago, this Nation made a choice that we would 
not immunize people against smallpox. We discontinued that 
immunization because the threat was low--thanks to Dr. 
Henderson and his colleagues, smallpox was eradicated. Now the 
threat has risen to a higher level once again.
    It is time to revisit that policy. We should appoint a 
high-level panel of experts from both the medical side of the 
community as well as the intelligence community so that we can 
look at the threat level, and at the risks and benefits, and 
truly reexamine once again whether we should look at immunizing 
our people against common bioterrorist agents like anthrax and 
smallpox.
    A lot more research needs to be done. We might find 
wonderful modalities. But I must submit to you that after 
seeing the firefighters and the EMTs and the paramedics working 
on the front line in New York City, the firemen running into 
the fire as others ran away, the same kind of situation will 
take place when there is a terrorist attack. These people have 
to go in, they have got to get folks out, and these people must 
be protected.
    The United States Army right now provides immunization 
against smallpox and anthrax to its people. We should seriously 
reconsider making available these vaccines to our firefighters 
and our front-line workers. It would be a tragedy if these 
people had to stand in line, waiting to get their antibiotics 
and their vaccines when they could be working and helping other 
people.
    Mr. Chairman, I appreciate greatly this opportunity and 
would be glad to answer any questions you and members of the 
committee might have.
    Thank you.
    The Chairman. Thank you very much, Dr. Akhter.
    [The prepared statement of Dr. Akhter follows:]
Prepared Statement of Mohammad N. Akhter, M.D., MPH, Executive Director 
               of the American Public Health Association
    Mr. Chairman and members of the Committee, my name is Mohammad 
Akhter, and I am the Executive Director of the American Public Health 
Association. APHA is the oldest and largest public health association 
in the world, representing approximately 50,000 public health 
professionals in the United States and abroad. I am honored to appear 
before you to discuss the role of our public health infrastructure in 
preparing for, preventing, detecting, and responding to a bioterrorist 
event.
    On behalf of our colleagues and members, I salute you, Mr. 
Chairman, and the members of the Committee for your timely recognition 
of the importance of public health in addressing the threats currently 
facing our great nation. My role today will be to assess how the public 
health infrastructure can and must be enhanced to respond to a 
bioterrorism emergency with greater speed, efficiency, and 
effectiveness.

Preventing a Bioterrorist Event is Preferable to Responding to One

    On September 1 1th, the Centers for Disease Control and Prevention 
issued precautionary instructions to health departments to be on 
special alert for possible clusters of unusual disease symptoms, and 
hospitals were notified by state and local health officials to report 
any such incidents promptly. This was an appropriate action in the face 
of an obvious disaster. But, a bioterrorist attack itself won't be 
obvious. Links must be established between the intelligence community 
and public health officials on a routine basis to discern the actual 
attack, eliminate the response lag-time of the agent's incubation 
period, and thereby prevent casualties. Public health must be included 
in the intelligence process, and given appropriate clearance to review 
suspicious occurrences and threats much earlier in the process. There 
must also be a new segment of the intelligence community that is 
devoted to detecting bioterrorist threats. Good intelligence is key to 
preventing attacks.

Communication and Coordination

    We have heard over the last several weeks that we must enhance our 
ability to gather information in an emergency, and to communicate it 
efficiently to all relevant parties. This means establishing linkages 
among emergency managers, local health departments, clinics, and 
hospitals so that critical data in an emergency situation can travel 
seamlessly to identify, contain, and respond to an emergency in the 
most efficient way possible. This is mandatory, not optional, and yet 
the reality is that approximately ten percent of the health departments 
in the United States do not even have e-mail.
    We must remember, however, that merely providing funding to bolster 
technical support is not enough. We also have to change the way we do 
business to meet the level of the threats now facing us. If a 
bioterrorist attack occurred on a Friday afternoon, there would be no 
report of it until Monday morning under the current staffing profile of 
most health departments. The events of September 11th demand that we 
now provide access to the public health network twenty-four hours a 
day.

Training and Expansion of the Public Health Workforce and 
                    Infrastructure

    Members of the Committee, you have heard before about the gaps in 
our most basic public health capacities. Indeed, this Committee, under 
the leadership of Senators Frist and Kennedy, led the charge last year 
with the Public Health Threats and Emergencies Act, and the public 
health community is both grateful, and ready to advance the objectives 
of that legislation. Recognizing that you are already familiar with 
gaps in staffing, training, laboratory and information capacity and 
coordination, I will focus on only a few specific points.
    CDC must expand its capacity to respond to more than one event. As 
the world's premiere agency for public health response, CDC must re-
consider its own surge capacity, when state and local health 
departments rely on the agency so heavily. As such, CDC should 
integrate into the Health and Human Services regional system, 
establishing a new layer of workforce and supporting capacity 
regionally. This will allow continued federal technical support in all 
regions if the national transportation system is affected, while also 
recognizing that metropolitan areas and bioterrorist attack zones 
themselves may cut across state boundaries.
    It is essential that every state have essential epidemiology 
personnel in place. CDC's Epidemic Intelligence Service Officers, the 
``Disease Detectives,'' can provide a set of very skilled hands to 
address a host of unanticipated events. Only 25 states have EIS 
officers at this time. Also, only 32 states employ a designated public 
health veterinarian. This is another lapse we can't afford. Seventeen 
of the 20 designated bioterrorism agents are either zoonotic, meaning 
they are transmitted from animals to man, such as plague; or they are 
fairly common diseases of animals, such as anthrax; or, they are 
foodborne illnesses such as Salmonella, about which public health 
veterinarians receive extensive training. These and other core 
communicable disease experts must be based in every state.

Training of the Medical Workforce and Enhancing Institutional Capacity

    Even if we succeed in enhancing our communication and intelligence 
capabilities, this will not suffice unless the workforce of first-
responders is adequately trained to detect and respond to bioterrorist 
threats. Last week in Florida, the first reported case of inhalational 
anthrax in the U.S. since 1976 was quickly identified, and appropriate 
therapy initiated. We are encouraged by this, but know that this might 
not be the norm. We cannot underestimate the importance of our front 
line health professionals; enhancing their technical expertise and 
knowledge of a broader array of health threats is of paramount 
importance at this time.
    The capacity of our hospitals to accommodate a large number of 
patients is also under scrutiny. Emergency rooms can barely address 
current needs. In the event of a terrorist attack, there would be a 
surge in need for trained personnel who can diagnose and treat rare 
diseases, and also for isolation areas and rapid mobilization of 
special drugs and vaccines. The economic efficiencies of the ``just in 
time'' drug inventory system clearly operate to the disadvantage of a 
population confronted with an epidemic. Despite the negative impact on 
the bottom line, we must maintain a sufficient inventory of essential 
vaccines and drugs, and develop more surge capacities on a daily basis 
if we are to approach an adequate level of preparedness for a 
bioterrorist event.

The Safety of our Food Supply

    So far, our only known domestic bioterrorist event occurred in 
1976, when members of a religious cult contaminated a salad bar with 
Salmonella, sickening more than 700 people. Our food supply remains 
vulnerable. The number of inspectors employed to safeguard our food 
supply is vastly insufficient, especially the workforce of the Food and 
Drug Administration. So much of our food is imported from countries 
that utilize few precautions in the production of their products, yet 
we lack the authority and the personnel to scrutinize these products 
properly. Jurisdiction over food safety is currently spread among a 
host of agencies. APHA has long advocated for a single agency to 
address food safety, and current events have validated the wisdom of 
this position. We are grateful that many members of this Committee 
have, over the years, engaged the problems of understaffing, imported 
food safety, and the regulatory structure.

Conclusion

    We have focused on recognition of unique illnesses that may signal 
an attack, and were an attack to occur, we hope we will all be ready. 
But I must caution that the agents themselves pose such a challenge; 
hardwired into them is their incubation period, unique for each one but 
always too long for our liking; smallpox, 7 to 19 days; anthrax, up to 
60 days; Ebola virus, 2 to 21 days. What does it mean, in a mobile, 
global society, if we recognize the first case of smallpox 7 days after 
exposure? And, there is the matter that for most of these agents, the 
symptoms are innocent and nondescript. No amount of money or planning 
or good intention can lower the hurdles the germs themselves impose. 
Our very best response can't approximate prevention.
    I was born and raised on the Indian subcontinent. I have lived 
through the outbreaks of smallpox, malaria, typhoid, Hepatitis A, and 
many other diseases. When the risk is high, we must re-evaluate our 
position about making vaccines available to the public. Mr. Chairman, I 
suggest that a national committee of experts from the medical, 
scientific and intelligence communities be formed to review the level 
of threat, as well as the risks and benefits of making smallpox and 
anthrax vaccines available to the population at large. Assessing the 
risk at this stage will help us protect our people from the most common 
agents that could be used against us by a terrorist.
    On behalf of the members of the American Public Health Association, 
I thank you for this opportunity to discuss this matter of critical 
national security, and I am happy to answer any questions you may have.

