[House Hearing, 108 Congress]
[From the U.S. Government Printing Office]

                           POSSIBLE EPIDEMIC?



                               before the

                              COMMITTEE ON
                           GOVERNMENT REFORM

                        HOUSE OF REPRESENTATIVES

                      ONE HUNDRED EIGHTH CONGRESS

                             FIRST SESSION


                             APRIL 9, 2003


                            Serial No. 108-9


       Printed for the use of the Committee on Government Reform

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

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                     TOM DAVIS, Virginia, Chairman
DAN BURTON, Indiana                  HENRY A. WAXMAN, California
CHRISTOPHER SHAYS, Connecticut       TOM LANTOS, California
JOHN M. McHUGH, New York             EDOLPHUS TOWNS, New York
JOHN L. MICA, Florida                PAUL E. KANJORSKI, Pennsylvania
MARK E. SOUDER, Indiana              CAROLYN B. MALONEY, New York
DOUG OSE, California                 DENNIS J. KUCINICH, Ohio
RON LEWIS, Kentucky                  DANNY K. DAVIS, Illinois
JO ANN DAVIS, Virginia               JOHN F. TIERNEY, Massachusetts
TODD RUSSELL PLATTS, Pennsylvania    WM. LACY CLAY, Missouri
CHRIS CANNON, Utah                   DIANE E. WATSON, California
ADAM H. PUTNAM, Florida              STEPHEN F. LYNCH, Massachusetts
EDWARD L. SCHROCK, Virginia          CHRIS VAN HOLLEN, Maryland
JOHN J. DUNCAN, Jr., Tennessee       LINDA T. SANCHEZ, California
JOHN SULLIVAN, Oklahoma              C.A. ``DUTCH'' RUPPERSBERGER, 
NATHAN DEAL, Georgia                     Maryland
CANDICE S. MILLER, Michigan          ELEANOR HOLMES NORTON, District of 
TIM MURPHY, Pennsylvania                 Columbia
MICHAEL R. TURNER, Ohio              JIM COOPER, Tennessee
JOHN R. CARTER, Texas                CHRIS BELL, Texas
WILLIAM J. JANKLOW, South Dakota                 ------
MARSHA BLACKBURN, Tennessee          BERNARD SANDERS, Vermont 

                       Peter Sirh, Staff Director
                 Melissa Wojciak, Deputy Staff Director
              Randy Kaplan, Senior Counsel/Parliamentarian
                       Teresa Austin, Chief Clerk
              Philip M. Schiliro, Minority Staff Director
                            C O N T E N T S

Hearing held on April 9, 2003....................................     1
Statement of:
    Heinrich, Janet, Director, Public Health Issues, U.S. General 
      Accounting Office; Dr. Margaret Hamburg, vice president, 
      Biological Programs, the Nuclear Threat Initiative; and Dr. 
      David Goodfriend, director, Loudoun County Health 
      Department.................................................    64
    Thompson, Tommy G., Secretary, Department of Health and Human 
      Services, accompanied by General Phil Russell (retired), 
      Commander, U.S.M.; and Steve Ostroff, Centers for Disease 
      Control....................................................    12
Letters, statements, etc., submitted for the record by:
    Clay, Hon. Wm. Lacy, a Representative in Congress from the 
      State of Missouri, prepared statement of...................    57
    Davis, Chairman Tom, a Representative in Congress from the 
      State of Virginia, prepared statement of...................     3
    Goodfriend, Dr. David, director, Loudoun County Health 
      Department, prepared statement of..........................    95
    Hamburg, Dr. Margaret, vice president, Biological Programs, 
      the Nuclear Threat Initiative, prepared statement of.......    85
    Heinrich, Janet, Director, Public Health Issues, U.S. General 
      Accounting Office, prepared statement of...................    66
    Maloney, Hon. Carolyn B., a Representative in Congress from 
      the State of New York:
        Article from the New England Journal of Medicine.........    40
        Prepared statement of....................................    44
    Shays, Hon. Christopher, a Representative in Congress from 
      the State of Connecticut, prepared statement of............    10
    Thompson, Tommy G., Secretary, Department of Health and Human 
      Services, prepared statement of............................    16
    Towns, Hon. Edolphus, a Representative in Congress from the 
      State of New York, prepared statement of...................   127
    Waxman, Hon. Henry A., a Representative in Congress from the 
      State of California, prepared statement of.................     7

                           POSSIBLE EPIDEMIC?


                        WEDNESDAY, APRIL 9, 2003

                          House of Representatives,
                            Committee on Government Reform,
                                                    Washington, DC.
    The committee met, pursuant to notice, at 10:45 a.m., in 
room 2157, Rayburn House Office Building, Hon. Tom Davis of 
Virginia (chairman of the committee) presiding.
    Present: Representatives Tom Davis of Virginia, Shays, 
Burton, Mrs. Davis of Virginia, Putnam, Duncan, Sullivan, 
Murphy, Janklow, Blackburn, Waxman, Towns, Maloney, Cummings, 
Clay, Watson, Lynch, Sanchez, Ruppersberger, and Norton.
    Staff present: Peter Sirh, staff director; Melissa Wojciak, 
deputy staff director; Keith Ausbrook, chief counsel; Ellen 
Brown, legislative director and senior policy counsel; Jennifer 
Safavian, chief counsel for oversight and investigations; John 
Hunter, counsel; David Martin, director of communications; 
Scott Kopple, deputy director of communications; Teresa Austin, 
chief clerk; Joshua E. Gillespie, deputy clerk; Susie Schulte, 
legislative assistant; Corinne Zaccagnini, chief information 
officer; Brien Beattie, staff assistant; Phil Schiliro, 
minority staff director; Phil Barnett, minority chief counsel; 
Sarah Despres, minority counsel; Karen Lightfoot, minority 
senior policy advisor/communications director; Josh Sharfstein, 
minority professional staff member; Cecelia Morton, minority 
office manager; Earley Green, minority chief clerk; and 
Christopher Davis, minority staff assistant.
    Chairman Tom Davis. A quorum being present, the Committee 
on Government Reform will come to order.
    I want to welcome everybody to today's oversight hearing on 
our public health system's response capabilities at the 
Federal, State, and local level to manage an emerging 
infectious disease.
    The global outbreak of Severe Acute Respiratory Syndrome 
[SARS], provides a valid test to the Nation's preparedness to 
handle any public health threat whether it's caused by 
naturally occurring infectious outbreak or bioterrorist attack.
    The Public Health Security and Bioterrorism Preparedness 
and Response Act provided substantial new funding for States, 
localities, and hospitals to boost preparedness to respond to 
highly contagious disease.
    The SARS threat is the first challenge to our Nation's 
health network capabilities. It provides us with a chance to 
evaluate existing procedures and safeguards. SARS has brought 
fear and confusion to everyone's lives, particularly 
international travelers, airline crews and health care workers.
    Currently there is no known cure and the disease is easily 
communicable. In a precautionary effort to prevent further 
spread of the disease, President Bush signed an Executive order 
on Friday, April 4, authorizing the use of quarantine if 
necessary. The President's unprecedented actions prove how 
serious the threat of SARS epidemic is to our country.
    SARS is believed to have originated in China in the fall of 
2002. It has since spread to 17 countries. As of today there 
have been over 2,600 SARS cases reported worldwide, with 98 
    In the United States the number of cases continues to rise. 
Today this country has approximately 148 suspected cases in 30 
different States, with the highest concentrations in New York 
and California. Fortunately, no deaths have been reported. 
We've actually seen two suspected cases of SARS nearby in 
northern Virginia. I'm pleased that we'll hear testimony from 
the director of the Loudoun County Health Department, who is 
responsible for the treatment of a SARS patient in early 
    It is important for our Nation's public health 
infrastructure to recognize what lessons can be learned from 
the SARS threat.
    I have a fairly lengthy statement that I'd ask unanimous 
consent go in the record, and we have a great selection of 
witnesses to provide testimony this morning. Secretary Thompson 
is going to provide the very latest information on this virus 
and will discuss efforts being taken at the Federal level to 
respond to SARS. He'll also describe preparedness coordination 
efforts with State and local authorities.
    Joining us on our second panel will be Janet Heinrich, 
Director of Public Health Issues for GAO. She'll discuss the 
GAO report released this week. The GAO report is timely and 
very applicable to the SARS threat. Dr. Margaret Hamburg, 
former commissioner of health for the city of New York, 
recently co-chaired the Institute of Medicine Committee that 
produced a noteworthy report on micro-biothreats to health. 
And, finally, Dr. Goodfriend, director of the Loudoun County 
Health Department will be sharing with us his experience in 
their first suspected case of SARS.
    I want to thank all of our witnesses for appearing before 
the committee. As I said, everyone's statement will go in the 
record. Secretary Thompson is limited here until 11:30, so we 
want to move quickly to your testimony.
    What I'm going to ask is that Mr. Waxman give a statement 
for the minority, our vice chairman, Mr. Shays, give a 
statement, and all other statements will be put in the record. 
Is there objection to that?
    [No response.]
    Chairman Tom Davis. If not, Mr. Waxman?
    [The prepared statement of Chairman Tom Davis follows:]
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    [GRAPHIC] [TIFF OMITTED] T7067.002
    Mr. Waxman. Thank you, Mr. Chairman. Thank you particularly 
for holding this hearing today on SARS, which is a highly 
contagious and potentially deadly new disease that has infected 
more than 2,600 patients in 17 countries and claimed over 100 
lives. Today in Hong Kong, just a single flight away from the 
United States, the schools are closed, residents of a city 
apartment building are living in vacation camps, which is a 
euphemism for quarantine, and police are searching the streets 
for people who are contacts with infected patients.
    This emerging epidemic reminds us, as Dr. Fauci of the NIH 
said to the committee last week, that nature is the most 
dangerous bioterrorist. At a time when it is unclear how much 
damage this epidemic will do in the United States, we have an 
urgent need to answer many important questions. There are 
questions of biology. How did SARS come about and what 
infection agent is the cause? There are questions of secrecy. 
Why did China fail to tell the truth about the epidemic in its 
early stages? And what can we do to assure international 
cooperation in the future? There are questions of medical care. 
When will we have the drugs to treat the most seriously ill 
SARS patients, and what are the prospects for a vaccine?
    Today we will focus on a practical question. Is our 
country's public health system prepared for SARS. We cannot 
claim that there was no warning. We have many examples in the 
past decade that were a wakeup call or should have been a 
wakeup call on the breakdown of our Nation's public health 
system and its vulnerability to new infections.
    Over the last decade our Nation has taken some important 
steps to combat emerging infections as we look back at the 
history from the hantavirus to the epidemic of West Nile Virus 
and the feared Bird Flu that led to the slaughter of chickens 
in Hong Kong. All these warnings have been presented to us, and 
over the last decade we have tried to respond to it. The 
Centers for Disease Control and other agencies have bolstered 
their disease surveillance around the world. With U.S. support 
the World Health Organization has developed an international 
system for identifying and responding to new diseases.
    In 2002 Congress appropriated $1.1 billion for bioterrorism 
preparedness at the State and local levels. The intent was that 
this money would go to shore up our public health 
infrastructure, and it is important that we do that. Despite 
these efforts, however, significant weaknesses remain. In 
October 2001, an investigation by my staff revealed critical 
shortages in hospital surge capacity. In March of this year the 
Institute of Medicine followed up its landmark 1992 report with 
a warning that, while 13,000 to 15,000 public health 
investigators and scientists are needed at the local level, 
many barriers exist to prevent public health agencies from 
hiring qualified staff. The IOM recommended the Nation take 
dramatic steps to improve surveillance, enhance response, and 
reduce antibiotic resistance. And just this week GAO found that 
many health officials lack guidance from the Federal Government 
on what they need to do to be prepared.
    It is not hard to understand why we have neglected core 
public health functions. There is very little political appeal 
to the nuts and bolts of epidemiology, laboratory capacity, 
communications systems, planning, and assuring adequate 
hospital capacity. By comparison, it is much easier to attract 
attention and funding to magic bullet technology solutions.
    By any measure our investment in State and local public 
health efforts pales next to what we are contemplating spending 
on drugs, antidotes, and vaccines for bioterrorist agents. I'm 
not saying we should not spend money for those vaccines and 
other agents. Of course we should. But as the SARS epidemic 
makes abundantly clear, a critical aspect of our response is 
the ability of the public health system to recognize disease 
and to contain it. That's why I believe Congress must do more 
than investigate SARS; we must take concrete steps to shore up 
our public health infrastructure as soon as we can, then we 
must sustain this commitment for the long term.
    As a starting place, Congress should adequately fund the 
smallpox vaccination effort so that critical resources are not 
diverted from core public health functions. We should also make 
sure that the public health threats are addressed adequately in 
the bioshield proposal. I commend Chairman Davis for the 
interest he expressed in this issue at last Friday's hearings.
    I am pleased that we are holding this bipartisan hearing 
today and that Secretary Thompson is with us. I also note that 
we have a very distinguished second panel of witnesses, and I 
very much look forward to their testimony.
    Chairman Tom Davis. Thank you very much.
    [The prepared statement of Hon. Henry A. Waxman follows:]
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    Chairman Tom Davis. Secretary Thompson, Mr. Shays has 
agreed to put his statement in the record so we can get right 
to you.
    [The prepared statement of Hon. Christopher Shays follows:]
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    Chairman Tom Davis. Would you stand please and be sworn as 
is customary of this committee.
    [Witnesses sworn.]
    Chairman Tom Davis. Thank you. Secretary Thompson, thank 
you so much for being with us today.

