[Senate Hearing 108-367]
[From the U.S. Government Publishing Office]



                                                        S. Hrg. 108-367

                      SARS: IS MINNESOTA PREPARED?

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

                                HEARING

                               before the

                PERMANENT SUBCOMMITTEE ON INVESTIGATIONS

                                 of the

                              COMMITTEE ON
                          GOVERNMENTAL AFFAIRS
                          UNITED STATES SENATE


                      ONE HUNDRED EIGHTH CONGRESS

                             FIRST SESSION

                               __________

                FIELD HEARING IN MINNEAPOLIS, MINNESOTA

                               __________

                            OCTOBER 8, 2003

                               __________

      Printed for the use of the Committee on Governmental Affairs



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                   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 Counsel
                      Amy B. Newhouse, 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

       Raymond V. Shepherd, III, Staff Director and Chief Counsel
                   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

                                 ------                                
Opening statement:
                                                                   Page
    Senator Coleman..............................................     1
Closing statement:
    Senator Coleman..............................................    31

                               WITNESSES
                       Wednesday, October 8, 2003

Dianne Mandernach, Commissioner, Minnesota Department of Health, 
  St. Paul, Minnesota............................................     4
Michael T. Osterholm, Ph.D., MPH, Director, Center of Infectious 
  Disease Research and Policy, and Professor, School of Public 
  Health, University of Minnesota, Minneapolis, Minnesota........     6
Jeff Spartz, HCMC Administrator, Hennepin County Medical Center, 
  Minneapolis, Minnesota.........................................    15
Mary Quinn Crow, Vice President of Patient Care Services, 
  Northfield Hospital, Northfield, Minnesota.....................    17
Ann Hoxie, Student Wellness Administrator, St. Paul Public 
  Schools, St. Paul, Minnesota...................................    19
Debra Herrmann, RN, PHN, LSN, District Lead Nurse, Marshall 
  School District, Marshall, Minnesota...........................    22
Rob Benson, Superintendent, Floodwood School District, 
  Floodwater, Minnesota..........................................    24

                     Alphabetical List of Witnesses

Benson, Rob:
    Testimony....................................................    24
    Prepared statement with an attachment........................    58
Crow, Mary Quinn:
    Testimony....................................................    17
    Prepared statement...........................................    48
Herrmann, Debra, RN, PHN, LSN:
    Testimony....................................................    22
    Prepared statement...........................................    56
Hoxie, Ann:
    Testimony....................................................    19
    Prepared statement...........................................    51
Mandernach, Dianne:
    Testimony....................................................     4
    Prepared statement...........................................    32
Osterholm, Michael, T., Ph.D., MPH:
    Testimony....................................................     6
    Prepared statement...........................................    36
Spartz, Jeff:
    Testimony....................................................    15
    Prepared statement...........................................    43

                                APPENDIX

Donna J. Spannaus-Martin, Ph.D., CLS (NCA), Director and 
  Associate Professor, Division of Medical Technology, University 
  of Minnesota, prepared statement...............................    61

 
                      SARS: IS MINNESOTA PREPARED?

                              ----------                              


                       WEDNESDAY, OCTOBER 8, 2003

                                       U.S. Senate,
                Permanent Subcommittee on Investigations,  
                  of the Committee on Governmental Affairs,
                                                    Washington, DC.
    The Subcommittee met, pursuant to notice, at 10:08 a.m., in 
room C350, St. Louis Park High School, Minneapolis, Minnesota, 
Hon. Norm Coleman, Chairman of the Subcommittee, presiding.
    Present: Senator Coleman.

