[Senate Hearing 108-74]
[From the U.S. Government Publishing Office]



                                                         S. Hrg. 108-74

          SARS: HOW EFFECTIVE IS THE STATE AND LOCAL RESPONSE?

=======================================================================


                                HEARING

                               before the

                PERMANENT SUBCOMMITTEE ON INVESTIGATIONS

                                 of the

                              COMMITTEE ON
                          GOVERNMENTAL AFFAIRS
                          UNITED STATES SENATE


                      ONE HUNDRED EIGHTH CONGRESS

                             FIRST SESSION

                               __________

                              MAY 21, 2003

                               __________


      Printed for the use of the Committee on Governmental Affairs



    Available via the World Wide Web: http://govt-aff.senate.gov or
                        www.senate.gov/~govt-aff



88-251              U.S. GOVERNMENT PRINTING OFFICE
                            WASHINGTON : 2003
____________________________________________________________________________
For Sale by the Superintendent of Documents, U.S. Government Printing Office
Internet: bookstore.gpr.gov  Phone: toll free (866) 512-1800; (202) 512ï¿½091800  
Fax: (202) 512ï¿½092250 Mail: Stop SSOP, Washington, DC 20402ï¿½090001

                   COMMITTEE ON GOVERNMENTAL AFFAIRS

                   SUSAN M. COLLINS, Maine, Chairman
TED STEVENS, Alaska                  JOSEPH I. LIEBERMAN, Connecticut
GEORGE V. VOINOVICH, Ohio            CARL LEVIN, Michigan
NORM COLEMAN, Minnesota              DANIEL K. AKAKA, Hawaii
ARLEN SPECTER, Pennsylvania          RICHARD J. DURBIN, Illinois
ROBERT F. BENNETT, Utah              THOMAS R. CARPER, Delaware
PETER G. FITZGERALD, Illinois        MARK DAYTON, Minnesota
JOHN E. SUNUNU, New Hampshire        FRANK LAUTENBERG, New Jersey
RICHARD C. SHELBY, Alabama           MARK PRYOR, Arkansas

           Michael D. Bopp, Staff Director and Chief Counsel
     Joyce Rechtschaffen, Minority Staff Director and Chief Counsel
                     Darla D. Cassell, Chief Clerk

                                 ------                                

                 PERMANENT COMMITTEE ON INVESTIGATIONS

                   NORM COLEMAN, Minnesota, Chairman
TED STEVENS, Alaska                  CARL LEVIN, Michigan
GEORGE V. VOINOVICH, Ohio            DANIEL K. AKAKA, Hawaii
ARLEN SPECTER, Pennsylvania          RICHARD J. DURBIN, Illinois
ROBERT F. BENNETT, Utah              THOMAS R. CARPER, Delaware
PETER G. FITZGERALD, Illinois        MARK DAYTON, Minnesota
JOHN E. SUNUNU, New Hampshire        FRANK LAUTENBERG, New Jersey
RICHARD C. SHELBY, Alabama           MARK PRYOR, Arkansas

                   Joseph V. Kennedy, General Counsel
        Elise J. Bean, Minority Staff Director and Chief Counsel
                     Mary D. Robertson, Chief Clerk


                            C O N T E N T S

                                 ------                                

                                                                   Page

Opening statements:
    Senator Coleman..............................................     1
    Senator Collins..............................................     4
    Senator Levin................................................     8
    Senator Lautenberg...........................................    18

                               WITNESSES
                        Wednesday, May 21, 2003

Julie L. Gerberding, M.D., M.P.H., Director, Centers for Disease 
  Control and Prevention, Department of Health and Human 
  Services, Atlanta, Georgia.....................................    10
Anthony S. Fauci, M.D., Director, National Institute of Allergy 
  and Infectious Diseases, National Institutes for Health, 
  Department of Health and Human Services, Bethesda, Maryland....    12
Michael T. Osterholm, Ph.D., M.P.H., Director, Center for 
  Infectious Disease Research and Policy, University of 
  Minnesota, Minneapolis, Minnesota..............................    14
Rodney N. Huebbers, President and Chief Executive Officer, 
  Loudoun Hospital Center, Loudoun Healthcare, Inc., Loudoun 
  County, Leesburg, Virginia.....................................    24
Thomas R. Frieden, M.D., M.P.H., Commissioner, New York City 
  Department of Health and Mental Hygiene, New York, New York....    26
Mary C. Selecky, Secretary, Washington State Department of 
  Health, Olympia, Washington, and President, Association of 
  State and Territorial Health Officials.........................    28
Lawrence O. Gostin, Director, Center for Law and the Public's 
  Health, Georgetown University Law Center, Washington, DC.......    36
Bruce R. Cords, Ph.D., Vice President, Environment, Food Safety 
  and Public Health, Ecolab Inc., St. Paul, Minnesota............    38
Vicki Grunseth, Chair, Metropolitan Airports Commission, 
  Minneapolis, Minnesota.........................................    40

                     Alphabetical List of Witnesses

Cords, Bruce R., Ph.D.:
    Testimony....................................................    38
    Prepared statement...........................................   121
Fauci, Anthony S., M.D.:
    Testimony....................................................    12
    Prepared statement...........................................    58
Frieden, Thomas R., M.D., M.P.H.:
    Testimony....................................................    26
    Prepared statement...........................................    86
Gerberding, Julie L., M.D., M.P.H.:
    Testimony....................................................    10
    Prepared statement...........................................    47
Gostin, Lawrence O.:
    Testimony....................................................    36
    Prepared statement...........................................   101
Grunseth, Vicki:
    Testimony....................................................    40
    Prepared statement...........................................   125
Huebbers, Rodney N.:
    Testimony....................................................    24
    Prepared statement with additional testimony attached........    73
Osterholm, Michael T., Ph.D., M.P.H.:
    Testimony....................................................    14
    Prepared statement...........................................    68
Selecky, Mary C.:
    Testimony....................................................    28
    Prepared statement...........................................    94

                                APPENDIX
                              Exhibit List

1. GDiagrams prepared by the Centers for Disease Control and 
  Prevention (CDC):
      a. GU.S. Reported Suspect and Probable SARS Cases..........   130
      b. GU.S. Probable SARS Cases...............................   131
2. GHealth Alert Notice, pamphlet prepared by the Centers for 
  Disease Control and Prevention (CDC)...........................   132
3. GCharts prepared by the National Institutes of Health:
      a. GExamples of Emerging and Re-Emerging Diseases..........   133
      b. GCoronaviruses..........................................   134
      c. GNIH Research on Cronaviruses/SARS......................   135
4. GFiscal Year 2003, Public Health Emergency Preparedness and 
  Hospital Preparedness Funding by State, Selected 
  Municipalities, Territory, chart prepared by Department of 
  Health and Human Services......................................   136
5. GNow To Confront A Greater Enemy, article written by Dr. Elin 
  Gursky, Senior Fellow for Biodefense and Public Health at the 
  ANSER Institute for Homeland Security, April 2003..............   138
6. GSARS And Its Implications For U.S. Public Health Policy--
  ``We've Been Lucky,'' Issue Report prepared by Trust for 
  American's Health, May 2003....................................   141
7. GStatement for the Record of the American Public Health 
  Association....................................................   153
8. GStatement for the Record of Discovery Laboratories, Inc......   159
9. GCorrespondence from Ecolab Inc. to the Permanent Subcommittee 
  on Investigations, dated July 1, 2003, relaying Ecolab's 
  recommendations on how the U.S. can be better prepared should 
  an outbreak of SARS reoccur in the United States...............   169

 
          SARS: HOW EFFECTIVE IS THE STATE AND LOCAL RESPONSE?

                              ----------                              


                        WEDNESDAY, MAY 21, 2003

                                   U.S. Senate,    
              Permanent Subcommittee on Investigations,    
                  of the Committee on Governmental Affairs,
                                                    Washington, DC.
    The Subcommittee met, pursuant to notice, at 9:04 a.m., in 
room SD-342, Dirksen Senate Office Building, Hon. Norm Coleman, 
Chairman of the Subcommittee, presiding.
    Present: Senators Coleman, Collins, Levin, Carper, and 
Lautenberg.
    Staff Present: Joseph V. Kennedy, General Counsel; Elise J. 
Bean, Democratic Staff Director/Chief Counsel; Mary D. 
Robertson, Chief Clerk; Laura Stuber, Democratic Counsel; 
Priscilla Hanley (Senator Collins); John Myers (Senator 
Specter); Marianne Upton and Rianna Brown (Senator Durbin); Bob 
Hall (Senator Dayton); Tate Heuer (Senator Pryor); Kate Eklund, 
Jason Hill, Dan Mullkoff, and Ahmed Khalil (Senator Levin); 
Rebecca Mandell (Senator Lautenberg); and Josh Handler (Senator 
Akaka).

             OPENING STATEMENT OF CHAIRMAN COLEMAN

    Senator Coleman. Good morning. We are going to call this 
hearing of the Permanent Subcommittee on Investigations to 
order. I want to thank everybody for attending my first hearing 
as Chairman of the Permanent Subcommittee on Investigations in 
our Nation's capital.
    Today, we address the issue of SARS. We address it from the 
vantage point of the ability of our Nation to address this, and 
future threats, at a local and State level. We address it from 
my stated position that it is my hope that this Subcommittee 
can find ways to improve and reform areas of American life, to 
improve our lives, and to make us safer and more secure.
    And today, against the backdrop of a Nation at war--with 
the national terror warning raised to its second-highest 
level--let us be clear that the stakes facing our Nation, and 
our world, could not be higher. Our ability as a Nation, to 
defend ourselves, against all enemies--foreign or domestic--or 
even Mother Nature--depends on our commitment to preparedness.
    The front lines of our Nation's war against nature's terror 
of communicable disease are, and will be, local governments. As 
a former mayor, I understand that. I will never forget that. 
The ability of our Nation to defend itself from the terror 
inflicted by man through the use of chemical or biological 
weapons of mass destruction will be through the efforts of 
local government officials.
    My friends, while there has been and remains great tragedy 
across the world as a result of SARS, and as Secretary of 
Health and Human Services Tommy Thompson warns us, America is 
not yet safe from SARS, let me say this. I believe we got lucky 
this time.
    While preparations on the war on terror have better 
positioned us to respond to threats and potential threats such 
as SARS, a confluence of events spared our Nation from the 
tragedy that has visited others such as Canada, Taiwan, and 
China, a tragedy that not only takes people's lives but is also 
halting their lives.
    For example, since SARS has emerged as a disease to be 
reckoned with, adoptions of Chinese children by Americans have 
been halted. In Toronto, untold economic damage has been 
sustained because of potentially unnecessary reactions to SARS 
on the part of organizations responsible for addressing the 
disease. We need to remember that SARS was not the worst 
disease that has ever plagued civilization, either in terms of 
ability to spread or its mortality. Even as we dealt with SARS, 
the World Health Organization was battling cases of Ebola and 
avian flu elsewhere in the world.
    As I am sure our panel of distinguished experts will 
attest, the evolution and transmission of the next disease is 
not a question of ``if,'' it is simply a matter of ``when,'' 
and I believe they will tell you that SARS is not yet done. It 
may mutate. It may become worse. It is not yet done killing.
    Nor are new diseases that will appear in our future, and 
when they do, our ability to contain them and survive them will 
largely depend on local responders who treat the first cases. 
It is vital that we continue our investments in making sure 
that these responders have the resources, training, and support 
necessary to protect us. In an era when even a few hundred non-
lethal cases imposed significant social and economic costs, we 
should regard these investments as prudent insurance against 
both intentional and naturally-occurring threats to our health.
    When a new disease such as SARS or the West Nile virus hits 
local communities, several things have to happen. First, local 
doctors need to know how to recognize that something new is 
happening and need to know who to turn to for information and 
support.
    Second, at the national and international levels, agencies 
must quickly develop information about the characteristics of 
the disease in order to treat patients and prevent its spread. 
The World Health Organization, the National Institutes for 
Health, and the Centers for Disease Control and Prevention 
perform this role well.
    Third, and this is most important, in my opinion, the 
information these agencies develop must be transmitted back to 
mayors, hospital administrators, and airport officials so that 
doctors, airline attendants, researchers, and average citizens 
know what to do in order to protect themselves.
    In the end, our goal ought to be to develop a national 
response, predicated on the understanding that the bulwark of 
that response is going to be at the local level--and by local 
government and elected officials.
    And that they must have the resources and the cooperation 
of the Federal Government to do so.
    This hearing will focus on the synergy that is necessary 
for an effective national response, driven by the talent and 
know-how at the local level. There are questions we must ask 
and solutions we must seek. There may be laws that must be 
changed and behaviors that must be modified.
    In the end, there can be no mistake that the issues we 
address today may very well shape and form our response to the 
next natural or man-made disease that violates our sense of 
safety as a human race.
    Recently, I sent a letter to the Commissioner of the 
Minnesota Department of Health. The questions I asked her are 
relevant today . . . and remain questions we must address 
locally on a national basis.
    What are States doing to prevent further outbreaks of SARS?
    Have we identified potential risk factors or are there 
segments of our population who are at particular risk?
    What are States and local governments doing to educate 
citizens about SARS and other potentially devastating diseases?
    Are there changes that must be made to our local, State, 
and national quarantine laws?
    Do local officials know where to turn to for information 
and support?
    What should local officials do in the first days and weeks 
when faced with a new disease with unknown characteristics?
    What are the resources available and what are the resources 
needed for local governments to be more effective?
    Are hospitals equipped to treat small numbers of cases and 
do they have the proper isolation facilities to accomplish this 
task?
    What are the plans and strategies of hospitals to handle 
new SARS cases or other potential diseases in the short- and 
long-term?
    Do local and State health departments have the personnel 
and resources they need to respond to potential disease 
threats?
    Today's witnesses will tell us that SARS was a wake-up 
call, and I suspect they also support my belief that, so far, 
we have been lucky.
    On the whole, our response to the outbreak was very good. 
Many of our cases came after the first case in Toronto so that 
local officials were already alert. It is also possible that 
Toronto received a more virulent strain than any of our cities 
experienced.
    We will also see that our responses were aided by the 
effort and resources expended since September 11 and the 
anthrax attacks. Over the past year, cities, States, and 
hospitals have begun preparing for a sudden outbreak of 
infectious disease.
    A recent GAO report indicates that we still have some way 
to go, however. The report found that gaps exist in the disease 
surveillance system and laboratory facilities and that there 
are workforce shortages. It also found that planning for 
regional coordination is still lacking between States, even as 
they develop plans of receiving and distributing medical 
supplies for emergencies. Finally, it found that most hospitals 
around the country lack the capacity to respond to large-scale 
infectious disease outbreaks.
    Our systems did a good job of protecting us this time, but 
we can always do better. In order to improve, we must first 
listen. Today's witnesses represent different parts of the 
national response to infectious disease. They each have a 
different perspective on how the system works.
    In the final analysis, our work is at its initial stages. 
It is my hope that we emerge from this hearing today with a 
sense of hope and confidence that the investments we have made 
in preparation and response are making a difference and that 
those areas that are preventing us from being more responsive 
and effective can be changed.
    As a former mayor, I am well aware of the power of local 
officials to confront and manage the dangers of this new era. I 
also know that those who are here today are eager to offer us 
more than just anxiety, they also offer us hope that we can, as 
a Nation, bear the burden of this new era in a positive and 
results-oriented manner that has been the hallmark of Americans 
for generations.
    With that, I will turn to my distinguished Ranking Member 
and former Chairman of this Subcommittee for his comments. 
Senator Levin.