                        DISEASE CONTROL

    Secretary Thompson. Thank you very much, Mr. Chairman, and 
thank you so very much for holding this hearing. Congressman 
Waxman, Congressman Shays, and Congressman Burton, all the rest 
of the Members of this distinguished panel, thank you for 
giving me this opportunity. I'm especially appreciative of my 
good friend Governor Bill Janklow being on this committee, so I 
know I'm in good shape, good stead.
    Chairman Tom Davis. Wait until the questions. Janklow is 
tough on the questions. [Laughter.]
    Secretary Thompson. Members of this committee, thank you so 
very much for inviting me. I also would like to introduce 
retired General Phil Russell, who is the Commander of USM, and 
also Dr. Steve Ostroff from the CDC. I'm going to have to leave 
at 11:30 because I'm meeting with all the vaccine manufacturers 
on SARS back in the office. I had set up this meeting. They're 
coming in and I feel I have to go back at that particular time. 
I appreciate this opportunity of giving the statement, but Dr. 
Steve Ostroff is going to stay and answer any questions if 
there still are questions after I leave. My colleagues and I 
are committed to doing everything we possibly can to protect 
the health of all Americans. Right now responding to the SARS 
outbreak is one of our top priorities.
    I also would like to just invite each and every member of 
this committee to stop over to the Department at your 
convenience to see our brand new communication war room in 
which we detect and from which we are able to monitor diseases 
and storms across the world, and I would appreciate if you 
would stop over. I'm confident that if you come over it would 
allay a lot of your fears. Congressman Shays has been over to 
see it, and I think he will confirm that it is state-of-the-
art. It's probably the most technologically advanced command 
center in the world. I would appreciate if you would all come 
over and see it.
    But right now responding to the SARS outbreak is one of our 
top priorities. More than 250 researchers and staff from the 
Centers for Disease Control and prevention are working around 
the clock in laboratories and on location in several affected 
nations to understand this new disease, devise appropriate 
protections, and work with State and local health departments 
in their efforts to do the same.
    Scientists from the National Institutes of Health are 
working with their colleagues at CDC, as well as the World 
Health Organization in order to develop diagnostic tests and 
explore a broad range of ideas for treatment and the possible 
development of vaccines.
    It was the researchers at CDC, ladies and gentlemen, who 
identified the virus that we think causes SARS, a coronavirus. 
A lot of other laboratories around the world thought it was a 
paramixovirus and made that determination. It was our doctors 
at CDC that said, ``No, it doesn't look like a paramixovirus, 
it looks more like the coronavirus.'' So I think we are very 
much in debt to the wonderful doctors that we have working for 
the Department and for the Nation.
    It obviously identifies the virus as critical to the 
development of antivirals as well as vaccines. As you probably 
know, Mr. Chairman, it looks like SARS began in the Guangdong 
Province in China last fall, probably in November of last year. 
From there it apparently spread to one floor of a hotel in Hong 
Kong by a physician from Guangdong who was also a professor who 
became infected while he was treating people at Guangdong 
Province who himself became ill and subsequently died caring 
for the patients. He stayed on the ninth floor of the Maripole 
Hotel in Kowloon Province in Hong Kong. He happened to stay in 
room 911, which got us very suspicious, and we were able to 
find out and followup, and we are fairly confident that there's 
no human involvement, no bioterrorism attack whatsoever in 
regards to the SARS epidemic.
    We are trying to improve our understanding the condition of 
this man, ladies and gentlemen, and the residents of the hotel 
floor. It was amazing that the seven individuals that he 
infected on that floor are the individuals that went out and 
transmitted the disease to Bangkok, to Hanoi, to Singapore, and 
to Toronto, and four out of the seven individuals that were 
infected from that one doctor who also died also subsequently 
died, so it was very much what we would have called a super 
transmitter was this doctor that transmitted to the individuals 
on the 9th floor of the Maripole Hotel, the residents of this 
hotel floor.
    In order to learn more about how this disease was spread, 
unfortunately the infection was carried to other countries by 
these travelers who stayed on that floor at the same time. 
Worldwide, thousands of people have already been infected, and 
103 have died, approximately 4 percent, at 3.9 percent of those 
infected are individuals that have fatally died from this 
disease. To put it in proper perspective, during the worldwide 
Pandemic Flu Epidemic of 1918 it was about 3.5 to 3.8 percent 
of the people died, which of course caused somewhere between 25 
and 40 million people to die and about 518,000 in America.
    As of yesterday there were 154 suspected cases in the 
United States. We can be thankful that all of them are still 
alive. Of those 154, definitive diagnostic information is 
currently only available from five of the cases, as 
demonstrated by two different laboratory tests. Four have 
evidence of coronavirus antibodies, indicating that they were 
indeed exposed to this novel virus. One had a positive culture 
of the virus of the 154, 53 have been hospitalized at some 
point, but only 1 of the individuals out of 154 required a 
ventilator. Thirty-one have tested positive for pneumonia.
    So let me stress that these are suspected cases. Once we 
have a good test, many of them may turn out not to have SARS at 
all. We expanded our definition so we would make sure that we 
got all those individual potential cases so that we could start 
controlling and making sure they would not infect other people. 
So out of the 154, we do not have definite tests on all of 
them, so there may be more than likely--probability is quite 
high--that it will be much less than 154 when we finally get 
up. We had one additional case as of yesterday.
    Other countries have not been as fortunate. According to 
the World Health Organization, the worldwide SARS total not 
counting the United States is 2,523 cases as of midnight last 
evening. We'll have an update at 3 p.m., when the World Health 
Organization reports in.
    The early symptoms of SARS are a fever of more than 100.4 
degrees, a headache, muscle ache, and a cough. People with 
severe cases may have difficulty breathing. CDC has asked 
people who have these symptoms to consult a health care 
provider for a diagnosis. The incubation period from exposure 
to symptoms is probably somewhere between 2 and 7 days, though 
a few reports suggest up to 10 days. That's why we have 
indicated that people who have the indications, the symptoms of 
it, we ask them to stay isolated for 10 days.
    SARS seems to be transmitted by coughing droplets, by 
sneezing, and by personal contact. American health care 
providers have been very good about protecting themselves while 
interacting with patients that they suspect are suffering from 
SARS. They've also provided excellent supportive care.
    As we speak, CDC and NIH are developing three diagnostic 
tests which we will soon be able to send to State laboratories 
as soon as they are ready and FDA approved. Two antibody 
systems require two samples of serum, one taken as early as 
possible and the other about 3 weeks later. When comparing 
these two samples from a given patient, it is possible to tell 
who has been exposed to this virus. We are also developing a 
polymerase chain reaction [PCR] test, for use as a diagnostic 
test--all developed at CDC in Atlanta.
    Rapid and accurate communications are absolutely crucial to 
ensuring a prompt and a coordinated response to any infectious 
disease outbreak. For this reason, strengthening communication 
among clinicians, emergency rooms, infection control 
practitioners and hospitals, pharmaceutical companies, and 
public health personnel have been of the utmost paramount 
importance to CDC for some time. And in the past 3 weeks CDC 
has held multiple teleconferences with State health officials 
to give them the latest information on SARS spread as well as 
the implementation of enhanced surveillance and infection 
control guidelines.
    CDC has also appreciated receiving their input in the 
development of these measures and processes. In addition, 
ladies and gentlemen, we have issued travel advisories to 
people returning from China, Hong Kong, Singapore and Vietnam. 
There are about 70 flights coming in from the affected 
countries. We hand out these particular pamphlets to each 
passenger as they come off the airplane and be able to give 
them information, telling them what they should do, how they 
should conduct themselves and how they should control this 
disease if they come down with it. It's very good. We've 
expanded our surveillance from 8 ports to 22 ports as of today. 
In addition, we would issue these travel advisories to people 
returning from China, Hong Kong, Singapore, and Vietnam. We've 
distributed now more than 200,000 of these health alert notice 
cards to airline passengers entering the United States from 
these areas. What these do is alert passengers that they may 
have been exposed to SARS. Mr. Chairman, these cards advise 
people to monitor health for 10 days and to consult a doctor if 
they develop fever or respiratory symptoms.
    So far, Mr. Chairman, the lessons that we can draw from 
SARS is that surveillance is absolutely critical and that 
surveillance works. Early detections of a pattern of symptoms 
have been able to give scientists critical time to start 
investigating this disease. In addition, we know that we have 
much more to learn about this virus and this disease so that we 
can develop the tools that we need to prevent, treat, and 
contain it. We continue to work around the clock and to learn 
more about every aspect of SARS.
    I want to assure you, Mr. Chairman and members of the 
committee, that this is not business as usual. We will not rest 
until we understand how to detect, treat, and prevent this 
    I look forward to your questions and thank you once again, 
Mr. Chairman, for giving me this opportunity to appear in front 
of you.
    Chairman Tom Davis. Secretary Thompson, thank you very 
    [The prepared statement of Secretary Thompson follows:]
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    Chairman Tom Davis. That was a pretty complete statement. I 
have just a brief question or two before I yield to Mr. Waxman 
and try to give everyone a question.
    To ensure the safety of our health care workers who might 
have come in contact with the SARS patient, we can issue 
bulletins and everything else, but as you get out into places 
like Loudoun County and some of the rural areas, people who 
have traveled, you know, who knows who they have come in 
contact with. Are first responders such as paramedics provided 
with protective gear? What other precautionary measures can we 
use and get the word out that they may be handling a potential 
SARS patient?
    Secretary Thompson. Congressman Davis, we are hooked up to 
90 percent of the health departments right now through the CDC 
and through the command center, which I hope you come over and 
see, at the Department. Every Friday we give out a report, the 
MMWR, talking about current diseases, infectious diseases and 
so on. The last two reports have been totally on SARS, how you 
protect yourself. We ask people to wear masks, the health care 
workers to wear masks, as well as goggles, because we're not 
sure but there may be the potential they can get in--the 
infection can get in through the eyes, as well. We also, of 
course, have every health worker wearing gloves. We also are 
putting out advisories how people can take care of people that 
may be infected in the home with the potential of SARS, about 
washing and about controlling any kind of diseases whatsoever, 
and that the individual that is a suspect for SARS should be 
wearing a mask. We got this information out throughout the 
    We are also putting out a video for all the airplanes 
coming in. We're filming that today. It's going to be put out. 
That's going to be shown to all passengers on planes coming in 
from the affected countries.
    Chairman Tom Davis. And that's really the critical part, to 
stop the importation of this----
    Secretary Thompson. That is correct.
    Chairman Tom Davis [continuing]. From other countries 
coming in at this point.
    Secretary Thompson. That's why we put out the advisory 
about travel conditions to other countries, and that's why 
we're handing these out for all those individual passengers 
coming back from affected countries, and that's why we're 
putting out so much information to health care workers 
throughout the country.
    Chairman Tom Davis. Thank you very much.
    Mr. Waxman.
    Mr. Waxman. Thank you, Mr. Chairman.
    Mr. Secretary, I'm concerned that we passed the 
bioterrorist bill and that's supposed to help the local, State, 
and local governments be able to deal with any emergency. 
They're using funds for a potential smallpox epidemic, but 
they're not adequately funded for that. But while they're 
spending money doing that, which comes to $200 a vaccine per 
person for first responders, I worry whether we're 
shortchanging the infrastructure to deal with a SARS epidemic. 
And I'd like to know what is the administration doing to assure 
that State and local governments do not have to sacrifice 
preparation for public health emergencies like SARS in order to 
prepare for a possible smallpox attack.
    I might take note that the IOM, Institute of Medicine, GAO, 
and the HHS Inspector General all have found major gaps in 
public health readiness at the State and local levels.
    Secretary Thompson. Thank you very much for the question. 
Let me first off thank you for your support on improving the 
infrastructure of the local State public health systems. You 
and I both know that we have avoided too long investing the 
dollars necessary to have a real, complete, comprehensive local 
State public health system. Now, thanks to you, thanks to all 
Members of Congress, on a bipartisan basis last year you 
appropriated $1.1 billion, which we sent out faster, I believe, 
than any department has ever sent out the dollars to local and 
State health departments.
    I am sad to be able to report to you that only 20 percent 
of that money has now been actually drawn down out of the 
Federal treasuries, and the States have that opportunity to do 
so. California, for instance, has only drawn down approximately 
59 percent, which is much higher, but undrawn still is about 41 
percent of the dollars that they can draw out.
    Mr. Waxman. So is your contention----
    Secretary Thompson. Could I just----
    Mr. Waxman [continuing]. That there's enough money for the 
State and local government to handle all of the possible health 
    Secretary Thompson. If you let me finish, I can explain it, 
    Mr. Waxman. Certainly.
    Secretary Thompson. Second, we have an additional $1.5 
billion that we can send out right now, and we're going to be 
sending 20 percent of that $1.5 billion out right now, and we 
are telling--the advisory is going out that States should use 
some of this money to pay for their smallpox.
    The third thing is in the budget resolutions going through 
there's $60 million approximately set aside--I think it was $55 
million, to be exact, set aside for smallpox on top of that 20 
percent, plus there's $16 million set aside for SARS in the 
budget resolution.
    If there was going to be any addition, I would think that 
maybe we want to bump up that SARS to $25 million, but that is 
a decision that you and other Members--but right now I would 
encourage you and other Members to contact your State Governors 
to start drawing down more of this money that we have, because 
we are in the process of sending out an additional $1.5 billion 
this year. And this is still fiscal year 2002 funds.
    Mr. Waxman. Mr. Secretary, I appreciate your sincerity in 
trying to make sure that we don't have gaps in our public 
health infrastructure and I know you're doing what you can, but 