    The Chairman. Dr. Osterholm?
    Mr. Osterholm. Thank you, Mr. Chairman, members of the 
subcommittee, and thank you, Senator Wellstone, for your kind 
introduction.
    I am Michael Osterholm, and I am director of the Center for 
Infectious Disease Research and Policy at the University of 
Minnesota where I am also a professor in the School of Public 
Health.
    For 24 years, I served with the Minnesota Department of 
Health, including 14 years as the State Epidemiologist. It was 
in that capacity that I testified before this committee in the 
past. I am here today to address the critical need for our 
country to prepare its homeland security against a potential 
bioterrorist attack. At the same time we can and must 
capitalize on that preparation to respond to the everyday 
growing threat of emerging infections that are not related to 
potential bioterrorism.
    My comments will reflect my combined experience in the 
trenches as one of those infectious disease epidemiologists, as 
a leader in several national infectious disease and 
microbiology professional organizations, my time as a personal 
advisor to His Majesty King Hussein of Jordan on this topic, 
and as an author of the recently published book, ``Living 
Terrors: What America Needs to Know to Survive the Coming 
Bioterrorist Catastrophe.''
    Today we are here because of the tragedy of September 11 
and the wake-up call to America that catastrophic terrorism is 
now a reality within the borders of our own homeland. The 
consequences of an infectious disease outbreak due to a 
bioterrorist attack dramatically illustrate the critical 
importance of shoring up our public health system. Without a 
comprehensive and timely response, we will realize both an 
increase in deaths and the potential for previously unseen 
panic and fear.
    Preparing us for such an event will also prepare us for the 
daily barrage of exotic agents from abroad, antibiotic-
resistant microbes, and the ever-growing problems of our food 
safety. This represents the very essence of dual-purpose 
resources.
    We have heard much over the past 3 weeks about the 
potential risk of a bioterrorism event occurring in this 
country. I will not address the issues any further other than 
to say that as a Nation, we cannot afford to be underprepared 
to respond to such an event as we are today.
    Recently, our center at the University of Minnesota 
convened a working group on bioterrorism preparedness that 
reflects the expertise and experience of a number of important 
front-line organizations whose members will be responsible for 
responding to a bioterrorist attack. They include the American 
Society for Microbiology, the Alfred P. Sloan Foundation, the 
Association of Public Health Laboratories, the Association of 
State and Territorial Health Officials, the Council of State 
and Territorial Epidemiologists, Emory University School of 
Public Health, the Infectious Disease Society of America, the 
Johns Hopkins Center for Civilian Biodefense Studies, the 
National Association of County and City Health Officials, the 
National Association of Public Health Veterinarians, and NTI.
    This group has provided a framework for your use for the 
public health action and bioterrorist preparedness we need. Out 
of this meeting grew a set of recommendations for critical 
funding for our public health activities. These members did not 
seek endorsement from their respective organizations for the 
recommendations contained in our report, and therefore it may 
not reflect the exact position of these respective 
organizations. However, we believe that at this time, this 
represents our best estimate of the necessary resources it will 
take to revitalize the public health system so it will pass the 
test of a catastrophic bioterrorist attack. The committee has a 
summary of that framework.
    The designated amounts, as you will note, are needed for 
hospitals and Federal, State, and local public health agencies 
to effectively recognize and respond to bioterrorism. At the 
State and local levels, it is essential for these activities to 
be housed within existing communicable disease programs--that 
is where the foundation for controlling communicable diseases 
exists. By enhancing these systems, we can maximize the 
efficiency of putting new resources to their best use in the 
quickest amount of time.
    I would also like to point out that the funds outlined are 
needed as an initial investment in building the surveillance 
systems, training programs, communication systems, and 
laboratory networks that are required to recognize a 
bioterrorist event.
    I can promise you that these numbers are not some inflated, 
``come to the table, give us all the money'' under an ideal 
time situation. We made an honest attempt to give you our best 
estimate of what it will really take to honestly and 
effectively deal with this system.
    Ongoing funding is critical to keep these systems 
operational at the level needed for effective homeland security 
over time. Let me provide you with a quick overview of the 
funding requirements with some discussion of what we are 
requesting. I would also note that many of our comments here 
reflect quite closely what we heard in the first panel this 
morning and some of the other ideas that have been proposed in 
terms of funding for bioterrorism preparedness.
    First, we are requesting $35 million for State and local 
agencies to develop and test bioterrorism response plans. This 
amounts to about $500,000 per jurisdiction, assuming about 70 
jurisdictions. A wide-scale bioterrorism attack would create 
mass panic and overwhelm almost every State and local system 
within a matter of just a few days. We know this from 
simulation exercises such as TOPOFF and Dark Winter. Therefore, 
State and local plans for recognizing and responding to a 
bioterrorism attack are urgently needed.
    We believe that these plans should be completed in the next 
90 to 120 days. In its last funding cycle, the Centers for 
Disease Control and Prevention funded 11 States to develop 
bioterrorism plans. Other State applications for funding were 
approved through the grant program but were not funded. Those 
applications should be funded immediately so that planning, 
which we heard about this morning and which we agree will be 
the critical step to any effective response, can be undertaken 
now.
    We also emphasize that it is important to include cities 
and counties in a meaningful way in any planning activity that 
takes place.
    Second, under the category of improving State and local 
preparedness, staffing, training, epidemiology and 
surveillance, we have requested $400 million. These funds 
amount to about $1.3 million per million population, or 
basically $1.30 per head.
    Activities under this category are broad and include the 
following. We have to develop the sensitive surveillance 
systems that can rapidly detect illnesses caused by 
bioterrorism. Part of developing these systems involves 
educating physicians and other health care providers about 
illnesses that may be caused by bioterrorism.
    Second, we must ensure that sufficient staff are available 
to collect epidemiologic data from suspected cases and to make 
the necessary connections as to the where, when, who, and why.
    Third, we must ensure adequate statistical and 
epidemiologic support is available to manage and analyze data 
from surveillance systems and from suspect cases if 
bioterrorism events occur, particularly when they are over 
large regions of the country.
    Fourth, we must ensure that adequate personnel are 
available to direct public health aspects of response to a 
bioterrorism attack, such as setting up triage systems and 
delivery systems for prophylactic medications and vaccine. 
Parenthetically, let me say that I headed up one of the largest 
emergency vaccine response programs in recent years in this 
country when we had to vaccinate 30,000 Minnesota residents in 
one community for a meningitis outbreak. We did that in a 
period of 4 days with one of the very best State health 
departments in the country, and it stretched us to the very 
edge of our ability. If today someone told me that we had to 
vaccinate 2.5 million Twin Cities residents, I would look at 
you and throw up my hands and ask ``How?''
    Fifth, we must assure that adequate personnel are available 
for containment and addressing issues of infection control in 
our hospitals, where secondary spread of agents like smallpox 
will cause additional panic and fear.
    And sixth, we must provide rapid and updated information to 
other public health officials, the medical community, and the 
public itself as the situation unfolds.
    Third, we are requesting $200 million to upgrade the rapid 
health alert networks and national communication systems. We 
heard about that earlier this morning. Sharing accurate 
information with those who need to know is essential during a 
time of crisis.
    We also believe that it is essential to have a national 
electronic reporting system so that data can be collected 
efficiently and rapidly analyzed--not on the back of an 
envelope. This kind of system is needed to monitor a national 
epidemic that could follow the release of a bioterrorism agent 
even in only one location.
    Agents such as smallpox or plague could set off widespread 
chains of illness that would require effective, accurate, and 
rapid communication about patterns of spread and needed control 
measures.
    Fourth, we are asking for $200 million to upgrade our 
laboratory capacity. Two systems need to be enhanced and 
broadly implemented. One is the Laboratory Response Network. 
This system puts into place a multilevel network that can 
receive and analyze laboratory specimens from a range of 
sources. The system is designed to ensure definitive 
identification of suspected bioterrorism agents as quickly as 
possible.
    The second system is the National Laboratory System. This 
is a communication system designed to rapidly share information 
between public health, hospital, and commercial laboratories. 
Such communication will be critical if we are to contribute to 
the early detection and effective monitoring of bioterrorist 
events.
    Additional laboratory resources for chemical terrorism 
preparedness are also needed and should be integrated into the 
laboratory improvements.
    Finally, resources for improved diagnostic testing and 
identification of potential bioterrorism agents by animal and 
wildlife laboratories are also needed, as is improved 
communication between human, animal, and wildlife laboratories.
    All of us in this room are very aware of the issue of West 
Nile virus and the relationship to the wildlife populations. 
That was clearly not a bioterrorist event, but should it be 
anthrax, should it be plague, any number of infectious agents 
associated with bioterrorism may very well show up in the 
animal population as the first sentinel of what is going on.
    Foodborne agents could be involved in a bioterrorist 
attack. Therefore, we are requesting $100 million be allocated 
to improve food safety in this country. Funds are needed to 
improve surveillance for foodborne disease at the State and 
local level, to improve outbreak response capabilities, to 
enhance rapid communication of information about foodborne 
disease outbreaks, and to provide Federal oversight for food 
safety activities.
    Additional funds are needed to upgrade other Federal 
programs for bioterrorism. These include enhancements at the 
CDC to conduct deterrence, preparedness, detection, 
confirmation, response, and mitigation activities; development 
of Federal expert response team--individuals such as Dr. 
Henderson and others who may not currently be part of the 
established Government structure. These teams would include 
experts who have extensive experience in management of 
outbreaks or have clinical experience with diseases caused by 
potential bioterrorism agents. The teams would be maintained on 
alert status and federalized as needed for deployment.
    Third is improvements in the national pharmaceutical 
stockpile. Ideally, we should have at least enough medication 
stockpiled to provide treatment or prophylaxis to up to 40 
million persons. Imagine the stockpile running out, the panic 
and fear that will ensue in this country if we have to tell 
people, ``I am sorry, you were not in line soon enough.'' 
Therefore, we should continue to build the stockpile and rotate 
medications as needed.
    Fourth, as heard earlier, we have to accelerate development 
of smallpox vaccines and research and development and 
production of other vaccines for civilian populations.
    Finally, we have to improve our international surveillance 
by the CDC and the Department of Defense, as we may actually 
have our first early warning occur across the shore when, even 
by accident, an agent intended for bioterrorist use gets out of 
somebody's laboratory. That will be a very important step.
    Finally, we need to assess what works and what does not 
work through implementation of applied research initiatives. We 