               OPENING STATEMENT OF SENATOR LEVIN

    Senator Levin. Thank you very much, Mr. Chairman. I commend 
you for convening this hearing. I know that you have had a very 
successful hearing in Minnesota, but this is your first as 
Chairman here in the Nation's Capitol and I congratulate you on 
that and commend you for calling this hearing today on such a 
critical subject.
    The front lines of the SARS battle, as the Chairman has 
mentioned, are drawn at our airports and our home communities, 
at border crossings and hospitals, and at local doctors' 
offices. Local health care providers need training and 
resources if we are going to protect our country from SARS. We 
have been relatively lucky so far, but we need more than luck 
to keep this public health threat under control. We need 
resources and planning.
    Right now, our knowledge of SARS is limited. We don't know 
where the disease comes from. We don't know how to rapidly and 
reliably test its presence. We don't have a cure. But we have 
learned that if we identify SARS patients quickly and isolate 
probable cases, that we can prevent the disease from spreading. 
That means our first and most important line of defense is 
having first responders who are trained to spot SARS symptoms, 
who have adequate resources, and who have workable, sensible 
plans to safeguard the public.
    We know that some countries have done a better job than 
others at preventing the spread of SARS. We know that China was 
not at first up front with its citizens about the disease, and 
as a result, both confusion and the disease have spread. In 
contrast, Vietnam successfully contained a possible SARS 
outbreak through swift action. To protect our own country, we 
need to learn from the experiences of others as well as to 
devise ways to support other countries' efforts to stem their 
SARS infections.
    When we look here at home, the facts paint a complex 
picture of our readiness to fight SARS. On the one hand, we 
have a public health system that is engaged in this battle and 
taking many of the steps that are needed. A few cases are being 
found, and there are no fatalities to date. But on the other 
hand, we have inadequate resources to support the good 
intentions and planning of our health care system.
    In my home State of Michigan, the SARS readiness picture is 
a promising one, but one that requires further support and 
development. Out of a total of 43 persons evaluated in Michigan 
for SARS to date, only four suspected cases have been 
identified. Those cases are being treated with no fatalities to 
date.
    My State of Michigan has taken a number of steps to mount 
an effective response to the SARS threat. It has determined 
that it has legal authority to quarantine individuals posing an 
imminent public threat. The Michigan Department of Community 
Health has assigned responsibility for combating SARS to a 
specific State office, the Public Health Preparedness Office. 
The State has issued guidelines to Michigan hospitals on how to 
identify and treat suspected SARS patients and sends out 
regular E-mail updates to hospitals in all 64 local county 
health departments.
    The University of Michigan Medical School has also taken a 
proactive role. It has created a SARS working group that meets 
weekly and includes representatives from local community health 
departments. The working group has set up a communications line 
called Telecare that takes calls from people with questions 
about SARS.
    These precautions are essential for the reason that they 
are essential everywhere, but also particularly because 
Michigan is the largest single area for border crossings 
between the United States and Canada. To limit SARS risks at 
its border crossings, Michigan is working actively with the 
CDC, Customs, border, and port personnel to screen persons 
entering the United States. If persons crossing the border show 
symptoms of SARS, Michigan and the CDC have designated three 
local health departments to evaluate and care for suspected 
patients, including possible hospitalization and quarantine.
    Many of these steps represent new and important 
improvements, and the near absence of SARS in Michigan shows 
that they seem to be working. But our officials have also 
uncovered major shortcomings that need to be addressed.
    For instance, when the City of Detroit drew up an action 
plan for homeland security, one of the first such plans for a 
major city in the United States, by the way, it determined that 
the city does not currently have a computerized database that 
can detect emerging public health problems. Health care workers 
and family members must have adequate supplies of masks as well 
as other key health care equipment, such as respirators.
    Another issue of importance is that, right now, Michigan 
doctors have to send their SARS diagnostic tests to CDC labs in 
Atlanta for analysis. Michigan laboratories want to set up an 
in-State testing service to speed up the results and to reduce 
the burden on CDC labs.
    Resource needs on the local level show how far we still 
need to go to protect this country against SARS. They are more 
than matched by questions on the international and national 
level. How do we assist China in getting its SARS outbreak 
under control to reduce SARS risks worldwide? Should the World 
Health Organization be given additional authority to monitor 
in-country disease outbreaks and quarantine procedures?
    We can isolate patients, but we cannot isolate our Nation. 
We need to work with the world community. We need the world 
community to work together to reduce the threat of SARS and 
other diseases which know no boundary, just as we need the 
world community to pull together in our war on terrorism.
    Recent press coverage indicates that the SARS threat is 
perhaps coming under control worldwide. I hope that is true. 
But responsible government calls for taking steps today to 
prevent the SARS problem from becoming a public health care 
nightmare tomorrow. We need the political will to take those 
steps. We need to invest in public health. A number of those 
programs have been cut in the proposed budget. That is a short-
sighted decision.
    Finally, we cannot rely on private philanthropy to deal 
with this kind of a public need. We have seen some wonderful 
examples of private philanthropy. The co-founder of Home Depot, 
Bernard Marcus, took a tour of the CDC's laboratory facilities 
in Atlanta and was so disturbed by their dilapidated state that 
he personally pledged $2 million to help the CDC equip a state-
of-the-art emergency response center that has played a very 
critical role in the battle against SARS. But it is just not 
the way to go, to rely on private citizens to step in to make 
up for the inadequate resources that the Federal Government has 
provided in such a vital area. We applaud his generosity. It 
has made a difference. But we cannot rely on that and we have 
to do what is necessary ourselves in devoting the resources 
that are essential.
    Mr. Chairman, because I am managing the defense bill on the 
floor in the Senate this morning, I am unable to stay to hear 
the testimony. I will surely be briefed on these important 
proceedings by my staff, but again, I commend you and I ask 
that the balance of my statement be placed in the record at 
this time.
    Senator Coleman. It will be placed in the record. Thank you 
very much, Senator Levin.
    [The prepared statement of Senator Levin follows:]

              PREPARED OPENING STATEMENT OF SENATOR LEVIN

    Today, the front lines of the SARS battle in the United States are 
drawn at our airports, our border crossings, our hospitals, and the 
local doctor's office. Our local health care providers need resources 
and training to protect our country from a SARS outbreak. We've been 
relatively lucky so far, but we need more than luck to keep this public 
health threat under control. We need resources and planning.
    Right now, our knowledge of SARS is limited. We don't know where 
the disease came from, we don't know how to rapidly and reliably test 
its presence, and we don't have a cure. But we have learned that if we 
identify SARS patients quickly and isolate probable cases, that we can 
prevent the disease from spreading. That means our first and most 
important line of defense is having first-responders who are trained to 
spot SARS symptoms, have adequate resources, and workable, sensible 
plans to safeguard the public.
    We also know that some countries have done a better job than others 
at preventing the spread of SARS. We know that China was not, at first, 
up front with its citizens about the disease and as a result, both 
confusion and the disease have spread. In contrast, Vietnam 
successfully contained a possible SARS outbreak through swift action. 
To protect our own country, we need to learn from the experiences of 
others, as well as devise ways to support other countries' efforts to 
stem their SARS infections.
    When we look here at home, the facts paint a complex picture of our 
readiness to fight SARS. The good news is that we have a public health 
system that is engaged in this battle and taking many of the steps 
needed. Few cases are being found, and no fatalities to date. But on 
the other hand, we have inadequate resources to support the good 
intentions and planning of our health care system.
    In my home State of Michigan, the SARS readiness picture is a 
promising one, but one that requires further support and development. 
Out of a total of 43 persons evaluated in Michigan for SARS to date, 
only 4 suspected cases have been identified. All four cases are being 
treated, with no fatalities to date.
    Michigan has also taken a number of steps to mount an effective 
response to the SARS threat. It has determined that it has legal 
authority to quarantine individuals posing an imminent public health 
threat. The Michigan Department of Community Health has assigned 
responsibility for combating SARS to a specific state office, the 
Public Health Preparedness Office. The state has issued guidelines to 
Michigan hospitals on how to identify and treat suspected SARS 
patients, and sends out regular E-mail updates to hospitals in all 64 
local county health departments.
    The University of Michigan Medical School has also taken a 
proactive role. For example, it has created a SARS working group that 
meets weekly and includes representatives from local community health 
departments. The working group has set up a communications line called 
Telecare that takes calls from people with questions about SARS. They 
have developed a questionnaire for health care providers to screen 
emergency room patients by asking about their travel history, exposure 
to potential SARS patients, and symptoms. They are also working on 
locating a facility that could be used to quarantine a large number of 
SARS patients, were that to become necessary.
    These precautions are essential, in part because Michigan is the 
largest single area for border crossings between the United States and 
Canada. Canada is the United States' top trading partner with over $1 
billion worth of goods and services crossing the border every day, and 
more than 40 percent of that trade moving between Michigan and Ontario. 
To give you some idea of the potential impact SARS could have on 
Michigan, every day over 36,000 vehicles--trucks, cars, and buses--
depart Canada and travel to Michigan. Furthermore, every day the number 
of people coming into Michigan from Canada on trains, cars, and buses 
exceeds 70,000. In addition, Great Lakes marine traffic and the Detroit 
international airport bring in cargos and passengers from all over the 
world. Together, these border crossings make Michigan a key gateway 
that must be protected to keep the United States safe from SARS.
    To limit SARS risks at its border crossings, Michigan is working 
actively with CDC, Customs, Border, and port personnel to screen 
persons entering the United States. If persons crossing the border show 
symptoms of SARS, for example, Michigan and the CDC have designated 
three local health departments in Chippewa County, St. Clair County, 
and Detroit to evaluate and care for suspected patients, including 
possible hospitalization and quarantine.
    Many of these steps represent new and important improvements, and 
the near absence of SARS in Michigan shows they seem to be working. But 
our officials have also uncovered major shortcomings that need to be 
addressed. For instance, when the City of Detroit drew up an Action 
Plan for Homeland Security, one of the first such plans for a major 
city in the United States, it determined that the city does not 
currently have a computerized database system that can detect emerging 
public health problems. Detroit Mayor Kwame Kilpatrick has now called 
for establishing a citywide disease surveillance system that, 
consistent with privacy protections, can track both infectious diseases 
and bioterrorism incidents, and communicate directly with health care 
professionals, state officials, and the CDC.
    Another ongoing issue is training and protections for local health 
care providers. In some countries, hospital workers such as nurses have 
suffered SARS infections despite using recommended safeguards. More 
work needs to be done to understand how they became sick and to protect 
them. One part of the problem may be that only certain types of 
surgical masks provide adequate protection from SARS droplets, and 
these masks need to be fitted carefully and changed daily. An even more 
basic issue is to ensure that health care workers and family members 
have adequate supplies of masks as well as other key health care 
equipment such as respirators.
    Another issue of importance is that, right now, Michigan doctors 
have to send their SARS diagnostic tests to CDC labs in Atlanta for 
analysis. Michigan laboratories want to set up an in-state testing 
service to speed up the results and to reduce the burden on CDC labs. 
Another open issue is who will pay for significant testing and 
quarantine costs, should those become necessary.
    Resource needs on the local level show how far we still need to go 
to protect this country against SARS. They are more than matched by 
questions on the international and national level. How do we assist 
China in getting its SARS outbreak under control to reduce SARS risks 
worldwide? Should the World Health Organization be given additional 
authority to monitor in-country disease outbreaks and quarantine 
procedures? How do we encourage rapid development of a SARS vaccine?
    We can isolate patients, but we can't isolate our country. We need 
to work with the world community, and we need the world community to 
work together to reduce the threat of SARS and other diseases which 
know no boundaries, just as we need the world community to pull 
together in our war on terrorism.
    Recent press coverage indicates that the SARS threat may be coming 
under control worldwide, and I hope that is true. But responsible 
government calls for taking steps today to prevent the SARS problem 
from becoming a public health care nightmare tomorrow.
    We need the political will to take those preventative steps. Last 
week, the Senate voted for more than $350 billion in tax cuts over the 
next 10 years. To help pay for its proposed tax cuts, the 
Administration has proposed cutting spending on a number of important 
programs, including for public health care. That is a short-sighted 
mistake.
    We can't rely on private philanthropy to deal with the public's 
need. One example shows why. After the 9-11 and anthrax incidents in 
2001, a U.S. citizen who is also a co-founder of Home Depot, Bernard 
Marcus, took a tour of the CDC's laboratory facilities in Atlanta. He 
was so disturbed by their dilapidated state that he personally pledged 
$2 million to enable the CDC to equip a state-of-the-art emergency 
response center, which has played a key role in the battle against 
SARS. It is incredible that a private citizen had to step in to make up 
for the inadequate resources of the Federal Government in such a vital 
area. While the generosity of Mr. Marcus has made a real difference, we 
can't rely on that approach to construct a workable disease 
surveillance system that can identify, monitor, and evaluate the 
severity of infectious disease outbreaks in the United States.
    I was a member of the Detroit City Council during the 1970's. I 
know that if a contagious disease were to have broken out in my city 
during those days, my phone would have started ringing and not stopped. 
The experiences of local health care professionals can tell us a lot 
about what is and is not working, and I commend Senator Coleman for 
holding this hearing today--his first, by the way, in Washington as 
Chairman of the Permanent Subcommittee on Investigations. I look 
forward to hearing today's testimony.

    Senator Coleman. Let me turn to the distinguished Chairman 
of the Committee on Governmental Affairs, Senator Collins.

              OPENING STATEMENT OF SENATOR COLLINS

    Senator Collins. Thank you very much, Mr. Chairman. Let me 
start by thanking you for holding this important hearing to 
evaluate the government's response to the outbreak of Severe 
Acute Respiratory Syndrome, or SARS.
    I have a very eloquent opening statement---- [Laughter.]
    But I know that you are eager to get to the witnesses 
today, so I would ask unanimous consent that it be submitted 
for the record.
    Senator Coleman. Without objection, Senator. Thank you very 
much, Senator Collins.
    [The prepared statement of Senator Collins follows:]

             PREPARED OPENING STATEMENT OF SENATOR COLLINS

    Mr. Chairman, thank you for calling this morning's hearing to 
examine how effective the State and local response has been to the 
outbreak of severe acute respiratory syndrome--or SARS--in the United 
States, and to take a look at how well the Federal Government has 
worked to support and coordinate these efforts.
    Severe acute respiratory syndrome, or SARS, is proving itself to be 
a formidable global threat. There is neither a treatment nor a cure for 
this deadly, highly contagious virus that is spreading throughout Asia, 
and into parts of Europe, Canada and the United States. To date, there 
have been almost 8,000 probable cases of SARS reported in more than 30 
countries worldwide and more than 660 people have died.
    It is true that the worldwide toll for SARS is relatively small 
compared with, say, the three million people who died last year of 
AIDS. If SARS continues to spread, however, its death toll could 
skyrocket. Moreover, while we should be reassured that quick action on 
the part of the CDC and our State and local health officials has 
resulted in a relatively low number of probable SARS cases in the 
United States with no deaths, we should not rest easy. Given that the 
virus can go wherever a jetliner can travel, it is a very real 
possibility that we have not yet seen the full extent of this epidemic 
in our country.
    In the wake of recent terrorist attacks and increasing fears about 
the spread of highly contagious diseases like SARS, our Federal, State 
and local governments have become increasingly sensitive to the need 
for an effective, coordinated response to such events. While there is 
absolutely no evidence that the spread of SARS is part of a planned 
attack, our institutional capability to deal with such an epidemic is 
the same whether it is the consequence of a terrorist act or a 
naturally-occurring event. In fact, a major side benefit of all of our 
efforts to strengthen our homeland defense capabilities should be an 
improved ability to respond to all kinds of emergencies.
    Over the past 2 years, the Congress has appropriated significant 
amounts of funding for public health activities at the Federal, State 
and local levels as part of our bioterrorism preparedness effort. 
Moreover, the supplemental appropriations bill passed earlier this year 
contains an additional $16 billion for CDC specifically to address the 
SARS outbreak. I therefore look forward to hearing whether these 
additional resources have improved our ability to respond to public 
health emergencies like SARS.
    In addition, since physicians, nurses, and other health care 
workers on the front lines are likely to be the first individuals to 
encounter cases of an emerging infectious disease like SARS, it is 
critical that they have the support and information that they need from 
Federal agencies like the CDC to identify and effectively contain such 
an outbreak.
    Mr. Chairman, I look forward to examining these and other issues 
this morning, and once again, I thank you for convening this hearing.]

    Senator Coleman. We will turn to Senator Lautenberg.

            OPENING STATEMENT OF SEANTOR LAUTENBERG

    Senator Lautenberg. Thanks very much, Mr. Chairman. I, like 
the Chairperson, will withhold my eloquent statement. It has 
yet to be written, and---- [Laughter.]
    But I do want to say, this is such an important topic and 
the consideration of how we deal with it is a major question, 
its effects not only on the individual, but the economy, the 
circulation of people and taking care of normal obligations 
raises a very serious problem for us.
    My question, and I will end with this, is will it depend on 
a given State's income capacity to deal with the problem? We 
know that all the States, with almost no exception, have 
difficult times meeting their normal obligations right now. 
Deficits are significant and very few States can just continue 
as they were before.
    Now the question is, if there is an outbreak of SARS, whose 
responsibility is it, not just to deal with it. We know that we 
have to have the health professionals and some facility 
particularly suited to treating SARS patients and whether or 
not they will be able to be isolated sufficiently. But then the 
question comes in about the capacity to afford. Now, if a given 
State is poverty-stricken--let me use that term--will the 
problem then become one of its neighboring States or the 
neighboring region, or will it be unintentionally exporting the 
disease?
    So the question is, how do we deal with this? Does it 
become primarily a Federal concern? I know the Chairman, I 
listened to your statement and it was very good and apparently 
Minnesota and you have gotten a great deal of attention paid to 
this. I don't know whether it has to do with your proximity to 
Canada and some of the problems that have erupted there, but 
this is a good opportunity to hear from our distinguished 
panel, Mr. Chairman. I look forward to hearing from them.
    Once again, the focus at the moment for me is how do we 
respond to this plague that we are dealing with in the best 
fashion and is it a responsibility for all the States, shared 
in equal terms, if the disease presents itself in their 
boundaries?
    Senator Coleman. Thank you very much, Senator Lautenberg, 
and I am sure the panel will be addressing the question and the 
way you have framed it.
    I would like now to welcome the first panel of witnesses to 
today's hearing, Dr. Julie L. Gerberding, Director of the 
Centers for Disease Control and Prevention in Atlanta, Georgia; 
Dr. Anthony S. Fauci, the Director of the National Institute of 
Allergy and Infectious Diseases at the National Institutes for 
Health in Bethesda, Maryland; and finally, Dr. Michael T. 
Osterholm, the Director of the Center for Infectious Disease 
Research and Policy at the University of Minnesota, 
Minneapolis, Minnesota.
    I thank all of you for your attendance at today's important 
hearing and look forward to hearing your perspective on what 
the broader health care community is doing to provide local 
officials with the information they need to deal with sudden 
outbreaks such as SARS.
    Before we begin, pursuant to Rule 6, all witnesses who 
testify before the Subcommittee are required to be sworn. At 
this time, I would ask you to please stand and raise your right 
hand.
    Do you swear the testimony you will give before this 
Subcommittee will be the truth, the whole truth, and nothing 
but the truth, so help you, God?
    Dr. Gerberding. I do.
    Dr. Fauci. I do.
    Dr. Osterholm. I do.
    Senator Coleman. Thank you. We will be using a timing 
system today. Please be aware that approximately 1 minute 
before the red light comes on, you will see the lights change 
from red to yellow, giving you an opportunity to conclude your 
remarks. While your written testimony will be printed in the 
record in its entirety, we ask that you limit your oral 
testimony to no more than 5 minutes.
    Dr. Gerberding, you have the opportunity to go first with 
your testimony. We will then hear from Dr. Fauci, and finally, 
we will finish up with Dr. Osterholm. After we have heard all 
the testimony, we will turn to questions.
    Dr. Gerberding.