              OPENING STATEMENT OF SENATOR COLEMAN

    Senator Coleman. This hearing of the Permanent Subcommittee 
on Investigations is called to order. It is a great pleasure to 
be at St. Louis Park High School this morning; one of the great 
high schools in the State of Minnesota and in America. 
Superintendent Pulliam, I believe, will say a few things, but I 
do want to say thank you to the district and to the school for 
affording us this opportunity to have a hearing on an issue 
that is very important to all Minnesotans throughout the State. 
And certainly today we will talk a little bit about the impact 
of the potential of a disease like SARS on schools and beyond.
    But as I said, it is a great pleasure to be here. And 
Superintendent, I would like to turn it over to you for a 
couple comments, first.
    Mr. Pulliam. Thank you very much, Senator. Good morning to 
all of you, and especially to you, Senator Coleman. Welcome to 
St. Louis Park School District.
    This is a children-first community, a school district that 
today has 16 national merit scholars, and one we consider to be 
the best-kept secret in the Metro Area.
    We are very proud and pleased to host your hearing today. 
SARS certainly is a virus that we all need to heighten our 
awareness level of, and the fact that you are going to hold a 
hearing today in our community to discuss how prepared we might 
be, should an outbreak occur, certainly does do us a great 
credit as a State, and especially as a community.
    I would also like to welcome the members of the health 
community that are here. Welcome to St. Louis Park, but welcome 
to this particular hearing. Again, I want to thank you for 
taking the time to visit with our children, especially. Our 
students are very proud to have you here, and to be able to 
interact with you. It is a great credit to your support of 
public education.
    Senator Coleman. Thank you, Superintendent. Let me tout the 
St. Louis Park schools--16 national merit scholars, four of 
them semi-finalists, one of four blue ribbon schools, recently 
recognized by the U.S. Department of Education and the State of 
Minnesota. I think last year you had perfect ACT and SAT 
scores. Very rare. The year before, two perfect SAT scores. So 
an outstanding program. And we are working very hard. St. Louis 
Park has an asset-builders program that we are working with, 
and I know our office is involved and looking for support for 
that program. It is really a wonderful model. So you have a 
great school here, great kids. And this is the future of 
Minnesota, and I am thrilled to be here.
    Mr. Pulliam. Thank you very much.
    Senator Coleman. Thank you. Today's hearing will focus on 
how Minnesota officials are preparing for a possible outbreak 
of SARS in the upcoming flu season.
    In the first outbreak of SARS, there were 8,098 cases in 28 
countries. The United States experienced 29 total probable 
cases of SARS--with the median age being 33--and thankfully no 
fatalities. Throughout the world, however, 916 people died of 
SARS-related complications.
    We are here today to discuss what we can do to ensure that 
the next outbreak of SARS isn't summarized with statistics of 
who got sick and died--but rather a case study that illustrates 
how lives can be saved when government and the health care 
communities--at every level--work together, not just hoping for 
the best, but being prepared for the worst.
    Today's hearing gives us an excellent opportunity to assess 
our preparedness. We will hear from two of Minnesota's leaders 
in the area of public health and infectious disease. We will 
also hear from local officials, and, in particular school, 
officials who represent the front line of our effort to contain 
any future outbreak.
    In a way, we're here to see what kind of grade we can give 
ourselves in Minnesota for our level of preparedness and our 
access to resources.
    In the end, our resolve ought to be to improve the grade in 
those areas where effort is being made, but greater results 
need to be seen. We should grade ourselves in a number of 
areas: Preparation, communication, resources, logistics, and, 
of course, understanding and knowledge of the disease.
    We will discuss the particular vulnerability of school 
children and workers, where students and adults spend the 
majority of their time in close contact. Any parent knows how 
one child's cold can spread throughout an entire classroom--and 
throughout the homes of those students--within a matter of 
days. And, as a parent, I can attest to that.
    Since failure to detect early cases of SARS can lead to 
rapid transmission, and also the great stress on resources to 
track down transmission, school officials must have a clear 
plan for treating individuals with symptoms of severe influenza 
or pneumonia.
    Since there is no reliable test for identifying SARS at the 
time of initial diagnosis, school and health officials must 
operate amidst a great deal of uncertainty. It is important 
that this uncertainty not create panic among schoolmates and 