do not want to spend money just to spend money. We should 
conduct research studies predominantly at the State and local 
level which tell us what is really effectively making a 
difference. We are requesting $50 million to fund several 
research initiatives in this manner.
    In conclusion, we as a nation must depend on our Government 
to provide us with the necessary resources to effectively and 
convincingly respond to a bioterrorist attack. Front and center 
to that response will be an effective and comprehensive public 
health, clinical laboratory and medical services system.
    Today we are here to address in part those systems. If we 
fail, I fear history will judge all of us in this room as well 
as other leaders negligent for having wasted the opportunity to 
prepare ourselves for the new world. We must never allow 
ourselves the possibility of experiencing a bioterrorist event 
which makes the pain and suffering of September 11 less 
significant.
    Thank you.
    [The prepared statement of Mr. Osterholm follows:]
Prepared Statement of Michael T. Osterholm, PhD, MPH, Director, Center 
for Infectious Disease Research and Policy, Professor, School of Public 
                                 Health
    Mr. Chairman and members of the subcommittee, my name is Michael T. 
Osterholm, PhD, MPH. I am the Director for the Center for Infectious 
Disease Research and Policy at the University of Minnesota. I am also a 
Professor, School of Public Health at the University.
    For 24 years, I served at the Minnesota Department of Health, 
including 14 years as the State Epidemiologist. It was in that capacity 
that I testified before this Committee in the past. I am here today to 
address the critical need for our country to prepare its homeland 
security against a potential bioterrorist attack. At the same time we 
can and must capitalize on that preparation to respond to the everyday 
growing threat of emerging infections that are not related to potential 
bioterrorism.
    My comments will reflect my combined experience in the trenches as 
an infectious disease epidemiologist in one of the premier outbreak 
investigation groups in the country, as a leader in several national 
infectious disease and microbiology professional organizations, my time 
as a personal advisor to His Majesty King Hussein of Jordan on 
bioterrorism and as an author of the recently published book, ``Living 
Terrors: What American Needs to Know to Survive the Coming Bioterrorist 
Catastrophe.
    First, let me remind all of us here that the substance of what we 
are talking about today, the need to adequately fund the ``Public 
Health Improvement Act'' authored by you, Mr. Chairman and Senator 
Frist, is no different now than it was last year. The importance of 
this issue was compelling before the passage of that important 
legislation; as microbial threats to our public health have continued 
to increase for the past decade. Last year I urged the Congress to pass 
and fund this legislation in an invited editorial in the New England 
Journal of Medicine.
    Today, we are here because of the tragedy of September 11th and the 
wake-up call to America that catastrophic terrorism is now a reality 
within the borders of our own homeland. The consequences of an 
infectious disease outbreak due to a bioterrorist attack dramatically 
illustrate the critical importance of shoring up our public health 
system; without a comprehensive and timely response we will realize 
both an increase in deaths and the potential for previously unseen 
panic and fear. Preparing us for such an event, will also prepare us 
for the daily barrage of exotic agents from abroad, antibiotic 
resistant microbes and the ever-growing problem with food safety. This 
represents the very essence of dual purpose resources.
    We have heard much over the past three weeks about the potential 
risk of a bioterrorism event occurring in this country. I will not 
address that issue any further other than to say that as a nation we 
cannot afford to be under-prepared to respond to such an event as we 
are today.
    Recently, our Center at the University of Minnesota convened a 
Workgroup on Bioterrorism Preparedness that reflects the expertise and 
experience of a number of important front line organizations whose 
members will be responsible for responding to a bioterrorist attack. 
They include the American Society for Microbiology, the Alfred P. Sloan 
Foundation, the Association of Public Health Laboratories, The 
Association of State and Territorial Health Officials, the Council of 
State and Territorial Epidemiologists, Emory University School of 
Public Health, the Infectious Disease Society of America, the Johns 
Hopkins Center for Civilian Biodefense Studies, the National 
Association of County and City Health Officials, the National 
Association of Public Health Veterinarians and NTI. This group has 
provided a framework for public health action and bioterrorist 
preparedness. Out of this meeting grew a set of recommendations for 
critical funding for these public health activities. The members did 
not seek endorsement from their respective organizations for the 
recommendations contained in our report and therefore it may not 
reflect the position of the respective organizations. However, we 
believe at this time that it represents our best estimate of the 
necessary resources it will take to revitalize the public health system 
so it will pass the test of a catastrophic bioterrorist attack. 
Enclosed is a summary of that framework.
    The designated amounts, as you will see noted, are needed for 
hospitals and federal, state, and local public health agencies to 
effectively recognize and respond to bioterrorism. At the state and 
local levels it is essential for these activities to be housed within 
existing communicable disease programs--that is where the foundations 
for controlling communicable diseases exist. By enhancing existing 
systems, we can maximize the efficiency of putting new resources to 
their best use. I would also like to point out that the funds outlined 
are needed as an initial investment in building the surveillance 
systems, training programs, communication systems, and laboratory 
networks that are required for recognizing a bioterrorism event. 
Ongoing funding is critical to keep these systems operational at the 
level needed for effective homeland security over time. Let me provide 
you with a quick overview of the funding requirements with some 
discussion of what we are requesting.
    First, we are requesting $35 million for state and local agencies 
to develop and test bioterrorism response plans. This amounts to about 
$500,000 per jurisdiction, assuming about 70 jurisdictions. A wide 
scale bioterrorism attack would create mass panic and overwhelm most 
existing state and local systems within a few days. We know this from 
simulation exercises such as TOPOFF and Dark Winter. Therefore, state 
and local plans for recognizing and responding to a bioterrorism attack 
are urgently needed. We believe that these plans should be completed in 
the next 90 to 120 days. In its last funding cycle, the Centers for 
Disease Control and Prevention (CDC) funded 11 states to develop 
bioterrorism plans. Other state applications for funding were approved 
through this grant program, but were not funded. Those applications 
should be funded immediately so that planning, which will be critical 
to any effective response, can be undertaken.
    Second, under the category of Improving State and Local 
Preparedness: Staffing, Training, Epidemiology and Surveillance, we 
have requested $400 million. These funds amount to about $1.33 million 
per million population. Activities under this category are broad and 
include the following. 1) Develop sensitive surveillance systems that 
can rapidly detect illnesses caused by bioterrorism. Part of developing 
these systems involves educating the physicians and other healthcare 
providers about illnesses that may be caused by bioterrorism. 2) Assure 
that sufficient staff are available to collect epidemiologic data from 
suspected cases and to make the necessary connections as to ``where, 
when, who and how.'' 3) Assure that adequate statistical and 
epidemiologic support is available to manage and analyze data from 
surveillance systems and from suspect cases if a bioterrorism event 
occurs. 4) Assure that adequate personnel are available to direct the 
public health aspects of a response to a bioterrorism attack (such as 
setting up triage systems and delivery systems for prophylactic 
medications and vaccines). 5) Assure that adequate personnel are 
available for containment and addressing issues of infection control. 
6) Provide rapid and updated information to other public health 
officials, the medical community, and the public as the situation 
unfolds.
    Third, we are requesting $200 million to upgrade rapid health alert 
networks and national communication systems. Sharing accurate 
information with those that need to know is essential during times of 
crisis. We also believe that it is essential to have a national 
electronic reporting system so that data can be collected efficiently 
and rapidly analyzed. This kind of system will be needed to monitor a 
national epidemic that could occur following release of a bioterorrism 
agent even in only one location. Agents such as smallpox or plague 
could set off widespread chains of illness that would require 
effective, accurate, and rapid communication about patterns of spread 
and needed control measures.
    Fourth, we are asking for $200 million to upgrade laboratory 
capacity. Two systems need to be enhanced and broadly implemented. One 
is the Laboratory Response Network. This system puts into place a 
multi-level network that can receive and analyze laboratory specimens 
from a range of sources. The system is designed to assure definitive 
identification of suspected bioterrorism agents as quickly as possible. 
The second system is the National Laboratory System. This is a 
communication system designed to rapidly share laboratory information 
between public health, hospital, and commercial laboratories. Such 
communication will contribute to early detection and effective 
monitoring of bioterrorism events. Additional laboratory resources for 
chemical terrorism preparedness also are needed and should be 
integrated into the laboratory improvements. Finally, resources for 
improved diagnostic testing and identification of potential 
bioterrorism agents by animal and wildlife laboratories also are 
needed, as is improved communication between human, animal, and 
wildlife laboratories.
    Foodborne agents could be involved in a bioterrorism attack; 
therefore, we are requesting that $100 million be allocated to improve 
food safety in this country. Funds are needed to improve surveillance 
for foodborne diseases at the state and local level, to improve 
outbreak response capabilities, to enhance rapid communication of 
information about foodborne disease outbreaks, and to provide federal 
oversight for food safety activities.
    Additional funds also are needed to upgrade other federal programs 
for bioterorrism. These include the following. 1) Enhancements at the 
CDC to conduct deterrence, preparedness, detection, confirmation, 
response, and mitigation activities ($153 million). 2) Development of 
federal expert response teams ($45 million). These teams would include 
experts who have extensive experience in management of outbreaks or 
have clinical experience with diseases caused by potential bioterrorism 
agents. The teams should be maintained on alert status and federalized 
as needed for deployment. 3) Improvements in the national 
pharmaceutical stockpile ($250 million). Ideally, we should have enough 
medication stockpiled to provide treatment or prophylaxis to up to 40 
million persons. Therefore, we should continue to build the stockpile 
and to rotate medications as needed. 4) Accelerated development of 
smallpox vaccine ($60 million) and research on the development and 
production of other vaccines for the civilian population ($100 
million). 5) Improvements in international surveillance by the CDC or 
the Department of Defense ($20 million).
    Finally, we need to assess what works and what doesn't work through 
implementation of applied research initiatives. These should be 
conducted predominantly at the state or local level. We are requesting 
$50 million to fund several research initiatives throughout the 
country.
    In conclusion, we as a nation, must depend on our government to 
provide us with the necessary resources to effectively and convincingly 
respond to a bioterrorist attack. Front and center to that response 
will be an effective and comprehensive public health, clinical 
laboratory and medical services systems. Today we are here to address, 
in part those systems. If we fail, I fear history will judge us 
negligent for having wasted the opportunity to prepare ourselves for 
the new world. We must never allow ourselves the possibility of 
experiencing a bioterrorist event which makes the pain and suffering of 
September 11th less significant.