I worry that we're not doing enough. When we hear from the 
Institute of Medicine, the General Accounting Office, and 
others who say there are major gaps and that we are spending 
money to deal with the smallpox possible epidemic, as we 
appropriately should----
    Secretary Thompson. Yes.
    Mr. Waxman [continuing]. And then they come back and tell 
us that they don't think that we're prepared if there is a 
surge in need for hospitals to deal with an emergency like a 
SARS epidemic, that there is a capacity to deal with it, that 
there are enough inspectors to go out and find out whether--can 
find the people that need to be found.
    I just would point out to you that the reports we're 
getting are that we're not doing enough. Do you feel that we 
are doing everything we should be doing?
    Secretary Thompson. No. I'll never say that, Congressman. 
But I'm telling you right now there's money available right now 
for States to draw down. As far as hospitals, last year we sent 
out $135 million, this year it is going to be $518 million for 
surge capacity, for improvements. And we could always use more, 
but this is a tremendous improvement. We have an additional 
$1.5 billion, including the 518 for hospitals to send out this 
year, for fiscal year 2003, and only 20 percent of the money 
that we sent out last year has actually been drawn down.
    Now, the States could have allocated it and are building 
for the infrastructure and haven't actually drawn down, but 
there's money in the pipeline and there's more going out. Plus, 
out of the $1.5 billion, 20 percent--part of that 20 percent 
can be used for smallpox.
    Mr. Waxman. Let me ask you what----
    Secretary Thompson. So I'm just saying, Congressman, 
there's money in the pipeline. We're working hard. And I would 
invite you to come over to the command center and see it, and I 
think we could allay a lot of your fears about all the things 
we're doing.
    Mr. Waxman. Let me ask you one last question. Last week the 
President added SARS to the list of quarantinable communicable 
diseases. Under what circumstances would you invoke your 
authority to order a quarantine?
    Secretary Thompson. That Executive order has not been 
amended since 1983. This is the first time there was any 
addition to the Executive order. It came about because a woman 
came back from Asia and she landed in California, she came down 
sick on the plane. We asked her to go in and get an X-ray and 
be examined by our doctors. She refused. She got on a train to 
go to New Mexico and we couldn't stop her. So we made the 
suggestion, went up through CDC, through my office, to the 
President asking him to expand the Executive order so we could 
do that. We would use our Executive order and I would use it in 
that kind of a question. We had a situation like that this past 
couple days in New York, and the State of New York used the 
authority and had this individual isolated. We don't use the 
word ``quarantine.'' It's ``isolation.''
    Mr. Waxman. Thank you.
    Chairman Tom Davis. Mr. Shays.
    Mr. Shays. Thank you, Secretary Thompson, for being here.
    I've used SARS as kind of a wake-up call, you know, a very 
real, live-fire exercise. This is, I believe, highly contagious 
and we don't have a cure.
    Secretary Thompson. That's correct.
    Mr. Shays. I want to first know, in the incubation stage 
can you spread the disease?
    Secretary Thompson. Pardon?
    Mr. Shays. In the incubation stage, can you spread the 
    Secretary Thompson. We're almost certain that it can.
    Mr. Shays. I would like to know, when you talk about 
surveillance as being the most important issue, which I think 
is, as well, let me just ask you this specific question because 
I don't have the comfort level that we do have the surveillance 
yet. If I just took my hospitals in my district--Greenwich, 
Stanford, Norwalk, two in Bridgeport, one in Danbury--are you 
saying right now that you know every day what they are 
experiencing, whether they have any outbreaks or not having 
outbreaks, or has it not gotten that sophisticated yet?
    Secretary Thompson. We know every day that the hospitals 
report in their occupancy of the beds. Hospitals report in to 
CDC on their particular cases, but----
    Mr. Shays. Every hospital?
    Secretary Thompson. I believe it is every hospital.
    Dr. Ostroff. Well, in particular in Connecticut, you know, 
most appropriately----
    Mr. Shays. Your mic is not on, sir. Sorry.
    Dr. Ostroff. Most appropriately, that information goes to 
the State health department, and in Connecticut there is an 
excellent system whereby the State monitors all of the 
hospitals within the State of Connecticut for unusual illness.
    Mr. Shays. On a real-time basis of what?
    Dr. Ostroff. On a real-time basis. Correct. They are one 
of--the State of Connecticut is one of our emerging infections 
programs recipients, so that's the type----
    Mr. Shays. Right. I know the claim----
    Dr. Ostroff [continuing]. Of activity they're doing.
    Mr. Shays. I'm sorry. I have only 5 minutes. I know the 
claim; I'm just a little concerned that in reality that's not 
happening. So how would you know? Do you have to get your 
information from the State?
    Dr. Ostroff. We do get our information from the State. We 
have a highly collaborative working relationship with them, and 
if there was an unusual event within the State of Connecticut, 
we feel quite confident that they would contact us.
    Mr. Shays. The problem is ``unusual,'' it may only be 
unusual if you compare from a lot of different places and then 
you see that maybe a pattern is happening, and so I want to 
know very specifically if there is an outbreak of some kind but 
rather small in Stanford so they don't think it's necessarily a 
big deal, but there may be something in Bridgeport--I'm just 
taking my own communities--would that be instantly or daily 
transmitted to--I mean, would the State be informed and would 
you be informed, as well, out of courtesy or legal requirement?
    Dr. Ostroff. There isn't a legal requirement that the 
States report to the Centers for Disease Control and Prevention 
those types of outbreaks. They would do it as a courtesy. 
Again, this is a very highly collaborative interaction and 
relationship that we have with them.
    Mr. Shays. Why wouldn't we want it legally required? Why 
wouldn't we want to legally require it? I mean, why would we 
even want to leave a doubt, because this whole system it 
strikes me is only going to work if you can contain it and box 
it in and you know about it soon enough. So is that something 
that is being considered?
    Secretary Thompson. I think we should consider it, 
    Mr. Shays. You don't have any Executive order to demand it?
    Secretary Thompson. No, we do not.
    Mr. Shays. OK. And that's important to know.
    Secretary Thompson. But we really have great collaboration 
and cooperation, and especially since we got the new dollars. 
We are hooked up through the Health Alert Network with 90 
percent of the health departments, and we have regular 
communication with them, and----
    Mr. Shays. I guess the Stakes----
    Secretary Thompson [continuing]. We have also the 
laboratories' capacity.
    Mr. Shays. The stakes are so high that I don't think this 
should be a model that is done by just general understanding. I 
think there should be legal requirements, and if you don't do 
it some penalties, frankly, because I think the stakes are very 
    I have tremendous confidence with CDC. I have tremendous 
confidence in NIH. WHO, World Health Organization, I think is a 
phenomenal organization. I think it is under-resourced. Do you 
agree that it is a huge and important element to our ability to 
protect the United States?
    Secretary Thompson. The World Health Organization?
    Mr. Shays. Yes.
    Secretary Thompson. Absolutely.
    Mr. Shays. And----
    Secretary Thompson. And we have direct collaboration with 
them. In fact, we've had--within the last 10 days we have had 
at least four teleconferences with the World Health 
Organization with NIH, FDA, CDC, and the Secretary's office.
    Mr. Shays. What kind of resources is our Government giving 
World Health Organization?
    Secretary Thompson. I think we--I'm not sure, but I think 
it is about 50 percent of their budget, but I'm not sure.
    Mr. Shays. Do you think it's enough? Do you think we should 
do more?
    Secretary Thompson. I think that at this point in time--I 
didn't expect to answer this question, but I would say off the 
top of my head, after being on the board of directors, I think 
it is enough.
    Mr. Shays. OK. Thank you, sir.
    Secretary Thompson. I think other countries should be doing 
    Mr. Shays. I just want to quickly state that I know you're 
doing a great job and I know you're working hard. You're using 
the laws that you have right now, but I do think that you need 
to have some authority that is clear and no doubts about it and 
it is not just on a gentleman or gentlelady's understanding.
    Secretary Thompson. I think that's true. I agree with you.
    Chairman Tom Davis. OK. Thank you.
    Secretary Thompson. Could I just say one thing to you, 
    Chairman Tom Davis. Yes.
    Secretary Thompson [continuing]. In response to a couple of 
questions you asked Steve. We also have a cooperative 
arrangement with the hospitals. If there is a mysterious 
illness in the hospital, they're supposed to get their 
specimens to the State laboratory and also a concurrent 
specimen to the CDC laboratory. We also have leased planes in 
which we can fly epidemiologists from Atlanta to a hospital at 
any particular time any time a mysterious illness comes in, and 
we have used that. We've had some false alarms on smallpox and 
we've sent our epidemiologists into several communities, and we 
have been able to do that on a regular basis. As soon as 
something comes in, we have told the hospitals and emergency 
wards throughout America, ``You've got something suspicious, 
don't wait. Don't tarry. Call us.''
    Mr. Shays. It only works though if they tell you.
    Secretary Thompson. Pardon?
    Mr. Shays. It only works if they tell you.
    Secretary Thompson. That's right. It only works if they 
contact us.
    Chairman Tom Davis. Thank you.
    Mrs. Maloney.
    Mrs. Maloney. Thank you, Mr. Chairman. And I thank all of 
the panelists for your important testimony. It seems that 
Lorrie Garrett's predictions in her book, ``Betrayal of 
Trust,'' have come true. I'd like permission to put in the 
record an article from the New England Journal of Medicine, and 
in that article it asks if we could possibly respond fast 
enough to contain this epidemic.
    To quote from the article: ``If the virus moves faster than 
our scientific communications and control capacities, we could 
be in for a long, difficult race against SARS. The race is on, 
the stakes are high, and the outcome cannot be predicted.''
    Chairman Tom Davis. Without objection, so ordered.
    Mrs. Maloney. Thank you.
    [The information referred to follows:]
    [GRAPHIC] [TIFF OMITTED] T7067.025
    [GRAPHIC] [TIFF OMITTED] T7067.026
    Mrs. Maloney. I want to know--I represent New York, and we 
have 8 million people in a very small area. How contagious is 
SARS? I've read articles that on the airlines you can catch it 
from someone who is infected that is sitting immediately next 
to you or in the immediate vicinity, but because of the 
sophisticated air handling system all the passengers on the 
plane would not be at risk. But in terms of mass transit, the 
subway systems that do not have the air handling system, could 
someone get infected by riding on the same subway train? Can 
you speak about how contagious it is?
    There have been many, many articles about airlines, but not 
about subways, buses, other forms of meeting halls or other 
ways that people could be----
    Secretary Thompson. Congresswoman, I'm going to ask one of 
the doctors to respond directly, too, but let me just set it up 
this way and tell you how much we are doing, because I think 
that may allay some of your fears from New York, as well as 
    CDC is working around the clock. We have the best 
laboratories, the best scientists, the best doctors doing this. 
When the rest of the world was looking at this and came up and 
said this is a paramixovirus, it was our scientists that said, 
``Hey, wait a minutes. We don't think so. We think it is the 
coronavirus.'' They are 99.9 percent sure that it's a 
coronavirus, and that's thanks----
    Mrs. Maloney. So you believe it is a naturally occurring 
    Secretary Thompson. Yes.
    Mrs. Maloney. It's not from any type of biological agent or 
    Secretary Thompson. We're almost absolutely certain that it 
is. We're not 100 percent, but we're going to get there 
hopefully, but we are very, very certain that it's not. Second, 
we also, within the last 3 weeks, we have been able to come up 
with three tests. The first thing you have to do is you have to 
find out what the virus is. We were able to determine that at 
    Second thing we have to do is come up with a test. We've 
already come up with three tests we're working on right now. 
We're hoping to be able to get it FDA approved very quickly, 
get that sent out to the State laboratories in New York and 
throughout the country so people can test. Of the 154 cases 
right now, we've only really tested approximately a handful, so 
out of the 154 we're not sure all of those will be SARS. The 
probability is they will not be.
    And the third thing is we're still learning a great deal 
about this disease. As far as the infections, we believe that 
there are what we call ``super transmitters,'' like this doctor 
that was in the Maripole Hotel on the 9th floor and gave it to 
the seven individuals that went out and spread it throughout 
the world. He was what we would call a ``super transmitter,'' 
and now as far as the medical I would either ask Dr. Phil 
Russell or Dr. Steve Ostroff to tell you.
    Mrs. Maloney. Could I just followup with another question 
very briefly? You said that it was similar to a cold. And 
    Secretary Thompson. The coronavirus is the family of the 
virus that causes the common cold.
    Mrs. Maloney. So if we haven't been able to develop a 
vaccine for colds, how can we develop a vaccine for SARS?
    Secretary Thompson. As soon as I leave here Dr. Phil 
Russell and I are meeting with all the vaccine companies. We've 
also asked all the pharmaceutical companies to come in with all 
of their research and all of their antiviral medicines in the 
pipeline for us to be able to test.
    Everybody has been cooperating. We're not certain that we 
can come up with it.
    Mrs. Maloney. But you will try.
    Secretary Thompson. Our specialists think that we're--we're 
working around the clock to do so.
    Steve, did you want to talk about the infection?
    Dr. Ostroff. Yes. What I would add to what the Secretary 
said is that we always have to keep our minds open and, as he 
emphasized, we're still learning a lot about this particular 
virus as we go along. The predominance of the evidence that we 
have up to this point indicates to us that, as is the case with 
many other types of cold viruses, that direct, very close 
contact with somebody else that's ill is probably the major 
mode of transmission. We always have to keep our minds open to 
the fact that in some situations where there are particularly 
sick people, that it might spread more widely than that. But, 
like with most of these respiratory viruses, close contact, 
direct transmission within a few feet seems to be the major way 
that this particular virus spreads.
    Secretary Thompson. Congresswoman, we also have vaccines 
for the coronavirus for animals, and I'd like to ask Dr. Phil 
Russell just to expand on that a little bit.
    Dr. Russell. That's true. The coronavirus genus has many 
members in the animal kingdom, including causes of disease of 
pigs and cats and so forth. There have been some very 
successful vaccines made in the veterinary community that are 
used on a regular basis. The virus also grows very well in cell 
culture systems that are currently used for manufacturing 
vaccines. So we believe we have an advantage here that might be 
able to be exploited. How fast we can do it and how successful 
we are going to be remains to be seen.
    Mrs. Maloney. Thank you. My time is up.
    [The prepared statement of Hon. Carolyn B. Maloney 