their parents. The fact is, every sniffle and every cold in 
schools and homes across America this fall and winter will be 
met with suspicion. With that in mind, we need to recognize 
that it is possible that we will have many false alerts before 
the first cases of SARS appear anywhere in the world.
    Since false alarms can overwhelm a public health system, 
and with it reduce our capacity to react with precision and 
accuracy to those true incidents of the disease, we must be 
ready for that, understand that.
    For this reason, the public needs to be aware of SARS; to 
know what it is, to know what it isn't, to know what our 
officials have done to prepare for the flu season. Knowing that 
public health officials and others are undertaking these 
precautions, I believe, will instill a greater degree of trust 
during times of illness.
    The Permanent Subcommittee on Investigations has already 
conducted two hearings on SARS. In its first hearing on May 21, 
2003, a large panel of experts testified that SARS is likely to 
reemerge, possibly in conjunction with the typical flu season. 
Dr. Osterholm was a key witness at that hearing. As a result of 
that hearing, I requested that the General Accounting Office 
conduct a study of best practices to identify, treat, and 
control SARS.
    The GAO reported its finding on June 30, 2003, at our 
second hearing. The GAO testified that a new outbreak of SARS 
would quickly strain local health care resources. It also 
emphasized that many of the best practices for dealing with 
SARS were already known to health care workers: Wash hands 
frequently--that is one of the things I found reassuring--the 
advice that our mothers all told us, wash our hands, is very 
good advice--listen to your mom. Isolate patients who show 
symptoms of frequent coughing and/or sneezing. And move quickly 
to trace known contacts.
    Knowing what to do and actually doing it are two different 
things. I organized today's hearing to focus on the concrete 
steps necessary to ensure that we are prepared for a new case 
of SARS. Many of these same steps will also improve our 
response to other cases of the flu, as well as other emerging 
diseases.
    I have asked each of today's witnesses to address three 
questions: First, what have they done so far to prepare for a 
possible outbreak of SARS? Second, what do they still need to 
do? In this connection, I also want to know what help the 
Federal Government should be providing. Third, if a suspected 
SARS case occurs within a school or workplace, how should 
people react?
    The last question is especially important, because it will 
take us some time to verify whether a suspected case is 
actually SARS. SARS is dangerous. First it is highly 
contagious. One person roaming untreated can infect dozens, 
even hundreds of other individuals. Second, it has a high 
mortality rate. Roughly 15 percent of the individuals who 
contracted SARS died from it. For individuals over 60 years 
old, the morality rate was 50 percent.
    Most individuals with serious symptoms are likely to have 
something else, less infectious and less lethal. Because SARS 
is such a danger, we must remain vigilant and aware of the 
risks that SARS poses. Toronto's experience shows us what one 
or two unrecognized cases can lead to. At the same time, we 
must avoid a sense of panic. Our society depends on continued 
interaction at a variety of levels. SARS threatens this. As a 
result, the indirect economic and social effects of SARS far 
outweigh the direct cost of the illness.
    Our goal, in the end, is not to give rise to unrealistic 
expectations of what we can, and cannot do, to prevent an 
outbreak of SARS. It is a foregone conclusion that we will see 
more cases of SARS in our country and across the world.
    In the end, we must be prepared with more than hope and 
prayers to confront this disease. We must have knowledge, 
coordination, communication, resources, and partnership to 
prevent SARS from wreaking havoc on people throughout the 
world.
    And with that, I would now like to welcome today's first 
panel of witnesses: Dianne Mandernach, the Commissioner of the 
Minnesota Department of Health in St. Paul, and Dr. Michael T. 
Osterholm, the Director of the Center for Infectious Disease 
Research and Policy at the University of Minnesota in 
Minneapolis. I thank both of you for your attendance at today's 
important hearing, and look forward to hearing your perspective 
on the three questions that I identified before. What has 
Minnesota done to prepare for a possible outbreak of SARS this 
year? What would we still need to do, and how can the Federal 
Government help? And how should schools, businesses and 
communities respond when someone they know develops a possible 
case of 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.
    [Witness sworn.]
    Senator Coleman. While your written testimony will be 
presented in the record in its entirety, we ask that you limit 
oral testimony to no more than 5 minutes. Commissioner 
Mandernach, we will have you go first with your testimony. You 
may proceed.