    The Chairman. Thank you very much.
    This is an excellent panel, and I regret we do not have a 
great deal of time. We have nine members and 3 or 4 minutes per 
member to inquire, and obviously, the panel can take some time 
to answer the questions. I would ask staff to keep track of the 
time.
    Senator Clinton has requested that she be able to inquire 
first since she has another engagement, so we will recognize 
her for that purpose.
    Senator Clinton. Mr. Chairman, I have to preside at noon, 
so I very much appreciate your kindness in letting me first of 
all thank the panel for this extraordinary testimony and the 
work and experience that brings each of you here. We look 
forward to working with you.
    I want to address very briefly just two issues--one that 
has been alluded to in several of the presentations, including 
by our colleagues, namely, food safety and security, which I 
think has to have a higher priority. I believe we have to 
increase the number of FDA inspectors as well as assure that 
the USDA has what it requires in order to cover the needs that 
we have to protect our food supply.
    But I also have a second issue that we have not addressed 
yet. I have grave concerns about our ability to protect and 
treat our most vulnerable citizens, namely, our children. I am 
very concerned that we are not paying adequate attention to the 
unique needs of children in our efforts to plan and prepare for 
any of these future possibilities.
    We know that children have special vulnerabilities related 
to bioterrorism. First, they are particularly susceptible to 
biological and chemical attacks. Some dense nerve gas agents 
like sarin concentrate lower to the ground, closer to the 
breathing zone of children. Also, because children have more 
rapid respiratory rates and larger surface-to-mass ratios, they 
are anatomically more vulnerable to exposures that might not be 
quite so serious with adults.
    Yet the tools for our response to bioterrorism are even 
less effective for children than they are for adults. As many 
of us know, particularly Senators Kennedy, Dodd, DeWine, and 
others who have worked on the pediatric testing issue, many 
pharmaceutical manufacturers have not tested or properly dosed 
antidotes, antibiotics, or other agents for use in children. 
And the CDC push-packs and other emergency response supply 
systems do not take into account the special needs of children. 
For example, adult-size gas masks can potentially suffocate 
children. A lot of people I know are rushing out to buy gas 
masks without any real understanding of how to use them for 
themselves, and especially without understanding of their 
potential dangers to children.
    So we have to add another item to this rather daunting 
agenda we face, and that is a particular emphasis on the needs 
of our children. I would hope to get the support of my 
colleagues on a bill that I plan to introduce in the next day 
or two to establish a national task force on children and 
terrorism to bring attention specifically to children's needs. 
In all the literature I have read as I have tried to educate 
myself, I rarely see any mention of children. Yet most mothers 
I speak to and fathers as well--but it is mostly mothers who 
have been coming to me in New York--their principal concern is 
their children. That is what they ask me to give them some 
reassurance on--how will we protect our children. And there is 
a whole agenda of protecting our children that I think we have 
to pay particular and special attention to.
    This task force would make very prompt recommendations, I 
would hope within the time that Dr. Henderson and others have 
suggested we need to have such recommendations from those who 
would be studying it, and perhaps it could even be a part of 
the ongoing work that is already undertaken, so that we could 
have specific protocols. If there are amendments to legislation 
that are needed to expedite treatments for children and 
preventive steps for children, we could begin the necessary 
research, training, and dissemination of information.
    We have got to begin testing for the proper treatment and 
doses of vaccines and antidotes. We have to ensure that we 
support model programs to train physicians and health care 
personnel in what we know about pediatric consequences, 
symptoms, and treatments of care. And I believe--and this will 
be part of the bill that I introduce--that we should set up a 
national clearinghouse to begin disseminating information to 
communities, health care providers, and schools on how best to 
prepare for a biological or chemical attack and to take 
whatever steps are necessary to ensure that children get the 
care they need.
    This is an area that I hope we can address specifically and 
very quickly, because most of the people with whom I come into 
contact, particularly in New York, are increasingly worried and 
have very specific questions about children that all of us need 
to answer.
    So I would appreciate getting just a very brief response 
from whichever panelists would like to respond.
    The Chairman. Dr. Henderson, do you want to start?
    Dr. Henderson. I think the Senator has a very good point, 
and it is particularly true with the antidote for chemical 
agents and certainly some antibiotics.
    I think this should be looked at--whether we need a special 
task force, I do not know--but we have had recently a number of 
discussions about this, and I think the point is well-taken.
    Senator Clinton. Thank you.
    The Chairman. Thank you very much.
    If I could, Dr. Henderson, many experts are concerned that 
potential biological weapons in the former Soviet Union are 
poorly secured. Do you share that concern, and if so, what is 
the best way to make sure that dangerous biological agents are 
accounted for and secured?
    Dr. Henderson. I do share that concern very much, Senator. 
The bioweapons research and development program of the former 
Soviet Union is very extensive, and many of the laboratories 
which were very active in this field are now at least partially 
open, doing other things--we are not quite sure whether they 
are all doing the right things. There are four laboratories 
which are under the ministry of defense which are completely 
closed even today.
    I think the problem is that there are many scientists who 
have left the laboratories where they were making biological 
weapons and are no longer there. Some of them are in this 
country, but some of them we are quite sure are other places.
    In the light of a new president in Russia, with different 
relationships--and most of these places are in Russia, not in 
the other states of the Commonwealth--I think a new approach to 
President Putin and perhaps opening up this subject--it may be 
an appropriate time to do this and to see what could be done in 
terms of providing--again, as has been done but on a very 
limited scale--alternative support for these people who do 
other types of research and perhaps actually persuade them to 
open up at least these four laboratories which are closed.
    The Chairman. I could not agree with you more.
    A final question for the panel, and I hope you can be 
brief. Based on your knowledge of the event, do you think the 
Florida anthrax incident resulted from an act of terrorism? We 
have seen reports that individuals have bought gas masks and 
large doses of antibiotics. Do you think there is any value to 
this?
    Dr. Osterholm, would you start?
    Mr. Osterholm. First, I think most of us would agree that 
the circumstances in Florida are beyond that of circumstantial, 
that there in fact is something that happened there. I think we 
all have to be very careful in making conclusions in the public 
about this, as these are obviously very fragile times.
    Whether this has anything to do with the events of 
September 11 or whether it is a totally separate event, I do 
not know, and I do not know if anyone knows right now. I think 
the important message from that, Senator, is that someone had 
anthrax out there; someone was able to put it into a situation 
where it did what it did. I think there has been much 
skepticism over the past several weeks, and I have heard it 
voiced by any number of individuals, and Dr. Henderson referred 
to it, that this is too technologically difficult.
    I think the point of the Florida experience is that 
somebody out there did grow anthrax; they put it into a form 
which could in fact potentially be used, and whether that was a 
very limited hit or a potentially large hit, it is another 
wake-up call to us that something is out there that we have to 
be prepared for, and we can no longer hide behind the 
explanation that it is just too tough.
    The Chairman. I will turn to the rest of the panel, and you 
might comment about how you would characterize our reaction.
    Dr. Akhter. I think the incident in Florida truly is not an 
isolated event. Somebody did something that was criminal, and 
until we have the complete FBI investigation, we just do not 
know the extent of it.
    If you find anthrax spores among two people, it does not 
really build my confidence to say there may not be a third 
person, a fourth person, or some other spot. So I will wait 
until I get the full investigation before I can say for sure.
    The Chairman. Dr. Heinrich?
    Ms. Heinrich. My initial reaction was amazement at how well 
the Federal organizations, CDC especially, and the State and 
local official actually worked together. I think it is quite 
remarkable. I also think it is quite remarkable that the State 
lab was able to so quickly identify the agent.
    The Chairman. That is an important point.
    Dr. Henderson, the final word.
    Dr. Henderson. I think the system worked in this case, and 
I was very impressed with the speed with which the diagnosis 
was made and the response initiated. But this is not a typical 
area, and I think there are a lot of places in this country 
where we would not distinguish ourselves at all, and I think 
there is a lot of work needed to strengthen the State and local 
health systems.
    I am a little reluctant at this time to say that I am 
persuaded that this is a release by a terrorist. I used to be 
in charge of dispatching teams on epidemics from CDC and then 
in WHO, and we would get all sorts of strange reports, and the 
preliminary reports would come in, and you would be inclined to 
draw conclusions only to find that there were strange things 
that happened. And there are some strange things here that do 
not quite make sense to me.
    We isolated anthrax from the man's nose, but he does not 
seem to have an anthrax illness. This is very strange. The 
organism that is involved is really a common, garden-variety 
anthrax that has been isolated, something like this, from 
animal outbreaks in different parts of the country. It is fully 
susceptible to antibiotics; it is not an engineered organism as 
far as can be told.
    I think we will get a lot more information when some of the 
surface samples come in and the further studies are done on 
that. So I think I would be inclined at this point not to draw 
the solid conclusion that this is a terrorist event until we 
have a little more information.
    The Chairman. A very solid recommendation.
    Senator Frist?
    Senator Frist. Thank you, Mr. Chairman.
    I will be brief. With regard to the last discussion, I 
think it is important that we address what is going on in 
Florida today because in many ways, it gives us a microcosm of 
how the system should work. And just looking at the last 
several days, the system is working well. We have the very best 
labs, the very best epidemiologists, the very best public and 
private sector people responding. So I am confident that we 
will get to the root of this.
    We do have to be careful in terms of speculation, yet in 
light of September 11, in light of what we have heard from both 
the first and second panels, that the threat is real, number 
one, and number two, it is increasing, in part because of 
technology so that we can aerosolize much better today than we 
could 5 years ago or 10 years ago, in part because, as I 
mentioned in my opening comments, Osama bin Laden, who has very 
much become the focus of what we in the United States are 
trying to address today, has specifically said that it is a 
goal of his to develop and to acquire biological weapons. When 
you put all of that together, I think it is worth us addressing 
in a very careful way as we go forward.
    We know that anthrax is deadly. We saw that this weekend--a 
death. There is 80 to 100 mortality from inhalational anthrax. 
There are three different kinds; that is one kind. And that is 
important for us to know.
    No. 2, we know and the American people should know that in 
terms of treatment, we have very good treatment for it. It has 
to be given in the asymptomatic stage, the very early stage.
    On vaccines, I will add, because everybody is calling, 
asking if they should get vaccinated, that that is an 18-month 
process, so it is an adjunct to treatment, not the treatment 
itself.
    So we know it is deadly, number one. No. 2--and we need to 
recognize this up front without being alarmist too much--
anthrax has been weaponized in the past. We have heard 
references to Russia. We all know that in Russia in 1979, one 
ounce of weaponized anthrax leaked from a manufacturing plant; 
there were 79 cases downwind and 68 deaths even when treated at 
that point in time. So number one, it is deadly. Yes, it is 
rare--there have been only 18 cases--but it has been weaponized 
in the past.
    The third thing I have to comment on because it has been 
mentioned--with one case, you think it could be happenstance, 
circumstance, spontaneous; with two cases, from a medical and 
epidemiologic standpoint, it does lower the threshold, and that 
is why you heard the comments over the weekend; and obviously, 
three cases lower it much more.
    So I guess my question--and Dr. Henderson, you are the 
best, because you have talked about what has happened in India 
with similar kinds of outbreaks--right now, the system is 
working very, very well. Careful investigation will get to the 
root of it, I am absolutely convinced. So whether it is a 
terrorist or somebody who just had bad intention, we will know 
the end of that, I believe. But what if it had been 100 cases, 
and we know that the incubation period is from several days, 
but because of spores, it could be several months, where people 
could travel around the country. Would we be as proud of our 
system as I think we should be in Florida if there were 100 
cases? How quickly could that potentially overwhelm our system?
    Dr. Henderson. I think we would find with 100 cases, 
Senator, that it would be another order of magnitude 
difficulty, because one of the things that we would want to do 
with people who might have been exposed to a plume or an 
aerosol of that anthrax would be to provide them antibiotics 
for 60 days. Providing antibiotic for 60 days to any large 
population is a huge effort.
    Anthrax is not spread from person to person, so that is not 
so much a concern, but we would then also be concerned that 
there would be other rumors, rumors of other cases, and there 
would be need to do laboratory studies in a number of different 
parts of the country just because of rumors and concerns.
    With the system we have, we do have a framework, but it 
certainly needs a lot of strengthening to really respond as 
well as we would like, and I think that is a point to be made.
    Senator Frist. Thank you.
    Dr. Osterholm, we have had a chance to talk, and in terms 
of the numbers you presented, we will take them and study them 
once again. But again, just so my colleagues will know, your 
numbers are very much in line with the numbers that Senator 