 TESTIMONY OF JULIE L. GERBERDING, M.D., M.P.H.,\1\ DIRECTOR, 
   CENTERS FOR DISEASE CONTROL AND PREVENTION, DEPARTMENT OF 
          HEALTH AND HUMAN SERVICES, ATLANTA, GEORGIA

    Dr. Gerberding. Good morning, Mr. Chairman and Senators. It 
is really a pleasure to be here to focus in on the local 
response to SARS because, as we say at CDC, ultimately, all 
public health is local and I think it is a timely opportunity 
to address the issue from that perspective.
---------------------------------------------------------------------------
    \1\ The prepared statement of Dr. Gerberding appears in the 
Appendix on page 47.
---------------------------------------------------------------------------
    The macroscopic view right now is that we have over 7,700 
cases of SARS globally with 643 deaths. In the United States, 
we have 67 probable cases of SARS, and I think I have a graphic 
here that shows the distribution of both the probable as well 
as the suspected cases of SARS across the United States. I 
illustrate it only to indicate that almost all States have been 
involved in the development of containment protocols for the 
isolated patients, and certainly this represents an enormous 
amount of work on the part of clinicians as well as local 
health officials across our country.
    There are many SARS stars and I would like to formally 
acknowledge the efforts that have been made by the CDC team, 
but I think in this effort, it is the front-line clinician and 
the front-line local health officials that really deserve the 
credit for the fact that, so far, we have been able to contain 
the epidemic in this country. We have been doing that not using 
the usual modern interventions, such as vaccines or antiviral 
treatment, but the old fashioned methods of isolation and 
quarantine.
    The first and foremost component of this is, of course, the 
alerting and the advice to travelers to affected areas, 
reminding them of what the risks are and the steps they need to 
take. We delivered more than one million of these health alert 
cards, which have proven to be a very important aspect of our 
response because they remind travelers returning from these 
areas that they could potentially have been exposed. And if 
they develop any illness in the next 10 days, they need to 
contact a clinician and seek medical care.
    We know the health advisory notices are working because 
people are self-referring for care and they are reporting very 
early at the onset of fever. So I think that has been a very 
important component of our ability to contain spread in this 
country. Of course, it only takes one highly-infectious person 
to set off a cascade of transmission if they are not identified 
and isolated quickly.
    A really critical component of containment at the local 
level is the front line, the hospital emergency rooms, clinics, 
and the clinicians who respond quickly to suspecting a case of 
SARS and implement the appropriate infection control 
precautions. We learned in Canada that you have to have a very 
high standard of infection control in the health care 
environment to prevent spread to other health care officials. 
This includes not just the containment in the room, but also 
the masks and the proper utilization of hand hygiene and the 
other measures to prevent spread. Isolation has been successful 
in the vast majority of situations where it has been properly 
introduced in health care settings, but as I said, you have to 
be highly compliant with those recommendations.
    In this country, we have not had to implement quarantine or 
measures for exposed people other than the active monitoring 
that health officials have been doing of people exposed to SARS 
cases in hospitals or in their homes. That really represents 
the part of this graphic that you don't see. Because for every 
case here on this map, there are many exposed people that are 
involved in an ongoing monitoring process, for the 10 days of 
incubation, to be sure that we detect the earliest possible 
signs.
    In this country, we have only two individuals who have been 
exposed to travelers and who are probable SARS cases. One of 
them is a health care worker and one of them was a household 
contact of a SARS patient. So we think our isolation and 
monitoring systems have been effective so far.
    The last really critical component of this is, of course, 
communication. We need the communication systems to 
electronically track illness and information, but we also need 
the information exchange that goes out through our health alert 
notification, through our Internet, through our spokespersons 
at the local level as well as the national and international 
level.
    I think what we have learned in SARS is that we can respond 
quickly, we can define the virus, develop tests, sequence it, 
and we can also get the communication and information about 
that out quickly enough. The question is, are we quick enough 
to really contain it if we are in the unfortunate situation to 
have a highly infectious person who sets off a cascade of 
transmission.
    We have seen that it can be done. Containment has been 
successful, even in developing countries, but it takes a 
prepared public health system. The weakest link in the system 
is the link that could allow a leakage and spread to occur. So 
we have to strengthen the entire public health system from the 
front-line clinician all the way through the Federal and 
international health agencies. We can do it, but it is going to 
take a sustained effort, and I thank you for the opportunity to 
present that perspective.
    Senator Coleman. Thank you, Dr. Gerberding. Dr. Fauci.

  TESTIMONY OF ANTHONY S. FAUCI, M.D.,\1\ DIRECTOR, NATIONAL 
    INSTITUTE OF ALLERGY AND INFECTIOUS DISEASES, NATIONAL 
INSTITUTES OF HEALTH, DEPARTMENT OF HEALTH AND HUMAN SERVICES, 
                       BETHESDA, MARYLAND

    Dr. Fauci. Thank you very much, Mr. Chairman. I appreciate 
the opportunity to present my testimony before you and Members 
of the Committee.
---------------------------------------------------------------------------
    \1\ The prepared statement of Dr. Fauci appears in the Appendix on 
page 58.
---------------------------------------------------------------------------
    As you can see from this slide, many versions of which I 
have presented before this Committee and similar committees 
regarding emerging and reemerging diseases, the SARS epidemic 
that we are facing really falls squarely within the spectrum of 
what mankind has been experiencing since the beginning of 
mankind and will experience throughout the evolution of our 
species to wherever it may go, and that is that interesting 
interaction between microbes that emerge and reemerge.
    Sometimes, these emergences are really minor blips in the 
radar screen that are curiosities, unfortunate for the people 
who get afflicted, but they do not have a major global health 
impact. And then occasionally, we get a disease that does.
    In the last century, the 1918 flu pandemic that killed 25 
million people worldwide, and the AIDS epidemic that was first 
recognized in the early 1980's, which we are now in the middle 
of, is another example of a true global pandemic.
    SARS is an epidemic that is still in its evolutionary 
phase. It has extraordinary potential. The death rate is 
alarmingly high, and as you mentioned in your opening 
statement, Mr. Chairman, in many respects, despite the fact 
that we have had good public health and infection control 
methods, we have been somewhat lucky, and for that reason what 
we really need to do is to continue the vigilance that Dr. 
Gerberding has mentioned, but also pursue a robust research 
agenda, and I would like to spend just a couple of minutes on 
that.
    We know from very rapid detective work on the part of the 
CDC, the WHO, and others that the etiologic agent of SARS is a 
coronavirus. Now, you might recall historically that it took us 
at least 2\1/2\ years to identify the virus associated with 
HIV. This was done in a matter of weeks and the virus was 
sequenced so that we know the molecular makeup of it.
    It falls within a category of viruses that we have had 
extensive experience with, the first coronavirus being isolated 
in 1937 in animals, and then in the mid-1960's in humans. It is 
most known for the fact that one of the groups of coronaviruses 
is the cause of the common cold, a very benign disease that 
rarely, if ever, causes serious consequences.
    But also, the coronavirus is seen among domesticated 
animals, such as pigs, cows, dogs, cats, etc., and this is 
important when one thinks in terms of where this virus may have 
come from. And I must say right off that we don't know at this 
point, but also it shows the importance of developing animal 
models so that we can study it. As you know, there are no 
specific therapies or human vaccines, even though we have been 
studying these types of diseases for a considerable period of 
time.
    What about the research agenda, we have now? Because of the 
seriousness of the threat and because of the fact that although 
there are reports, as you mentioned, that things might be 
leveling off, there are two issues. One, we could just as 
easily have a rebound, and that is the reason for the vigilance 
that Dr. Gerberding mentioned, but also, there is the 
possibility, if not likelihood, that we will not be finished 
with this even when the cases no longer spread in this season 
or at this particular time. So we must be prepared for serious 
consequences in future years.
    For that reason, there is a robust research agenda, 
including basic research and understanding of what we call the 
pathogenesis of disease. How does it make people sick? That is 
still somewhat of a mystery, because when one looks at the 
pathologic specimens of individuals, it is likely that not only 
the virus is causing direct damage, but the inflammatory 
response seen in the lungs of individuals with the Severe Acute 
Respiratory Syndrome is causing a considerable amount of 
damage.
    We also need to think in terms of therapies. We are right 
now in collaboration with our colleagues at the CDC and at 
USAMRID screening a number of drugs that have already been 
developed for other reasons to see if, in fact, we could get 
what we call a hit or an indication that this particular drug 
or class of drug might have activity against the SARS virus. We 
have had some interesting preliminary hits, but they have only 
been at concentrations of the drug that would not make them at 
all feasible to use in a pharmacological sense. But it at least 
points us in the right direction of the class of drugs.
    We are also, now that we have the sequence, doing targeted 
drug design against potential particularly vulnerable parts of 
the virus replication cycle.
    And then there is the question of vaccine. Again, since 
this virus, lucky for us, grows very robustly in tissue culture 
using monkey tissue culture cells, the virus is now being grown 
in a number of institutions, including the National Institutes 
for Health, for the purpose of making the first generation of a 
vaccine, which is a killed vaccine. We will likely be 
successful in proving a concept in an animal model, but once we 
do that, it will take years, at least, to develop a safe and 
effective vaccine for humans.
    So in summary, Mr. Chairman, the research agenda is robust 
and the challenge of emerging and reemerging infectious 
diseases will be with us forever and SARS is a dramatic example 
of that. Our most critical weapons against the threats are 
vigilance, public health and infection control capabilities, 
and the robust research agenda that I briefly summarized for 
you and which I have described.
    With these factors working in synergy, we feel confident 
that they will provide the best hope of protecting the citizens 
of the world and of our Nation against the inevitable threats 
to public health that will follow. Thank you, Mr. Chairman.
    Senator Coleman. Thank you very much, Dr. Fauci. Dr. 
Osterholm.

TESTIMONY OF MICHAEL T. OSTERHOLM, PH.D., M.P.H.,\1\ DIRECTOR, 
 CENTER FOR INFECTIOUS DISEASE RESEARCH AND POLICY, UNIVERSITY 
              OF MINNESOTA, MINNEAPOLIS, MINNESOTA