  TESTIMONY OF DIANNE MANDERNACH,\1\ COMMISSIONER, MINNESOTA 
           DEPARTMENT OF HEALTH, ST. PAUL, MINNESOTA

    Ms. Mandernach. Good morning, Mr. Chairman. Thank you for 
the opportunity to discuss what Minnesota has done in 
preparation for SARS, or potential return of the SARS issue.
---------------------------------------------------------------------------
    \1\ The prepared statement of Ms. Mandernach appears in the 
Appendix on page 32.
---------------------------------------------------------------------------
    In many respects, Minnesota got off easy during last year's 
SARS outbreak. Using the CDC's definition, we had only 11 
possible cases of SARS, and none of them were actually or 
eventually confirmed in the laboratory. Still, we recommended 
isolation for a number of people with possible SARS, and we 
placed many of the health care workers who cared for these 
people under close observation for symptoms of SARS.
    Next time, the impact of SARS in our State could be much 
greater. The Minnesota Department of Health, local public 
health agencies, and hospitals are preparing for it in a number 
of ways. I would like to address four of those initiatives.
    First, we are working to maintain and strengthen our 
disease surveillance system, which is already recognized as one 
of the best in the country. Our State public health lab is 
prepared to provide diagnostic testing of SARS. The lab will 
play a key role in providing coordination and technical support 
for public health and medical laboratories throughout the State 
as they respond to the threat of SARS.
    We are also working to strengthen the disease surveillance 
role of infection control professionals in our hospitals 
throughout the State. This group of professionals is in a 
unique position to identify the possible cases of SARS, both in 
patients and in health care workers.
    Second, we recognize that in the absence of an effective 
vaccine or treatment, isolation and quarantine will continue to 
be our primary tools for containing SARS. Minnesota State law 
currently provides a legal framework for isolation and 
quarantine. This law is due to sunset in 2004. We are working 
with our legislative partners to ensure that we retain the 
right and the authority after the law sunsets for quarantine 
and isolation.
    The protection of rights that this law provides for people 
who are subject to quarantine is vitally important. We need 
clear procedures for implementing the law, and we are working 
out the details with the State attorney general, county 
attorneys, judges and the law enforcement officials. We also 
need adequate resources if we are to deal with a large number 
of SARS cases out in the community, rather than just a limited 
number in a health care setting.
    Next time around, we may need to isolate or quarantine 
large numbers of people, both in the hospital and at home. We 
are working with a challenge of providing food and other vital 
services to those individuals who would be quarantined in their 
home.
    Third, we need effective procedures to prevent the spread 
of SARS in hospitals and clinics. We are working with the 
infection control professionals to develop procedures for 
controlling the spread of SARS to patients, staff, and visitors 
in the hospital setting. We are also working on upgrading 
protocols for clinics and ambulatory care settings with an 
emphasis on controlling the airborne spread of respiratory 
illness.
    Fourth, we must be prepared to communicate effectively with 
the public about SARS. What is happening, what are we doing 
about it, and why are we doing it? That is essential if we want 
people to cooperate and accept the measures associated with 
isolation and quarantine. Those communication methods are being 
developed as we speak.
    That is some of what Minnesota has done in terms of being 
prepared, anticipating this. But we also need help at the 
Federal level. Adequate Federal support will be critically 
important in responding to a possible outbreak of SARS, and 
that support can come in a number of ways. I have five specific 
recommendations.
    No. 1, a successful response must be coordinated at the 
national and the international level. We have a global 
community. We need rapid reporting, investigation and sharing 
of information by the CDC. That coordination is best achieved 
at the Federal level.
    No. 2, we need a stockpile of the personal protective 
equipment and other supplies required for isolating large 
numbers of people, including items like masks, gowns, gloves, 
and goggles, separate from the existing national stockpile of 
medical supplies. For example, we have learned from the 
Canadian experience that you need 5,000 N-95 masks to care for 
each SARS patient. These items are needed for the protection of 
both the patients and the health care workers. Health care 
workers may be unwilling to care for others if they are fearful 
of becoming infected themselves.
    No. 3, we need help in developing the surge capacity for 
handling a large outbreak; hospital beds, hospital workers, and 
the resources needed for large-scale quarantine. We will need 
just-in-time training that is similar across the country. 
Hospitals are likely to be overwhelmed during a large-scale 
outbreak, which would drastically increase the staffing needs, 
while reducing the staff available. When hospital workers could 
become ill, this would increase the workforce shortage issue. 
Non-SARS cases may need to be diverted to other sources of 
care.
    No. 4, the financial impact of SARS could also be 
significant and burdensome; escalating costs for hospitals, the 
financial risk for physicians and hospital workers, and lost 
income for people placed in isolation or quarantine. An 
emergency fund similar to natural disaster insurance could help 
compensate for those costs.
    And finally, No. 5, we need to begin aggressive research on 
vaccine, treatment and a better test for SARS. That will 
require leadership at the Federal level. I want to emphasize 
that preparedness for SARS and other public health emergencies 
is a long-term commitment. We need to sustain the generous 
funding that the Federal Government has given us in terms of 
providing opportunities and for preparedness. At the same time, 
we need to make very certain that these resources do not come 
at the risk of cutting our other programs. This occurred in the 
1980's, where critical public health issues and initiatives 
were cut, and it led to the resurgence of diseases like TB and 
measles. We cannot repeat that experience.
    Thank you for your time and your support in looking to be 
prepared for the issue that may emerge again this season. Thank 
you.
    Senator Coleman. Thank you, Commissioner Mandernach for 
your testimony.
    Before Dr. Osterholm I would like to note the presence of 
the State epidemiologist, Dr. Harry Hull. Pleased to have you 
here. And certainly, Dr. Osterholm, you are familiar with that 
position. So it is great to have you here. And with that, I 
will turn it over to Dr. Osterholm.