Kennedy and I have put together in terms of State and local 
preparedness, hospital preparedness, improving disaster 
response, improved research and development, international 
surveillance, the FDA, which we have talked about and the first 
panel mentioned, and smallpox vaccine. All of our numbers are 
very much the same. Areas the where you add--upgrading CDC 
further than we recommend; improving the national 
pharmaceutical stockpile beyond what we have proposed--we will 
be looking at very carefully. So I appreciate in fact the 
entire panel and the information that you have given us today.
    Thank you, Mr. Chairman.
    The Chairman. Senator Mikulski?
    Senator Mikulski. Thank you very much, Mr. Chairman.
    First of all, to the panelists and those of you who 
represent the field of public health, I think you should know 
that we are really proud of you. You are really the germ 
warriors, and you have been at this for a long time--and germs 
are germs, whether they are these deadly diseases that could 
affect large populations or whether it is issues around the 
day-to-day things that our public health system deals with--so 
we are really very proud of you. We also know that public 
health personnel, the training available for them, and the 
infrastructure have been long neglected.
    So I think this is an opportunity while we are dealing with 
this crisis. But while we are talking about managing the sick 
and our response--and I will come back to that--I would like to 
talk about the issue of panic, which is equally insidious and I 
believe equally dangerous. When rumors occur, when there is an 
isolated incident, when people could confuse flu symptoms with 
anthrax symptoms, I am concerned that panic will ensue.
    What we are hearing is that America is already scared. 
America is really scared. I have a gas mask manufacturing 
facility in my home State, and requests are up 3,000 percent. 
People are driving in from all parts of the country wanting to 
buy gas masks and willing to pay any price.
    We also hear about this underground effort where people are 
going to their doctors and their pharmacists to stock up on 
antibiotics and the hoarding of antibiotics.
    The panic is already here--it is not visible. Then, we have 
these really unusual circumstances in Florida, and 
congratulations to all who have properly responded, but now we 
are into rumor. The press comes up with all kinds of questions, 
certainly to us but to others, pouncing on every rumor like 
they are looking for something, exacerbating the tensions. At 
the same time, we hear on the 24-hour cable stations people who 
are so-called experts, which I am sure causes you to blanch, 
listening to the most ghoulish of predictions, sounding like 
they write more for the ``X-Files'' than carefully written 
plans for disaster management.
    So my question to the panel is how can we now get a grip on 
the fear that America is facing without placating; and number 
two, what practical advice can we give parents in particular 
who, as Senator Clinton has said and I know all of us are 
hearing from constituents, what can moms and dads do, even 
within our own families.
    I know this is a big question. I grew up during World War 
II. My father helped out as an air raid warden, and he was also 
a grocer. We had a little space downstairs. I always felt that 
the war was someplace ``over there,'' but that if something 
happened in our community, my father could protect me. I do not 
know if fathers feel they can protect their children now. So I 
think this is a big issue that needs to be addressed. I do not 
know if you would even recommend that experts go on television, 
organized by Secretary Thompson and President Bush, to talk 
about this and get everybody where they need to be.
    Do you have any thoughts on this, Dr. Osterholm?
    Mr. Osterholm. Yes, Mr. Chairman, Senator Mikulski. First 
of all, obviously, this is not a new topic to you. You have 
covered this in the past. But part of the issue that we have 
today, frankly--and I am one of those who abide by the fact 
that being scared is not a bad thing if it is scared for the 
right reasons and the right reflexes and the right responses 
occur because of it. Physiologically, when you are scared, 
adrenaline flows, and a lot of good things happen. The issue is 
when inappropriate things happen or nothing productive.
    Frankly, I will be real honest with you in this committee--
you are part of the problem. Part of the problem that we have 
is that we have been coming to you for the last 5 years, 
telling you about this issue, and other than Senator Kennedy 
and Senator Frist and some of the efforts which were passed but 
not appropriated, we have had to continue to build out there a 
kind of groundswell to come to you to say we need help.
    Well, that does require citizens to get more interested and 
more involved in this issue. So what we are really trying to do 
today is come to you and say the best thing we can do for panic 
and fear is to provide the resources so that we can honestly 
and certainly assure the population a) that we will detect it, 
b) we will respond effectively, and c) we will make sure that 
you are told honestly that this is what we have available, and 
this is what you will have access to.
    I think that that is going to be a very important piece of 
downplaying or minimizing that. None of us wants to be on the 
air informing citizens of this issue when the only thing they 
can do is write their Congressmen. We can take that off the 
agenda----
    Senator Mikulski. Well, I do not think so, Dr. Osterholm. 
One, I take the criticism; I think it is an accurate one. But 
number two, I am telling you that with all that is going on the 
air right this minute, writing your Congressman is not what 
they want to hear. But your point is well-taken, and I am not 
minimizing it. I think we have to have a sense of urgency about 
how to address this issue, really within the next 72 hours.
    Yes, Dr. Akhter?
    Dr. Akhter. Senator, I think there needs to be a very quick 
dissemination of information among the health officials 
throughout the country. In 1994, there was a water crisis in 
Washington, DC., and I happened to be the health commissioner. 
Each jurisdiction has its own view, and there is always 
disagreement about how to deal with something. Somebody wanted 
water to be boiled for 1 minute; others want it boiled for 10 
minutes.
    Once we started to share information quickly, each health 
officer had the same information, and they got on the 
television in their own jurisdictions and said, ``This is what 
we need to do. You are safe. We are taking action.'' That is 
what needs to happen now. Somebody from the CDC needs to have 
the central information that should be available to all health 
professionals in a timely manner. The media goes to other 
people when we are unable to provide them the information when 
we do not have it.
    Senator Mikulski. Dr. Henderson, did you want to comment?
    Dr. Henderson. Yes. I think there is really a concern out 
there, as you point out. What is very difficult is to try to 
convey to a broad public that we have a risk here, we think it 
is a small risk--that is, that in any given area, there is 
going to be a release--that it is a small risk, but if it 
happened, it would be catastrophic, and we need to be prepared 
for it, and not to feel that there is going to be anthrax in 
your back yard tomorrow.
    So it is trying to hit some sort of balance, and this does 
not come across very well.
    It seems to me that what we need more than anything else is 
to explain to the public by, say, the CDC or what-have-you, in 
an authoritative way where are we really. I think we need to be 
honest. I think we need to keep it in perspective. I think we 
need to work to convey that message.
    I was pleased, actually, on a number of the reports with 
regard to anthrax in Florida how the first case came up on page 
5 or 6. I think a lot of media covered this with some balance. 
But there are people calling us asking what can parents do, and 
the last thing you would recommend is that they get a gas mask, 
which is really useless and in fact can be dangerous. There 
were a number of Israeli adults and children who actually 
suffocated with gas masks. So this is certainly not going to 
help in the biologic event, and you are not going to be 
carrying it around with you all the time for a gas event.
    As far as stocking up on antibiotics, we recommend that 
they not do so, because there is a shelf life, will you have 
the right antibiotic, this is costly, etc.
    People ask, ``Well, what do we do?'' and we ask them, 
``Well, what are you doing to protect your family against an 
airplane coming out of the sky?'' You really cannot do 
anything. You are depending on your Government to be ready to 
respond and take precautionary measures.
    I think this is the best thing we can do is to convey that 
your Government is actively involved in a number of activities 
all the way from the intelligence side to stockpiling to 
responding quickly to providing you protections should an 
outbreak occur. And I think the fact that the Congress is 
acting as they are acting this time to identify those 
initiatives and that we can then go to the public and say we 
are doing these things, and we are prepared to respond, and 
this is the danger that we have--I think this is the only way 
that I can see that we can really act on this.
    Senator Mikulski. I really appreciate everyone's testimony. 
I have just one follow-up question.
    Dr. Heinrich, as you have looked at all these responses in 
an excellent report--and many thanks--is public information, an 
organized effort for public information, included in the plan 
either for Federal or State in a way that there would be a 
mandate to have a one-stop shop for appropriate information to 
the public? Did you note that in your report?
    Ms. Heinrich. No, there was no such one-stop shop focus on 
public information, although we certainly found when we did the 
investigation of the West Nile outbreak that the need for 
public information is tremendous and in fact in that instance 
really overwhelmed the local and State authorities.
    Senator Mikulski. Thank you.
    My time has expired, but to you, Mr. Chairman and 
colleagues, I would say that I think this is something we need 
to incorporate very quickly into whatever is going to be our 
plan, picking up on the excellent recommendations.
    And Dr. Henderson, in your role with Secretary Thompson, I 
think we have got to get that pretty quickly included, because 
I think it could be one of our most important tools. I would 
much rather hear from germ warriors like you than from those 
who have come out of the X-Files.
    Thank you, Mr. Chairman.
    The Chairman. Senator Hutchinson?
    Senator Hutchinson. Thank you, Mr. Chairman. Thanks for 
holding the hearing today, and I want to thank our panel.
    I would like to touch on something that we really have not 
dwelled on much today, and that is the issue of vaccine 
production.
    Dr. Heinrich, I thank you also for the GAO report. In your 
conclusions, you mention that ``there are too many Federal 
agencies responsible for various bioterrorism coordination 
functions, with limited accountability and hindered unity of 
effort.'' I think that that is so true, and I hope the 
appointment of Governor Ridge is going to help alleviate that 
problem.
    Dr. Osterholm, you said that September 11 was a wake-up 
call, and it was. But the first wake-up call occurred back in 
the early 1990's when we went into the Gulf War and sent our 
troops over there--and I serve on the Armed Services as well as 
the HELP Committees, and I am on the Emerging Threats 
Subcommittee, and we have become keenly aware of what is a 
tragic saga over the last decade, one that we must not allow to 
be repeated.
    At that time, there was a DOD report that said that we 
needed to establish a Government-owned, contractor-operated 
facility to produce vaccine to protect our forces when we sent 
them into dangerous areas. The Department of Defense for 
whatever reason rejected that recommendation and instead went 
to the commercial sector and contracted with a commercial firm, 
Bioport, up in Michigan to produce that vaccine. We know that 
over the last decade, they have failed to receive FDA approval. 
So that while we went through this entire PR campaign where the 
Secretary of Defense received an anthrax vaccination and 
various other public officials did, DOD officials, to show that 
it was safe, and we convinced our troops that it is safe for 
the most part, and then did not have the vaccine to give them. 
So that today we are sending thousands of our troops into 
harm's way unprotected.
    So Dr. Akhter, when you said that they are protected, that 
we vaccinate our troops, we really do not today, because we do 
not have a facility that is producing that vaccine.
    So I think there are a lot of lessons that we need to 
learn.
    I authorized another report last year in DOD authorization. 
We got another report, and DOD has once again recommended that 
we have a Government-owned facility producing this vaccine. And 
Dr. Satcher, our Surgeon General, wrote a letter to Secretary 
of Defense Donald Rumsfeld saying in effect--and I will 
summarize it, and I would like it to be included in the record, 
Mr. Chairman----
    The Chairman. It will be so included.
    Senator Hutchinson [continuing]. Essentially, the Surgeon 
said that if we do it--and we should--we ought to do it not 
just for our troops, but we should make it available for our 
civilian population for domestic preparedness. I think that 
that is so essential.
    Now, a decade later, here we are. Our troops are 
unprotected and our civilian population is unprotected from a 
vaccine standpoint. I think there are some conclusions here. We 
cannot have a sole source for vaccine, so the idea of saying 
let us contract with the private firm and let them do it is 
misguided. A sole source is an easy target for terrorists; we 
are too reliant upon a single producer. If they fail, we are in 
the situation that we are in today.
    We cannot rely on the commercial sector alone. They do many 
things in a great way, but these are not necessarily 
financially feasible vaccines--and I am not talking just about 
anthrax but other deadly pathogens. We have to have the 
Government involved in this.
    Senator Wellstone. Excuse me. Could I hear that again? I 
did not hear what you just said.
    Senator Hutchinson. I am for the Government doing this, 
Paul.
    Senator Wellstone. I got it.
    Senator Hutchinson. There are certain things only 
Government can do, and in this case, the private sector has 
failed us terribly. And I am glad to repeat that, and I am glad 
you caught that.
    We cannot limit it to just one pathogen like anthrax, 
because there are others that we are going to be threatened 
with. That is why I think this facility, this production 
capability, is so critical.
    So with that background and with all of my biases now laid 
out, let me just ask the panel how important is such a 
production capability, production facility; should the 
Government own it, at least have the guarantee of the 
Government's backing; and if we made a national commitment--
because I have heard 5, 6 years for such a production facility 
to be up and running--but if we made a national commitment to 
it, and we coordinated with FDA, the Department of Defense, the 
CDC, and these various agencies, how quickly could we get this 
kind of protection available?
    Let us begin with Dr. Osterholm and then anybody else who 
would like to comment.
    Mr. Osterholm. First of all, thank you very much for those 
comments. I think there are many people who are in complete 
agreement with you on the public health side. We need these 