    Chairman Tom Davis. Thank you.
    The gentleman from Indiana?
    Mr. Burton. I'm just going to ask two quick questions, and 
then I'll yield to Mr. Janklow for a question.
    Either developing a vaccine or going to try to develop a 
vaccine for SARS, what about the people who are older or who 
have immune problems already like AIDS patients or senior 
citizens who have problems like that? How are you going to deal 
with them and help those who may get infected in the upper age 
levels? And are we going to use anything like--are you going to 
recommend anything like eucalyptus which is a natural oil which 
has some properties that does fight some of these viruses?
    Secretary Thompson. Dr. Phil Russell is probably one of the 
world's most noted virologists, and I would ask him to respond 
directly to it.
    Mr. Burton. Sure.
    Dr. Russell. I think the populations you describe are at a 
very high risk, and whether we're going to be able to provide 
substantial help for high-risk individuals remains to be seen 
in the future. A very aggressive program attempting to screen 
all the potential anti-viral drugs that we can get our hands on 
will be underway soon. It's already started. There are some 
reports that steroid treatment is of some use from the Chinese 
or from the Hong Kong experience. But I have fundamentally a 
very pessimistic view of dealing with an acute, severe virus 
illness in those populations you described.
    I think controlling the spread of the disease with a 
vaccine is probably our best hope after we--if it gets around 
all of our quarantine and isolation methodology.
    Mr. Burton. I hope when they're looking at these vaccines 
and so forth they'll look at some of the natural remedies that 
might be of assistance, like the eucalyptus and other things 
like that, just in the course of looking in to see if that 
might be a help.
    Dr. Russell. I think going forward we're going to look at 
every possible option.
    Mr. Burton. OK. Mr. Janklow, I yield to you.
    Chairman Tom Davis. This will be the last question, because 
I know you have to leave, but we'll make this a Governor-to-
Governor question.
    Mr. Janklow. Thank you very much.
    Secretary Thompson. Always the toughest, I might add.
    Mr. Janklow. Thank you very much, and thanks for yielding. 
A quick question. There have been about 3,000 cases worldwide, 
and those 3,000--in that period of time that you've become 
aware of it, you have put out 200,000 pamphlets on airplanes, 
you're preparing a tape, you've dealt with the isolation issues 
with respect to your legal authorities. In addition to that, 
you've had many teleconferences with State officials. You've 
called the pharmaceutical reps together in a teleconference. 
You're now meeting with them.
    The point that I'm trying to make is that this is a 
phenomenal response. But my question is: have we pursued or 
will we pursue the reason that the Chinese Government sat on 
this? Congressman Shays' question dealt with our hospitals 
reporting things to you. China sat on this, fibbed about it, 
covered it up. And now may not be the time to deal with it, but 
will there be a time when this is addressed for China so this 
kind of problem with respect to world health can be dealt with 
in a more satisfactory manner? And is there anything we can do 
to assist in that process?
    Secretary Thompson. I think it is the time to deal with it, 
because this started in Guangdong Province in late October, 
early November, and we had a very difficult time getting our 
people to get into Guangdong Province. In fact, we didn't get 
in there until--I think it was last Tuesday was the first day. 
It required myself calling the Minister of Health. It required 
the World Health Organization putting on a tremendous amount of 
pressure. It required the CDC saying that, ``We helped you set 
up a CDC counterpart,'' and we went through that avenue, and 
finally they came out. And we didn't get our people in. It was 
led by Dr. Robert Brenman from CDC, and he had to subsequently 
leave and go back, and now we've got a Dr. Mark McGuire who is 
leading our efforts there.
    So they've opened up, and they have now come back, 
Congressman Janklow, to contact us and say, ``We want more 
collaboration.'' In fact, they want us to go into Beijing, they 
want us to go into Shanghai and help them diagnose this and 
help to control it. The Chinese have been very forthcoming 
since last Tuesday, and they want more collaboration rather 
than less, which is unusual for the Chinese. So it seems that 
they have moved a great deal. Plus, the Minister of Health had 
a press conference and actually apologized, and we've never 
heard that happen before, so I think that's a good sign.
    Chairman Tom Davis. Thank you very much. Governor, thank 
you. I know you have to leave. Dr. Ostroff, I understand you're 
going to stay here for additional questions as we move to Mr. 
    Mr. Ruppersberger. Thank you, Mr. Chairman.
    The issue of outreach, obviously we have the best doctors 
and researchers in the world, and we need and we're helping 
them and I think doing a great job. I'm glad that we are on top 
of this. But what about the plan for the public outreach 
besides nightly newscasts? What about health departments, both 
local and State? How does that work, and what plan do we have 
from a public outreach point of view to educate not only the 
public and the other governments, but also the physicians who 
might be dealing with this problem?
    Dr. Ostroff. Well, we've used a variety of different 
mechanisms to try to make sure that we keep our front line 
public health workers, that we keep our health care providers, 
and that we keep the public informed about what is happening 
not only here in the United States but what's happening 
elsewhere. We've done this through having constant press 
conferences and telebriefings to all of our State health 
departments. Our Web site has a tremendous amount of 
information on SARS, and according to our public affairs people 
at CDC, even in comparison to our experience with anthrax 2 
years ago, the number of calls that our hotline is receiving 
from the public exceeds the numbers that we had during the 
anthrax outbreak in 2001. And, in addition to that, our Web 
site is getting hundreds of thousands of hits over the course 
of the last several weeks. So clearly the public is accessing 
the information that we have available. And we're using every 
modality that we can think of to keep the public informed about 
what is happening with this syndrome.
    Mr. Ruppersberger. Do you rely more on State and local 
health departments to educate, say, physicians about what they 
need to look for, where you need to go, or is it more----
    Dr. Ostroff. Well, we've had communications with all of the 
professional organizations, as well, and we keep them informed 
about what is happening, and through the professional 
organizations they've also been keeping their membership 
informed about what is happening with this disease, and they 
have been distributing our information, as well.
    Clearly, we rely on a partnership with all of the States 
and with the local health departments to help us make sure that 
they get information to those who are out on the front line.
    Mr. Ruppersberger. Do you have a special team that goes 
into a certain location in the event that there is an outbreak?
    Dr. Ostroff. We have many such teams at CDC. It is 
important to point out that we always have to go in at the 
invitation of the State health department in order to provide 
assistance to them in conducting those----
    Mr. Ruppersberger. Have you had problems with that in the 
    Dr. Ostroff. I think that on balance it is a highly 
collaborative working relationship and it continues to get 
better all the time.
    Mr. Ruppersberger. OK. Thank you.
    Chairman Tom Davis. Ms. Davis.
    Mrs. Davis of Virginia. Thank you, Mr. Chairman, and thank 
you, Dr. Ostroff. A couple of questions. One, you say that it 
started with the doctor on the 9th floor treating other folks. 
One, I don't know why he was treating the other folks unless 
they had something together. I don't know what. But how did it 
originate with that doctor? I mean, where did it come from? 
That's question one.
    The second question you may not be able to answer because 
it refers to what Secretary Thompson said when I believe it was 
Mr. Waxman that asked him were we doing enough, and he very 
quickly said no. Well, if we are not doing enough, what else do 
we need to be doing? That's the second.
    And the third question is to you. When you responded to Mr. 
Shays, you talked about how great Connecticut was. Well, what 
about the other 49 States.
    Dr. Ostroff. Thank you for those questions. In response to 
the first question, let me try to clarify the situation with 
the physician who came to Hong Kong. He actually came to Hong 
Kong to attend a family affair. He was from Guangdong Province. 
He was directly involved in the care of patients that were ill 
with the syndrome that was subsequently identified as SARS in 
Guangdong Province. He had a family affair to attend in Hong 
Kong. He and his wife traveled to Hong Kong. He wasn't directly 
taking care of people while he was at the hotel. He arrived 
ill. He attended the family event. The following morning he was 
hospitalized and then 24 hours later he died.
    We do know that a number of people that were staying at the 
hotel, as was pointed out, subsequently became ill, and in 
addition to that several of the other family members that 
attended the event that he was attending, which was a wedding, 
also became ill. And so that's how we think that this 
originated, and that from his providing direct health care in 
China that's how he got exposed.
    Mrs. Davis of Virginia. To people who had the same thing. 
Well, where did they get it? I mean, where did it start? The 
chicken and the egg--where did it start?
    Dr. Ostroff. That remains a very significant question, 
which is to try to get back to the origins of the disease in 
Guangdong Province and to try to get back to some of the first 
patients that look like they had this syndrome, which, as the 
Secretary pointed out, appears to have occurred back in 
    The collaborators in China have identified those 
individuals that they consider to be the first identified cases 
in at least seven different locations in Guangdong Province, 
and they actually have done a great deal of work, as has been 
relayed to us by the team that we had on the ground in 
Guangdong looking into the circumstances of those people to try 
to get some clues as to where this may have come from.
    Mrs. Davis of Virginia. Did you forget the other two 
    Dr. Ostroff. Sorry. The question about the capacities in 
the other 49 States, we have cooperative agreements with all of 
the State health departments to try to work with them to 
enhance their capacities. We have two types of programs. One is 
for basic epidemiology and laboratory capacity. All of the 
State health departments receive that assistance from us. And 
in a certain number of instances in 10 different locations 
around the United States we have a more-sophisticated program 
that's known as an ``emerging infections program'' whereby they 
can conduct their surveillance activities on a much more active 
basis. So we have a number of different programs that we use to 
support all of our partners at the State level.
    Mrs. Davis of Virginia. Are they pretty much up to speed, 
most of the States, all of the States?
    Dr. Ostroff. Well, I think that the Secretary said it very 
appropriately that we certainly have made great strides over 
the last several years. That has come both from these types of 
resources as well as from the funds that are being used for 
bioterrorism, because it has always been recognized that those 
funds are basically dual-use funds. They are used primarily for 
bioterrorism-related activities, but they also are used by the 
States to build their intrinsic capacity to recognize both 
intentional as well as naturally occurring diseases. So I think 
all of those resources have been used to enhance capabilities.
    And, as I think we would all say, and I think you will hear 
from our partners at the State and local level, this is a 
continuous process. We have to keep on building the system as 
we move forward.
    Mrs. Davis of Virginia. And I'll have to refer the other 
question to Secretary Thompson, I suppose. Thank you. Thank 
you, Mr. Chairman.
    Chairman Tom Davis. Thank you.
    The orders that I have on the Democratic side are Watson, 
Lynch, Clay, and Norton, and I have Duncan, Murphy, and 
Janklow. If that's not correct, I need to be corrected. But Ms. 
Watson, you have the floor.
    Ms. Watson. Thank you so much, Mr. Chairman. I want to 
thank Tommy Thompson and his team for being here.
    During his presentation, the Secretary mentioned the draw 
down of money that is proposed to be allocated and that 
California has only drawn down 51 percent. I want to know what 
the process is for drawing down the money. Do they have to have 
a plan proposed or in operation to be entitled to this money? 
That's my first question.
    And I also want to know is this smallpox threat a reality 
now to take precedence over the SARS threat, because I did hear 
it mentioned that 20 percent of the moneys can be used for 
smallpox. So if a State doesn't want to have that program 
enforced, does that get in the way from getting the money for 
the other kind of epidemics or biothreats?
    If you could address those points?
    Dr. Ostroff. Well, let me try to address your questions.
    Ms. Watson. OK.
    Dr. Ostroff. I certainly can't go into the same level of 
detail that the Secretary did.
    Ms. Watson. Yes. I understand.
    Dr. Ostroff. But what I can tell you is that all of the 
States, as a condition of receiving the bioterrorism funds, had 
to develop a very detailed plan. That detailed plan had to 
address a number of different issues. There were, I think, 16 
different priority areas that had to be developed in their 
operational plans before any of the funds could be released. It 
was a very rapid process because we wanted to get the funding 
out there as quickly as we possibly could. But over a process 
of a couple of months last year, all of the State plans were 
eventually approved. And once those approvals came through, 
then the States could start drawing upon the resources.
    In terms of your question about the threat of smallpox 
versus the threat of something like SARS, it is hard to compare 
and contrast because they are quite different threats. What I 
can say to you is that we would consider both of them to be 
very important, and both of them very much deserving of 
enhancements in preparedness.
    Ms. Watson. Here is my concern: California is a Pacific Rim 
nation. It is the first stop when people are coming from 
Southeast Asia at LAX. The airlines might hand out or that 
yellow card might be handed out, and I was wondering if there's 
any requirement for them to hand out the masks. It makes sense 
to me that if you are going to fly across the Pacific Ocean, 
the number of hours that it takes--6 to 8 hours--we ought to be 
giving out face masks if they come from one of the affected 
    But my other problem is, in trying to think it through as I 
was listening to the testimony, is that we are having a 
tremendous problem meeting the deficit in California. We are 
closing in my county, Los Angeles, we're closing the clinics, 
the public health clinics. That's where the indigents are taken 
care of. And is there some way to expedite the applications for 
this money so that we can get it out there? Can they proceed 
the detail planning, because we're closing our clinics, and the 
threat is greater on the coastal areas of the United States, 
particularly on the West Coast. And I'm thinking that the 
paperwork that's required--I have been in Government for a long 
time--slows that process down. So can you--and I'm throwing 
these things at you because they're on my mind.
    Dr. Ostroff. Right. Well, in response to the second part of 
your question, we've tried to move as expeditiously as we 
possibly could once the money became available to make sure 
that the States had developed their plans and that the plans 
were approved by us so that we could move the resources as 
rapidly as we possibly could.
    In response to the first part of your question concerning 
the issue of masks and other ways of potentially preventing 
transmission--and I think, in response to some of the questions 
that Congressman Davis also raised concerning specific guidance 
for various types of groups, we have been working very, very 
hard to develop recommendations and guidance for all types of 
situations, including airlines, including emergency responders, 
etc., so that they would have information about what is 
appropriate to do in terms of protecting themselves from 
potential exposure.
    In terms of the guidance that both we and the World Health 
Organization have provided around airline circumstances, we do 
not routinely recommend that people wear masks. The emphasis in 
the airline setting has been the prompt identification of 
somebody who may potentially be ill, isolating that passenger 
from the rest of the passengers, preferably placing a mask on 
the ill individual rather than all of the other passengers.
    Ms. Watson. Excuse me, if you will allow me. How in the 
world would you know? When I have come out of the Far East 
there are hundreds--and I know my time is up. I'll just finish 
with this if you don't mind 1 second.
    Chairman Tom Davis. Thank you.
    Ms. Watson. How would you know, in the crowds that are 
coming through, getting on those planes? I think we ought to 
err on the side of requiring, because you could be sitting next 
to that infected person that showed no signs as they come up to 
the desk, go through security. Who is there checking them out? 
I just throw that out. Think about it. You don't even have to 
    Thank you, Mr. Chairman.
    Chairman Tom Davis. I thank the gentlelady.
    At this time the Chair recognizes Mr. Duncan.
    Mr. Duncan. Thank you, Mr. Chairman. Actually, my first 
question is somewhat related to that last line. How difficult 
is this to diagnose? And is there some simple test or 
procedure, or can it be quickly, easily identified, or is it 
something that it takes a test that you have to send off and 
wait a day or two?
    Dr. Ostroff. Well, up until 2 weeks ago we didn't even know 
what the potential cause was.
    Mr. Duncan. Right.
    Dr. Ostroff. And so it is only once you identify what the 
causative agent might be that you can develop--start developing 
tests that would be directed specifically against that 
diagnosis. The syndrome, itself, particularly early on, is 
pretty non-specific. It looks like many other types of 
respiratory illnesses. And so there is nothing, at least 
initially, that distinguishes it from other types of diseases. 
That's why we've gone to such great lengths to use a very wide 
net in terms of being able to recognize people with the 
appropriate travel histories so that we can take the 
appropriate precautions and make sure that we can reduce the 
risk to the minimum possible to have them potentially transmit 
to other individuals.
    As far as where we are with the diagnostic tests, we have 
been making great strides since we identified the coronavirus 2 
weeks ago to develop these tests. Right now these tests are 
being refined in our laboratories in Atlanta, and when we're at 
the point where we think that the tests perform the way that we 
think the test ought to perform, both in terms of recognizing 
people who really have the disease, as well as excluding people 
who don't, then we will begin distributing it to all of the 
States so that they can more rapidly make the diagnosis 
    Mr. Duncan. Well, hopefully we are going to be able to come 
up with some way to contain and eradicate this disease very 
shortly, but let me ask you this: what other steps can we take 
if we don't come up with something very quickly, because 
obviously you mentioned a few minutes ago that you're getting 
more calls and more hits on the Web site than even the anthrax 
scare, which was a pretty big scare, and I think you said, 
what, 100,000 hits or something?
    Dr. Ostroff. Hundreds of thousands.
    Mr. Duncan. Hundreds of thousands. So obviously the concern 
is very great. And the West Coast, of course, is the front 
line, I suppose, but we have people flying in from all over the 
world in my home town of Knoxville, TN, and all over the 
country. What can we do? If this thing starts to explode in 
some country, can we require that all passengers coming in from 
that country be tested or something done before they start 
spreading this all around the country, or what can we do?
    Dr. Ostroff. Right. Well, before we get to that point we 
have to have the test and we have to make sure the test works 
the way that we think that it ought to work.
    Mr. Duncan. Because some of these people may be carrying 
this without realizing it.
    Dr. Ostroff. Right. One of the things that the World Health 
Organization has recommended is that on the embarkation end, 
when people are getting on airplanes from the areas in which 
there's evidence that there is local transmission occurring, 
that these passengers in some way, shape, or form be screened 
before they get on the airplane so that ill individuals can be 
recognized and make sure that they don't get on the airplane in 
the first place.
    Mr. Duncan. That's good.
    Dr. Ostroff. And then, in addition to that, they've 
provided this information about what to do if somebody may not 
necessarily have been sick at the time they got on board but if 
they become sick en route.
    In terms of what happens if this does explode and gets 
bigger and bigger and we run into situations like have been 
seen in some other parts of the world, I think the best defense 
against that is some of the things that Secretary Thompson and 
General Russell mentioned in terms of trying to come up with 
specific therapeutics and trying to come up with preventative 
measures that we can use to prevent people from getting the 
disease in the first place. They obviously will take some time 
to get into that position. But hopefully that would enhance the 
tools that we have available to control this in the future.
    Mr. Duncan. Well, I think Vice Chairman Shays made a good 
point in saying that we maybe need to give you some more 
authority, especially to do things concerning people who fly in 
from these other countries, if this thing gets bigger and 
    Thank you very much, Mr. Chairman.
    Chairman Tom Davis. Thank you very much.
    Mr. Lynch.
    Mr. Lynch. Thank you, Mr. Chairman. I want to thank you and 
also Ranking Member Waxman for your leadership on this issue. I 
want to thank the Secretary for coming in, and also you, 
    I heard you mention in your earlier testimony that we are 
having people on the ground in Guangdong Province, and, while I 
have not been in Guangdong Province in over 2 years, I am quite 
familiar with the city of Guangzhou and the province, itself. 
Now, we probably have close to 7 million people in the city of 
Guangzho. It is the provincial capital. You have one of the 
major regional markets there. And while I need to be mindful of 
the cultural sensibilities, environmentally and from a public 
health standard those systems have been compromised in that 
city. It is just simply overwhelmed.
    Also, and to my point, we have the major U.S. and European 
adoption center located at the White Swan Hotel right in the 
middle of Guangzho, and on an average weekend there--and I've 
seen it with my own eyes--you might have anywhere from 300 to 
500 families coming in. Usually one parent comes in, adopts the 
child, flies out the same weekend. And all of this is 
exacerbated by the China one child policy and the fact the that 
Chinese Government has taken really a--kind of closed one eye 
to the adoption process, and they're sort of doing this thing 
without recognizing they're doing it.
    We've got a situation there that is not adoption as we 
would view it in this country. You're really looking at a 
humanitarian effort there and we're rescuing kids. We're saving 
their lives. I have in my District recently a woman and her 
sister went over and adopted a young child, which is fairly 
customary, and came back, and now the child is infected and the 
sister is infected, as well, in Springfield, MA.
    My question is this: given the whole situation then, do we 
have any protocol in place to address that situation? Have we 
allocated any additional resources to State or to anybody else, 
to your own people, to help that situation, given the fact that 
these adoptions need to go forward and we need to protect our 
    Dr. Ostroff. Right. Thank you very much, Congressman, for 
asking that question. We, too, have been very concerned about 
that situation because virtually all international adoptions 
from China come from that particular region of the country.
    We have been working on a highly collaborative basis with 
the international adoption agencies that deal with adoptees 
from China--with all of them. There are a number of them in the 