    Dr. Osterholm. Thank you, Mr. Chairman. I want to applaud 
you and the Members of the Subcommittee for addressing this 
very timely and critical issue in terms of the effectiveness of 
our Nation's response to SARS. I believe that this 
international public health crisis is here to stay, as you so 
eloquently stated, and will pose an ever-increasing risk to the 
citizens of the United States. My comments reflect my 
professional experience in State and Federal public health 
programs, academia, as well as my participation in such groups 
as the National Academy of Sciences Institute of Medicine.
---------------------------------------------------------------------------
    \1\ The prepared statement of Dr. Osterholm appears in the Appendix 
on page 68.
---------------------------------------------------------------------------
    In that latter regard, I want to refer the Subcommittee to 
a very important report which was issued in March of this year, 
just as SARS became a public crisis. Ironically, our committee, 
which for the past 2 years detailed the reasons why emerging 
infectious diseases are of such importance, actually considered 
the very issue of a type of SARS-like agent becoming a critical 
public health problem. Our committee report also provides a 
series of recommendations for assuring that we have an 
effective and timely detection and response to these new agents 
in the future. I urge the Subcommittee to review this report.
    I am here today to address the critical need for our 
country to continue in its beginning journey to prepare its 
homeland security against both human-made and Mother Nature-
made biological agent attacks. In general, we must capitalize 
on the collaborative preparation to respond to the everyday 
growing threat of emerging infections, as well as the potential 
for the use of biologic agents as terrorism weapons.
    Before I detail my concerns and suggestions for the 
Subcommittee, I want to take this opportunity to offer my 
highest compliments to the response to the SARS epidemic both 
abroad and at home. This response has involved a number of 
Federal agencies, particularly the Department of Health and 
Human Services and Department of Homeland Security, as well as 
State and local public health departments as well as front-line 
health care facilities and workers.
    Specifically, I would like to acknowledge the leadership of 
my two co-witnesses, Dr. Gerberding and Dr. Fauci, who have 
continued to play critical roles in defining a proactive and 
well-articulated response on behalf of our Federal public 
health agencies. Both of these individuals have served as 
trusted and articulate voices in hundreds of media appearances 
and policy briefings. As a result, I believe that this time, 
the American public has received the facts in a meaningful and 
very thoughtful way.
    In addition, State and local health agencies have put in 
countless hours investigating possible SARS cases, working with 
local health care delivery systems to accommodate the needed 
infection control security for individuals who might have 
contact with SARS patients, as well as serving as a credible 
public voice for the many questions that have arisen from the 
local community.
    While our experience today with SARS can be interpreted as 
having been successful in our efforts to limit its impact in 
this country, like you, Mr. Chairman, I have to admit we have 
been lucky. As you have heard during the past several weeks, 
the City of Toronto has known firsthand the devastating impact 
of the SARS epidemic. This impact includes not only the 
morbidity and mortality associated with the disease, but the 
economic and social implications of being labeled a community 
with SARS transmission.
    We must never forget, what happened in Toronto could just 
as easily have happened in Buffalo, Cleveland, Detroit, or 
Minneapolis-St. Paul. Imagine what any one of these American 
cities would have experienced had an epidemic unfolded in their 
community and subsequently had an international advisory issued 
urging no travel to that community.
    As an epidemiologist who has investigated hundreds of 
infectious disease outbreaks, including some caused by 
previously unrecognized infectious agents, both my learned 
opinion and my best bet is that we have not yet begun to see 
the worst of SARS. It is my belief that despite the heroic 
efforts made by countless professionals in the health care and 
medical care systems to control localized epidemics in 
locations such as Toronto, Hong Kong, Hanoi, and Singapore, the 
ongoing transmission of SARS in parts of China and Taiwan 
signals a very important message that this is a disease 
transmitted via respiratory route that has now seeded itself in 
a sufficant number of humans such as to make its elimination 
impossible.
    If this is true and this disease follows the pattern of 
other similarly transmitted agents, we can expect to see 
increasing case numbers associated with seasonality, in other 
words, in the winter months in the Northern Hemisphere. In 
short, the reduction in new cases throughout the world is 
undoubtedly due in part to the heroic efforts just mentioned 
and also likely reflects the waning of cases during the summer 
months.
    Believing this to be true, I am convinced with the advent 
of an early winter in the Northern Hemisphere in just 6 short 
months, we will see a resurgence of SARS that could far exceed 
our experience to date. If this projection is correct, we have 
every reason to believe that this disease may show up in 
multiple U.S. cities as we continue to travel around the world 
in unprecedented numbers and speed. Imagine now the possibility 
of simultaneous disease outbreaks in multiple U.S. cities.
    You may ask, is this likely to occur? Honestly, no one 
knows, but as a student of the natural history of infectious 
diseases, I am convinced that, just as we saw in the early days 
of HIV, we are now in the early days of the SARS epidemic.
    I have provided for the Subcommittee a series of points 
that I believe must be considered in response to the SARS 
epidemic. First, we are under-invested in our public health 
system. You will hear from other panels to the extent to which 
that has occurred.
    Also, we must coordinate the roles of Federal, State, and 
local agencies in our response to this problem. I believe that 
you have sitting at this table in Dr. Gerberding and Dr. Fauci, 
two of the leaders for which their agencies must play prime 
roles and primary response roles to this particular problem.
    Finally, it is going to be important for us to understand 
the resources and capabilities of our health care delivery 
systems and the private sector in responding to this problem 
and the need for the critical coordination and resource 
development in these areas.
    In conclusion, let me just say I again want to thank you 
for this very important and timely hearing. I only wish that 
this would be the last hearing necessary in terms of responding 
to the SARS crisis, but I fear that will not be the case. 
Nevertheless, your ongoing oversight of the resource needs and 
collaboration of Federal, State, and local public health 
agencies will provide a critical road map for helping us to 
assure our Nation's safety and security from all of the 
emerging infectious diseases of the future. Thank you.
    Senator Coleman. Thank you very much, Dr. Osterholm.
    I would be interested to know whether, Dr. Gerberding and 
Dr. Fauci, if you share Dr. Osterholm's perspective that we 
have not yet seen the worst of SARS? Clearly, he has raised the 
concern that when the winter months approach, and in Minnesota, 
we know about those winter months, that we can expect to see 
new cases. Do you share that perspective?
    Dr. Gerberding. I hope he is wrong, but I fear that he is 
correct. Most of the respiratory viruses follow this pattern 
and I think we need to be vigilant and anticipate that could be 
the case.
    Senator Coleman. Dr. Fauci.
    Dr. Fauci. I share both Dr. Osterholm and Dr. Gerberding's 
concern. As Dr. Gerberding mentioned, it would be distinctly 
unusual for a respiratory disease that is spread the way this 
is spread to all of a sudden just disappear.
    Senator Coleman. I want to get focused on the local level. 
I have some basic questions, but let me ask a broader question 
first. As I have listened to the testimony, what should Toronto 
have done differently? I would ask you all to--if you ruled the 
roost, what would you have told them to do or what should they 
have done that was different?
    Dr. Gerberding. I think there is very little that they 
could have done differently because the patient who was 
infectious arrived there before information about the epidemic 
was available. So they didn't have that opportunity to put into 
place the kinds of systems that we now know are necessary for 
containment. That was bad luck.
    Senator Coleman. Dr. Fauci.
    Dr. Fauci. It could just have easily have happened to us. 
We often get asked that question. We really, in general, don't 
have better public health measures nor better experience, at 
the local level than other developed nations, particularly like 
Canada, have. They didn't know it was coming and it hit them. 
We knew it was coming just days before. We did a very good job, 
particularly under Dr. Gerberding's leadership at the CDC, but 
we could have been hit much worse. So I don't think that there 
is any reasonable criticism of how the Canadians handled it. 
They did a very good job.
    Senator Coleman. Dr. Osterholm, any comment?
    Dr. Osterholm. Yes.
    Senator Coleman. And by the way, I am not looking to 
criticize. I am just trying to understand, is there something 
in that experience that now the message should go out to every 
other city, go down this path rather than another path. Dr. 
Osterholm.
    Dr. Osterholm. Lest you think this was rehearsed, I happen 
to agree strongly with my colleagues here at the table, but let 
me add one additional point. Also being from the lakes of 
Minnesota, you understand well what it is like to have a leaky 
boat. If you have got one leak, you can bail for quite a while 
and do quite well. That was a single hit in one city.
    What I am very concerned about is that if we see a greater 
pressure on a worldwide basis in terms of cases in the 
developing world, they are going to spin out many more new 
infections that will come into the developed world through 
travel. What do we do if we are experiencing four, five, six, 
seven, or eight of these outbreaks in 10 cities simultaneously? 
Resource allocation issues will end up to be very different.
    So I would urge that we understand the Toronto experience, 
as much as it was a potential problem, imagine if that had been 
simultaneous in many different North American cities and what 
resources we would have been able to provide on a local, State, 
and Federal level. I think that is the concern that we must 
have for the future.
    Senator Coleman. Do local responders today have a single 
point of contact to get information or to report concerns? Is 
there a hotline to one place that folks, by the way, not just 
in the Minneapolis, St. Paul, or Chicago, but in the St. Cloud, 
the Sleepy Eyes, the smaller communities, is there within our 
country today at the local level an awareness of a single point 
of contact, either to report information or get information?
    Dr. Gerberding. I would like to think that the fact that 
CDC does serve as a broker of information is a useful tool at 
the local level. We certainly have a website that has been 
visited more than two million times over the SARS epidemic. We 
also operate a hotline for clinicians and a hotline for the 
general public so people can have access to that information, 
even in other languages, on a regular basis.
    But we also recognize that we can't prescribe the details 
of the response or the measures at the local level and so that 
system has to include input up and down the entire public 
health system.
    Senator Coleman. Dr. Osterholm, I know you have experience 
working at that local level----
    Dr. Osterholm. There actually are--it's a variety of 
different systems that exist at State and local areas, but like 
Dr. Gerberding said, I agree that there are well-recognized 
points of contact.
    The problem we have, however, is that as the number of 
problems continue to increase, I see nothing in our human 
biology to suggest that the number of new problems are not 
going to increase. Today, telephones are ringing off the hook 
at health departments throughout the United States. As a result 
of the BSE issue in Canada, is it safe to eat my hamburger?
    The same people that often have to answer these questions 
are the same people that are responding to SARS, who are 
responding to trying to get people vaccinated for smallpox, and 
who are dealing with any number of infectious disease problems. 
And so it is like when your 911 system gets overloaded. What is 
happening is while those points of contact exist, they are all 
occurring simultaneously. So SARS has now been added onto the 
back of that point of contact.
    Senator Coleman. Thank you. Senator Lautenberg.
    Senator Lautenberg. Thanks, Mr. Chairman.
    The hearing that we are holding here demonstrates its 
importance as we listen to the testimony. Frankly, I wish we 
had a more optimistic picture than we have seen.
    The question for me is, when was the first evidence of SARS 
discovered? Do we know where?
    Dr. Gerberding. In retrospect, we believe that the first 
cases of SARS, or at least the first outbreaks of SARS were 
occurring in the Guangdong Province in November and December. 
We did not get reliable information from that area and that is 
one of the weaknesses in our global detection system, that we 
don't have the sentinels out there that we can trust or that we 
can get information from when it is happening.
    It was recognized in February in Hong Kong because a 
traveler from Guangdong was involved in an outbreak that 
occurred in a hotel in Hong Kong and that really initiated the 
international cascade. So it was several weeks after the 
epidemic was initiated in China that it became known in the 
Western world, and then it was a couple of weeks after the 
outbreak in Hong Kong that we were able to isolate the virus 
and recognize that this was not influenza or not some common 
problem, that this was, in fact, a new coronavirus infection.
    Senator Lautenberg. Is it assumed that we are dealing more 
capably with this because we have had, as Dr. Fauci said in his 
testimony, a chance to take a look right after the problem came 
up in Toronto and prepare ourselves a little better for it, 
because I am interested in the fact that this locale, this 
region seemed to have induced the quickest spread of the 
disease. Could something like this have resulted from an 
activity by people who were looking to manufacture something? 
You get an obvious connection here between the threats that we 
have been enduring. Mr. Chairman, it is really a terrible 
scenario that we look at.
    Dr. Osterholm, the calls that I have been getting don't 
relate so much to SARS but to fear of a problem that is facing 
us. In this case, this Committee has significant jurisdiction 
over homeland security and I have had the kind of calls that 
say, well, should I not go to New York, from people in my 
State, in my region. Should I not plan my vacation with my kids 
to Florida? We are talking now about different kinds of 
dangers, but nevertheless, dangers.
    The thing that concerns me is the tendency to try to 
isolate ourselves from the communities in which we live, work, 
travel, etc., because as I heard, isolation looks like, if I 
understood you right, Dr. Gerberding, isn't isolation the first 
step that you take when someone is suspected of having SARS?
    Dr. Gerberding. Isolation is what we do when someone is 
infectious and we put them in the hospital and use the 
precautions for preventing spread. Quarantine is what we do 
with uninfected people who might have been exposed, and the 
quarantine can be anything from complete segregation to simply, 
you have been exposed, take your temperature every day and let 
us know if you have a fever. We haven't had to implement the 
more aggressive forms of quarantine in this country, we haven't 
recommended them here, but that is a step that was necessary in 
other parts of the world to control the problem.
    With respect to your issue about is this terrorism--
everything about this disease looks natural. Its mode of 
transmission, its pattern, everything is consistent with the 
natural evolution of a coronavirus. But we have had an open 
mind about this from the very beginning, and, of course, we 
were alert to that in the same way that you were.
    Dr. Fauci. Senator, one point that I might make has to do 
with information and the kind of calls that you get and the 
kind of calls that we get and why it is so important to do what 
we have been trying to do, is to be very proactively up front 
in trying to educate the American people as to what a real risk 
is and how you should respond to the risk.
    You might recall that back during the anthrax crisis, when 
the anthrax attacks were in Florida and in New York and in 
Washington, DC, we were getting calls from people in Los 
Angeles and in Pittsburgh saying, should we be taking 
ciprofloxacin, because they read this in the newspaper. Well, 
there is absolutely no reason for them to take ciprofloxacin if 
they are not exposed. And I think the point that Dr. Gerberding 
is making is very important.
    We should be very vigilant, but we shouldn't have people 
now in our country be afraid to go anywhere in this country.
    Senator Lautenberg. Exactly, and that is the kind of 
message that I am looking for, and that is if it is a natural 
phenomena, natural conditions often, if something goes awry, 
create a danger--street crossings, etc., airplane flying in 
normal course, car driving, all those things. I would like not 
to have a message that says, hey, we have to retreat to our 
homes. We can't function. We couldn't function.
    One thing that Dr. Osterholm said that rings my bell, and 
that is we are not spending enough on the whole public health 
issue, and this brings it full forward to us. You heard Senator 
Levin's comment about the fact that the fellow from Home Depot 
decided to reach into his pocket to make the facility workable, 
that is part of the Federal Government.
    It is a terrible thing, because I believe that security and 
strength has to be built from within the society as well as 
that which protects us externally beyond our boundaries. The 
demands today, there is an awareness that we never saw before 
that results from the instant access to communications, the 
awareness of people to things that I don't think were quite as 
they were before. We have not only got to work with the 
condition itself, but with the fallout that results from 
knowledge and--you said two million hits on the website. Is it 
thought that they were primarily from the professional 
community? I am talking about health care providers, first 
responders, etc., or is it John Q. Citizen who is looking for 
some information to protect themselves and their families?
    Dr. Gerberding. I think we see both. Our website has 
information for clinicians. It also has information for the 
general public and we hope people do go there as a credible 
source of information.
    But I really agree with your point about trying to balance, 
there is a problem. These are the sensible things that need to 
be done to control it. On the other hand, we don't want to 
overdo it and have people unnecessarily concerned or take steps 
that really are detrimental to the kind of balance that we want 
to have in our life, and that has been our challenge with this 
one.
    Senator Lautenberg. Mr. Chairman, just 1 minute more. Dr. 
Fauci, did you suggest in your comments that this is a 
relatively low-lethality disease?
    Dr. Fauci. No, not at all. In fact, to the contrary. If you 
look at influenza, which is spread much more readily than SARS, 
the mortality is less than 1 percent in a normal year of 
influenza. If you look at a very bad situation, like the 
pandemic of 1918, that was just a few percent, 3 or 4 percent. 
The mortality right now, if you look at it, is between 8 and 9 
percent, and some may think as high as 14 or 15 percent.
    Senator Lautenberg. Thanks, Mr. Chairman. Thank you very 
much.
    Senator Coleman. Thank you, Senator Lautenberg.
    I want to focus again now, in following up a little on some 
of the concerns that Senator Lautenberg just raised. At that 
local level, not the public side now, the private side, we have 
Northwest Airlines in Minneapolis-St. Paul, a direct connecting 
link to China. I know that they have been impacted by fear of 
flying.
    Can you talk a little bit about, on the private side, the 
kind of information that a Northwest Airlines or someone else 
is getting? Who is telling them whether they have to sanitize 
planes? Who is providing information about whether it is safe 
to be on the same plane that flew to somewhere in China but is 
on another route? Who has that responsibility? Who has that 
information, and how do folks on the private side get the right 
information?
    Dr. Gerberding. CDC has a large responsibility for the 
health conditions in our transit system and that particularly 
is handled by our Division of Quarantine and Global Migration. 
So our quarantine officers are at the borders and are 
responsible for any of the health measures that need to be 
taken on vessels or on airplanes or other means of 
transportation. So we have been working with the trade 
associations representing airlines as well as airline crews to 
get information out about what is necessary as well as what the 
concerns and issues are at the individual employee level.
    Just last week, we prepared, at CDC, a videotape, a 2-
minute video briefing that will be available to all the 
airlines to show on board the plane to help the passengers 
understand what is going on, why are they getting this card, 
and what does this all mean. So we do this in partnership and 
are very open to being responsive to additional needs.
    Senator Coleman. Is there a greater need to communicate to 
the general public, those who are getting on one of those 
airplanes, to answer any concerns they have about infection 
passing on, and if there is, who has that responsibility?
    Dr. Gerberding. Again, it is a partnership. I don't think 
there is ever enough communication in the setting of a health 
problem, at least enough reliable communication. But we work 
through the local health agencies as well as through the media 
to try to get information in the hands of travelers. We are 
also working with the associations of travel agents and people 
who are going to get the kinds of questions when someone is 
booking their reservation. So there are a lot of different 
channels of information and we are pushing it out there as fast 
as we can.
    Senator Coleman. Dr. Osterholm, I know you again know in 
your experience in dealing with the local level with some of 
these issues of infectious diseases. Talk to me a little bit 
about the mechanism for the average citizen to have concerns 
dealt with.
    Dr. Osterholm. Well, first of all you are really dealing 
with competing interests here. We have 24/7 television cameras 
today that are going to, in some cases, fuel the fire of fear. 
I am very afraid of that issue. But on a whole, I think that 
most of the media has been quite responsible reporting on the 
SARS issue and has tried to represent the facts. In particular, 
the print media has done a very good job of detailing that.
    What we need to do is do a better job of driving the public 
to reliable information. For example, the CDC has on its web 
site right now, two very thoughtful documents about should 
people travel to this country for business purposes, if they 
come from a SARS-infected area, or should they travel to those 
counties? We at the University of Minnesota, for example, have 
a number of foreign students coming to our campus from China 
very soon. We have used the CDC documents extensively to help 
us decide what to do. I think that has been very helpful.
    So part of it is making people aware that information is 
there. Again, we are making great efforts that way.
    Senator Coleman. And finally, Dr. Fauci, you talked about a 
robust research agenda. How is the funding for that agenda?
    Dr. Fauci. Well, right now we are, as you well know, 
between budget cycles, so we are using our emerging infectious 
diseases resources to jump-start programs and we are now in the 
process of putting together a projection of what our resources 
will be needed for. In fact, at a hearing that Senator Specter 
held, our Appropriations Chair asked Dr. Gerberding and I to do 
that, and we are in the process of doing that and putting it 
through the clearance of our Department. So we are actually 
working on that right now.
    Senator Coleman. Thank you. We are going to have a vote, I 
believe, at 10 o'clock, but I will turn to my distinguished 
colleague. Senator Lautenberg, do you have any additional 
questions, and if you do, after Senator Lautenberg's question, 
we will finish with this panel, have a 10-minute recess so that 
we will be able to go vote, and then continue the hearing. 
Senator Lautenberg.
    Senator Lautenberg. Where does the responsibility lodge 
between CDC, NIH, etc? How do you bring the various departments 
together? How are they coordinated?
    Dr. Gerberding. Secretary Thompson has made a very strong 
commitment to have all one HHS, and it actually is working that 
way. One of the ways we coordinate is through the Secretary's 
command center. So every morning, I get an update from our 
people all over the world on the state of SARS and then I sit 
down through a video terminal and speak directly to the 
Secretary's command center, where Dr. Fauci and Dr. McClellan 
and others from the various Federal agencies participate, as 
well as people from the Department of State, Department of 
Defense, and other areas, and I give a morning update on the 
status of the SARS epidemic. We identify any major strategic 
decisions that the Department or that the Federal Government 
needs to address, and then the Secretary and his team take it 
from there.
    So the coordination of the response has been working 
beautifully through our operations center model. I think, in 
general, we have an extremely collaborative relationship with 
NIH. Dr. Fauci and I are in constant communication and I think 
we pass that baton back and forth with great enthusiasm and 
sometimes even a little fun.
    Senator Lautenberg. How does the non-specific medical 
information, the demographics, and the geographic, where does 
that kind of data reside?
    Dr. Gerberding. We publish each day a daily SARS report 
that gets distributed through the various people who are 
tracking the epidemic. This is also on our website. We make 
information available to the media through a similar mechanism.
    Each week, at least once a week, we also have a televised 
briefing for the public and the press where we give the updated 
information or describe what is going on, and then through our 
health alert system, which is the way we communicate urgent 
information to State and local health officials and clinicians, 
any time there is something new, like last night we changed the 
case definition for SARS, so we pushed that out through the 
system so that people on the front line know what is going on.
    We also have regular phone calls, many with health 
officers, with clinicians, with various stakeholders in the 
effort. So it sounds like a lot of different things going on, 
and that is the case, but it is actually very well coordinated 
through our operations center.
    Senator Lautenberg. Dr. Osterholm, you are free of any 
government restraints here. What do you think we, in 
government, could do besides just providing funds? Is there 
anything else that you would recommend to help us get a handle 
on this threat that we see from SARS?
    Dr. Osterholm. I think the issue of funds is a very clear 
piece of it, particularly for the State and local level. We 
also have the issue of human resources, meaning do we have the 
trained individuals in this country we need to respond?
    I think earlier, Senator, you asked a question that I think 
is right at the heart of the issue here today, what is the 
source of this epidemic? And from a perspective of humankind 
today, it is mind-boggling to think about, that there are 
actually 6.1 billion people on the face of the earth. One out 
of every nine people who has ever lived in the history of 
mankind is on the face of the earth today, and most of those 
people live in the developing world in conditions that Charles 
Darwin would have written about as the ideal microbial 
laboratory.
    For example, the largest population of hogs in the world 
live in China, along with the largest population of people, and 
most of those pigs live in the backyards of these people, as 
well as the largest aquatic bird population of the world. 
Should we be surprised we are going to see all kinds of new 
infectious agents coming out of there as these factors mix and 
match in this kind of environment?
    So I think that this government has to be prepared to 
understand that what has historically happened with new 
infectious agents should not be used as a measure of what will 
happen in the future. Travel, as well as all these other 
demographic factors I talked about will continue to change. I 
think that is a very important fact, and we can't plan on 
resources by biennium or budget cycles for a problem that we 
can't anticipate 2 and 3 years down the road. We are going to 
have more and more of these unexpected problems where we need 
the ability to move resources and get resources quickly.
    Senator Lautenberg. Mr. Chairman, there is a message to 
remember.
    Senator Coleman. Sobering.
    Senator Lautenberg. Thank you all very much.
    Senator Coleman. Thank you all very much.
    This hearing will be recessed for 10 minutes.
    [Recess.]
    Senator Coleman. This hearing is called back to order.
    I would like to introduce now our second panel of witnesses 
at this time. We welcome Dr. Rod Huebbers, the President and 
CEO of the Loudoun Hospital Center in Leesburg, Virginia; Dr. 
Thomas R. Frieden, Health Commissioner of the New York City 
Department of Health; and finally, Mary Selecky, the Secretary 
of Health of the Washington State Department of Health in 
Olympia, Washington, and President of the Association of State 
and Territorial Health Officials.
    I thank all of you for your attendance at today's hearing. 
I look forward to hearing your testimony this morning and your 
unique perspective on how local and State officials have 
responded to the SARS outbreak and whether there are any 
lessons that we can use to improve our response to the next 
outbreak.
    Pursuant to Rule 6, all witnesses who testify before the 
Subcommittee are required to be sworn. At this time, I would 
ask all of you to please stand and raise your right hand.
    Do you swear the testimony you will give before this 
Subcommittee will be the truth, the whole truth, and nothing 
but the truth, so help you, God?
    Mr. Huebbers. I do.
    Dr. Frieden. I do.
    Ms. Selecky. I do.
    Senator Coleman. We will be using a timing system today, as 
I said for the first panel. Please be aware that approximately 
1 minute before the red light comes on, you will see the lights 
change from green to yellow, giving you an opportunity to 
conclude your remarks. While your written testimony will be 
printed in the record in its entirety, we ask that you limit 
your oral testimony to no more than 5 minutes.
    Mr. Huebbers, you will proceed first with your testimony. 
We will then hear from Dr. Frieden and finish up with Ms. 
Selecky. After we have heard all of your testimony, we will 
turn to questions. Mr. Huebbers.