resources however we can get them and effectively keep them on 
line is what we are trying to do.
    Right now, I believe honestly--and this goes back Senator 
Mikulski's very good question about panic and fear--the very 
most important thing that will allay panic and fear is being 
prepared. And I think you have hit on a very important issue, 
that having the access and the capability to produce these 
vaccines is one way in which the public will feel assured.
    Unlike my colleague here, I am not sure that we are ready 
to talk about routine population-based immunization yet for a 
lot of reasons, but I know darn well that if I were in the 
middle of a firefight and an outbreak right now, and we had the 
vaccines we needed, and we had the pharmaceutical products we 
needed, that would be a major, major asset in trying to fight 
that epidemic both from the standpoint of the actual epidemic 
but also the panic and fear.
    So I very much support your point of view. I do not know if 
any of us have the exact answer on how to do it, but we all 
know the current system is not working and has to be addressed, 
so I thank you for that.
    Senator Hutchinson. Thank you.
    Dr. Akhter?
    Dr. Akhter. It is a wonderful question, and I must say that 
I tend to agree with you. We need to have a Government facility 
to do the research and development, because nobody else will 
see it worth their while to do it, because you cannot sell 
these things commercially, and there is not a market out there. 
So this is something that really comes very close to home. It 
is the Government's responsibility to really do that.
    Now, we could have private contractor in addition to the 
Government itself so that the contractor really concentrates on 
these areas and makes the resources. Having two sources is 
important not only from the point of view that one could be 
destroyed or attacked, but also from the point of view of 
comparison so that we can compare the two vaccines and make 
sure which one is better and continue to study that and make 
sure we have adequate supplies when the need arises.
    I tend to agree with my colleague here that we need to have 
an adequate supply of vaccine so that I can stand up and look 
into the eyes of the American people and say, ``Folks, we are 
ready, as ready as can be humanly possible. We have the 
vaccine, and in case something happens, we can provide it to 
you.''
    Senator Hutchinson. Dr. Heinrich?
    Ms. Heinrich. Yes, I just wanted to mention that we will be 
doing work for Senator Frist and Senator Kennedy on vaccine 
shortages and what are the issues underlying what is happening 
currently in the commercial sector. As these issues play out, 
it is interesting, because we are currently short of tetanus, 
which is a common vaccine, and there is only one sole source 
manufacturer at this point in time. We studied what was going 
on with the flu vaccine and the reasons for the shortage last 
year and the slower production this year, and there are many, 
many factors involved.
    I guess, being from GAO, I would be hardpressed to say that 
one approach, the Government taking over vaccine production, is 
the only answer, but I do think we need to better understand 
what is happening in production in newer plants, what 
incentives can we put in place so that we do have a healthy 
market.
    We also know that there are certain vaccines where there is 
not going to be a large market in the United States. I know 
that CDC and DOD and FDA currently have a contract in place to 
develop plans for such a facility that is Government-operated.
    Dr. Henderson. I think there is a problem with vaccines as 
has been pointed out, and it extends across the board. It is 
not just these vaccines, but it is the childhood vaccines, 
where many of them have just one manufacturer, and we have been 
running into shortages.
    Traditionally, in many countries, vaccines have been 
produced by government manufacturers. This has been the 
experience a long time ago. Many places made vaccines--
Massachusetts, Michigan, and Texas had their own vaccine 
production facilities.
    So I think it needs to be explored, there is no question, 
to see how to accomplish this to ensure that we do have 
vaccines. The private sector does not seem to be doing all that 
well at the moment.
    There is a second piece to this, and that is the research 
and development, where I think we need a plan to develop 
vaccines. There is, for example, a second-generation anthrax 
vaccine which was developed within the military at USAMRD that 
looks very, very promising, and it really needs to be 
accelerated. The research on this should be accelerated. I 
think many of us who have looked at the question of what 
vaccines should we provide would say that if we had today an 
anthrax vaccine of the second generation, which perhaps could 
immunize with two doses, would we recommend it--I think we 
would for first responders and many others. It would be a very 
good thing to do.
    We would not recommend a smallpox vaccination simply 
because of the complications given the risk. But if somebody 
walks through O'Hare Airport tomorrow and we find that he is 
carrying smallpox virus, that risk-benefit ratio could change 
overnight.
    So that yes, with the smallpox, they are now looking for a 
second manufacturer so there would be two manufacturers and a 
long-term supply of that vaccine.
    Senator Hutchinson. Thank you, Doctor. I thank all of the 
panel for their excellent responses.
    Mr. Chairman, I would just say that the Department of 
Defense is saying they are going to be making a decision, but 
if they determine to go Government-owned, contractor-operated, 
the civilian population ought to get the benefit of that, too. 
We do not need to be duplicating those kinds of efforts when it 
is going to require such a huge investment.
    So thank you very much for your timely comments.
    The Chairman. Senator, we should have a hearing on that 
subject. It is another feature of this whole issue. Senator 
Frist and I have asked the GAO to do some definitive work.
    There are enormous ethical issues--and time is moving 
along, and other colleagues want to question--but we have 
issues between killed and live vaccines. If you remember years 
ago, if a child received the killed vaccine, they had 
protection, but none of the other children in the classroom had 
any protection. If they used the live vaccine, the other 
children got protection and that child got protection, but you 
had one in a million cases resulting in the child getting the 
disease. So you had a defined number of 12 to 15 children 
getting the disease, and you can imagine the mothers out there, 
appearing before this committee, saying, ``I was thoughtful 
enough to bring my child down there to get the vaccine, and now 
my child is going to be paralyzed for the rest of his life.'' 
And other mothers who did not bring their children, their 
children were immune, and how can you have that as a matter of 
public policy.
    So there are enormous ethical issues, and we still do not 
know the right answer. These are ethical and moral issues and 
questions--as Dr. Henderson pointed out, we produced vaccines 
in my own State of Massachusetts, and Michigan and other States 
did as well. So this is something that we ought to give good 
thought to, and we should get some recommendations from Pharma.
    A fellow who is very interested in this is named Leschley, 
who is with SmithKline. He has talked about the failure of 
doing research into drug-resistant bacteria. Not many of the 
pharmaceutical companies are doing it. It is complex, it is 
expensive, but it needs to be done in terms of the public 
health. As a public health issue down the line, that is 
somewhat of a different issue, but some of these things 
overlap.
    I thank the Senator for bringing this up. It is very 
important, and maybe we will ask our staffs to get together and 
give us a sense about how we can get good information in the 
committee.
    Senator Wellstone?
    Senator Wellstone. Thank you, Mr. Chairman.
    I appreciate this hearing. I do not think Dr. Osterholm 
will be that sympathetic to what I am about to say, but in a 
lot of ways, I am having to pinch myself to realize that we are 
having this hearing. You cannot help but be very serious when 
focusing on these issues.
    We have been talking about panic, but I do not know if that 
is the right word as I think about how people in our country 
are thinking about this now. The other night, our youngest 
grandchild had a 6-year-old birthday, and all the kids were 
there and grandchildren, and I said to Sheila as we left--I 
have never talked like this before in my life--but I said, ``We 
are 57, and we have had a good life, but what is ahead for 
them?''
    I do not know that that is panic, but people are very 
focused and worried and frightened. I have been thinking about 
this, and I have a particular question to ask you, and it is a 
small one. I do not want to repeat what others have said. I 
have learned something today, a lot, but there is one thing in 
particular. There has got to be--and I think, Dr. Henderson, 
you started to touch on this--there is a dilemma for you and 
for us as well, because to the extent that you want people to 
be aware of it and know this is ahead of us, you have to figure 
out how to do it without just terrifying people or making them 
just numb in their sense of hopelessness and powerlessness, and 
you have to know how to draw that line.
    I have thought about this, too, Michael, back home. This 
would be an easy thing to do to get a lot of coverage. I could 
meet with you alone--I am serious--with people in the State, 
and everybody would come. But what I think would be better is 
if you can, at the same time you are outlining the problems, 
you can outline the action plan. So the whole thing is rapidity 
of response. The airline industry came in and the carriers said 
on Friday, ``If we do not get indemnified by Monday, we are not 
going to be able to fly''--and by God, we passed a $15 billion 
package just like that.
    So I think the key is the rapidity of response, and I think 
we need to do this in the public health field just as we did 
for the airlines. So what I look forward to very soon is to 
meet with our people in Minnesota, our local people--all of you 
have put emphasis on State and local--and to be able to say, 
``Tell me what you need,'' but at the same time be able to say, 
``This is exactly what we are going to do,'' so people hear 
about both--they hear about the problems, but also, about the 
action plan and what is being done by Government now. To me, 
that is the key, rapidity of response.
    My quick question--and maybe it is because this is an area 
that I work in--in this whole public health infrastructure of 
care, it is my own belief that mental health services ought to 
be a part of this. It is part of the area that I work in, and 
it has not been discussed today, and I wanted to get your 
response. Whatever we are dealing with, trying to head off 
people becoming too frightened, if something has happened, 
trying to deal with a lot of different people--to what extent 
should this be part of the infrastructure that is there in our 
local and State communities?
    Mr. Osterholm. Senator Wellstone, let me say that I think 
it is as two levels that you have identified. One is for the 
individuals themselves out there, and clearly this is an 
important area. I do not think there is anyone in America who 
did not lose sleep, who was not restless or concerned, after 
September 11. We are not used to that kind of phenomenon, and 
that is an important mental health consideration.
    I am in a very selfish way concerned about it, because 
frankly, how one of these episodes could unfold is going to be 
dependent not just on the bug and who is exposed, but on the 
psychology behind it. And for us to contain, control, and 
basically direct an outbreak investigation and the outbreak 
itself is going to be in part dependent on the population 
psychology, which I think we have very little experience with 
in modern times. What will happen; how will people actually 
respond to Government directives? How will they believe in 
their Government? Will they in fact do the things that we are 
recommending? Will they feel confident that we can respond in a 
way that allows them to stay rational and move forward?
    I think that all of us who have been involved in this issue 
have talked about the fact of the relative absence of 
information on that kind of study of the mental health of the 
population when that happens, and that will be a key part of 
what we do to respond.
    Senator Wellstone. Dr. Henderson?
    Dr. Henderson. You raise a very good point indeed, and I 
think one of the most important concerns we have as we go 
through the exercise of an epidemic is how we communicate with 
the public. This has not received as much attention as I think 
it deserves on how we work through and anticipate how we 
communicate a message to the public.
    There is a second piece, and that is the mental health 
piece. We have a group of cultural anthropologists who are 
working with us, trying to identify what the reactions of 
people will be or might be in an epidemic situation, and they 
have been off on several different kinds of exercises. It is 
easier, of course, to identify something like an explosion or a 
crash, but it is hard to find an epidemic that is big enough to 
get a sense of just what it is going to be like in a serious 
circumstance.
    As we look at it historically, we have not had a serious 
infectious disease epidemic in the United States since 1918, 
and we are just not at all sure how people are going to respond 
or how the medical profession is going to respond. Are they 
going to flee? Are they going to work? Are people going to flee 
the city? What are they going to do?
    So I think this deserves a lot of attention, and we have a 
unit on that at the moment, and I think we are finding some 
interesting things, but that is, of course, for another time to 
describe all of that.
    Dr. Akhter. I think there are two other components that are 
absolutely essential. One is dealing with people who are 
suffering grief reaction because they have lost somebody or 
because they themselves are hurt. The second is posttraumatic 
stress syndrome. The closest we have come is the New York 
incident, for example. A lot of people needed grief counseling, 
the people who are dealing with it, the firemen, the police, 
everybody else--but also, 800 families, 4 weeks after the 
incident, have signed up because their children are having 
difficulty sleeping, difficulty concentrating, having 
nightmares, not being able to go to school, and these are the 
children who need long-term care.
    So a really good mental health response, also ready, is an 
important component.
    Senator Wellstone. I thank all of you. Mr. Chairman, this 
is an area where you all have done so much of the work, but it 
is one area where I want to dig in. This whole mental health 
area is really near and dear to my heart, and I think it fits 
in.
    I would like to thank each of you. Dr. Osterholm, thank you 
for coming to Minnesota, and thank the University of Minnesota 
for giving you to us.
    The Chairman. Thank you very much, Senator Wellstone.
    Senator Collins?
    Senator Collins. Thank you, Mr. Chairman.
    I want to start by praising your efforts and leadership, 
along with Senator Frist, in really being out front on this 
issue.
    As I listen to the testimony today outlining the weaknesses 
and the unevenness of our public health infrastructure, and I 
hear Dr. Akhter talk about the criticality of the first 24 to 
48 hours in identifying an outbreak, and Dr. Henderson talking 