  TESTIMONY OF MICHAEL T. OSTERHOLM, Ph.D., MPH,\1\ DIRECTOR, 
     CENTER OF INFECTIOUS DISEASE RESEARCH AND POLICY, AND 
 PROFESSOR, SCHOOL OF PUBLIC HEALTH, UNIVERSITY OF MINNESOTA, 
                     MINNEAPOLIS, MINNESOTA

    Mr. Osterholm. Thank you, Mr. Chairman. My name is Michael 
Osterholm. I am the Director for The Center of Infectious 
Disease Research and Policy at the University of Minnesota, and 
also a professor at the School of Public Health at the 
University. And I serve as a special advisor to Secretary Tommy 
Thompson and the Department of Health and Human Services. I had 
a chance to talk to both of them last night, and they wanted me 
to share my warm regards for you.
---------------------------------------------------------------------------
    \1\ The prepared statement of Mr. Osterholm appears in the Appendix 
on page 36.
---------------------------------------------------------------------------
    As you are aware, I had the opportunity to testify at your 
first hearing on SARS regarding State and local preparedness. 
Mr. Chairman, I continue to applaud your efforts, and those of 
the members of staff of the Subcommittee to address this very 
critical issue, the effectiveness of our Nation's response to 
Severe Acute Respiratory Syndrome, SARS.
    As I indicated in my testimony last May, I believe that 
this international public health crisis is here to stay. It 
will impose an ever-increasing risk to the citizens of the 
United States. As you may recall, in the first hearing, Senator 
Lautenberg asked Drs. Gerberding, Fauci, and me if we believe 
the SARS virus will return. We all answered in the affirmative, 
and even commented that though it appeared to be eliminated 
from the Toronto area, it may have been a prematurely declared 
victory.
    Two days later, the second wave of SARS hit the Toronto 
area, and it would be another 6 weeks before that outbreak 
could be brought under control. I also suggested at that time 
that the reduction of new cases of SARS throughout the world 
was due in part to the heroic efforts of public health and 
nursing communities, and the likely waning of cases with the 
oncoming summer months. I still believe that conclusion to be 
true.
    I am convinced that with the advent of winter in the 
northern hemisphere just a few months away, we may very well 
see a resurgence of SARS that could far exceed the experience 
of last year. 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. With this 
backdrop, let me provide a few comments on State and local 
preparedness.
    First of all, I want to compliment Commissioner Mandernach 
and the staff of the Minnesota Department of Health for what I 
believe is an outstanding response to the possibility of SARS 
here in Minnesota, both in terms of their activities this last 
spring and the ongoing efforts to prepare us for the 
possibility of SARS this next winter. I think the Commissioner 
has provided a very thoughtful outline of issues that confront 
us as a State in terms of preparedness as we move into this 
winter season. I think it is extremely comprehensive, and one 
that I believe with every point.
    I, too, believe that Minnesota got off very easy in the 
last SARS outbreak. Make no mistake, we were just lucky. We 
have all had an opportunity to witness the SARS outbreaks in 
Asia and Toronto by the extensive news media coverage. However, 
unless you were there, it is very difficult to get a true sense 
of the impact of this disease on the community. To better 
understand that impact, I would urge all of you to review the 
testimony of the hearings conducted last week by the Canadian 
SARS Commission.
    Three days of chilling and frightful testimony from elected 
officials, health care workers, patient contacts, and citizens 
can be found on the SARS Commission website, WWW.SARScommis-
sion.CA. In addition, I urge all of you to read the 234-page 
report released this week by the SARS Commission. It is highly 
critical of Canada's level of preparedness last spring, and its 
preparedness now to deal with the resurgence.
    After reading these firsthand accounts of the many issues 
facing officials charged with stopping the epidemic, health 
care administrators, and workers responsible for patient care, 
you will get a sense of the complexity of the SARS preparedness 
and response issue.
    Very shortly, the Centers for Disease Control and 
Prevention will issue a document, Public Health Guidance for 
Community Level Preparedness in Response to SARS. I have a 
draft copy of it here that is currently going through the 
Department of Health and Human Services' final approval.
    The CDC has undertaken an extensive review of the outbreak 
investigation data from Asia and Canada, and together with 
representatives of professional organizations and State and 