    TESTIMONY OF RODNEY N. HUEBBERS,\1\ PRESIDENT AND CHIEF 
EXECUTIVE OFFICER, LOUDOUN HOSPITAL CENTER, LOUDOUN HEALTHCARE, 
            INC., LOUDOUN COUNTY, LEESBURG, VIRGINIA

    Mr. Huebbers. Good morning, Mr. Chairman, and thank you for 
the opportunity to appear before this Subcommittee. My name is 
Rodney Huebbers and I am the President and CEO of Loudoun 
Healthcare, which is a community nonprofit health care 
organization serving Loudoun County, Virginia, as the principal 
health care provider, and we are the local first line of 
defense that we have been talking about this morning.
---------------------------------------------------------------------------
    \1\ The prepared statement of Mr. Huebbers with additional 
testimony attached appears in the Appendix on page 73.
---------------------------------------------------------------------------
    Loudoun County is the second fastest growing county in the 
United States. We are bordered on the east by Dulles Airport, 
which is a key factor for us, to the north by the Potomac 
River, and to the west by the Blue Ridge Mountains and the 
Shenandoah River, and we are also home to a diverse business 
and residential population. We are also home to the FAA's 
center for the National Capital Region and we are a major 
emergency evacuation route for the District of Columbia.
    With respect to our size and experience, at the time of 
presentation in our emergency departments, Severe Acute 
Respiratory Syndrome had not been yet identified nor clinically 
defined with respect to symptoms of treatment. On February 17, 
2003, a woman who had recently traveled to Guangdong Province 
in China presented in our ER with pneumonia-like symptoms. We 
obtained a personal history of the patient, including her 
recent travel itinerary, which included a report of unusual 
pneumonias being seen in Guangdong Province.
    While symptoms did mirror pneumonia, a typical dry cough 
and respiratory distress proved an unknown, prompting the 
patient's isolation in a negative-pressure room as a means of 
infection control. Subsequently, the hospital's infection 
control chief and the Loudoun County Health Department were 
notified as part of our infectious disease algorithm that we 
had established. In turn, the Virginia Department of Health and 
Centers for Disease Control and Prevention were also notified.
    Prior to this SARS presentation, it is important to note 
that before September 11, our hospital had a specific disaster 
plan in place that included coordination with county, State, 
and Federal authorities, and following September 11, with the 
advent of all the biological and chemical terrorism threats, 
our protocols were further refined on paper as well as in 
practice.
    Loudoun County has been confronted with a variety of 
communicable disease issues, including anthrax, Virginia's 
first human death from West Nile virus, as well as three 
locally acquired cases of malaria, and literally, Loudoun 
Hospital is the front-line provider and had been in all those 
cases. So, hence, we have practical experience from which to 
draw conclusions as to our own protocol evolution and the 
quality of assistance from regulatory offices.
    As to the performance of Loudoun Hospital's ER triage 
training as well as our already heightened awareness in the 
development of infection protocols combined to serve us well on 
February 17. The documentation of symptoms, along with a 
predetermined history, including the travel inquiry volunteered 
by the patient's family, in consultation with the Loudoun 
County Health Department, proved critical in the initial 
decision to isolate and contact infection control authorities. 
From there, the notification algorithm worked very well as 
designed.
    While the patient herself was of great concern, so, too, 
were the clinical and non-clinical staff who had either 
incidental or clinical contact with the patient. Again, SARS 
was not known at this time, but given the symptomatic issues 
identified, it was obvious that infection was a distinct 
possibility. Our emergency response team began the process of 
identifying those with whom the patient had contact with during 
the admission process, and within hours, we had a list of 
individuals and had begun contacting them for testing.
    At the time of the SARS presentation, the hospital's most 
notable infection control protocol in place was for 
tuberculosis. Now, of course, we have a SARS protocol which, 
based upon information supplied by various authorities, has 
been amended in keeping with clinical findings.
    As for staff reaction during and following our SARS 
presentation, I would characterize it as informed and 
collaborative. Given the unknown symptoms of SARS at the time, 
common sense, admission information, and proper infection 
protocols combined for an adequate medical response on behalf 
of the patient and staff alike. The hospital's existing 
emergency preparedness committee lecture series on emerging 
diseases and bioterrorism threats, evolving policies and 
algorithms related to infection control, and improved 
communication with Northern Virginia hospitals via dedicated 
rapid notification radio frequency, continue to provide threat 
mitigation.
    There were some gaps identified during our review that, in 
this case, did not impact patient care. They include 
insufficient testing materials pre-placed in Northern Virginia 
for all the individuals we needed to test. There were 
procedures in place to transport specimens quickly to the 
Virginia State Lab, but the procedures for quickly shipping 
these specimens to Atlanta during the weekend were lacking. 
Multiple agencies were involved, which at times pitted patient 
care against regulatory expectations. At times, the staff was 
torn between specimen collection and delivery, symptomatic 
consultation with multiple agencies, and actually caring for 
the patient and others.
    In particular, our patient only spoke Chinese. Had it not 
been for a family member accompanying the patient, vital 
information impacting patient care may not have been 
communicated easily.
    At our hospital, we have provided additional instruction in 
the taking of sample and chain of custody procedures to 
accelerate the diagnostic process, and a general concern of 
ours continues to be multiple isolation patients requiring 
negative pressure rooms.
    Three elements, however, played a key role in the 
successful outcome of this case. Plans were in place in the 
emergency room to isolate the patient and notify key personnel. 
Effective communication patterns preestablished throughout the 
public health sector from hospital to Federal authorities 
worked well. And positive working relationships between the 
hospital and the local public health office proved critical in 
diagnosis and in containment.
    In conclusion, the largest single gap experienced between 
our hospital and expectations of State and Federal health 
authorities as well as the public to whom we are dedicated is 
the additional cost associated with clinical education, 
supplies, and ultimately prevention on a local, regional, and 
national infectious disease issue. Local hospitals like Loudoun 
Hospital have spent considerable time, man hours, and capital 
in emergency preparedness for all levels of trauma and 
infection associated with accidental or hazardous situations. 
It has taxed us heavily, and while we carry the burden to meet 
expectations, assistance by way of appropriated dollars would 
certainly provide the means to assure a successful rapid 
response by your front-line provider.
    Although all the links in the chain of defense must be 
strong, it is imperative that the strongest link be at the 
local level with the front-line provider.
    I thank you very much again for the invitation to present 
here today.
    Senator Coleman. Thank you very much, Mr. Huebbers. Dr. 
Frieden.

TESTIMONY OF THOMAS R. FRIEDEN, M.D., M.P.H.,\1\ COMMISSIONER, 
  NEW YORK CITY DEPARTMENT OF HEALTH AND MENTAL HYGIENE, NEW 
                         YORK, NEW YORK

    Dr. Frieden. Good morning, Chairman Coleman. I am Dr. 
Thomas Frieden, Commissioner of the New York City Department of 
Health. Thank you for the opportunity to discuss New York 
City's response to SARS.
---------------------------------------------------------------------------
    \1\ The prepared statement of Dr. Frieden appears in the Appendix 
on page 86.
---------------------------------------------------------------------------
    Every single day, New York City welcomes more than 100,000 
incoming air travelers, of whom more than 30,000 are coming 
from international destinations. On Saturday morning, March 15, 
just 3 days after the World Health Organization first issued 
its SARS alert, we were notified of a traveler from Singapore 
with suspected SARS. The traveler was a physician himself, an 
infectious disease specialist, like myself actually, who cared 
for two index patients with SARS in Singapore. He had attended 
a large conference in New York City. He saw a New York City 
doctor for his illness, then flew home to Singapore. He was 
taken off the plane in Frankfurt, Germany, and hospitalized. 
His wife and mother-in-law, who were both traveling with him, 
both developed SARS.
    That afternoon and evening, we faced a series of critical 
decisions and rapidly took the following actions. With 
facilitation from CDC, we spoke with the patient's doctor and 
determined that the patient met the case definition. We 
interviewed the patient by phone from his isolation room in 
Germany. We determined who he had been in contact with in New 
York City and we contacted them. We notified the conference he 
had attended. We found the doctor who treated him in New York 
City and monitored him and his staff for illness.
    The same day, using blast fax and E-mail technology, we 
contacted health care workers throughout New York City, 
including every emergency department, every intensive care 
unit, and many others about SARS and the importance of rapid 
detection isolation. We heightened the index of suspicion in 
our state-of-the-art syndromic surveillance system. This system 
tracks every ambulance run, most emergency department visits, 
many pharmacy prescriptions, and absentee data.
    We created a public communications strategy, including 
targeted outreach to Asian communities. We emphasized that this 
is a disease of travel, not ethnicity.
    Our response illustrates that a detection and response to 
an infectious disease outbreak, whether natural or intentional, 
requires both a strong public health infrastructure and an 
effective working relationship with the medical community.
    Today, we have a stronger system, thanks to Federal 
funding. We are able to be available 24/7 to evaluate potential 
SARS cases, ensure that appropriate lab specimens are obtained, 
provide guidance about patient isolation and care, and actively 
monitor all cases. We continue to prepare for a possible 
outbreak, and when needed, we have mandated the isolation of 
patients.
    Partly due to early proactive response and partly due to 
our good fortune in not having had a super-spreader, SARS has 
not spread in New York City. However, given outbreaks around 
the world, New York City and the United States cannot afford to 
be complacent. A disease that spreads like the common cold, 
kills one out of six people it infects, and for which there is 
no rapid test, no vaccine, no cure, and no way to predict its 
future course is something we must all be extremely concerned 
about.
    Federal funding is woefully inadequate for our city. For 
example, bioterrorism funding is not currently directed toward 
the extraordinary needs of places high on the list of potential 
targets. Cities like New York, already a target more than once, 
must be prioritized. More than 11 million people live or work 
in New York City every day, with a population density 300 times 
greater than the national average.
    We appreciate the Federal funding that has already been 
provided, but it is not nearly enough. I request a chart that I 
will provide be read into the record.\1\ It shows that, 
incredibly, New York City ranks 45 out of 54 grant recipients 
in Federal per capita bioterrorism funding, 10 percent less 
even than the national average. New York City gets one-sixth as 
much per capita as Washington, DC, one-fourth as much as 
Wyoming, one-third as much as Vermont, Alaska, North and South 
Dakota.
---------------------------------------------------------------------------
    \1\ The chart appears in the Appendix on page 136.
---------------------------------------------------------------------------
    The spread of SARS could rapidly overwhelm our ability to 
respond. My department has immediate needs requiring at least 
$104 million additionally. Our most urgent unmet need is to 
upgrade our public health laboratory. Despite fiscal crisis, 
the city has dedicated more than $30 million to upgrading the 
lab, but this is only about half of what is needed. We must 
retrofit facilities for emergency use, plan and establish sites 
for mass preventive treatment, acquire equipment and technology 
for rapid response. New York City public hospitals need an 
additional $35 million to address their immediate emergency 
response needs.
    To ensure speed and effectiveness, it is critical that 
Federal funding continue to come directly to New York City. We 
must continue to strengthen the Nation's public health 
infrastructure. CDC's laboratory and infectious disease 
resources need to be greatly increased. Threats of terrorism 
and new and reemerging infectious diseases will remain a 
concern for the foreseeable future. Only a concerted, sustained 
Federal investment in public health will ensure our capacity to 
respond and protect our communities. Thank you.
    Senator Coleman. Thank you very much, Dr. Frieden. Ms. 
Selecky.