about that we only have 80 labs that would be able to identify 
anthrax, I cannot help but think that if the anthrax case or 
cases in Florida had happened in another part of the country, 
we still might not realize what we are dealing with. And while 
this may well turn out not to be a terrorist attack, the 
implications of someone deliberately exposing a larger 
population are really frightening in terms of our ability to 
quickly identify, contain, and treat, and that is the 
overwhelming impression that I am getting from the panel today.
    I want to talk about another issue that we really have not 
dealt with, and that is the vulnerability of our food supply to 
a bioterrorism attack. I held extensive hearings a couple of 
years ago in my Permanent Subcommittee on Investigations to 
look at the FDA system for inspecting imported fruits and 
vegetables. What we found was not reassuring.
    I got interested in this after reading about cases where 
tainted raspberries from Central America had come into the 
United States and resulted in dozens of people getting sick. I 
learned that our system was really no system at all, that only 
about one percent of food shipments that are imported are 
subject to inspections, that there were all sorts of 
opportunities for unscrupulous shippers to avoid inspection.
    So this is of great concern to me, because although my 
subcommittee made a number of recommendations, only some of 
them were implemented, and part of it was for more resources.
    So I would like to have each of you comment on the 
vulnerability of our food supply and, starting with Dr. 
Henderson, I would also be interested to know whether the new 
bioterrorism advisory committee is going to take a hard look at 
FDA's procedures for screening imported foods, because what I 
found was very disturbing in terms of our vulnerability.
    Dr. Henderson?
    Dr. Henderson. I think the real expert on the food supply, 
actually, is Dr. Osterholm. Clearly there is a risk with the 
food supply. There is more food coming in from overseas and all 
sorts of different places. It is very difficult to inspect, and 
this is one very difficult problem, there is absolutely no 
doubt about it.
    We are not well-prepared to deal with this, and I think 
there is a lot of research that could be done that we have just 
not taken advantage of, or should take advantage of, and trying 
to do something about it.
    It is a problem, and I think we have focused more on 
aerosol dissemination of agents as being a way by which the 
worst of the agents we can imagine are best distributed, and 
looking at the moment on catastrophic events recognizing that 
the food supply may be even more likely to occur, but some of 
the more catastrophic agents, you cannot distribute in food, 
there is a balance here.
    Clearly that needs to be looked at. We have focused on 
food, but we have also looked at water and come to the 
conclusion by and large that our water systems are really not 
that much of a problem, that food is a bigger problem, and I 
think this needs to be looked at.
    What our council will do, I really don't know, but that 
should be on our agenda, no question.
    Senator Collins. I want to share our report and hearings 
with you.
    Dr. Osterholm, I am going to turn to you now and then go 
back to the other two witnesses, because I remember reading a 
lot of your work when we were doing the investigation, so if 
you would comment, please.
    Mr. Osterholm. Senator, thank you. I was one of those who 
was very impressed with and appreciative of what you did and 
your attention to that issue. You drew early attention to some 
of the changing problems that we are seeing with the food 
supply.
    To follow up on what Dr. Henderson said, fortunately, the 
food supply does not pose the risk of the catastrophic agents, 
but the problem is--I have worked up the largest outbreak of 
salmonella in the country of 300,000 cases in contaminated ice 
cream--today the problem is that our system is so vulnerable 
because we now feed literally thousands to millions of people 
off of single-source supplies that are easily contaminated. I 
think that one of the ares that we need to look at is that 
vulnerability, not just from Mother Nature-made, but also 
manmade attempts. I think industry is very concerned about 
that, and we have to do that.
    I think we would all like to be part of the dialogue about 
how that is done. Frankly, some of us are concerned that more 
inspectors will not really make any difference, but there may 
be things that could make a difference, and we would very much 
like to be a part of that.
    One of the areas I would draw your attention to as part of 
the ongoing continuity of the food supply--and I think Senator 
Edwards mentioned it very briefly--is agri-terrorism issues and 
the concerns we have around that.
    I think that frankly today--and we are all careful about 
how we talk about this, but it has been rather publicly talked 
about--if we have just one incident of foot-and-mouth disease 
entered into this country intentionally, and we can understand 
the implications of that and how well we are prepared to 
respond.
    The other area, frankly, that we are very worried about is 
the hoax situation where, if I just tell you that your food is 
contaminated, what does that do to the trust, the integrity, 
and in many cases the actual ability to sell certain products.
    So we need to work much more closely with industry, and 
industry itself recognizes this. We have been approached at our 
center by many, many different industry representatives over 
the last 3 weeks saying, ``Help us. We really believe it now. 
We know that we have to do something.'' And I think Government 
has to be a key piece in that.
    So I do not have a prescription for you today other than to 
say that your concerns are well-founded and right on target. We 
need to do something about that, because loss of confidence in 
our food supply has, I think, tremendous economic implications 
besides the illness cost issues.
    Senator Collins. Thank you.
    Dr. Akhter?
    Dr. Akhter. I think that with the terrorist threats now, 
business as usual is not acceptable. It is no longer possible 
for us to continue to have 12 different agencies of the Federal 
Government deal with food. I think this needs to be 
coordinated. We at the American Public Health Association had a 
position on this of creating a single food agency. This is 
something which everyone uses every, single day, and we need to 
make sure that things are coordinated, that all agencies are 
working together; maybe they could be brought under the new 
department that is being created.
    I also believe that we need to have more inspectors to make 
sure that food is inspected, not only when it enters our 
borders, but at the source, and work with the producers to make 
sure we avoid contamination of food coming into this country.
    Senator Collins. Thank you.
    Dr. Heinrich?
    Ms. Heinrich. Just a brief comment, and that is that the 
U.S. Department of Agriculture really has minimum funding and 
programming related to bioterrorism, and they certainly 
reminded us that the pathogens that affect humans also affect 
animals. And also just to reinforce your point that there are 
very low levels of inspection of imports, and we know that we 
import a lot of food items.
    Senator Collins. Thank you.
    Thank you, Mr. Chairman.
    The Chairman. Thank you.
    Senator Edwards?
    Senator Edwards. Thank you, Mr. Chairman.
    I thank the panel very much. Let me just follow up briefly 
on the issue that Senator Collins was just asking about. As 
probably all four of you know, Senator Hagel and I have 
included in our legislation some specific provisions addressing 
the problem of food safety and agri-terrorism.
    Dr. Heinrich, you just commented that there is a low level 
of inspection of imports. That is one of the issues that we 
have tried to address with our legislation, but could you talk 
more about what you think needs to be done?
    Ms. Heinrich. At this point, it would be very hard for me 
to address what needs to be done. There are others at GAO who 
are doing work specifically targeted in this area. I do not 
think any of us at this point has recommendations on what would 
be done.
    Senator Edwards. But you do recognize that something needs 
to be done.
    Ms. Heinrich. Yes.
    Senator Edwards. Do any of the other witnesses have 
comments on that subject?
    Mr. Osterholm. Senator Edwards, first of all, having been 
very involved with foodborne diseases over the years, I do not 
want to take on a ``sacred cow'' to say the least, but I think 
we ought to look at what role inspectors really play. I can 
honestly tell you that I do not know what someone who looks at 
a product coming in from a foreign country does to add value to 
that product when it is a microbial level of contamination.
    So while we are very concerned about it, and we agree with 
you that it definitely needs to be addressed, it is an area 
where I think the apparent solution may be more cosmetic than 
real.
    One area that we have looked at is how do you actually 
provide the integrity of the product control from the time that 
it is actually grown in the fields to the point where it is 
actually given to the consumer; how do you trace issues back. 
One area where we have run into many problems is that when we 
have outbreaks or possible outbreaks, you can never trace back 
to the source of the product because there is such a poor 
product tracing chain there which then does not allow you to 
make the definitive answer as to whether it is or is not really 
a problem, and if it is, what product is involved.
    How many times have we had to have a nationwide recall of 
melons or berries because nobody knew where they all went 
because they got mixed and mingled; if we could have just 
identified that field source, we could have done something 
about it.
    So we would be very happy to work with your staff. I talked 
with Senator Hagel about that this morning. I think that your 
interest in this is right on target, as I mentioned just now to 
the Senator, and we would be very happy to work with you on 
that piece--and it is needed desperately.
    Senator Edwards. Yes, it is clearly desperately needed. 
Thank you very much.
    If I could switch gears for a moment, the GAO report 
indicated that there was a real fragmentation at the Federal 
level in our efforts to deal with this issue of bioterrorism. I 
wonder if any of the witnesses--this is not directed at any 
particular witness--could comment on that and what needs to be 
done, or what is being done, to deal with that issue of 
fragmentation, to have our Federal agencies operating more 
efficiently and more cohesively.
    Dr. Henderson. Senator, that is a $64,000 question and not 
easy at all.
    Senator Edwards. Yes--I saw everybody backing away from the 
microphones.
    Dr. Henderson. I think what is true here as we get into 
this is that this is one of the most complicated undertakings, 
trying to be ready to detect and to detect and investigate and 
so forth, involving so many different agencies, State, Federal, 
and local, that to try to put together a group of people all 
working together from FBI to physicians in hospitals to those 
in the public health sector to various people coming from 
Washington and the different agencies with a concern--it may 
even involve EPA or the Defense Department. This has been a 
problem that we have all thought a lot about and are trying to 
figure out just how you can do it, and the new agency that is 
being created is I think one more effort to do this.
    The only thing I can say is that it is not easy. The 
department that I am working with mainly now is the Department 
of Health and Human Services, and I think a lot can be done to 
bring that together and at least have one agency that has fewer 
pieces to it. But there are many agencies and many different 
components to this, and how to do it is probably one of the 
most difficult responses that one could have in, let us say, a 
Government action.
    Senator Edwards. But you agree that it is critically 
important that they be able to operate cohesively?
    Dr. Henderson. Absolutely. I think that is critical, yes.
    Senator Edwards. Other witnesses' comments?
    Dr. Akhter. I think, Senator, that whenever there is a 
national emergency, all of us roll up our sleeves and come out 
and work together to get the job done. I think the real 
challenge is when there is no emergency, how can we all work 
together. And there are many ways, but it must start from the 
top. We must have a domestic security council type of situation 
where all parties sit around the table on a regular basis and 
really talk this stuff out, because if top people are not 
working together, do not expect the lower level folks to 
really----
    Senator Edwards. It is impossible, yes.
    Dr. Akhter. So it takes the same kind of coordination, and 
it takes many, many years before we really get down to a smooth 
working relationship among the agencies.
    Senator Edwards. Dr. Heinrich?
    Ms. Heinrich. Certainly in the past, some of our colleagues 
who work in defense have put forward some basic principles on 
what you need to have if you are going to have the kind of 
coordinated effort that we see that we need here in 
bioterrorism.
    What we have found in our overview of the Federal agencies 
is that there are oftentimes overlapping areas of jurisdiction 
and responsibility, and when that happens, it is not clear who 
is in control, and that leads to no one organization or group 
having accountability.
    So that certainly one thing that can be done is 
clarification of those areas of jurisdiction.
    What is interesting to me is that when you look at some 
functions such as research for vaccines, for example, there are 
different agencies that have responsibility--NIH, Department of 
Defense, CDC, FDA--but in that instance, they seem to be very 
clear about what the function of each organization is, and 
there seems to be a lot of collaboration, both formal and 
informal, but in other areas such as response teams or the 
kinds of materials or grants that local agencies can apply for, 
there is a lot of overlap and not the same kind of coherence.
    Senator Edwards. Clearer lines would obviously help. Thank 
you.
    I thank the witnesses very much for their work, and Mr. 
Chairman, thank you so much for your leadership on this issue.
    The Chairman. Thank you.
    I want to thank the panelists as well as my colleagues. I 
think you could tell both by the number of our colleagues 
present and the probing aspects of their questions and the 
issues that they have raised that this is something that we are 
all very, very much interested in. We want to try to be 
responsive and take the recommendations that so many of you 
have helped us with as a result of a lifetime of experience in 
this area. We are very fortunate to have you here.
    I think all Americans are mindful--as we are meeting today 
in the late morning--of our service men and women and all the 
support that they are receiving overseas. We must recognize 
that we have another battle here. It is of enormous importance 
and incredible consequence as we are committing as a nation to 
make sure that we have the best-trained, best-led, with the 
best equipment overseas, that we ought to do no less for the 
children and the families who are left behind. And you have 
given us a very important blueprint to try to follow. We 
understand that there will be a number of different policy 
issues and questions as we go down the road, but we ought to 
get about the business of doing that at this time.
    I thank all of you for being here. The committee stands in 
recess.
    [Additional material follows:]