local health partners, have developed this very extensive 
guidance document. It contains a comprehensive overview of 
SARS, preparedness and response, a review of necessary command 
and control structure, required for response, the rationale and 
goals, as well as plans for SARS surveillance, necessary 
preparedness and response in health care facilities, the 
rationale and goals as well as methods for community 
containment, the management for international travel-related 
risk, laboratory diagnosis, and finally, a review of the need 
for comprehensive communication and education.
    Our great challenge will be to translate this information 
into meaningful State and local preparedness plans, and 
identify the necessary resources for comprehensive 
implementation, should SARS cases return. Unfortunately, I am 
not optimistic that we are prepared at the State or local level 
to do this at this time. And that is any State or local level 
within this country.
    SARS preparedness goes well beyond State and local public 
health systems. It also includes our health care delivery 
system of hospitals, nursing homes and medical clinics. Today, 
we are all too well aware of the lack of any substantial surge 
capacity in our health care delivery system for public health 
emergencies due to serious financial limitations and an aging 
and vanishing work force.
    Mr. Chairman, I don't expect, nor do I believe, anyone in 
this room expects that your Subcommittee can take on all of 
these critical issues and solve them overnight. If you did, we 
would be one very grateful Nation. Thus, we must be honest with 
the citizens of this country in establishing the expectations 
that should a problem like SARS occur in any of our 
communities, the health care delivery system, just like in 
Toronto, has every potential to be overrun. This will not be 
solved by a simple discussion about what do we do to respond to 
SARS, but will require a much larger government and citizen-
based examination of how we address health care financing and 
our expectations of medical care delivery here in this country.
    For example, in this country, there is an estimated 43.6 
million Americans without health care insurance. It is 
difficult for public health authorities to urge citizens who 
might be in the earliest stages of the disease such as SARS to 
seek effective medical care if they can't pay for it. Yet, 
infectious disease containment requires that these patients are 
quickly identified and isolated.
    There are many other barriers to providing a comprehensive 
and effective response to a potential SARS problem. For 
example, Commissioner Mandernach mentioned the important need 
for using historically time-tested tools of quarantine and 
isolation. I remind you, quarantine is the following or 
surveillance of individuals who may have been exposed to an 
infectious agent, but have not yet developed symptoms.
    With the SARS epidemic in Canada, the quarantine approach 
largely was a voluntary effort where individuals were notified 
of their possible exposure, and asked to stay home and report 
to health officials at the earliest signs or symptoms, should 
they become ill. While in practice this makes great sense and 
can be extremely effective, there are issues regarding the 
reimbursement of these individuals who stay away from work and 
do subsequently lose their wages, even their jobs, as happened 
in Toronto.
    Senator Coleman. I would ask that you summarize, if you 
can. And for the record, your entire statement will be 
submitted.
    Mr. Osterholm. For the public good, we must find every 
possible way we can to financially and socially support these 
individuals. We will need to apply with such action as to 
contain the SARS epidemic. We have none at this time.
    Mr. Chairman, I would suggest that while there are numerous 
competing priorities for homeland security and public health 
preparedness, we can't expect a wish list to be our top 
priority. Having said that, we are not honest as public health, 
health care and health delivery system professionals and 
elected leaders if we take consolation in cosmetic answers. We 
will be held accountable one day, just as is happening now in 
Canada, to explain why we weren't prepared to handle this or 
similar infectious disease problems.
    We look forward to working very closely with your 
Subcommittee to set the agenda for determining what and how the 
Federal Government can help us at the State and local level to 
prepare for this potentially difficult situation.
    Thank you, Mr. Chairman, for this opportunity to appear 
before you today.
    Senator Coleman. Thank you very much, Dr. Osterholm. Let me 
throw out the first question. We haven't heard much about SARS 
for a while--whether it is fabulous outside--the cold and flu 
season isn't upon us yet. It has been pretty quiet. Both Dr. 