United States--to make sure that we have protocols in place so 
that we can provide information to the parents before they go 
over there about what measures they can take to reduce their 
risk, and we have been also working quite well with all of 
these agencies in collaboration with our States and our local 
health departments to make sure that we can monitor these 
children as they do come so that we can minimize any potential 
impact not only from the child but also from potentially the 
parents. And so we've recognized this as a considerable issue, 
and we have been working quite strenuously to make sure that we 
address it in the most sensitive and appropriate way.
    Mr. Lynch. Thank you, Doctor. Thank you, Mr. Chairman.
    Chairman Tom Davis. I thank the gentleman.
    Mr. Janklow, you have the floor.
    Mr. Janklow. Thank you very much, Mr. Chairman.
    Doctor, in Secretary Thompson's testimony on page 7 they 
talk about this is a very infectious--SARS is very infectious 
during the symptomatic phase of the disease. Then it goes on to 
say, ``However, we do not know how long the period of contagion 
lasts once they recover from the illness. We do not know 
whether or not they can spread the virus before they experience 
symptoms. The information our epidemiologists have suggests the 
period of contagion may begin with the very onset of the 
earliest symptoms of the viral disease.''
    Then on page 8 it says, ``People who are living in a home 
with a SARS patient who are otherwise well, there's no reason 
to limit activities currently.''
    Well, why do we draw that conclusion, sir, if we don't know 
at what stage it is transmitted? And are we suggesting to 
people that it is OK if you live with a SARS patient to just go 
on about your business around the community if, in fact, it is 
maybe transmittable before you have any of the manifestations 
of the onset of the illness? Do you understand what I'm saying?
    Dr. Ostroff. Right. No, I understand, Congressman. We have 
been very rapidly accumulating a great deal of information, not 
only here in the United States but also through our teams that 
are working overseas where most of these cases are occurring, 
to try to answer some of the questions that you are raising, 
and the way to do this is through the collection of serial 
    Mr. Janklow. But, sir, if we're telling people don't go to 
Hanoi, don't go to Guangdong, Guangzho, don't go to Hong Kong, 
but if you have a SARS patient in your house you can go out and 
go to the supermarket, I mean, how is the public supposed to 
understand what it is that we really think is the cause for 
    Dr. Ostroff. Right. Well, looking at the situation here in 
the United States, you know, most of our cases are considerably 
milder than what has been seen in other parts of the world. 
Obviously, for those individuals who are ill, most of these 
people have been put in the hospital appropriately and have 
been put in appropriate isolation. In instances where there are 
some of these milder cases, as a routine recommendation we have 
made the recommendations that these individuals stay at home, 
remain in their homes, and for family members of these 
individuals that are living in the same household, that they 
monitor themselves for illness. In the absence of illness, 
however, we do not recommend that they self isolate themselves.
    Mr. Janklow. But, Doctor--and I'm not trying to argue with 
you, but the testimony indicates that if someone is a SARS 
patient and they're cared for at home, that they should stay at 
home for at least 10 days----
    Dr. Ostroff. Correct.
    Mr. Janklow [continuing]. After they are no longer 
    Dr. Ostroff. Correct.
    Mr. Janklow. If they should stay at home for 10 days, 
aren't we really pushing our luck to suggest it is OK for the 
family members to come and go and wander around the community 
while I'm staying at home for 10 days after I have no more 
    Dr. Ostroff. Well, until there is information to suggest 
that isn't the correct thing to do----
    Mr. Janklow. OK.
    Dr. Ostroff [continuing]. We have difficulty making 
recommendations that non-ill people stay at home. Now, this is 
an important point because in some other countries they, 
indeed, have taken measures, based on their local 
circumstances, to restrict well individuals that have been in 
contact with SARS patients from going into the community. At 
this point, we have not seen any reason to do that in this 
    Mr. Janklow. OK.
    Dr. Ostroff. And so far this has worked quite well here in 
the United States.
    Mr. Janklow. Doctor, some of the literature we were given 
says coronaviruses can mutate and change rapidly. This is the 
reason why this virus stand was not included in this year's 
influenza vaccine. Is that really a conclusion by somebody?
    Dr. Ostroff. Well, one influenza vaccine has nothing to do 
with coronavirus.
    Mr. Janklow. OK. I'm just reading the sentence that was 
given to me in the briefing papers.
    Mr. Janklow. Right. They are two completely different types 
of viruses. The influenza vaccine has--is directed against 
three different types of influenza, only. As was mentioned 
earlier, there are no human vaccines against coronaviruses.
    Mr. Janklow. OK. Thank you.
    Chairman Tom Davis. At this time the Chair recognizes Mr. 
Clay. Thank you for your patience.
    Mr. Clay. Thank you, Mr. Chairman.
    Doctor, in a 1992 report on micro-biothreats to health, the 
Institute of Medicine recommended the development of a 
worldwide disease surveillance system. This recommendation was 
made again in the IOM's 2003 update to the 1992 report. Can you 
tell us what steps the administration has taken to implement 
this recommendation and what steps are planned for the future?
    Dr. Ostroff. Well, I think I can try to address what steps 
that we've been taking at CDC and in HHS to work 
collaboratively with the World Health Organization to try to 
enhance global capacity to be able to address the threat of 
emerging infectious diseases.
    Again, as was mentioned, we have been providing resources 
to WHO so that they can do their job better. WHO has been 
working, and I think we are seeing the fruits of many of the 
things that WHO has done in terms of their ability to work 
collaboratively with all of the countries in Asia that are 
affected by this and be able to monitor the world's situation. 
They have a global alerting network that they've built to be 
able to rapidly provide information about outbreaks that are 
occurring in other parts of the world. We support that.
    In addition to that, we are working toward building similar 
types of programs to those that I described in Connecticut in 
other parts of the world, as well. This is a program that we've 
just started within the past couple of years. One of them 
currently exists in Thailand in Bangkok, and that program, 
itself, has been one of the instrumental tools that we've had 
to help provide assistance in Asia with the SARS problem. And 
so we have been working to try to improve global capacity, but 
I think that there would be little question, both in our minds 
as well as in the minds of WHO, that there is a great deal more 
that needs to be done.
    Mr. Clay. Thank you. In October 2001, the minority staff of 
this committee reported on the growing problem of ambulance 
diversions because of crowded emergency rooms in cities across 
the United States, indicating serious implications for a public 
health crisis. Are there any known cases of ambulance 
diversions documented by public health authorities that relate 
to SARS? And, if so, how many and when did it occur?
    Dr. Ostroff. I am not aware of specific circumstances, but 
that doesn't mean they haven't necessarily occurred.
    Mr. Clay. Are SARS cases being turned away from medical 
facilities because of lack of health care insurance that you 
know of?
    Dr. Ostroff. None that have particularly come to my 
attention. Others may have other information. Obviously, many 
health facilities around the country are very concerned about 
the potential risk that such patients may pose. From our 
perspective, it is important that all hospitals have the 
appropriate infection control procedures and precautions in 
all, both outpatient as well as inpatient settings, so that 
these people can be appropriately cared for.
    Mr. Clay. OK. Can this disease manifest itself in our food 
and water supply?
    Dr. Ostroff. It's way too early to be able to answer those 
types of questions. Again, we are basing everything on knowing 
about the existence of the virus, itself, for only 2 weeks, and 
it is far too soon to be able to answer those types of 
    Mr. Clay. OK. And along those lines then is there any 
reason to think that SARS is or is not related to a 
bioterrorism effort?
    Dr. Ostroff. Well, as the Secretary mentioned, all of the 
information that we have currently available to us suggests 
that this is a naturally occurring event. Nature, you know, has 
a lot of tricks up its sleeve of its own, and these viruses are 
constantly changing and mutating, and we constantly are seeing 
new naturally occurring, emerging infectious diseases. However, 
we haven't done everything that we need to do until we have 
been able to look at the entire genetic sequence of the virus 
to be able to say with 100 percent certainty that might not be 
the case. We remain open to that possibility. But at least 
everything that we've heard up to this point suggests that this 
is naturally occurring.
    Mr. Clay. Thank you, Doctor. I thank you for your answers.
    [The prepared statement of Hon. Wm. Lacy Clay follows:]
    [GRAPHIC] [TIFF OMITTED] T7067.029
    [GRAPHIC] [TIFF OMITTED] T7067.030
    Mr. Shays [assuming Chair]. Doctor, we're almost done. I 
would just like to ask you a few questions, and then we'll get 
to the next panel, and maybe the Governor has a question or two 
to followup.
    I want outstanding understanding, because we've said it. I 
want to know if it is true. Is this a highly contagious disease 
or is it not? In a scale of 1 to 10, how does it fit in, 10 
being highly contagious?
    Dr. Ostroff. Well, I'm not sure that we necessarily have 
all of the answers yet to be able to properly give it a score. 
What I can say is that in most circumstances it does not appear 
to be highly transmissible. However, what concerns us is that 
we have seen a number of instances in Asia and also in Toronto 
where there seems to be what the Secretary referred to as the 
``super spreaders'' where all of a sudden we see explosive 
numbers of cases in their close contacts, particularly in the 
health care setting and, as I'm sure many are aware, in the 
apartment complex in Hong Kong and in the hotel setting in Hong 
Kong, as well, and we need to understand a little bit better 
the circumstances of those particular events and why they 
happened and what may have been responsible for why one 
individual seems to transmit the disease to so many people 
while, in the vast majority of cases, they don't seem to do 
that. It may simply have something to do with the stage of 
disease. It may have something to do with the severity of the 
illness at the time that individual was being cared for or was 
    So we can't say with absolute certainty, so I can't give 
you a definite score, but certainly if you look at a virus, 
say, like measles where almost everybody that is within an area 
will--you know, if they're not vaccinated, that are exposed 
will develop the disease. It doesn't appear to have that degree 
of contagiousness. But, again, most of these respiratory 
viruses go from one person to another, and until we gather more 
information we can't say exactly what degree of contagiousness 
this one has.
    Mr. Shays. What is the sense of our ability--how do we 
determine whether something is natural or by the malevolent act 
of man, something tampered with? How do we know whether it is 
an act of a terrorist or just a natural act of----
    Dr. Ostroff. Well, again, it is looking at the structures 
of the virus, itself, and looking at the genetic material----
    Mr. Shays. But there is a way to tell?
    Dr. Ostroff [continuing]. And looking to see whether or not 
there are sequences that would correspond with other sequences 
that would suggest that maybe something was introduced into the 
virus. All of that, you know, would go into making a 
determination that something may not necessarily be natural.
    Mr. Shays. Let me be clear on this. Do we learn from 
analyzing the virus, the pathogen, or do we learn by just 
tracking it down to its beginning and then learn that way?
    Dr. Ostroff. Well, it is both.
    Mr. Shays. OK.
    Dr. Ostroff. Clearly. And that's one of the reasons why we 
have been making such great efforts to try to get back to some 
of these very early cases in Guangdong Province so that we 
could learn about the types of exposures that these individuals 
had that may give us some clue as to exactly what you're 
talking about. But a lot of it is also based on what we learn 
about the virus, itself.
    Mr. Shays. You're one seat over from a gentleman who was at 
our hearing on national security about 3 years ago, and he 
closed--he was a doctor of a major medical magazine, and he 
shared with us his biggest concern. His biggest concern was 
that a small group of dedicated scientists would alter a 
biological agent such that there would be no antidote and it 
would wipe out humanity as we know it. He was not saying that 
in an attempt to draw attention; he was just answering an 
honest question and giving an honest answer. That scared the 
hell out of me, though, and it makes me very interested just to 
come back again, because I don't have a handle or a sense of 
the concept of surveillance, which we believe is the most 
important issue. I think the Secretary has said that.
    When will a national surveillance system with real-time 
data be put in place?
    Dr. Ostroff. Well, what I can say in addressing that issue 
is this is a system that we are working on developing.
    Mr. Shays. Right.
    Dr. Ostroff. We are looking at ways to access data on a 
real-time basis at the national level, collect that 
information, be able to analyze it and look for aberrancies. 
That work is going on as we speak. It's a system that we refer 
to as biointelligence.
    Mr. Shays. And when will this biointelligence--when do you 
think--what's your time table for getting this in place?
    Dr. Ostroff. We hope that we will be able to move toward 
pilots of such a system in the not-too-distant future. When 
will a national system be in place? I think it is a little 
    Mr. Shays. I don't know about not-too-distant future. I've 
got to pin you down a little more.
    Dr. Ostroff. Well----
    Mr. Shays. This is too important. You know, I mean, you 
have to have some time. If you want to say within the next year 
or you want to say within the next 5 years----
    Dr. Ostroff. Well, we would certainly hope to have pilots 
in place within the next year, Congressman.
    Mr. Shays. OK. Within the next 12 months. And what does 
``pilots'' mean?
    Dr. Ostroff. Well, again, to look at different mechanisms 
to be able to collect the information and try to figure out 
which is the best way to do it efficiently.
    Mr. Shays. OK. So presently we have a basic ad hoc system 
that hospitals report to the States in some States and that you 
try to grab any information where you can get it, directly from 
the States or directly from New York City, and maybe the State 
of New York, any way you can do it, and you're trying to 
compile it. But right now we don't have a nationwide system 
that captures in real time all the data around the country in a 
matter of seconds or minutes all at once to be able to compare 
data, right?
    Dr. Ostroff. No. I think it is fair to say that we don't 
have such a system, but I'd also point out to you that, at 
least in our experience, a one-size-doesn't-fit-all system, and 
what might necessarily work, say, in Connecticut may not 
necessarily work in Los Angeles. That's why we have been--you 
know, with the bioterrorism resources, one of the major efforts 
of those resources is to develop the type of syndromic 
surveillance that you have been describing, and there are many 
different models that are being used at the State and local 
level to be able to do that.
    Mr. Shays. Let me just say my time has run out. I'm just 
going to go a few minutes longer and then go to my other 
    Mr. Janklow. Very briefly?
    Mr. Shays. Sure.
    Mr. Janklow. Very briefly, I have three very quick 
    One, you say there's indications that it may be weaker in 
this country. Does that give us hope that this thing may kind 
of peter itself out as it continues to move through society, 
that there's any logical reason for it?
    Dr. Ostroff. I think, Congressman, the term ``weaker'' is 
probably not the right term. The spectrum of illness that we've 
seen so far in the United States seems to be milder than what 
has been seen elsewhere. We believe that's probably a 
phenomenon of the fact that we're casting a very wide net, and 
as you cast a wide net and become less specific in terms of 
what you're looking for, to try to be as sensitive as possible 
to find all even theoretically possible cases, we're probably 
picking up people with milder illness who have something else.
    Mr. Janklow. Sir, the second thing, when you were asked the 
question by the gentleman from Maryland about cooperation, you 
took a deep breath, let it out, and you said ``on balance, 
things are highly collaborative.'' Is there a problem at all 
with collaboration with the other health agencies in the 
country? And I realize I put you on the spot, sir, but it is 
very important as we're talking about this kind of problem.
    Dr. Ostroff. Right. Congressman, what I can say is that we 
work on a highly collaborative basis with all of our partners 
at the State health departments.
    Mr. Janklow. Is that happening now with this disease?
    Dr. Ostroff. Absolutely.
    Mr. Janklow. OK.
    Dr. Ostroff. All of--you know, we've had--currently we've 
had reports of suspected cases from, you know, that we have 
been including on our line listing from at least 30 States. I 
don't know what today's count will be, but at least 30 
different States. And, in addition to that, there have been 
many hundreds more, individuals that have either directly 
contacted us, their health care providers have contacted us----
    Mr. Janklow. I'm talking about the agencies, not----
    Dr. Ostroff [continuing]. Or the States have.
    Mr. Janklow. Not the individuals.
    Dr. Ostroff. Or the States have. And we have worked 
collaboratively with every single health department in this 
country to be able to investigate those cases and figure out 
    Mr. Janklow. One last question.
    Dr. Ostroff [continuing]. They meet our definition.
    Mr. Janklow. Thank you. One last question, sir. There's a 
suspicion that this may have jumped from animals to people. Do 
we know of any animal that has carried this disease in the past 
that gives us that suspicion?
    Dr. Ostroff. Right. This coronavirus, at least based on the 
work that we have done up to this point, appears to be unique 
and new, different than other coronaviruses that we've seen. We 
do know that there are a number of coronaviruses that naturally 
infect animals, and so what we have been doing is we have been 
doing additional work to actually look at the virus, itself, 
and see if it will give us any clues as to the type of animal 
that it may have come from. We're not there yet.
    Mr. Janklow. Thank you, Mr. Chairman.
    Mr. Shays. Thank you. We're almost done here. This is a 
live-fire exercise. If it was more contagious, obviously we 
would be presented with a more difficult challenge. There's 
nothing in nature's law that says there couldn't be something 
more contagious, correct?
    Dr. Ostroff. Oh, absolutely.
    Mr. Shays. Yes. So in one sense this is a good practice for 
us, would you agree?
    Dr. Ostroff. Well, all I can say is that we remain highly 
concerned about even this particular virus and the potential 
impact it can have, not only around the world but also here in 
the United States.
    Mr. Shays. OK.
    Dr. Ostroff. I think we have to be very vigilant about the 
potential for this virus.
    Mr. Shays. OK. And we have to move as quickly as we can to 
get those pilot programs----
    Dr. Ostroff. Absolutely.
    Mr. Shays [continuing]. Moving, and I think, frankly, if I 
could express an opinion, not a question, a little more 
forcefully, I think that the Secretary and you and others have 
to be a little more outspoken. I tend to think that the 
Secretary doesn't want to alarm people because obviously that's 
not healthy, but at the same time he doesn't want us to feel 
like things are moving along and we don't need more resources 
or we don't need more legislation. It strikes me that we need 
to push the surveillance as quickly as we can.
    It's a fact, isn't it, that a terrorist act could tamper 
with a biological agent or they could take a natural agent and 
just try to spread it, and then it's a little more difficult to 
know because you can't know from looking at the virus or the 
pathogen where it hasn't been altered, it hasn't been changed, 
it's natural in that sense, correct?
    Dr. Ostroff. That's correct. I mean, it is important to 
have some baseline of other viruses to be able to compare it 
    Mr. Shays. One last area real quick. At one point we were 
going to destroy the smallpox virus, both sites. The Russians 
had it, we had it. And there were a number of us who said, 
``We're not sure that's a good idea.'' Even within HHS also had 
some concerns. But ultimately we didn't do it, and it is 
probably proved wise that we haven't. But in the process of 
creating a vaccine, is it possible that someone can take from a 
vaccine and create the virus from a vaccine? Is that possible?
    Dr. Ostroff. Well, you know, to some degree. It depends on 
the virus. We certainly know many live virus vaccines where--
and probably the best example of that would be, for instance, 
polio, where even the vaccine strains can revert themselves in 
nature to become more virulent and actually produce disease, 
and so it is----
    Mr. Shays. What about----
    Dr. Ostroff [continuing]. Theoretically possible to do 
    Mr. Shays. What about smallpox?
    Dr. Ostroff. Well, the smallpox is not so much of an issue 
because the vaccine, itself, is a different virus.
    Mr. Shays. Well, let me ask you this, though. Why is it, 
though, that if one partner in a marriage can't take the 
vaccine the other doesn't? In other words, if you're pregnant 
you choose not to, so the husband is determined that he should 
not, you know, have the----
    Dr. Ostroff. Right.
    Mr. Shays. And why would that be?
    Dr. Ostroff. Well, because the virus, itself, is 
transmissible from one individual to another through direct 
    Mr. Shays. Well, is----
    Dr. Ostroff. And because of that and because of the health 
threat that the virus could potentially pose to pregnant women 
and other people with immunocompromised health conditions, the 
recommendation is that if there is someone in your household 
who fits into one of those categories that you defer from 
    Mr. Shays. OK. I don't want to dwell on this. I just want 
to understand it, though. I want to understand that--is that--
are you saying, in essence, that someone could basically have 
the vaccine--is it called a vaccine, smallpox vaccine?
    Dr. Ostroff. The smallpox vaccine is vaccinia.
    Mr. Shays. Right. OK. You have the vaccine. It is possible 
that someone could contract smallpox from a person who has had 
a--I'm seeing a shaking of the head behind.
    Dr. Ostroff. No. Not smallpox.
    Mr. Shays. OK. Some other----
    Dr. Ostroff. Vaccinia in some circumstances can produce 
    Mr. Shays. OK. It would be an illness, but not----
    Dr. Ostroff. Not smallpox.
    Mr. Shays. Happy to have that on the record.
    Dr. Ostroff. OK.
    Mr. Shays. We'll be real clear.
    Dr. Ostroff. Right.
    Mr. Shays. You can't transmit it. OK.
    Dr. Ostroff. Thank you.
    Mr. Shays. Thank you very much. We appreciate it, Doctor.
    We're going to our second panel, which is: Janet Heinrich, 
Director, Public Health Issues, U.S. General Accounting Office; 
Dr. Margaret Hamburg, vice president for biological programs, 
the Nuclear Threat Initiative; and Dr. David Goodfriend, 
director, Loudoun County Health Department.
    If you'd remain standing, we'll swear you in. If you'd 
raise your right hands.
    [Witnesses sworn.]
    Mr. Shays. Note for the record our witnesses have responded 
in the affirmative.
    Chairman Tom Davis [resuming Chair]. Thank you for being 
patient with us. The rules of the committee, 5 minutes to give 
your testimony. Your full statement is going to be in the 
record. There's a light on in front of you. When it turns 
orange, that means 4 minutes have expired, you've got a minute 
to sum up. When it turns red, we'd appreciate your moving to 
summary as quick as you can, and then we can get right to the 
    We'll start with Ms. Heinrich and move to Dr. Hamburg and 
then to Dr. Goodfriend. Thank all of your for your patience and 
for being with us today for what we think is a very important 
    Ms. Heinrich, you may proceed.