 TESTIMONY OF MARY C. SELECKY,\2\ SECRETARY, WASHINGTON STATE 
   DEPARTMENT OF HEALTH, OLYMPIA, WASHINGTON, AND PRESIDENT, 
     ASSOCIATION OF STATE AND TERRITORIAL HEALTH OFFICIALS

    Ms. Selecky. Thank you, Mr. Chairman and Members of the 
Subcommittee. I am Mary Selecky, Secretary of Health in 
Washington State and President of the Association of State and 
Territorial Health Officials.
---------------------------------------------------------------------------
    \2\ The prepared statement of Ms. Selecky appears in the Appendix 
on page 94.
---------------------------------------------------------------------------
    In my remarks today, I would like to make four points. 
Substantial Congressional investments in preparedness funding 
have enabled States to respond more effectively to emerging 
infectious diseases, such as SARS.
    Second, great progress has been made in enhancing public 
health capacity, but as you just heard, much more needs to be 
done and sustained support is essential.
    Third, Federal, State, and local public health agencies in 
collaboration with their international counterparts and other 
key partners are working cooperatively to address this serious 
public health concern.
    And fourth, as Dr. Osterholm said, the greatest obstacle to 
our efforts to combat SARS and future threats like this is the 
serious workforce shortage facing health agencies at the local, 
State, and Federal levels, both public and private. That 
shortage must be addressed if we hope to quickly, efficiently, 
and effectively respond to emerging infectious diseases.
    For the past 2 years, Congress has appropriated significant 
amounts of funding for public health preparedness activities at 
the Federal, State, and local levels. There is no doubt that 
these resources have improved our ability to respond to SARS. 
In Washington State, we have 29 suspect and probable cases. We 
have a double-digit number. Other States have single-digit 
numbers. We all have to have the same capacity.
    With the investments that have been made in Washington 
State, public health preparedness funds have added four 
epidemiologists to our State communicable disease epidemiology 
unit, providing us with the additional capacity needed to 
respond to SARS questions and to assist local health agencies 
and local clinicians, including our hospital partners. These 
same funds have been used to organize 9 public health emergency 
preparedness regions among our State's 35 counties that are 
organized in local public health. We have added additional 
epidemiologists and we have provided leadership across the 
State, State and local together, in being able to deal with 
SARS.
    Washington State, like most other States, is using the 
health alert network that Dr. Gerberding mentioned to 
disseminate official messages from CDC across the public health 
system and through local health agencies, as noted in New York, 
to clinicians and hospitals, and we are all using websites, 
borrowing, and sending around to each other.
    Cooperation and collaboration among public health agencies 
and other key partners is critical to our SARS activity. Our 
colleagues at CDC have done a terrific job in identifying and 
tracking the epidemic. As you heard, through numerous 
conference calls, video conference broadcasts, international 
broadcasts, we have shared the information across a wide 
spectrum.
    As a former local health official for 20 years in a very 
rural part of Washington State, the Fifth Congressional 
District, I know firsthand about the importance of the 
capabilities that must be in place so that all citizens are 
protected. In a local rural area, we rely clearly on our fellow 
local, our State, and our Federal health agencies, but we all 
have distinct roles to play.
    We are a State that borders another country and we are next 
to British Columbia. We serve as a major port of entry and we, 
the State, as well as the locals, must work together with our 
international partners in order to address issues like this, 
and let me give you our example.
    On March 22, a container ship was due to arrive in Tacoma, 
Washington, after visiting Singapore, Hong Kong, and Taiwan. 
Several of the 26 crew members had developed non-specific upper 
respiratory symptoms that fit the evolving case definition.
    As the ship approached, my staff worked closely with the 
local health department, Tacoma, Pierce County, CDC's Division 
of Global Migration and Quarantine to plan a response. We had 
questions about the symptoms, who had the authority, would we 
isolate, would we quarantine, who is it that would address this 
issue? The Port of Tacoma was engaged, as well as the shipline 
owner. We were all working together, and this was new territory 
for all of us. Calls for assistance and questions quickly 
overwhelmed CDC's Division of Global Migration and Quarantine. 
If there is anything singular that stands out, there has been 
underfunding of that particular part of CDC.
    We boarded the ship together. We determined that we were 
not dealing with SARS at that moment. We were able to work 
together to alert the other ports in California and Hawaii as 
to what had gone on; it is that cooperative and collaborative 
relationship of which I speak.
    For a moment, I will highlight some of our workforce 
concerns. The same public health workers who work on 
communicable diseases at the State and local level, and even 
most recently with smallpox vaccinations, upcoming summer West 
Nile virus, or should anthrax ever appear, are the same ones 
that are today answering the phone about BSE, beef in Canada, 
and have been dealing with SARS. They are public health nurses, 
disease investigators, environmental health specialists, and 
laboratorians. We need them all.
    Clearly, the recent progress that has been made in 
strengthening our public health infrastructure has helped, but 
much more needs to be done. Questions will arise if we in this 
country could deal with what Toronto went through. I believe we 
could, but we would be stretched to the max. We, as you 
yourself said, have been lucky. Someone is smiling on us.
    In closing, I wish to thank Congress for the preparedness 
funding that has come. It was a critical beginning, but it 
can't be a two-shot effort. It clearly must be sustained. Thank 
you.
    Senator Coleman. Thank you very much, Ms. Selecky.
    Thank you to the entire panel. Dr. Frieden, your chart will 
be entered into the record.
    Let me first start with Mr. Huebbers, and again, with all 
the testimony, I am very impressed with the quickness with 
which we responded. You talked about an evolving definition of 
SARS. Mr. Huebbers, you mentioned when this first report came 
in, there were some unusual things happening in Guangdong 
Province. I think you indicated SARS has not yet been 
designated as what we were dealing with. Where did you get your 
information from? Was it official, unofficial? How did that 
work?
    Mr. Huebbers. Actually, in reality, what occurred was we 
identified that it was unusual when the patient presented the 
symptoms and we contacted public health. We have a fairly fast-
acting triage process, that when we deem something is highly 
unusual, it goes beyond--involves administrators and everybody 
else, and literally went on the Internet and went to a search 
engine, typed in ``Chinese pneumonia'' and came to a website 
that had indications or had information there about the 
disease. And at the same time I am doing that at home, people 
at the hospital were doing it, because this occurred at about 
11 o'clock at night. So that is--we were able to get that 
information between public health and articles that were on the 
website.
    Senator Coleman. I am not sure whether this is a question 
for you or Ms. Selecky, but the way in which you responded, is 
that a product of you being near Dulles, part of the kind of 
major Washington community? Do you have a level of 
sophistication that perhaps the rural area that Ms. Selecky 
worked in wouldn't have?
    Mr. Huebbers. I would say most probably. It was a 
combination of we did get lucky. We have, because of our 
proximity to Dulles, we have had experience in dealing with 
malaria, anthrax, and West Nile. But we are in a unique 
situation because of being near Dulles and the Washington area.
    Senator Coleman. Talk to me about the capacity, and I am 
going to ask Dr. Frieden that same question. When we listened 
to the first panel, the concern is fall comes, increased 
capacity. Do you have the ability to handle multiple cases? Is 
there bed space available?
    Mr. Huebbers. We agree, and actually had started planning 
several weeks back, because we agree with the hypothesis that 
come the fall or winter of next year, we are not going to see 
the end of SARS. Actually, we believe at Loudoun that this is 
just the beginning.
    We have already met with both regional and State health 
officials. We have the capacity at what we would call our old 
hospital--we are in a new facility that is 5 years old. The old 
campus has been maintained. We can bring that campus online in 
a very quick fashion to handle upwards of 100 patients, and, in 
fact, that has been part of our planning process. Both regional 
and State officials agree, and its ability to handle surge 
capacity is critical.
    Our issue is money. To do that, to bring it online and 
sustain it from here on in, which the community, being the 
second fastest growing county in the country, there is also the 
need for some capacity there, but we just don't have the funds 
to do it. I mean, in an emergency, we would figure it out, 
but----
    Senator Coleman. I have to go vote again. Dr. Frieden, I am 
going to come back to this issue of surge capacity in an area 
like New York. We will adjourn this hearing for not more than 
10 minutes to allow me to vote and come back.
    [Recess.]
    Senator Coleman. This hearing is called back to order.
    Dr. Frieden, what we were talking about and Mr. Huebbers 
had talked about, surge capacity. Talk to me about New York, 
bed space available, how do you create capacity?
    Dr. Frieden. Well, in New York City, we have the experience 
of West Nile virus. We have the tragic experience of the World 
Trade Centers. We have the experience of anthrax. And so we 
have dealt with surge capacity in the past, and I think our 
gaps in this area are primarily three.
    The first and most urgent is laboratory capacity. This is 
true at the national, many State, and certainly our local and 
other local levels. In the health care system, the laboratory 
is often the poor relation in the landscape of medical care and 
public health, and that is the case here, as well. We would 
need to be able to test, presuming that we have a rapid and 
accurate test down the line that can definitely rule in or rule 
out infection within less than 3 weeks, which is what we are 
dealing with now. Presumably, if we have a test, we would need 
to be able to do it rapidly, 24/7, 7 days a week, and we don't 
have that capacity.
    The second issue is surge capacity in terms of isolation 
beds, medical facilities, and, potentially, quarantine 
facilities. We have to consider what we would rather not have 
to do, but if we had large groups of people who needed to be 
separated from others, we would have to find places for those 
people to be.
    Hospitals have been downsizing, but there is a difference 
between having space and having staff. And so the critical 
distinction is between beds and staffed beds. We know that SARS 
affects hospitals directly. Today's paper talks about nurses 
and doctors resigning en masse in Taiwan. The challenge would 
be not just to find the physical space, but the staff to be 
able to attend to patients.
    And, of course, personnel is also a critical issue, as Dr. 
Osterholm and Ms. Selecky mentioned. We have the same staff who 
are doing smallpox, the same staff who are responding to 
outbreaks of infectious diseases every day of the year, the 
same staff who are dealing with West Nile virus, and with our 
syndromic surveillance system. These are the staff who are 
answering calls on SARS or other things and it really is not a 
sustainable situation to be in, even without a major outbreak, 
and with a major outbreak, it strains the system to the 
breaking point.
    Senator Coleman. Understanding that staff, it is hard to 
just kind of put together this is the SARS team and have them 
waiting for the fall, the next outbreak, but talk to me a 
little bit about the ability to investigate. I read somewhere 
an article, maybe in the New York Times this weekend, that 
talked about setting up teams and New York City having teams. 
Are those infectious disease teams or are they SARS teams or 
tell me a little bit about how you are doing that.
    Dr. Frieden. We are very fortunate in New York City. We 
have many dozens of highly trained medical epidemiologists. We 
have disease investigators in a wide variety of programs 
relating to everything from typhoid to tuberculosis, West Nile 
virus, and so we are able to field teams to track individual 
patients or outbreaks and we do that all the time. That is the 
bread and butter work of public health. If we get a case, we 
have a cluster of pertussis or measles, we are able to rapidly 
respond and contain that before it becomes a major public 
health problem. Again, if the team is working on one thing, 
they can't be working on something else, so that limits our 
ability.
    We also shouldn't forget that although we need to continue 
and strengthen our ability to respond to infectious diseases, 
the thing that is killing seven out of ten Americans now is 
non-communicable diseases and local public health departments, 
State health departments, and Federal agencies have not fully 
stepped up to the plate of that challenge. And so as we try to 
deal with the things that are killing people today, we need to 
not stop dealing with the things that are likely to be coming 
back as significant problems now and in the future.
    Senator Coleman. That is very helpful, and I do want to 
note, Dr. Frieden, that I certainly support your call for 
bioterrorism funding that needs to be prioritized. I think that 
is important, and we are certainly having discussions about 
that in this body. But I do think that we have to be moving in 
that direction. The reality is, in New York or Washington, 
threat levels are different than in, as I said before, Sleepy 
Eye or Hibbing, Minnesota, and I think we should recognize that 
certainly in the funding stream, so that conversation is going 
on.
    Ms. Selecky, I keep getting back to that rural perspective. 
I know you are not in that role now, but are you confident that 
folks at a rural level, hospital rural level, if faced with a 
patient that showed some SARS signs, that they would have the 
capacity to react in the appropriate manner?
    Ms. Selecky. Mr. Chairman, we are much better prepared 
today than we were in the past and it will get better. I think, 
clearly, our ability to do very quick communication, the 
investment we have done as a public and private system in how 
we communicate and getting real-time information back and forth 
has been important.
    I still live in that rural area of Washington State. I have 
to stay in the State capital during the week, but I travel that 
7 hours across the great State of Washington and I have 
responsibility for 39 counties, be they rural or urban, as do 
my counterparts across the country. Our ability to make sure 
that people are aware of what is emerging, what is happening--I 
will use West Nile as an example.
    It could be in an urban area, or our first dead raven with 
West Nile virus was in Ponderey County, where I used to be the 
health officer. It was just as important for that person who 
picked up that dead bird to be able to take it to their local 
health department, who then sent it to us at the State level--
we all have roles. But our level of sophistication at the State 
level was greater than at the local level. We share the 
information and we worked with our Federal partners. That is as 
good of an example as with SARS.
    Our hospitals have been squeezed to such small margins, be 
they public hospital districts that rely on tax dollars to open 
the door, or larger hospitals in our urban area that are 
counting on great numbers of encounters to help them open the 
door. But they both need the same amount of information for 
identification. That is what is really important, is about 
understanding information through the system.
    Senator Coleman. But they both don't have the same level of 
resources.
    Ms. Selecky. No, they do not.
    Senator Coleman. As I listened to Mr. Huebbers talk about 
the protocol that they followed in terms of backtracking, 
finding out where folks were, going through the whole process, 
I would suspect, in some of those rural hospitals, you wouldn't 
have the capacity.
    Is this something that we should be looking at a regional 
approach to, to have certainly the investigatory capacity, or 
does it have to simply fall on the shoulders of those at the 
grassroots level?
    Ms. Selecky. Quite frankly, the charge that Congress has 
given to us in the States is to look at how this would work 
within our States. The fact that you have said to States, you 
need to come up with a plan, it needs to include all of these 
partners, and you are responsible for making sure the system 
works inside your State, is absolutely essential.
    We have somewhere in the neighborhood of 5,000 hospitals. 
To disperse the money from a central location at the Federal 
level to 5,000 doesn't build the system. To hold the States 
responsible for the coordination of that system is important.
    Now, in Washington State and in the State of Nebraska, for 
example, a regional approach was used. In some other States, in 
New York, New York City clearly has its own needs that are very 
different than other parts of New York, whether it is up in 
Eire County or wherever the case is. And I think that is what 
has allowed the States to do is that flexibility. Mandating a 
regional approach, I am not sure that is a one-size-fits-all, 
but it is one that has been encouraged for us to share those 
resources across boundaries.
    Senator Coleman. When you had the example of the cargo ship 
coming in, who called the shots? Who was in charge? Who had 
ultimate authority?
    Ms. Selecky. That was clearly an interesting sorting out, 
because at that time, SARS was not listed as one of those 
diseases over which CDC had authority to do quarantine and 
isolation. And because the ship would dock in a local 
community, what we had sorted out would be, as in Washington 
State, our rule, which we had already updated, the local health 
official has the first call. The State health official is there 
for back-up, and the Feds are in a tertiary, and that was 
appropriate--but the important part is us working together 
collaboratively.
    We all went onto the ship. It was an incredibly learning 
moment, the thought of staff going up a Jacob's ladder from a 
tugboat to get on the ship to see what was going on before we 
would allow them to come to port, because we didn't want that 
one little crack through the wall, as it were, to happen. We 
were very fortunate, but indeed, as what followed was the 
President did declare that SARS would be one of those diseases 
for which you could quarantine and isolate, if that is what was 
needed.
    Senator Coleman. Getting back to the question of who is in 
charge, and we are going to have a legal expert in the next 
panel, but I am kind of throwing it open to everyone here, are 
folks confident they have got the legal authority to take tough 
steps if that is called for? If we move to a quarantine 
situation, is there any question about your legal capacity to 
do the things that you believe as health professionals need to 
be done to ensure the safety of your community? I will start 
with Ms. Selecky.
    Ms. Selecky. One comment I would make. I know in Washington 
State, we do, and it is written in certainly the law and the 
rule that we have the enforcement authority to ask our local 
law enforcement or our State patrol to assist us. But the 
actual enforcement of how you get that done, I think in a 
society that prides itself on individual freedoms and 
individual liberties, when we have to take collective action as 
government officials to protect the public's health, is going 
to be a very tough test in this country.
    Senator Coleman. Dr. Frieden.
    Dr. Frieden. There is reasonable Federal guidance on this, 
but it remains a State and local issue and a State and local 
jurisdiction. In New York City, actually 10 years ago, I helped 
to modify the statute for how we detain patients with 
infectious and potentially infectious tuberculosis, when I was 
in charge of tuberculosis for New York City, and we put into 
place a system that has been tried, tested, and, in fact, 
challenged in court and upheld in court, whereby we can both 
protect the public's health and also protect an individual's 
right to due process and to an individualized determination of 
whether they actually need to be detained.
    We had to actually use those powers in two cases so far in 
the SARS outbreak, for individuals who did not wish to remain 
isolated. And so we do have the authority to do it. We have 
done it. We are also further modernizing that statute now to 
address a wide variety of potential public health threats--
smallpox, contact to smallpox and other communicable diseases.
    Senator Coleman. Is that an issue that you think there 
should be a single standard for the country, or do you----
    Dr. Frieden. Absolutely not.
    Senator Coleman. OK.
    Dr. Frieden. Absolutely not. I think it is a very important 
question, Mr. Chairman. There are important differences between 
different States and different localities and the cookie-cutter 
approach can actually be very damaging because the statute here 
has to interact with a wide range of other statutes and 
resources. While a Federal guidance and a model statute is 
helpful, in fact, when you get around to implementing it in a 
local area, you have very specific local jurisdictional issues 
that may be different.
    New York City, for example, is an independent vital 
registration area, independent even though it is within New 
York State, and so that has a whole host of other implications, 
which means that the State's statute really has to take that 
into cognizance. The City has its own Board of Health with 
legislative authorities.
    Senator Coleman. Great. Thank you very much. Mr. Huebbers.
    Mr. Huebbers. Because we have had the experience with 
malaria, anthrax, West Nile, and SARS now, we have tested the 
system and we think it works pretty well both locally and on 
the State level, so we are comfortable.
    Senator Coleman. Great. Thank you.
    I want to thank the panel. You have been very helpful.
    I would like to call our final panel of witnesses at this 
time. We welcome Lawrence O. Gostin, the Director of the 
Georgetown University Center for Law and the Public's Health; 
Dr. Bruce R. Cords, Vice President for Environment, Food Safety 
and Public Health at Ecolab in St. Paul, Minnesota; and 
finally, Vicki Grunseth, Chairman of the Metropolitan Airports 
Commission in Minneapolis.
    I thank all of you for your attendance at today's hearing. 
Welcome. Pursuant to Rule 6, all witnesses who testify before 
the Subcommittee are required to be sworn. At this time, I 
would ask you all to please stand and raise your right hand.
    Do you swear that the testimony you give before this 
Subcommittee will be the truth, the whole truth, and nothing 
but the truth, so help you, God?
    Mr. Gostin. I do.
    Dr. Cords. I do.
    Ms. Grunseth. I do.
    Senator Coleman. Thank you very much.
    As I have indicated before to the other panels, we will be 
using a timing system today. One minute before the red light 
comes on, you will see lights change from green to yellow, 
giving you an opportunity to conclude your remarks. While your 
written testimony will be printed in the record in its 
entirety, as I have indicated to the other panels, we ask you 
to limit your oral testimony to no more than 5 minutes.
    Mr. Gostin, we will have you go first with your testimony. 
Then we will hear from Dr. Cords and finish up with Ms. 
Grunseth. As with our last panel, after we have heard all the 
testimony, we will proceed to questions. Mr. Gostin.