                          ADDITIONAL MATERIAL

 The Center for Infectious Disease Research and Policy, University of 
       Minnesota, and The Workgroup on Bioterorrism Preparedness
    The Center for Infectious Disease Research and Policy, University 
of Minnesota, brought together a Workgroup on Bioterrorism Preparedness 
on October 3, 2001. The Workgroup included members from the following 
organizations: the American Society for Microbiology, the Alfred P. 
Sloan Foundation, the Association of Public Health Laboratories, the 
Association of State and Territorial Health Officials, the Center for 
Infectious Disease Research and Policy at the University of Minnesota, 
the Council of State and Territorial Epidemiologists, Emory University 
School of Public Health, the Infectious Diseases Society of America, 
the Johns Hopkins Center for Civilian Biodefense Studies, the National 
Association of County and City Health Officials, the National 
Association of State Public Health Veterinarians, and NTI. The members 
did not seek endorsement from their respective organizations for the 
recommendations contained in this report and the recommendations may 
not reflect the position of the respective organizations. The meeting 
of the Workgroup was supported by NTI.
      recommended federal funding for a public health response to 
                              bioterrorism
    The following amounts are needed for hospitals and federal, state, 
and local public health agencies to effectively respond to 
bioterrorism. The funds identified below represent an initial 
investment in upgrading the public health system for biodefense. 
Additional funds will be needed to effectively maintain such systems 
over time. The numbers provided below represent a first effort to 
achieve broad consensus in the public health community regarding 
funding for bioterrorism; the numbers will likely be refined with 
further discussion.




1. Improve State and Local Preparedness
    a. Bioterrorism Preparedness             $35 million
     Planning...........................
    b. Staffing, Training, Epidemiology,    $400 million
     and Surveillance...................
    c. Information and Communication        $200 million
     Systems............................
    d. Laboratory Enhancement...........    $200 million

       TOTAL...........................  ..............    $835 million

2. Upgrade CDC Capacity for Bioterrorism  ..............    $153 million
2. Develop Federal Expert Response Teams  ..............     $45 million
2. Improve Hospital Response              ..............    $295 million
 Capabilities...........................
2. Improve Disaster Response Medical      ..............     $62 million
 Systems................................
2. Improve International Surveillance...  ..............     $20 million
2. Improve Food Safety..................  ..............    $100 million
2. Develop and Implement Applied          ..............     $50 million
 Research Initiatives...................
2. Improve the National Pharmaceutical    ..............    $250 million
 Stockpile (NPS)........................
2. Accelerate Development of Smallpox     ..............     $60 million
 Vaccine................................
2. Develop Other Vaccines for Civilian    ..............    $100 million
 Use....................................

        TOTAL...........................  ..............   $1.97 billion


               justification for funding recommendations

1a. Improve State and Local Preparedness: Bioterrorism Preparedness 
                    Planning--(Amount: $35 million)

     Every state and certain key local metropolitan areas 
should have a bioterrorism preparedness plan in place and the plan 
should be validated through simulation exercises. Planning at the state 
level or local level should involve the public health agency (or 
agencies) and all other agencies that would be involved in responding 
to a bioterrorism event. An estimated $500,000 is needed for each 
jurisdiction to immediately develop and test a comprehensive plan 
(assuming up to 70 jurisdictions).
     In 1999, many states applied for CDC funding for 
bioterrorism preparedness planning, but only 11 were funded. For those 
states whose applications were approved but not funded, the existing 
CDC cooperative agreement provides a mechanism to fully fund those 
activities and to rapidly move funds out to those states for 
implementation.

1b. Improve State and Local Preparedness: Personnel, Training, 
                    Epidemiology, and Surveillance--(Amount: $400 
                    million)

     State and selected local health departments must improve 
their ability to recognize and respond to bioterrorism events by 
integrating bioterrorism preparedness activities into existing 
communicable disease prevention and control programs.
     The CDC's Emerging Infections Programs, which are now 
operational in nine states, have been highly successful in enhancing 
the kind of long-term capacity needed at the state level and should be 
redesigned to include bioterrorism activities and expanded to other 
states and selected large metropolitan areas.
     Additional funds are needed to train public health 
practitioners (epidemiologists, physicians, nurses, educators, and 
other program staff) to respond to bioterrorism events and to rapidly 
and effectively coordinate their actions across local, state, and 
federal agencies. Resources also are needed to recruit and train more 
public health practitioners (including medical and veterinary 
epidemiologists) through schools of public health and other colleges.
     An effective response will require close coordination 
between federal, state, and local agencies. Expertise must be available 
at each level to meet the demands of a bioterrorism crisis. Although 
federal leadership will be critical, too much reliance on federal 
resources may limit the overall effectiveness of a response. An 
estimated 1.33 million dollars is needed per 1 million population per 
year to implement and maintain bioterrorism preparedness activities.

1c. Improve State and Local Preparedness: Information and Communication 
                    Systems--(Amount: $200 million)

     Several essential information systems have been developed 
(or are in development) to effectively disseminate outbreak and disease 
information within or across jurisdictions. Funds are needed to expand 
or fully implement these systems to assure an effective response to 
bioterrorism.
     A system for emergency alerts (i.e., the Health Alert 
Network or HAN) must be in place in each jurisdiction so that public 
health agencies can rapidly communicate critical health information 
with each other in the event of a bioterrorism attack. Additional 
funding is needed to assure that all jurisdictions have fully 
operational alert systems in place.
     The National Electronic Disease Surveillance System 
(NEDSS) is a system designed by CDC to integrate a myriad of separate 
databases for public health surveillance so that reporting can be 
simplified and outbreaks (including bioterrorism attacks) can be 
rapidly detected and characterized across the different systems. 
Additional funds are needed to fully implement NEDSS.
     Epi-X is a rapid secure communication system for public 
health agencies that is sponsored by CDC for sharing information about 
outbreaks and critical health events as they unfold. This system would 
allow rapid communication of critical public health information in the 
event of a bioterrorism attack. Ongoing funds are needed to maintain 
the operation of Epi-X.
     Rapid communication systems (such as two-way radios or 
other systems) also are needed to allow state and local agencies to 
effectively communicate during times of crisis when conventional modes 
of communication may not be accessible.

1d. Improve State and Local Preparedness: Laboratory Enhancement--
                    (Amount: $200 million)

     The Laboratory Response Network (LRN) is critical to a 
successful response to bioterrorism. The LRN is a multi-level 
laboratory network composed of county, city, state, and federal public 
health laboratories and is designed to receive and analyze laboratory 
specimens from a range of sources. The system is designed to assure 
definitive identification of suspected bioterrorism agents as quickly 
as possible. Additional funding is needed to assure that LRN 
laboratories are prepared to accurately identify potential for full 
implementation.
     The National Laboratory System (NLS) is a communication 
system designed to rapidly share laboratory information between public 
health, hospital, and commercial laboratories. Such communication will 
contribute to early detection and effective monitoring of bioterrorism 
events. Additional funding is needed for full implementation.
     Chemical terrorism preparedness also is needed and should 
be integrated into the laboratory improvements.
     Resources for improved diagnostic testing and 
identification of potential bioterrorism agents by animal and wildlife 
laboratories also are needed, as is improved communication between 
human, animal, and wildlife laboratories.

2. Upgrade CDC Capacity for Bioterrorism--(Amount: $153 million)

     CDC is the lead public health agency for federal 
bioterrorism preparedness and must be able to provide effective 
leadership to the public health and medical communities. Additional 
funding is needed for CDC to conduct deterrence, preparedness, 
detection, confirmation, response, and mitigation activities.

3. Develop Expert Response Teams--(Amount: $45 million)

     Public health management of a bioterrorism attack will be 
extremely challenging. Teams of national experts who can deal 
effectively with the demands of such a crisis should be recruited and 
trained. These experts should have extensive experience in management 
of outbreaks or have clinical experience with diseases caused by 
potential bioterrorism agents. The teams should be maintained on alert 
status and federalized as needed for deployment.

4. Improve Hospital Response Capabilities--(Amount: $295 million)

     Hospitals must be able to effectively triage and treat 
victims of a bioterrorism attack. This requires improvements in 
infection control (i.e., adequate isolation capabilities), expanded 
ability to provide intensive care, and adequate protections for 
healthcare workers (antibiotic prophylaxis, personal protective 
equipment, and vaccines [if available]).

5. Improve Disaster Response Medical Systems--(Amount: $62 million)

     Adequate disaster response systems are needed to 
coordinate disaster management during a bioterrorism event.

5. Improve International Surveillance--(Amount: $20 million)

     International surveillance is needed to monitor the 
occurrence of illnesses caused by potential bioterrorism events in 
other areas of the world.

5. Improve Food Safety--(Amount: $100 million)

     Foodborne agents could be involved in a bioterrorism 
attack. Funds are needed: 1) to improve surveillance for foodborne 
diseases at the state and local level, 2) to improve outbreak response 
capabilities, 3) to enhance rapid communication of information about 
foodborne disease outbreaks, and 4) to provide federal oversight for 
food safety activities.

5. Develop and Implement Applied Research Initiatives--(Amount: $50 
                    million)

     Applied research is needed (particularly at the state and 
local level) to assess effectiveness of various public health 
strategies, such as evaluation of surveillance methods, evaluation of 
laboratory preparedness, and evaluation of rapid communication 
networks.

9. Improve the National Pharmaceutical Stockpile (NPS)--(Amount: $250 
                    million)

     Additional stockpiles of anti-infective agents are needed 
to effectively provide treatment and prophylaxis to large populations 
in the event of a wide scale bioterrorism attack. Ideally, enough 
medication to treat or provide prophylaxis to 40 million persons should 
be stockpiled. These supplies will need to be rotated on an ongoing 
basis.

10. Accelerate the Development of Smallpox Vaccine--(Amount: $60 
                    million)

     Release of smallpox virus has serious global public health 
ramifications. Containment measures, including the ability to conduct 
mass vaccination campaigns, will be critical to a successful response 
effort. Enhanced production of smallpox vaccine is urgently needed to 
contain the spread of smallpox if this agent is released through a 
bioterrorism attack. Also, lack of vaccine availability will cause 
widespread panic in the face of an epidemic, which will be extremely 
difficult to control. Ideally, enough vaccine should be available to 
vaccinate the entire US population.

11. Develop Other Vaccines for Civilian Use--(Amount: $100 million)

     Development and production of vaccines for civilians 
(other than smallpox as indicated above) is important to the long-term 
protection of the U.S. population against bioterrorism attacks.

    [Whereupon, at 1 o'clock p.m., the committee was 
adjourned.]