    Ms. Heinrich. Mr. Chairman and members of the committee, I 
appreciate the opportunity to be here today as you consider the 
Nation's preparedness to manage a major public health threat. 
Whether an outbreak occurs naturally, as with influenza 
epidemics or the new SARS or is due to the intentional release 
of a harmful biological agent by a terrorist, much of the 
initial response would occur at the State and local level. In 
particular, hospitals and their emergency departments, as well 
as physicians and nurses, would be the first to respond as 
individuals with symptoms seek treatment.
    Public health agencies would be involved in gathering 
information about the extent of the problem and initiating a 
global response effort. There is widespread concern, however, 
that our public health agencies and hospitals do not have the 
capacity to manage a major public health event.
    We have been examining the capacity of State and local 
preparedness for a bioterrorism attack as part of a mandate in 
the Public Health Improvement Act of 2000. My remarks will 
focus on what we know about the preparedness at the State and 
local level, about hospital preparedness for such an event, and 
Federal and State efforts to prepare for an influenza pandemic, 
an important component of public health preparedness. All of 
these issues have become much more pertinent in light of 
emerging infectious diseases like SARS.
    As you noted, we released our review of State and local 
preparedness for bioterrorism on Monday. In visiting selected 
States and cities, local officials reported varying ability to 
respond to a major public health threat. They recognize gaps in 
elements such as communication to the public, and have begun to 
address these. However, gaps remain in elements such as disease 
surveillance, laboratory capacity, and the trained work force. 
Although States have moved to electronic systems to compile 
data, for the most part they still rely on voluntary reporting 
of unusual diseases by health care providers. Such passive 
systems suffer from chronic under-reporting and time lags 
between diagnosis of a condition and the health department's 
receipt of the report. State officials were planning to 
purchase new equipment for public health laboratories, hire 
additional staff, and incorporate clinical laboratories into 
cooperative systems. Hiring epidemiologists and laboratory 
personnel trained to do the appropriate investigations in an 
emergency has been hampered by a general shortage of these 
trained individuals and by non-competitive salaries, as well.
    Other recent work shows that progress in improving public 
health response capacity has lagged in hospitals. Although most 
hospitals across the country reported participating in basic 
planning activities for large-scale infectious disease 
outbreaks and had provided training to staff on symptoms to 
watch for and likely biological agents, few have acquired the 
medical equipment and isolation facilities they would need.
    For example, from our survey of almost 1,500 hospitals, we 
found that almost all hospitals had at least one ventilator, 
one protection suit, or an isolation bed, but half of hospitals 
had less than six ventilators, three or fewer protective suits, 
and less than four isolation beds per 100 staffed beds.
    Even before September 11th, the need to plan for a 
worldwide influenza pandemic was acknowledged. In the 20th 
century, there have been three such pandemics, the last in 
    While efforts to develop plans have been in the works for a 
while, officials have been slow to finalize plans. Thirty-four 
States are in various stages of completion of preparing a 
pandemic response. Key Federal decisions related to vaccines 
and antiviral drug distribution have yet to be made, such as 
the amount of vaccines and antiviral drugs that will be 
purchased at the Federal level, the division of responsibility 
between the public and private sectors for the purchase, 
distribution, and administration of these vaccines and drugs, 
and how population groups will be prioritized.
    In summary, many actions taken at the State and local level 
to prepare for a bioterrorist event have enhanced the ability 
of response agencies to manage a major public health threat; 
however, there are significant gaps in public health capacity, 
local hospitals' ability to handle large-scale infectious 
disease outbreaks, and the supply and distribution of vaccines 
and drugs in short supply. Clearly, progress has been made and 
much more needs to be done.
    Mr. Chairman, that completes my remarks. I'm happy to 
answer any questions.
    Chairman Tom Davis. Thank you very much.
    [The prepared statement of Ms. Heinrich follows:]
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    Chairman Tom Davis. Dr. Hamburg, thanks for being with us.
    Dr. Hamburg. Thank you. Mr. Chairman and members of the 
committee, I really appreciate the opportunity to testify and 
thank you for holding this timely and important hearing.
    SARS is a serious public health threat that has surprised 
government officials and scientists around the globe, 
constrained travel, shut down schools and businesses, and 
caused widespread fear. At present, no one can predict how far 
the disease will spread and how much higher the toll will be. 
Will this outbreak be contained or will it become the next 
global pandemic?
    Many organizations and their leaders should be commended 
for the robust international response mobilized, yet SARS 
demonstrates gaps in our systems for disease prevention, 
response, and control. These will require increased domestic 
attention, but also demand greater global cooperation and 
support. For example, the failure of China to initially report 
was a missed opportunity for rapid investigation, adding 
unnecessary delay to an already difficult diagnostic and 
disease control challenge, and clearly we need research to 
provide better diagnostic tools, as well as the drugs and 
vaccines necessary to treat or prevent disease.
    In addition, SARS has demonstrated how easily health care 
systems can be overwhelmed and has revealed troubling questions 
about how and when travel and commerce should be constrained in 
the context of communicable disease. On both the domestic and 
international level, a great deal must be done to develop 
appropriate policies, define authorities, and design strategies 
for implementation. We must recognize that SARS is but one of a 
series of new and deadly infectious diseases that have emerged 
in recent times, not to mention old diseases that have 
resurged, often in new and more frightening forms because of 
the development of drug resistance.
    What is more, we live in an age when we must think 
seriously about the intentional use of biological agents to do 
    The ability of infectious agents to destabilize 
populations, economies, and governments is fast becoming an 
unfortunate fact of life. Over the past decade, the United 
States has taken important steps to strengthen capacity to 
address the threats posed by infectious diseases, but were 
inadequately prepared. Public health is public safety, and an 
important pillar in our national and international security 
framework. We must do more to improve our ability to prevent, 
detect, and control microbial threats to health.
    Several weeks ago the Institute of Medicine released a new 
report, ``Microbial Threats to Health,'' focused on just these 
concerns. The report represents an effort to describe the 
spectrum of microbial threats, the factors affecting their 
emergence and resurgence, and measures needed to address them. 
The major thrust of this report and its recommendations are 
almost uncannily relevant to our current experience with SARS. 
As co-chair of this effort, I'd like to briefly discuss some of 
our major themes and conclusions.
    More than a dozen factors, some reflecting the ways of 
nature, most reflecting our ways of life, are described in the 
report to account for new or enhanced microbial threats. Any of 
these factors alone can trigger problems, but their convergence 
creates especially high-risk environments where infectious 
diseases may readily emerge, take hold, and spread. In our 
transforming world, conditions are ripe for the convergence of 
multiple factors to create microbial perfect storms, yet, 
unlike meteorological perfect storms, these events are not to 
be once-in-a-century events, but frequent or ongoing. SARS is 
not an isolated phenomenon.
    An effective national response to infectious diseases must 
be global, so our recommendations begin with a strong call for 
the United States to support enhancement of global disease 
surveillance and the capacity to respond to infectious disease 
threats. The report also stresses the need to bolster the U.S. 
public health infrastructure. State and local health 
departments represent the backbone of response to a major 
outbreak of disease, whether naturally occurring or 
bioterrorist attack, yet we've never adequately equipped these 
agencies to do that job.
    Upgrading current public health capacities will require us 
to strengthen and extend effective disease surveillance 
systems, laboratory capacity, and systems to ensure the rapid 
use and sharing of information. These efforts will require 
enhancement of both the capacity and expertise of the work 
force, greater partnership between public health and medicine, 
and the need to develop and use better diagnostics.
    It was felt that we faced a serious crisis in vaccine and 
drug development, production, and deployment, as well. A more 
coordinated approach among government, academia, and industry 
is necessary, and issues of identification of priorities for 
research, determination of effective incentive strategies for 
developers and manufacturers, liability concerns, and 
streamlining the regulatory process must be addressed in a more 
meaningful and systematic fashion.
    Other recommendations address ways to reduce microbial 
resistance, control vector-borne diseases, and the need for 
interdisciplinary approaches to infectious disease research.
    In conclusion, prevention and control of infectious disease 
is fundamental to individual, national, and global security. 
Failure to recognize and act on this essential truth will 
surely lead to disaster. Recent Federal investments in 
bioterrorism preparedness are resulting in some improvements; 
yet, while we've taken some steps forward, we are at risk for 
serious backsliding. Cutbacks in crucial but nonbioterrism 
programs at the Federal level, such as in CDC's emerging 
infectious disease program or USAID dollars for global disease 
surveillance, combined with cuts to public health programs in 
State budgets across the country, along with the many competing 
priorities at the State, local, and Federal level means that 
overall dollars to build and sustain the necessary elements for 
infectious disease preparedness and response may not be there.
    Our country has always been willing to meet the 
requirements and pay the bills when it comes to our military 
defense needs. We must now be willing to do the same when it 
comes to public health needs. SARS is yet another wakeup call. 
While there is an enormous human and economic toll, it is a far 
milder version of what we might experience with a more deadly 
or contagious disease.
    The best defense against any outbreak is robust public 
health, both science and practice. Given our significant and 
growing vulnerabilities, markedly greater attention and 
resources must be devoted toward this end. Effective strategies 
will require sustained efforts, as well as greater coordination 
and cooperation with partners around the globe. We must 
endeavor now to create a system that really works so that we 
will be prepared for the next attack, whether it is Mother 
Nature or an act of bioterrorism.
    Thank you.
    Chairman Tom Davis. Thank you very much.
    [The prepared statement of Dr. Hamburg follows:]
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    Chairman Tom Davis. Dr. Goodfriend, thanks for being with 
    Dr. Goodfriend. Mr. Chairman and distinguished Members, 
thank you for the opportunity to discuss current responses to 
public health threats at a local level, particularly during 
National Public Health Week.
    Loudoun County, VA, is one of the Nation's fastest-growing 
communities and includes Washington Dulles International 
Airport. The Loudoun County Health Department is part of 
Virginia's Department of Health. It includes about 75 State and 
county employees who perform a variety of functions, all tied 
to the protection of the public's health, such as permitting 
well and septic systems, conducting restaurant inspections, 
providing direct care to pregnant women and children, 
administering immunizations, and investigating outbreaks of 
disease, whether occurring naturally or through terrorist 
    During my 2 years as its director, our Health Department 
has confronted numerous communicable disease challenges within 
Loudoun County, including an anthrax attack, Virginia's first 
human death from West Nile Virus, and three cases of locally 
acquired malaria. Lessons learned from these experiences--in 
particular, the necessity of having effective partnerships with 
other involved agencies, with our local media and citizenry, 
and with our health care community--put us in a good position 
to effectively respond to the Nation's first suspect case of 
Severe Acute Respiratory Syndrome [SARS].
    Specifically, since September 11, 2001, the Loudoun County 
Health Department has developed an e-mail distribution list to 
send out timely public health information to key hospital 
personnel and to a large majority of physicians in our county, 
it has taken an increasingly active role in our hospital's 
Infection Control Committee and our County's EMS Advisory 
Council, has established the ability of citizens concerned 
about bioterrorism or other unusual diseases to contact us 24 
hours a day, and has been conducting daily reviews of the 
complaints of all patients seen in our local emergency 
department as part of the syndromic surveillance that was 
discussed earlier.
    We have also taken a much more active role in regional 
agencies, and with interactions with our other northern 
Virginia health departments.
    Loudoun Hospital Center, our county's only hospital, has 
responded to these threats by creating an Emergency 
Preparedness Committee, sponsoring numerous lectures on 
emerging diseases and bioterrorism, and instituting new 
policies and algorithms for quickly diagnosing, isolating, and 
treating any patient presenting with a potentially communicable 
disease. They have also improved communication with other 
hospitals in the region, including establishing a radio 
frequency for rapid notification.
    On February 17, 2003, a woman who had recently traveled to 
Guangdong Province in China presented to Loudoun Hospital 
Center's Emergency Department with pneumonia. SARS had not yet 
been identified as a syndrome, but there had been reports of 
unusual pneumonias being seen in Guangdong. As a precaution, 
hospital staff quickly moved the patient into an isolation 
room. They then contacted the hospital's infection control 
chief, who is with me today, and the Health Department as part 
of their infectious disease notification algorithm.
    The patient was subsequently admitted to Loudoun Hospital 
under airborne and droplet precautions and started on empirical 
antibiotic therapy. Anita Boyer, who is also here with me 
today, is one of our two new employees funded through a Federal 
bioterrorism grant. She investigated the case the following day 
and quickly consulted with her counterparts at the Virginia 
Department of Health and the Centers for Disease Control and 
Prevention. Over the course of that weekend, all hospital and 
household contacts were interviewed either by hospital staff or 
by the Health Department, and any ill person was tested.
    Our investigation found that the patient had not 
transmitted her infection to any one else, and she was 
discharged when she was medically stable and we were confident 
she was no longer contagious.
    Three elements combined to ensure successful outcome in 
this case, both for the patient's health and for the prevention 
of disease spread: one, having plans in place in the Emergency 
Room to isolate the patient and notify key personnel quickly; 
two, having effective communication patterns established 
throughout the public health chain from the hospital to the 
local and State health departments and to the CDC; and, three, 
having a history of established partnerships between our local 
medical community and public health.
    Some gaps were identified during our review, which in this 
case fortunately did not negatively impact on patient care.
    First, there were insufficient materials preplaced in 
northern Virginia for all the contacts we needed to test.
    Second, we had procedures in place to transport specimens 
quickly to our State's lab, but similar procedures didn't exist 
for transportation to the CDC over the weekend.
    And, third, all hospitals in northern Virginia are equipped 
with isolation rooms, but there is limited additional surge 
capacity to handle an epidemic of respiratory diseases in the 
region. If there had been many suspected SARS cases presented 
to hospitals throughout the region, it would have been 
difficult to appropriately isolate all potentially contagious 
    There are many challenges currently facing local health 
departments. In addition to an increasing demand for our core 
environmental health and safety net medical services, our staff 
are responding to new naturally occurring threats such as West 
Nile Virus, as well as preparing for the potential of chemical, 
biologic, or radiologic attacks.
    Our federally funded local and regional epidemiologists 
were crucial to the successful handling of this country's first 
suspect SARS case. Appropriate funding, training, and 
leadership are essential to meeting the ongoing and emerging 
public health challenges facing our communities. Equally 
important, though, is the need to continuously work to maintain 
and improve effective communication with all our community 
stakeholders and with related agencies at
the regional, State, and Federal levels.
    I thank you again, and I would be happy to address any 
questions you may have.
    Chairman Tom Davis. Thank you very much.
    [The prepared statement of Dr. Goodfriend follows:]
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    Chairman Tom Davis. Let me start the questioning with Dr. 