 TESTIMONY OF LAWRENCE O. GOSTIN,\1\ DIRECTOR, CENTER FOR LAW 
  AND THE PUBLIC'S HEALTH, GEORGETOWN UNIVERSITY LAW CENTER, 
                         WASHINGTON, DC

    Mr. Gostin. Good morning, Mr. Chairman. I am Lawrence 
Gostin. I am a professor of law at Georgetown University and 
Johns Hopkins University and Director of the Center for Law and 
the Public's Health, which is a CDC-collaborating center.
---------------------------------------------------------------------------
    \1\ The prepared statement of Mr. Gostin appears in the Appendix on 
page 101.
---------------------------------------------------------------------------
    I am going to talk about, first, antiquated laws in the 
United States; second, a model State emergency public health 
act that we wrote at the request of the Centers for Disease 
Control and Prevention; third, a new model law for non-
emergencies, including potentially for SARS; and then fourth, 
if I have got time or during questions, I will talk about the 
public health infrastructure and the ethics and logistics of 
quarantine. It is a big agenda.
    The CDC and the Department of Health and Human Services, as 
well as the Institute of Medicine, have all recommended reform 
of antiquated public health laws, and the reason why that is 
true is that most public health laws--actually, New York City 
is one of the exceptions--are very antiquated. They go back to 
the last 19th and early 20th Century, and as a result, they 
have a number of very serious problems.
    First, they may have ineffective powers, particularly for 
novel infectious diseases. If you take the New York example, 
just in the middle of the tuberculosis epidemic, they had to 
change their laws, and we don't want that to happen with SARS. 
We want to be prepared. So many of these laws may be 
ineffective for basic public health powers like reporting, 
testing, physical examinations, medical treatment, isolation, 
and quarantine.
    Second, these laws may be constitutionally suspect because 
most of them were passed before the Supreme Court's modern 
constitutional era. As a result, they don't have clear criteria 
for action, and also they don't have procedural due process or 
a fair hearing. This would have potentially very serious public 
health consequences because in the midst of an epidemic, you 
have to ask, is my law constitutional? It may result in 
indecision and delays. That is part of the reason why in some 
of the earlier modeling exercises, TOPOFF I and Dark Winter, 
there were problems with quarantine and one sees it with every 
new novel infectious disease.
    And finally, these laws are inconsistent, although I do 
very much agree with testimony from New York City that we do 
not want a cookie-cutter approach. On the other hand, we don't 
want completely inconsistent rules, so that even within a 
single State, they will have different rules for different 
diseases, and then if you have adjoining States, like Maryland, 
Virginia, and the District of Columbia, or New York, 
Connecticut, and New Jersey, if you are dealing with an 
epidemic and you have completely different rules in those 
States, it doesn't make any sense because diseases, pathogens, 
cross State lines and you need some form of uniformity. But 
obviously, it has to fit in with the structure of the public 
health and legal system within a particular State.
    I do agree that CDC, particularly Dr. Julie Gerberding, and 
State and local health departments have done an excellent job 
in relation to SARS, but there is a great deal of progress that 
needs to be done, particularly on legal powers.
    After September 11 and the anthrax outbreak, the CDC asked 
the Center for Law and the Public's Health to draft an 
emergency powers act. It is called the Model State Emergency 
Health Powers Act. That act has been transformed by the 
National Conference of State Legislators into a checklist and 
most of the States have used that checklist against their own 
laws. Twenty-two States and the District of Columbia have 
passed the model law or a version of the model law. That is 
great progress, but there are still significant problems.
    One is that many States have not passed the model law, and 
the other is that the model law requires the governor to 
declare an emergency, and for an undeclared potential 
emergency, like SARS, you run into significant problems.
    It is for that reason that the Center is currently working 
with the Robert Wood Johnson Foundation and its Turning Point 
Initiative, with a consortium of States and national experts 
throughout the public health sector to draft a model public 
health law that would apply to SARS and all emerging infectious 
diseases, basically getting our public health laws into the 
21st Century. That statute has now been sent out to a wide 
variety of national organizations, attorneys general, public 
health commissioners, legislatures, and others across the 
country for comment. It has been ongoing for 2 years and it is 
expected to be ready for consideration by the States by the 
fall legislative sessions. Again, it is not intended as a 
cookie cutter. We don't want States to simply adopt it. But we 
want to make sure that they have model language they can use 
for a uniform approach.
    And then, finally, I just wanted to reinforce what all your 
other panelists have told you about the public health 
infrastructure. I am a member of the Institute of Medicine and 
also a member of IOM's Board on Health Promotion and Disease 
Prevention and I served as a committee member for its report on 
``The Future of the Public's Health in the 21st Century,'' 
which just came out recently. That report reiterated what CDC 
and others have said, which is that public health 
infrastructure is, in the words of the IOM, still in many 
respects, ``in disarray.'' They have insufficient laboratory 
structures, insufficient workforce development, insufficient 
surveillance capacity, and insufficient data systems.
    And the reason for that is the United States spends more on 
health than any other country in the world, but we spend less 
than 5 percent of all health dollars on public health, that is, 
population health and prevention. We need to do better than 
that, and in fact, as a result, the richest, most powerful, 
most wonderful country in the world has health indicators that 
lag well behind most other leading economic powers.
    I will just simply conclude with a brief examination of 
logistics of a mass quarantine, because one of the concerns I 
have is that we are prepared for a small quarantine, but most 
hospitals only have a couple of negative pressure rooms. If we 
have to have a mass quarantine, the logistics of providing 
care, treatment, sanitary facilities, infection control, 
clothing, methods of communication, hearings are not in place, 
and I think it is something that we need to do both legally and 
as a matter of ethics.
    So thank you very much, Mr. Chairman.
    Senator Coleman. Thank you very much, Mr. Gostin. Dr. 
Cords.

    TESTIMONY OF BRUCE R. CORDS, PH.D.,\1\ VICE PRESIDENT, 
 ENVIRONMENT, FOOD SAFETY AND PUBLIC HEALTH, ECOLAB INC., ST. 
                        PAUL, MINNESOTA

    Dr. Cords. Thank you. Good morning, Mr. Chairman. Thank you 
for the opportunity to speak to you regarding our company's 
response and challenges relating to the global SARS crisis. My 
name is Bruce Cords. I am currently Vice President of Food 
Safety and Public Health for Ecolab, headquartered in St. Paul, 
Minnesota. I am responsible for food safety and public health 
technology strategies across all Ecolab divisions. In this 
role, I have the lead technical responsibility for the 
company's response to the SARS crisis.
---------------------------------------------------------------------------
    \1\ The prepared statement of Mr. Cords appears in the Appendix on 
page 121.
---------------------------------------------------------------------------
    Ecolab provides products and services in over 160 countries 
with global sales of $3.4 billion in 2002. Among other things, 
Ecolab's expertise is in the practical application of 
disinfection and cleaning technology to help manage and respond 
to exposures in the workplace and in a wide variety of 
community environments. These include health care facilities, 
schools, lodging, restaurants, food processing facilities, 
military installations, and public transportation.
    Our customers, worldwide, depend on Ecolab to provide 
advice, products, and systems to address problems with 
infectious diseases such as SARS. As the outbreak of SARS was 
peaking in March and April, many international hotel chains 
asked for help to make sure that they had the latest training 
and information to deal with the virus. We continue to receive 
numerous information requests regarding SARS from both 
customers and industry officials.
    We have been closely monitoring the situation via the World 
Health Organization and CDC. There is still much to be learned, 
and until many of the open questions have been answered, we can 
only make recommendations based on the best scientific 
information available from sources such as CDC and the World 
Health Organization.
    As an aside, Dr. Gerberding and her staff at CDC have done 
an excellent job of regularly updating the public and health 
officials on the global status of outbreaks and any new 
information on the virus and its epidemiology.
    Initially, experts believed that the virus would survive 
for only a few hours on environmental surfaces. More recent 
information from the Chinese University of Hong Kong suggests 
that the virus may survive for days on environmental surfaces. 
Some examples include plastered walls, 24 to 36 hours; plastic 
surface, 36 to 72 hours; on stainless steel for 36 to 72 hours; 
and even on a paper file cover for 24 to 36 hours. This 
possibility of extended survival, places more importance on 
cleaning and disinfection of potentially contaminated surfaces.
    Some of the examples of questions we are receiving include: 
If we suspect the hotel room has been occupied by a SARS-
infected person, what cleaning and disinfection procedures 
should be followed? What hand care products and procedures are 
effective against the SARS virus? How do you inactivate SARS on 
carpet and upholstery? What are recommended cleaning and 
disinfection procedures for an airplane that has arrived from a 
country with active SARS infections?
    As you may know, the EPA has not approved any commercial 
products for claims against the SARS virus. Consequently, we 
and other companies have followed the general recommendations 
provided by the CDC to prevent the spread of the disease. The 
CDC specifically recommends, (1) aggressive hand washing and 
the use of an alcohol gel hand sanitizer containing 60 to 95 
percent denatured ethanol or isopropanol; (2) disinfection of 
environmental surfaces such as faucets, hand rails, restrooms, 
elevators, and other surfaces touched by multiple individuals 
with an EPA-registered hospital disinfectant; and (3) use of 
gloves and respirators for people in direct contact with 
potentially infected persons or environments.
    We have provided our customers with this information 
through direct contact with our district sales managers, our 
technical support staff, and have also made the information 
available on our public website, ecolab.com. The information 
provided includes general information on how the virus may be 
spread, Ecolab hand care and disinfection products which are 
consistent with CDC recommendations, and specific 
decontamination procedures for institutional settings.
    I want to emphasize that simply identifying products does 
not provide the user with the ``how to'' guidance they need. 
For example, in response to the earlier question, ``if we 
suspect a hotel room has been occupied by a SARS patient, how 
do I clean it?'', we give them specific information such as: 
(1) the personnel cleaning the room should wear a surgical mask 
and rubber gloves; and (2) cleaning personnel should clean 
frequently-touched surfaces, disinfect, such as light and air 
control switches, faucets, toilet flush levers, doorknobs, TV 
and radio controls. There are many items that may be missed 
without specific instruction. They also ask questions about 
laundry. We recommend that the laundry be segregated and heated 
to a temperature adequate for virus inactivation. So we 
basically give them specific procedures on the ``how to use.'' 
We do not simply sell them the product and say, ``Go to it.'' 
We give them the actual procedures.
    As mentioned earlier, no commercial products carry a claim 
of efficacy against this virus. Today, the CDC recommendations 
are based on extrapolation of data to other related viruses. 
Ultimately, products must be tested against the virus and 
products which carry an efficacy claim against this virus would 
provide the highest degree of confidence and performance.
    For this to occur, a reliable method for enumeration of the 
virus must be developed. It is my understanding the CDC is 
working in this area at the present time. The EPA must then 
approve a protocol for testing commercial products against the 
virus or a surrogate. During the recent foot-and-mouth disease 
threat and anthrax incident, Ecolab worked closely with EPA to 
expedite product approvals. Likewise, we look forward to EPA 
working to expedite approvals for products effective against 
SARS so that these products are available should the virus 
reappear in the United States.
    In summary, based on the latest scientific information, and 
working with appropriate government authorities, Ecolab will 
continue to provide our global customers with information on 
products and best practices to prevent the spread of this 
disease. Thank you for your attention.
    Senator Coleman. Thank you very much, Dr. Cords. Ms. 
Grunseth.

