[Senate Hearing 107-440]
[From the U.S. Government Publishing 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
U.S. GOVERNMENT PRINTING OFFICE
75-731 WASHINGTON : 2002
____________________________________________________________________________
For Sale by the Superintendent of Documents, U.S. Government Printing Office
Internet: bookstore.gpo.gov Phone: toll free (866) 512-1800; (202) 512-1800
Fax: (202) 512-2250 Mail: Stop SSOP, Washington, DC 20402-0001
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.
---------------------------------------------------------------------------
\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.
---------------------------------------------------------------------------
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.
---------------------------------------------------------------------------
\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.
---------------------------------------------------------------------------
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\
---------------------------------------------------------------------------
\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.
---------------------------------------------------------------------------
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.
---------------------------------------------------------------------------
\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.
---------------------------------------------------------------------------
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.
---------------------------------------------------------------------------
\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).
---------------------------------------------------------------------------
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.
---------------------------------------------------------------------------
\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.
---------------------------------------------------------------------------
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.
---------------------------------------------------------------------------
\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.
---------------------------------------------------------------------------
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.]