Goodfriend. When did the Federal Government inform the County 
Health Department of the potential threat of SARS?
    Dr. Goodfriend. SARS as a syndrome? Well, we were aware of 
unusual pneumonias before the diagnosis of SARS came out----
    Chairman Tom Davis. Right.
    Dr. Goodfriend [continuing]. Through a variety of 
    Chairman Tom Davis. But specifically when they identified 
SARS, how long did it take them to get the word to you in 
    Dr. Goodfriend. When it came out in mid-March, actually we 
heard about it when the rest of the world heard about it as a 
syndrome. It was only in retrospect that we went back and 
looked at this case, when we saw what the case definition that 
the CDC and the World Health Organization had for SARS, and 
realized that this patient actually did meet the case 
definition for SARS.
    Again, this patient became symptomatic in the beginning of 
February, and SARS as a syndrome didn't come out until mid-
    Chairman Tom Davis. So you had this patient, you started 
treating them, and, frankly, as soon as it was identified the 
Federal Government did--you think was timely in terms of its 
    Dr. Goodfriend. Yes. At the time there was concern of 
unusual pneumonias in Guangdong Province, and particular 
concern of an influenza type called Avian Flu, and that was the 
main reason that we were very concerned at that time. The 
process we went through is we notified our State. The State 
talks to the CDC. And from our view the CDC did exactly what 
they should do for us.
    Chairman Tom Davis. Great.
    Dr. Goodfriend. They provided the expertise and offered 
bodies if we needed them, and in this case we didn't need them 
but they were willing to fly them up that night to us to assist 
in doing the contact investigations.
    Chairman Tom Davis. After handling the SARS case, did your 
Health Department recognize any deficiencies in the 
coordination, the communication, and capacity at this point, or 
did everything go about as well as you could expect?
    Dr. Goodfriend. I think as I said, the communication went 
very well. The patient came in on a Sunday afternoon. Both the 
head of the Emergency Department and our epidemiologist were 
notified that afternoon. The patient was isolated 
appropriately. We then had discussions with the State and with 
the CDC, and the good news is during all that time the patient 
was isolated, so there wasn't a concern of ongoing spread to 
patients in the hospital or staff.
    Chairman Tom Davis. So from your perspective at least the 
dissemination of information on SARS to State and local 
governments, as it applies to you, at least, it was fine?
    Dr. Goodfriend. Yes. And since then I have been very 
impressed with how the CDC has been getting information out. We 
all have a piece of this. The CDC, from our standpoint, has 
been doing a great job. Their Web site, if people haven't seen 
it, on SARS is tremendous, really targeted at different 
individuals. The general public, the health care community, 
public health community--all in different languages.
    The key piece for us is getting that to the local level, 
since many people don't have access to the Internet.
    Chairman Tom Davis. And how did you ensure the safety of 
your own health care workers? For a while you are kind of 
flying blind, not sure what's going on. It doesn't seem to have 
spread to anybody else. Once you found out the type of disease 
it might be or suspected that, obviously you took some steps to 
    Dr. Goodfriend. In this case fortunately we didn't find out 
it was a suspect SARS case until over a month after we came in 
contact with the person.
    Chairman Tom Davis. Right.
    Dr. Goodfriend. But we take the same precautions no matter 
what, whether it is a potential SARS case or a potential 
tuberculosis case. Our nurses are not going to visit someone 
who is coughing without wearing an M-95 mask.
    Chairman Tom Davis. OK. Dr. Hamburg, you stated that micro-
biothreats to health are global problems and really require 
global solutions. What can we do, the United States, to develop 
a worldwide mechanism and solutions that will be followed by 
the nations of the world?
    Dr. Hamburg. Well, I think that SARS represents an example 
of how progress has already been made. The World Health 
Organization I think has been providing critical leadership in 
response to SARS, and we need to continue to support them and 
help add to their capabilities for leadership and coordination 
of global efforts. Through various of our own Federal agencies, 
we can contribute--we have in the past but can do so more 
extensively in the future--to strengthening global disease 
surveillance, both in terms of helping to expand the cadre of 
trained personnel to do disease surveillance and epidemiology, 
to support expanded laboratory capacity around the world, and 
by efforts to better coordinate and integrate communication 
systems so we can both share information about emerging 
problems, we can analyze information as it is available, and we 
can have that important feedback loop as we gain new 
understandings, make sure it gets to where it needs to get for 
action, wherever that may be around the world.
    Chairman Tom Davis. Well, let me ask both you and Ms. 
Heinrich, drawing from your experience with micro-biothreats, 
any feel for whether the SARS virus will continue to spread at 
the same rate, or do you think it will lose strength? Or is 
that an unwritten chapter and it depends how we handle it? Any 
inclination on that?
    Dr. Hamburg. Well, I think your characterization of it as 
an unwritten chapter is exactly apt. We are learning more every 
day. There are some encouraging signs in terms of dropoff, in 
terms of number of cases in certain areas, but we also are 
seeing ongoing spread and cases appearing in new countries and 
new areas, so I think we need to watch it carefully and we need 
to continue to implement some of the control measures that are 
in place, and certainly as we know more about the etiologic 
agent and can develop actual diagnostic tests and even perhaps 
better treatment strategies, we'll have new opportunities to 
enhance our control.
    Chairman Tom Davis. OK. Ms. Heinrich, any reaction?
    Ms. Heinrich. We are really very dependent on infection 
control measures in our emergency rooms, our hospitals, and, as 
Dr. Hamburg says, it could get out of control. It's possible, 
because not all hospitals are as well equipped or as well 
trained as others.
    Certainly in our extensive survey of hospitals we found a 
great deal of variability in how well hospitals are equipped.
    Chairman Tom Davis. Great. All right. Thank you very much.
    Mr. Shays.
    Mr. Shays. Thank you. I think this is a great panel, and I 
am intrigued. We have Ms. Heinrich. You basically have looked 
at what our capacity is in surveillance right now and where we 
are at, and I want to get into it. Dr. Hamburg, basically you 
were the co-chair of this document. Was it completed this year 
    Dr. Hamburg. It was released 3 weeks ago, I think.
    Mr. Shays. I had--before I chaired the National Security 
Subcommittee of this full committee, I chaired the Human 
Resource Committee, and for 4 years we had oversight of HHS and 
CDC and FDA and so on, and I just found the committee 
fascinating. But your executive summary I think should be read 
by everyone in this. It is quite excellent, in my judgment.
    Dr. Hamburg. Thank you.
    Mr. Shays. I want to nail down, to the best we can, where 
we are in the surveillance side of it. Dr. Hamburg, you should 
be able to add, and Dr. Goodfriend, as well. Should I feel 
comfortable right now that we have a real-time sense of what is 
happening all around the United States, or should I feel that 
we have a good sense what's happening maybe in New York City 
and maybe not, and maybe in Washington, and a few places? So 
tell me where do you think we are in that ultimate system, it 
would seem to me, of knowing every hour what the condition is 
in every area around the country. How far away are we from 
    First off, is that something we should want every hour or 
at least every 24 hours? What would be the model?
    Ms. Heinrich. I'll start with an initial response to the 
question. What we found again is that it is highly----
    Mr. Shays. Before we know what we found, I want to know 
what the model should be. What is our target? What do we want 
to achieve ultimately. So tell me what you think we want to 
achieve, each of you, in terms of surveillance, monitoring, so 
    Ms. Heinrich. If it were possible, you'd want to have very 
fast reporting from hospitals, emergency rooms to the State or 
local health department, and that would go quickly to CDC so 
that you could, in fact, analyze the overall picture.
    Mr. Shays. So CDC should be the one to capture this 
    Ms. Heinrich. Well, it should be captured at the State 
level, as well as at the CDC level.
    Mr. Shays. Goes to State and then--and this should be able 
to happen, transmitted pretty instantly. So would we want to 
have an update every hour, every 3 hours, every 10 hours? 
First, Ms. Heinrich, what do you think? And if you don't have 
an opinion, that's fine.
    Ms. Heinrich. Yes. Well, it depends on what kind of 
electronic systems you have for reporting from the hospitals, 
and what you don't have then in that equation is your private 
physicians or physician groups, and they are another component.
    Mr. Shays. I don't want to know the obstacles yet. I want 
to know what we want to achieve and then I want to--Dr. 
    Dr. Hamburg. Well, perhaps I can offer some perspectives. I 
think we need to recognize that disease surveillance serves 
many important purposes, and it needs to be done in a variety 
of different complementary and integrated ways to give us the 
best possible picture. We want to use disease surveillance to 
detect emerging problems as early as possible so that we can go 
in and investigate them and implement what needs to be done.
    We also want disease surveillance to give us the tools to 
monitor trends over time in disease that allows us also to get 
a sense of whether our interventions are making a difference.
    I think what we need to do--and it needs to be done on a 
regional as well as a national level, but I think that you are 
absolutely right that CDC must play an absolutely central role, 
and that we have to recognize that, especially with infectious 
disease threats, they don't respect State borders. We need to 
have harmonized disease tracking standards, data collection 
standards, etc.
    Mr. Shays. But should the data collection be updated every 
hour, every----
    Dr. Hamburg. What we need is a system that will allow us to 
collect information in an ongoing way that reflects information 
about diseases in a community, but we also need a system that 
allows us to get that early warning about an emerging problem 
that may not yet even have a name.
    Mr. Shays. Right.
    Dr. Hamburg. So we need to continue and strengthen 
traditional disease reporting, notifiable disease reporting. We 
need to enhance that with better diagnostics and information 
technology that will allow us to use electronic patient records 
and electronic laboratory reporting that can feed right into 
health departments at the local, State, and Federal level.
    We also need to pursue new tools of surveillance, the so-
called ``syndromic surveillance,'' that allows us to really tap 
into various kinds of data bases to give us that early warning. 
It may be over-the-counter sales of anti-diarrheal medications 
to tell you something is going on in the community where people 
haven't even gone in to see their doctors. We need to monitor 
visits to emergency rooms, ambulance runs, etc., so that we 
can, if there's unusual symptoms or patterns emerging, we can 
catch them early.
    Mr. Shays. I understand why we want to do that. I do. And I 
understand, just from reading your summary in the publication--
you point out, for instance, AIDS is natural causes, not 
terrorist induced, 20 million people have died, many are 
infected. If we had a better surveillance system worldwide, 
clearly in the United States but worldwide, would we have been 
able to do so much more than we ultimately--would the condition 
of AIDS today be very different?
    Dr. Hamburg. I think AIDS is an interesting example because 
it speaks to the fact that it depends on not just collecting 
information but the appropriate recognition of the importance 
of that information and the response. I think, had we 
understood decades ago, when the first cases of so-called 
``Slim Disease'' were being reported out of Africa that this 
might have important international public health significance 
and really taken a greater interest in that, we might have 
gotten a huge head start on our understanding of HIV/AIDS. If 
you look at West Nile, it was a couple of astute clinicians who 
really triggered the investigation, not a fancy surveillance 
system. You need an infrastructure of systems in place, but you 
also need educated and trained personnel.
    Mr. Shays. My time has run out times 10, and I know Mr. 
Waxman is--but with the indulgence of the Chair and Mr. Waxman 
I just want to nail down this one issue. I have a briefing that 
I have to go to at 1. I want to understand, one, is this a--and 
it doesn't take a long answer on this--is this a meaningful and 
absolute requirement that we have a nationwide surveillance 
system? And if we did, would we be able to protect the American 
people in a very significant way? And I'd like all of you to 
answer that question.
    Dr. Hamburg. Well, in my view the answer to your question 
is yes, but it is not one system, it is a system of systems 
that are integrated, coordinated, and harmonized.
    Mr. Shays. Fair enough. Ms. Heinrich.
    Ms. Heinrich. And I do want to emphasize that there has 
been progress made in terms of our States, counties----
    Mr. Shays. Right.
    Ms. Heinrich [continuing]. Moving toward an electronic 
system. But you keep use the term ``real time.'' It is not real 
time. You're still--it's passive. You are depending on 
clinicians, hospitals voluntarily reporting.
    Mr. Shays. Dr. Goodfriend.
    Dr. Goodfriend. I agree with what has previously been said. 
From our view and our experience since we have been doing 
syndromic surveillance since September 12, 2001, it missed 
anthrax. It's not good at this point enough, with what we're 
doing, to pick up a sentinel event, one strange case. So we're 
attacking it on two fronts--one is making the surveillance 
better and removing to a better system so that we have one 
system for all the national capital region, and second is 
keeping people educated, as was said, so when they do see 
something strange, someone in pneumonia in a postal worker, 
they'll give us a call, and that's the best way they'll pick it 
    Mr. Shays. Thank you for the Chair's indulgence.
    Chairman Tom Davis. Thank you very much.
    Mr. Waxman.
    Mr. Waxman. Thank you, Mr. Chairman.
    Dr. Hamburg, the Institute of Medicine concluded just last 
month that the U.S. public health system is in a state of 
disrepair and is vulnerable to an emerging epidemic, and I 
asked Secretary Thompson about this finding this morning. He 
said that, while there is always more to be done, HHS has 
significant funding available to send to States and to patch 
holes in the system. I'd like to ask you your opinion. Do you 
think that the funds now available to States are sufficient to 
fix the public health care system and protect us to the maximum 
extent possible against SARS?
    Dr. Hamburg. Well, I think we have made progress, but it 
needs to be understood that our public health system has 
suffered from years of underfunding and neglect. We have a 
great deal that needs to be done to build fundamental 
capabilities in many parts of our country, and certainly 
looking internationally it's even more true. So we have a need 
for a sustained investment of resources to build a set of 
critical needs. I think your concerns about the competing 
demands and priorities created by the smallpox immunization 
campaign and other things is a very real one. We have at the 
moment a fragile set of systems and we don't have adequate on-
the-ground personnel to use all of that money and to put in 
place some of these programs. We're going to have to build this 
over time. It is going to be an incremental process.
    I think we also have to recognize that, while there was a 
chunk of new money for bio-defense, and very important in terms 
of strengthening the public health infrastructure at the State 
and local level, there have been cuts in other critical 
components of CDC activity and other activity that is necessary 
to help support our public health system and our medical care 
system to respond to a naturally occurring or a bioterrorist 
threat, and there are very significant cuts, as I'm sure you 
know, severe fiscal constraints at the State and local level, 
which has caused the overall dollars available for public 
health at the State and local level to be compromised.
    So I think we're moving in encouraging directions, and I am 
just astounded and delighted by the renewed appreciation of the 
importance of public health and the necessity to fund it, but 
we certainly are not there yet. We can't be complacent that 
we're doing enough. And I think Congressman Shays suggested we 
better use SARS as yet another wakeup call to make sure that we 
do the things that need to be done, and they can be done, and 
they will afford us broad health protection, greater public 
safety, and strengthen our national and international security.
    Mr. Waxman. Ms. Heinrich, your findings on hospital 
preparedness are striking. It is startling to think that our 
Nation's health care system may have trouble handling a surge 
of severe respiratory illnesses. This morning Secretary 
Thompson expressed enthusiasm about additional funding that 
will be available or is already available to the States. Will 
the funding now available to States, localities, and hospitals 
significantly increase the capacities of hospitals to care for 
SARS patients?
    Ms. Heinrich. The money that is currently available to the 
States to work with hospitals is primarily for planning 
purposes, so what States reported to us is that they were 
planning to plan, if you will. So what they're beginning to do 
is identify the needs.
    When we went out with our survey of hospitals, we found 
that the hospitals had planned or have plans in place, they 
were beginning to coordinate with other local agencies in that 
planning process. They have done some training, but they have 