Osterholm and Commissioner Mandernach, are you surprised at the 
lack of activity? As we sit here today, how likely is it that 
we will see cases of SARS in Minnesota in the coming months?
    Mr. Osterholm. Well, first of all, it has been relatively 
quiet, as you may know. We actually had a confirmed case of 
SARS that occurred approximately 3 weeks ago in Singapore. A 
laboratory worker that we believe actually was associated with 
ongoing contamination within that laboratory from SARS isolates 
that were obtained last spring. This always is a reminder to us 
that that virus is still out there, even in laboratories. And 
for no other reason, somebody who may want to potentially 
initiate a situation can do so without Mother Nature being 
involved. That was not the case here, but is a reminder of 
that.
    As far as the potential for this to come back, I think that 
we believe it is very high. Once you have a virus like this in 
a reservoir or a location of animals that are wild in the 
population or confiscated and used for a food source, that is a 
constant source of that virus being reintroduced into the 
population, much like influenza or other seasonal viruses like 
that. So I think it is possible. Will it come to Minnesota? 
That is the million-dollar question. And frankly, it is a 
crapshoot. I hope not, but I think we have to be prepared for 
that event.
    Senator Coleman. Dr. Mandernach, anything you have to add 
to that?
    Ms. Mandernach. I would agree with those comments. I think 
one of the issues that when we look at the global nature of our 
economy, even in Minnesota, and the fact that we have daily 
transport in and out of the major metropolitan airport, that 
leads to issues in one part of the world coming to Minnesota, 
too.
    Senator Coleman. OK. Dr. Osterholm, you have continued to 
raise concerns about the level of preparation at the State and 
local level. From the course of hearings I have had, I get a 
sense the CDC has done a pretty good job, I think a very good 
job, of getting information out. That even in the most rural 
areas, that their health care professionals are aware of the 
information that is out there. Help me understand the nature of 
your concern, and talk to me about how we address it.
    Mr. Osterholm. Mr. Chairman, again, as I laid out in my 
testimony, this is a response that is going to require a number 
of different arms in our local and State partners. The health 
care delivery system, which you are going to hear more about 
today in the next panel, is going to be a very key partner. And 
today we don't have the surge capacity to basically allow us to 
quickly respond in a way that is going to effectively shut this 
down.
    Senator Coleman. Can you explain surge capacity, please?
    Mr. Osterholm. Surge capacity is where suddenly if 
hundreds, thousands of individuals need to be seen, and health 
care provided. And in many instances, these individuals may be 
actually put into certain kinds of rooms, called protective 
isolation rooms, where their air that they are sharing with all 
of us will not go and affect others. That is exactly what 
happened in Toronto. We had a number of examples where patients 
who were infected with the SARS virus were in open rooms like 
this, and infected a number of other individuals, and it became 
an epidemic. In this State, we have a very limited number of 
those beds available. They are expensive to maintain, require 
certain ventilation characteristics, and require other very 
specified types of equipment. And on any one given day, most of 
those beds are already being used for transplant patients, 
cancer patients, etc., so we just don't have that ability. And 
the same thing is true that as Commissioner Mandernach 
mentioned about masks, we have a just-in-time delivery system 
today for so much of our economy. There are only a very few 
companies in this world that actually produce N-95 masks for a 
high level of protection. And one of them is right here in the 
Twin Cities, the 3M Company. I can tell you that last year, at 
the height of the SARS epidemic, 3M Company was backlogged by 
years for orders of N-95 masks without much capacity to expand 
their production. So the point is that if we get into this next 
season, and because of the way we run our economy, the just-in-
time delivery phenomenon, we will run out of N-95 masks, I 
think Commissioner Mandernach said very clearly, are we going 
to have health care workers who refuse even to come to work, 
because now they're concerned that basically coming to work is 
putting their life on the line. And I think those issues are 
much larger than this Subcommittee can directly deal with, but 
we have got to have that discussion, or we won't be able to 
contain that here in this community.