 TESTIMONY OF VICKI GRUNSETH,\1\ CHAIR, METROPOLITAN AIRPORTS 
               COMMISSION, MINNEAPOLIS, MINNESOTA

    Ms. Grunseth. Thank you, Mr. Chairman. I am Vicki Grunseth, 
Chair of the Metropolitan Airports Commission in Minneapolis. 
The Commission operates Minneapolis-St. Paul International 
Airport, MSP, and six reliever airports in the seven-county 
region of the Twin Cities.
---------------------------------------------------------------------------
    \1\ The prepared statement of Ms. Grunseth appears in the Appendix 
on page 125.
---------------------------------------------------------------------------
    MSP is the eighth busiest airport in the United States and 
the 12th busiest in the world. In the year 2000, 37 million 
passengers went through MSP. We annually have 500,000 
operations. I want to thank you for the opportunity to appear 
today on behalf of the aviation industry.
    SARS is obviously a major concern for airports. The airport 
is like an artery through which people and things pass into the 
heart of our country. Most of the things that flow through the 
artery are good. Many, in fact, are critical to our economic 
strength. But threatening things can flow into middle America 
through the airport artery, too, including potentially life-
threatening viruses like SARS. If we don't act swiftly to stop 
them or contain them, they can wreak havoc in the heartland and 
throughout our Nation.
    Stopping SARS is important to us first and foremost from a 
public health consideration, but it is also important to us 
from an economic standpoint. We need to ensure the traveling 
public has the information they need to feel safe while flying. 
I want to speak for a few minutes about the Metropolitan 
Airport Commission's role in responding to SARS. Next, I want 
to highlight the airlines' efforts to combat the spread of the 
disease. And finally, I want to address the assistance the 
collective aviation community has received from the Federal 
Government.
    In many respects, MSP operates like a municipality. We have 
our own 911 communications department, and our own fire 
department, our own police department. Each of our fire 
fighters is a trained emergency medical technician. Typically, 
they are the first responders to an emergency at the airport.
    Consider the population of people potentially threatened by 
SARS at our airport. On average, 100,000 passengers travel 
through Minneapolis-St. Paul every day. That doesn't count 
their colleagues, their friends, their family that drop them 
off or pick them up. There are thousands of people who work at 
the airport, 17,000 airline employees, 3,500 food and retail 
workers, 2,200 ground transportation providers, 1,400 Federal 
agency staff and 540 Airport Commission employees. Clearly, the 
potential for the spread of infection is enormous if we don't 
respond effectively to diseases like SARS.
    We have a physician on contract to the Metropolitan 
Airports Commission who reviews airline plans for responding to 
SARS. Northwest Airlines, which accounts for 80 percent of the 
operations at MSP, includes service to Asia. Northwest screens 
passengers at ticketing and boarding areas in affected areas, 
such as Hong Kong, China, Singapore, and Taiwan, and I should 
add Toronto. Airline representatives ask passengers whether 
they have experienced SARS-like symptoms and whether they have 
been in contact with infected persons during the last 10 days. 
If travelers have, they are referred to a medical facility to 
be assessed for their suitability to fly.
    If anyone exhibits SARS-like symptoms during the flight, 
they are isolated from other passengers as much as is possible. 
It is important to note that not a single case of SARS has been 
transmitted on airline flights since the World Health 
Organization recommended in late March that passengers from 
affected nations be screened. The World Health Organization's 
leadership, together with swift Federal action and cooperation 
from the aviation community, has effectively minimized the 
potential transmission of SARS on aircraft.
    Working with international health officials, the Federal 
Government provided valuable resources to airlines like 
Northwest and airports like MSP to prepare for and to respond 
to suspected SARS incidents. First, we benefit from the Centers 
for Disease Control and Prevention. Like most Americans, we 
first heard of SARS from the news media. Within days, though, 
we had access to reliable, science-based information from the 
CDC. The CDC website, in particular, serves as a clearinghouse 
for reliable SARS-related information. The site specifically 
addresses information regarding SARS and air travel. It advises 
travelers and provides information that enables airports to 
develop a higher awareness of the disease and its potential 
threat.
    We also found very useful the information from the World 
Health Organization which was communicated to us through the 
Transportation Security Administration and through our trade 
association, Airports Council International-North America.
    The second and perhaps most important resource is the 
Federal staff assigned to our airport to specifically respond 
to the SARS threat. On April 16, the CDC assigned a staff 
member to MSP as a central resource for SARS information and 
planning. The CDC has maintained staff at MSP on a rotating 
basis since that time, and our understanding is they will 
remain there for the duration of the crisis. Their presence has 
been pivotal to our SARS response. In addition, they provide 
round-the-clock phone support from a quarantine supervisor in 
Chicago.
    The process has worked very well. As you may know, we had 
an infant arrive from Beijing at MSP who exhibited SARS 
symptoms and we were able to deal effectively with that child 
and passengers on the plan. We were prepared, we operated in a 
coordinated fashion, and we took the steps necessary to 
safeguard the traveling public.
    The Metropolitan Airports Commission is very grateful to 
the assistance provided by the CDC. Federal interaction and 
coordination is the key to our ability to respond effectively. 
We don't know what is going to flow into the airport artery, 
but whenever possible, we want to stop harmful things from 
flowing out of it.
    Thank you for the opportunity to address you today. I will 
be pleased to answer any questions.
    Senator Coleman. Thank you, Ms. Grunseth.
    I will kind of work in reverse order. I was going to ask a 
question about whether the Airport Commission has an 
epidemiologist as part of your staff. I take it that CDC helps 
fill that role?
    Ms. Grunseth. We don't. We have a physician that we 
contract with to provide information, but the CDC is now 
providing that information on site.
    Senator Coleman. Do you see a need for a specific agreed-
upon protocol for handling these cases or is it sufficient 
simply to rely upon that relationship with CDC as to how best 
to proceed?
    Ms. Grunseth. I think in this case, our first information 
came by some action taken by the Airports Council, which is our 
trade association, and they worked in conjunction with the CDC 
to get accurate information out to the airports.
    Senator Coleman. Northwest is, in effect, a tenant of your 
community.
    Ms. Grunseth. Right.
    Senator Coleman. They, as I understand it, are doing the 
screening. Is that screening protocol something that is 
discussed with the Airports Commission? Do you have any input 
in that? How do you, again, assuming they have got a big stake 
in making sure that there is safety, but is that something that 
they work with you in terms of quality and the completeness?
    Ms. Grunseth. They have their own direct relationship with 
the CDC and then, in addition, with Dr. Jetzer, who serves as 
our Airports Commission consultant liaison to the airlines. I 
think it is kind of a triumvirate that exists.
    Senator Coleman. Great. Thank you.
    I have to say generally, and I am going to say it again, I 
am actually very pleased to hear the very positive statements 
about CDC and what they are able to provide. Clearly, there are 
some resource issues, capacity issues, and a whole range of 
issues that a number of witnesses have talked about, but I must 
say, I began this hearing with some trepidation about our 
capacity to respond, where we were going in the future with 
this and other similar circumstances that we are bound to face, 
as Dr. Osterholm laid out. But I certainly leave with a much 
better sense of what the CDC is doing in coordination with 
folks at the local level. So I think that message has been 
delivered.
    Dr. Cords, talk to me a little bit about the private 
sector-public sector interaction in terms of research. What is 
it that--you talked about the amount of time that this virus 
may be alive, may be active, and you indicated that is 
changing, that the perception of that is changing. How closely 
is the private side able to interact with CDC to get the 
information that you need?
    Dr. Cords. Their website is fairly complete, plus we have 
contacts that we talk to on a regular basis. So we are up to 
date on everything that they are doing. One of the things 
before we can do a whole lot more research on disinfectants and 
which ones are more effective or less effective than others is 
an enumeration method. We have to be able to count the virus or 
to determine effectiveness of products.
    One of the things we are doing now is recommending the use 
of hospital-level disinfectants, which have a little bit more 
strength than a general disinfectant you would have in your 
home. Some of those products have claims, and have been tested, 
against related viruses of the corona family. But none have 
ever been tested against this specific virus and I think that 
needs to be done. We know it is different than the common cold 
corona virus. We have seen that, in terms of its infectivity 
and its effect on humans. But does that mean that it could be a 
little bit different in terms of its resistance to 
disinfectants? We don't know that and I think we need to find 
that out pretty fast.
    Senator Coleman. Who does the testing?
    Dr. Cords. There aren't very many labs set up to do it now, 
and I would imagine the first screening tests for that would be 
done by CDC. Then there are a few labs that would have the 
proper level of containment to handle this type of testing. I 
am not sure how widely we are going to distribute this kind of 
a virus. It may be better to compare it to a virus and then 
have a surrogate that is actually the test organism or the test 
virus.
    Senator Coleman. Who would make that decision?
    Dr. Cords. CDC and EPA.
    Senator Coleman. Is there any role for universities in 
this?
    Dr. Cords. There may be a role for universities. I doubt 
that very many would have that level of a containment facility.
    Senator Coleman. You talk about, in your testimony, you 
talked about EPA approving a protocol and the importance of 
moving quickly, and this may be a question for Dr. Gostin, but 
how expeditious is the process today? Does there need to be 
some change, either statutorily or administratively, to 
accelerate the approval process?
    Dr. Cords. I think if the EPA acts as they did during the 
anthrax threat we will have rapid crisis exemption to certain 
products that had been tested against either anthrax itself or 
had been tested against surrogates. Even though people didn't 
have them on their label, they basically gave us a crisis 
exemption. So in that case, they moved quite rapidly.
    Senator Coleman. And Dr. Gostin, just from your knowledge 
of the EPA approval process, are we in good shape, structurally 
good shape today with the process that allows us to move very 
quickly to deal with the threats of SARS or SARS-like 
conditions?
    Mr. Gostin. Yes. I think the Federal agencies, the 
regulatory agencies like EPA and FDA have done a lot better. 
They have learned their lessons from past epidemics and I think 
they are moving much more quickly.
    Senator Coleman. You indicated that 22 States have model 
laws that certainly go beyond the antiquated systems we have 
before. By calculation, that leaves 28----
    Mr. Gostin. That is right.
    Senator Coleman [continuing] Way over half that don't. What 
has to be done to accelerate the pace at which those other 28 
States deal with their quarantine and public health laws?
    Mr. Gostin. It is highly controversial because you have--
ideas of quarantine and compulsory testing and screening and 
the like raise a number of civil liberties issues. What we need 
to do is try to get the message across that actually these 
modern laws need to be and actually are, in terms of our model 
law, very attentive to constitutional rights, and so that you 
want to try to have it both ways. You want to have strong, 
decisive modern laws that are also protective of civil 
liberties. I think if we can start to get that leadership at 
the Federal and State level there, then we will do a better job 
in getting people to try to enact these statutes.
    Senator Coleman. Who should be carrying the ball on that? 
Is it States' attorneys general or the National Attorneys 
General Association? Is there a role for Congress?
    Mr. Gostin. Well, we are working certainly with the Federal 
Government, with CDC and the Department of Health and Human 
Services who have urged it, and at the State level, we are 
working with the National Association of Attorneys General, the 
Association of State and Territorial Health Officers, NASHO, 
National Conference of State Legislatures, all of the right 
people.
    Certainly, leadership in Congress would be very helpful to 
underscore this, and it would even be possible, if one wanted 
to go this way, to have as a condition of funding for a number 
of public health activities to make sure that States do have 
modern, effective public health laws.
    Senator Coleman. That is a very helpful suggestion.
    Kind of concluding with one open to all three of you, do 
you think the public has a good sense of what the threat is and 
how we are handling it? Do you think the general average 
citizen out there is comfortable with what airports are doing, 
what the private side is doing, what the legal situation is? 
Ms. Grunseth.
    Ms. Grunseth. I think the theme I heard this morning and 
that you hear all the time is information is a good thing and 
people, if they can inform themselves, they are not afraid of 
what they know. They are afraid of what they don't know, and 
contrast that with the situation in China, which was, I think, 
the exact opposite. If we can watch combat operation in Iraq 24 
hours a day, we can probably handle more information about 
things like infectious diseases.
    Senator Coleman. Dr. Cords, from the business community, 
the hotel patrons, etc., do you think they have a level of 
comfort in terms of the information that is out there and 
ability to deal with this?
    Dr. Cords. I think they have a level of comfort with what 
is available to deal with it today. I don't think they 
appreciate, as Mike Osterholm said this morning, that we could 
be looking at a second wave. I think there is a bit of a 
relaxation going on right now and I am not sure that people are 
anticipating a second wave of the virus.
    Senator Coleman. Thank you. Mr. Gostin, any final comments?
    Mr. Gostin. I think that we have done a much better job 
than we did with anthrax, where we had problems of 
communication, and I think the Federal leadership and the State 
leadership is much better and people have a better idea of risk 
perception.
    But my big worry, it is a worry about the public and also a 
worry about political leadership, is that we tend to look at 
silos. It is bioterrorism, it is SARS, it is the next disease. 
What we really need to do in America is to make sure that we 
have a generally strong public health infrastructure. We have 
neglected not only the law but the infrastructure of public 
health for more than a century and now what we have to do is 
stop the silo funding and more generalized funding and capacity 
level at the State and local level.
    Senator Coleman. That message is certainly being heard here 
today.
    Due to time constraints, the Subcommittee was unable to 
invite all of the parties affected by this issue to present 
oral testimony. This week, we have received written statements 
from the American Public Health Association and Discovery Labs, 
Inc. Without objection, these statements will be included in 
the record.
    I want to thank all our panel members for being here today. 
I have a closing statement. I will simply enter that into the 
record. I will note that I am encouraged by what we have 
accomplished. I am still deeply concerned about what the future 
may hold.
    This hearing is adjourned.
    [Whereupon, at 11:51 a.m., the Subcommittee was adjourned.]
      
                            A P P E N D I X

                              ----------                              

[GRAPHIC] [TIFF OMITTED] T8251.001

[GRAPHIC] [TIFF OMITTED] T8251.002

[GRAPHIC] [TIFF OMITTED] T8251.003

[GRAPHIC] [TIFF OMITTED] T8251.004

[GRAPHIC] [TIFF OMITTED] T8251.005

[GRAPHIC] [TIFF OMITTED] T8251.006

[GRAPHIC] [TIFF OMITTED] T8251.007

[GRAPHIC] [TIFF OMITTED] T8251.008

[GRAPHIC] [TIFF OMITTED] T8251.009

[GRAPHIC] [TIFF OMITTED] T8251.010

[GRAPHIC] [TIFF OMITTED] T8251.011

[GRAPHIC] [TIFF OMITTED] T8251.012

[GRAPHIC] [TIFF OMITTED] T8251.013

[GRAPHIC] [TIFF OMITTED] T8251.014

[GRAPHIC] [TIFF OMITTED] T8251.015

[GRAPHIC] [TIFF OMITTED] T8251.016

[GRAPHIC] [TIFF OMITTED] T8251.017

[GRAPHIC] [TIFF OMITTED] T8251.018

[GRAPHIC] [TIFF OMITTED] T8251.019

[GRAPHIC] [TIFF OMITTED] T8251.020

[GRAPHIC] [TIFF OMITTED] T8251.021

[GRAPHIC] [TIFF OMITTED] T8251.022

[GRAPHIC] [TIFF OMITTED] T8251.023

[GRAPHIC] [TIFF OMITTED] T8251.024

[GRAPHIC] [TIFF OMITTED] T8251.025

[GRAPHIC] [TIFF OMITTED] T8251.026

[GRAPHIC] [TIFF OMITTED] T8251.027

[GRAPHIC] [TIFF OMITTED] T8251.028

[GRAPHIC] [TIFF OMITTED] T8251.029

[GRAPHIC] [TIFF OMITTED] T8251.030

[GRAPHIC] [TIFF OMITTED] T8251.031

[GRAPHIC] [TIFF OMITTED] T8251.032

[GRAPHIC] [TIFF OMITTED] T8251.033

[GRAPHIC] [TIFF OMITTED] T8251.034

[GRAPHIC] [TIFF OMITTED] T8251.035

[GRAPHIC] [TIFF OMITTED] T8251.036

[GRAPHIC] [TIFF OMITTED] T8251.037

[GRAPHIC] [TIFF OMITTED] T8251.038

[GRAPHIC] [TIFF OMITTED] T8251.039

[GRAPHIC] [TIFF OMITTED] T8251.040

[GRAPHIC] [TIFF OMITTED] T8251.041

[GRAPHIC] [TIFF OMITTED] T8251.042

[GRAPHIC] [TIFF OMITTED] T8251.043

[GRAPHIC] [TIFF OMITTED] T8251.044

[GRAPHIC] [TIFF OMITTED] T8251.045

[GRAPHIC] [TIFF OMITTED] T8251.046

[GRAPHIC] [TIFF OMITTED] T8251.047

[GRAPHIC] [TIFF OMITTED] T8251.048

[GRAPHIC] [TIFF OMITTED] T8251.049

[GRAPHIC] [TIFF OMITTED] T8251.050

[GRAPHIC] [TIFF OMITTED] T8251.051

[GRAPHIC] [TIFF OMITTED] T8251.052

[GRAPHIC] [TIFF OMITTED] T8251.053

[GRAPHIC] [TIFF OMITTED] T8251.054

[GRAPHIC] [TIFF OMITTED] T8251.055

[GRAPHIC] [TIFF OMITTED] T8251.056

[GRAPHIC] [TIFF OMITTED] T8251.057

[GRAPHIC] [TIFF OMITTED] T8251.058

[GRAPHIC] [TIFF OMITTED] T8251.059

[GRAPHIC] [TIFF OMITTED] T8251.060

[GRAPHIC] [TIFF OMITTED] T8251.061

[GRAPHIC] [TIFF OMITTED] T8251.062

[GRAPHIC] [TIFF OMITTED] T8251.063

[GRAPHIC] [TIFF OMITTED] T8251.064

[GRAPHIC] [TIFF OMITTED] T8251.065

[GRAPHIC] [TIFF OMITTED] T8251.066

[GRAPHIC] [TIFF OMITTED] T8251.067

[GRAPHIC] [TIFF OMITTED] T8251.068

[GRAPHIC] [TIFF OMITTED] T8251.069

[GRAPHIC] [TIFF OMITTED] T8251.070

[GRAPHIC] [TIFF OMITTED] T8251.071

[GRAPHIC] [TIFF OMITTED] T8251.072

[GRAPHIC] [TIFF OMITTED] T8251.073

[GRAPHIC] [TIFF OMITTED] T8251.074

[GRAPHIC] [TIFF OMITTED] T8251.075

[GRAPHIC] [TIFF OMITTED] T8251.076

[GRAPHIC] [TIFF OMITTED] T8251.077

[GRAPHIC] [TIFF OMITTED] T8251.078

[GRAPHIC] [TIFF OMITTED] T8251.079

[GRAPHIC] [TIFF OMITTED] T8251.080

[GRAPHIC] [TIFF OMITTED] T8251.081

[GRAPHIC] [TIFF OMITTED] T8251.082

[GRAPHIC] [TIFF OMITTED] T8251.083

[GRAPHIC] [TIFF OMITTED] T8251.084

[GRAPHIC] [TIFF OMITTED] T8251.085

[GRAPHIC] [TIFF OMITTED] T8251.086

[GRAPHIC] [TIFF OMITTED] T8251.087

[GRAPHIC] [TIFF OMITTED] T8251.088

[GRAPHIC] [TIFF OMITTED] T8251.089

[GRAPHIC] [TIFF OMITTED] T8251.090

[GRAPHIC] [TIFF OMITTED] T8251.091

[GRAPHIC] [TIFF OMITTED] T8251.092

[GRAPHIC] [TIFF OMITTED] T8251.093

[GRAPHIC] [TIFF OMITTED] T8251.094

[GRAPHIC] [TIFF OMITTED] T8251.095

[GRAPHIC] [TIFF OMITTED] T8251.096

[GRAPHIC] [TIFF OMITTED] T8251.097

[GRAPHIC] [TIFF OMITTED] T8251.098

[GRAPHIC] [TIFF OMITTED] T8251.099

[GRAPHIC] [TIFF OMITTED] T8251.100

[GRAPHIC] [TIFF OMITTED] T8251.101

[GRAPHIC] [TIFF OMITTED] T8251.102

[GRAPHIC] [TIFF OMITTED] T8251.103

[GRAPHIC] [TIFF OMITTED] T8251.104

[GRAPHIC] [TIFF OMITTED] T8251.105

[GRAPHIC] [TIFF OMITTED] T8251.106

[GRAPHIC] [TIFF OMITTED] T8251.107

[GRAPHIC] [TIFF OMITTED] T8251.108

[GRAPHIC] [TIFF OMITTED] T8251.109

[GRAPHIC] [TIFF OMITTED] T8251.110

[GRAPHIC] [TIFF OMITTED] T8251.111

[GRAPHIC] [TIFF OMITTED] T8251.112

[GRAPHIC] [TIFF OMITTED] T8251.113

[GRAPHIC] [TIFF OMITTED] T8251.114

[GRAPHIC] [TIFF OMITTED] T8251.115

[GRAPHIC] [TIFF OMITTED] T8251.116

[GRAPHIC] [TIFF OMITTED] T8251.117

[GRAPHIC] [TIFF OMITTED] T8251.118

[GRAPHIC] [TIFF OMITTED] T8251.119

[GRAPHIC] [TIFF OMITTED] T8251.120

[GRAPHIC] [TIFF OMITTED] T8251.121

[GRAPHIC] [TIFF OMITTED] T8251.122

[GRAPHIC] [TIFF OMITTED] T8251.123