not, in fact, expanded their facilities for isolation purposes, 
for example, and they had not invested in equipment such as 
    Mr. Waxman. So we have funding for planning, but we don't 
have funding to deal with the actual demand that the hospitals 
are going to be placed under with an epidemic like SARS?
    Ms. Heinrich. Not so far.
    Mr. Waxman. So far. And the House appropriated $95 million 
in the emergency supplemental for implementing the smallpox 
vaccination program. Will this money be sufficient to allow the 
States to carry out this vaccination program without forcing 
the States to sacrifice funding for other public health care 
    Ms. Heinrich. What we had found when we reviewed the 
progress reports of the States that we had visited for the 
report that we did on State and local preparedness, we found 
that at least two of the States had already committed their 
moneys, over 70 percent. By now it would be much higher than 
that. And most of the States we visited had committed over 50 
percent. So I would suggest that from that Federal money many 
States and certainly the counties would not have the additional 
funds for the smallpox program.
    Mr. Waxman. So they're going to have to take funds from 
what they'd spent on their core public health programs to help 
pay for the deficit in the money for smallpox?
    Ms. Heinrich. They'd have to find it from something. Maybe 
our county health officer can tell us how he has managed.
    Mr. Waxman. I want to hear from him, but let me ask him the 
question maybe, then he can further elaborate on this issue. In 
your testimony you said the hospital system in Loudoun County 
might not be able to handle a large respiratory outbreak. How 
many critically ill SARS patients would you be able to handle 
without being overwhelmed, and would Federal support to 
increase the capacity to care for victims of an epidemic be 
essential because of the cutbacks at the State and local levels 
on funding for health issues?
    Dr. Goodfriend. Well, Loudoun Hospital Center has two 
isolation rooms in their Emergency Department and five 
isolation rooms on the floor, and definitely we want SARS 
patients, if they are going to be hospitalized, to be in 
isolation, but there are other patients that also may need to 
be in isolation--active tuberculosis cases and others that may 
have unusual pneumonia--so you may not have all of those rooms 
    If there were multiple cases, we'd have to look elsewhere 
of where we would have those people separate from the rest of 
the hospital community. But, as you can see, with that small 
number of beds in our county--and it is probably a very similar 
answer in surrounding counties--it doesn't take many cases to 
overwhelm that system.
    Mr. Waxman. So what we have is a public health 
infrastructure that has been neglected for some period of time. 
Federal Government has now appropriated money to deal with 
smallpox but not enough. The States are squeezed because of the 
recession and their lack of revenues, so they are cutting back 
on health care infrastructure expenditures. And we're looking 
at a new epidemic of SARS that could overwhelm the whole 
hospital system in your county and maybe the whole public 
health system throughout the Nation. Is that a fair statement 
of where we are?
    Dr. Goodfriend. Well, if I could say it from my 
    Mr. Waxman. Yes.
    Dr. Goodfriend [continuing]. One of the things we look for 
and why we do surveillance is to make that difference between 1 
person with SARS in your community or 50 people.
    Mr. Waxman. Sure.
    Dr. Goodfriend. And so we want to get that one person not 
only identified and isolated as quickly as possible----
    Mr. Waxman. Prevent it spreading. Sure.
    Dr. Goodfriend [continuing]. But so that we don't have that 
problem. And so far the good news is that we haven't seen that 
as a problem here, and probably for various reasons in 
different communities. And I think from our community I think 
it was because the person was isolated quickly. And again it is 
the same thing that we do every day with tuberculosis--keeping 
the active person with tuberculosis away from others so we 
don't have 10----
    Mr. Waxman. Tuberculosis we know about, SARS is new, and it 
is spreading rapidly. And while we certainly need to detect the 
one case to prevent others, we may not be able to control it 
because it is an international epidemic that is moving very 
rapidly. And my concern is whether you are going to be able to 
deal with that epidemic should it hit.
    Dr. Goodfriend. And there are two related issues. The 
public health issue related to that is how do we identify them 
and make sure they're isolated somewhere, which is a little 
different from the hospital's capacity issue of where to put 
them. Hopefully, in theory if people are communicable but 
otherwise doing well, they don't have to necessarily be in a 
hospital and so don't have to use an isolation bed, because 
again, at this point, as far as we've been told, if people are 
doing pretty good there's not much treatment we're going to 
offer them anyway in the hospital aside from isolating them 
from others.
    From our perspective we have been beefed up with 
bioterrorism dollars with two positions, and that has helped us 
with this because our epidemiologist, although she was hired to 
do smallpox and Ricin, has been very busy doing malaria and 
West Nile and SARS.
    But, going to your point of the other functions, we have 
cut back on some of the other things we have been doing in 
order to meet this need, and that's what we always do in public 
health. Again, going back to tuberculosis, whether we need to 
take our nurses out of the clinic to do directly observed 
therapy on people in the community, whether it's investigating 
malaria, whether it is investigating SARS, that takes nurses 
out of providing care for pregnant women or providing 
immunizations to children, and that has happened to us in 
Loudoun County.
    Mr. Waxman. Thank you.
    Thank you very much, Mr. Chairman.
    Chairman Tom Davis. Thank you very much.
    Mr. Janklow.
    Mr. Janklow. Thank you very much, Mr. Chairman.
    Dr. Goodfriend, when I look at the symptoms of SARS--fever, 
chills, headache, body aches, and a dry cough--and at this 
point in time there's no test for it, I think those symptoms 
describe most maladies that people get at different times of 
the year. Historically, they tell you to take a couple of 
aspirin. As a matter of fact, the aspirin bottle describes all 
of these as things that they can deal with. So, I mean, my 
question is: first of all, what percent of people--and maybe 
Dr. Hamburg, you or Ms. Heinrich know--what percent of the 
people so far that have contacted SARS have been hospitalized, 
because we're talking about overwhelming the system. What 
percent have had to be hospitalized? I know some have to be 
incubated and ventilated, but does anybody know the percentage?
    Dr. Goodfriend. I don't know.
    Dr. Hamburg. I don't actually know.
    Mr. Janklow. Pardon?
    Dr. Hamburg. I don't know. I apologize.
    Mr. Janklow. OK. And when we talk about the surveillance 
system that we have in place, out there are an immense number 
of facilities--county health laboratories, city health 
laboratories, State laboratories, Federal through the military 
and other laboratories. We have a lot of laboratories. We talk 
about the collaboration that we have, and everybody has got 
regional associations. I mean, part of our problem is that we 
don't have a history in this country of serious outbreaks until 
of recent vintage. We have been able to stay on top of it, and 
I think you, Dr. Hamburg, talk about that in your presentation. 
In today's world where we have extraordinary increase in 
travel, the urban settings the way they are, agricultural 
practices, the continuing difficulties of translating existing 
medical knowledge--I mean, all of these things have changed the 
dynamic as they come together of these new emerging sicknesses, 
diseases, and weapons, if I can use it that way.
    How do we really devise a system, given what we have today? 
And I'll ask all of you, how do we devise a system to really 
get the kind of surveillance and reporting that we need? And, 
Dr. Goodfriend, I think you highlighted it very well. I don't 
think anybody could question the competence of you and your 
organization, and as you said, ``We noticed some additional 
pneumonia type things, but nobody had it figured out.''
    Obviously, you work off of clusters, but how do we really 
bring about this coordinative collaboration that is necessary 
for survival?
    Ms. Heinrich. Let me try to answer first. One of the things 
that is happening at the local level is that they are beginning 
to link their clinical laboratories with the State 
laboratories. One of the issues is not all laboratories are 
equipped and trained to be able to identify all kinds of 
biological agents.
    Mr. Janklow. But there isn't enough money in America to 
equip all the laboratories----
    Ms. Heinrich. And so some of----
    Mr. Janklow [continuing]. With all the equipment they have 
to have to deal with all the biological agents.
    Ms. Heinrich. Right, and so we are beginning to see some 
regionalization, and that's also where CDC comes in with their 
expertise and actually taking a real lead in having special 
laboratories and people that have special training. There's 
also then the linkages with a worldwide network, and I think we 
have seen that working especially well with SARS.
    Mr. Janklow. If I can modify my question a little, if we 
were designing a system from scratch, would it look like what 
we're starting to work with today?
    Ms. Heinrich. I think that we are a very pluralistic 
society and our public health system is as pluralistic as other 
aspects of society.
    Dr. Hamburg. If I can make an attempt to answer your 
question, which is a big one, you are absolutely right: in the 
world we live in today, we need to expect that we are going to 
be facing a whole array of new infectious disease threats, the 
resurgence of old ones, and possibly the intentional use of 
biological agents as weapons, and so we need--and we have 
limited resources to make a difference. So we need to really 
try to build systems that will make us better able to prevent, 
detect, and respond to what is an uncertain but significant set 
of future threats.
    I think the basic framework that we are trying to build on 
today is the right one--to strengthen disease surveillance, 
extend it, and also to bring new tools for better surveillance 
to give us new capacities for early warning. To support that, 
you have to have trained personnel, you have to strengthen 
laboratories, and on a regional basis you're right--not every 
laboratory can do each and every diagnostic test, but we need 
to have regional capacities that are significantly upgraded, 
and we need to have systems so that people know, when they see 
an unusual case, when they have a specimen that may require 
special attention, that they know how to feed into the system 
so that it will get the attention that it needs.
    We also need to dramatically improve the ability of all the 
different levels of government and the private partners--
because a lot of health care in this country is in the private 
sector, clearly--we need to enhance those communication systems 
and bring to bear, you know, the tools of the Information Age 
on our activities. We also have to support a short-term and 
long-term research agenda because we need better diagnostics, 
we need new drugs and----
    Mr. Janklow. If I could, let me add one other factor. My 
time is up, but I need, if I could, add one other factor. 
Historically we have dealt with what I'll call the ``normal 
progression'' of sickness, illness, whether it starts in a 
village some place and moves slowly or, as you say, Dr. 
Hamburg, as you delineate here in your testimony, far more 
rapidly in a world where everybody is on an airplane. But we've 
got to add a new dimension to that now, and that is someone who 
gets on an airplane, or many someones, and travels the world to 
deliberately spread an illness will change in a phenomenal way 
the dynamic of how disease spreads and the number of people 
that are going to contract the illness at a particular point in 
time. That will overwhelm any system that anybody can devise.
    What can we do? Is there anything we need to do in the law, 
other than funding--let's take funding and put it on a shelf 
for a second. Is there anything that we need to do in terms of 
national law--let me ask all three of you--that will better 
facilitate the investigation or the determination of a new 
illness that's circulating some place around the globe? What 
can we do? Is there anything we can do other than money? And I 
realize money is important, but, you know, is there anything 
else we can do, or is everything else fine?
    Dr. Hamburg. Well, certainly building greater global 
cooperation and collaboration is key, you know. If we had 
fuller disclosure of what was going on in Guangdong Province 
back in the fall, I think the opportunity to much more rapidly 
understand what was going on and contain spread might have----
    Mr. Janklow. No, but I mean we the Congress. Is there 
something we can do? Is there a law we can pass? Is there a 
hearing we can hold? Is there something we can do to facilitate 
the solution to this type of problem?
    Dr. Hamburg. Well, a lot of it does have to do with money. 
I mean, you know, we do know a lot about what needs to be done 
    Mr. Janklow. That's on the shelf.
    Dr. Hamburg [continuing]. And it needs to be done. I think, 
you know, that there are opportunities to look at other 
important components of the problem and controlling disease 
that are outside of some of the stuff we have been talking 
about now with respect to strengthening the public health 
infrastructure and the health care system to respond and the 
research base. For example, just one example, but Congresswoman 
Maloney mentioned about airplane travel, and you raised it 
again. And while, you know, we have not seen a lot of spread on 
the airplanes of SARS to date, it certainly is a concern, and 
we may learn more about it as time goes on, but, you know, a 
systematic look at some of the environmental conditions that 
may either help to reduce or help to foster spread is 
    When I was health commissioner in New York City, we were 
dealing with an epidemic of tuberculosis and greatly concerned 
about possible transmission on airplanes, and what I understood 
at that time was that we had actually reduced our protections 
in terms of how air was handled, making us more vulnerable to 
potential spread of disease on airplanes. Airlines don't need 
additional costs at the moment, that's for sure.
    But, you know, I do think, you know, for example, looking 
at some of the environmental conditions, ventilation systems on 
airplanes and in buildings is important in terms of other 
protections that might be important, and there are other 
examples like that where you can look at where are some of our 
vulnerabilities and how can we shore them up. Public health and 
medical care is a critical component, but there are other 
elements, as well.
    Mr. Janklow. Thank you very much. Thank you, sir.
    Chairman Tom Davis. Thank you very much. I appreciate very 
much your testimony here today. It has been helpful to us. Let 
me just kind of ask a question. How can we upgrade our current 
health capacities at the local and the State level, where most 
of the response to bio-terrorism attack or infectious disease 
outbreak would occur? I mean, it is the local level that is 
going to have to respond. We have the Center for Disease 
Control. We can have outreach and everything else at the 
Federal level, and that's important. Is there anything else we 
can do at the local level? I mean, we're sending money. It is 
not all spent. Any of you have any thoughts on that?
    We'll start with you, Ms. Heinrich, as you issued the 
    Ms. Heinrich. Well, certainly one of the things that we 
found after doing our work and talking with local officials is 
they did say that they wanted more guidance from CDC. And the 
other thing that they said is that they really wanted to know 
about best practices. In other words, what have other 
communities done that really works well and how can we learn 
from that. And so I would think that focusing some resources to 
make that happen would be very helpful at the local level.
    The other thing they need--and I don't know how, you know, 
we assure this, but to really make some of the big changes that 
they have to put in place, they need the sustained funding. 
Sorry about the dollars here, but they can't hire people if 
they can't guarantee the person that they will be employed for 
more than a year, and that's especially true for highly trained 
epidemiologists, nurses, across the board--laboratory 
technicians. And I think that's harder, the work force. The 
trained work force issue is harder for them than even upgrading 
a laboratory.
    Chairman Tom Davis. Dr. Goodfriend, would you agree with 
    Dr. Goodfriend. I do agree. And one of the challenges in 
public health--and I've worked in various settings, in the 
military and Federal and State and rural before coming here--is 
every local health department is different, and what will help 
them is very different. There are many health departments who 
don't have a physician full time employed. They are contracted 
out to sign off on forms, which makes it very difficult to have 
those communications. And we know that smallpox can show up as 
easily in Washington, DC, as it can in southwest Virginia or in 
the midwest.
    From my standpoint, the funding with the fewest strings 
attached is the best way that we can use it, and in our case in 
Loudoun County we would use that funding to improve training, 
to improve education with not only our local health care 
providers, but our fire rescue people who are at the front 
lines of all this, our school nurses who are maybe the first 
ones to find it in the student coming in to work, and our local 
officials, etc.
    Chairman Tom Davis. All right. Well, thank you all very 
much. I want to thank all the witnesses for their testimony 
today. I'd like to thank the committee staff that worked on 
this hearing from the majority and the minority staff.
    This hearing is now adjourned. Thank you.
    [Whereupon, at 2:12 p.m., the committee was adjourned, to 
reconvene at the call of the Chair.]
    [The prepared statement of Hon. Edolphus Towns and 
additional information submitted for the hearing record