    Senator Coleman. Commissioner, you gave a figure as to the 
number of masks per patient. I thought I misheard the figure. 
Could you give that figure again?
    Ms. Mandernach. Five thousand per patient.
    Senator Coleman. Per patient. Pretty stunning. You also 
raised, Commissioner, an issue that I haven't heard a lot of 
discussion about. And that is the economic consequences of 
dealing with isolation and quarantine. I presume someone has 
still got to pay a mortgage, pay rent for their family, if we 
have isolation and quarantine.
    Can you give us a better sense of what we have done to 
address that, and what are the possibilities, and where do we 
have to go to deal with that issue?
    Ms. Mandernach. I think, Mr. Chairman, that is one of the 
things as we begin to look at the ramifications of quarantine 
and isolation, there is so much that we have not thought 
through completely, but we have individuals that we can begin 
to talk with, and that is the Toronto people. I had an 
opportunity to hear my counterpart talk about the Toronto 
experience. And when you look at individuals who were in their 
home that needed food, and yet they couldn't go to the grocery 
store, there's that whole aspect.
    There is also the issue of yes, they can't have employment 
during that time, so how do you make them whole? Or do you make 
them whole on their wages? And yet at the same time, they have 
their bills that they have to pay for the economy of their 
household. How do you do that? The ramifications that Toronto 
individuals talked about are huge. How they begin to prepare 
for that aspect, and look at all of those ramifications, I 
think that really needs to be done at the national level, 
whether that is a FEMA type model, I am not certain. But it is 
going to take a much wider source of funding than any one 
State.
    I think there is also the aspect of what happens to the 
institutions, the physician practices. If the physician is one 
of the people who gets sick, what happens to his source of 
income? What happens to his patients? What happens to his 
practice? What happens to the clinics and the hospitals that 
care for these people, and maybe have to divert their elective 
procedures, which tend to be revenue-producing, to take care of 
these other individuals. The ramifications of this really need 
to be examined seriously.
    Senator Coleman. You have mentioned the issue of physicians 
perhaps being sick. And either Commissioner Mandernach or Dr. 
Osterholm, tell me a little bit about the incidents of SARS 
among health care professionals, and as the Toronto and Chinese 
examples went on, how much better did we get at dealing with 
that? And it has multiple questions, but they all kind of fit 
together. How would you assess that risk today?
    Mr. Osterholm. Well, there are several, almost what I would 
call perfect storm factors, that come together to make this 
really a very difficult issue. First of all, we do not have a 
good laboratory test that will identify a SARS patient when 
they walk into the office or into the health care facility. So 
in a sense, we are going to have to treat a lot of people who 
may have similar symptoms to early SARS as possible SARS cases. 
That by itself creates a very major economic disincentive for 
an institution to want to see SARS patients.
    Senator Coleman. If I could interrupt you there, if you 
call your doctor and you have a bad cold--I have had bad colds. 
What is the difference today when I go see my doctor versus 
pre-SARS in terms of the way that they are going to respond? I 
am just calling and saying, ``Doc, I have got a cold that is 
just killing me.'' Can you help us practically understand what 
it is that we are looking for here?
    Mr. Osterholm. Well, first of all, you have to put it in 
the sense of time and place. If you wake up in a sweat in 
Minneapolis and hear hoof beats, it is probably not SARS. But 
if you wake up in Kenya, it might be. So one of the things is 
if we don't have SARS already here in this country or evidence 
of anywhere in the world, it is not likely that any physician 
today is going to immediately consider that respiratory illness 
that you have is SARS. But we have to have a very tight 
interface to know that in some parts of the world we are going 
to have to be extra vigilant, and that will be the first alarm 
that gets sounded.
    So today I think anyone who comes with a respiratory 
illness in this country would not be automatically thought of 
SARS. But in the presence of SARS, that is going to be 
complicated, because by the time someone becomes infectious 
with the SARS virus, they may not have much more than a cough, 
some cases are going to be difficult to distinguish from other 
respiratory illnesses, and that was exactly the experience in 
Toronto.
    Some of the patients we had up there we had transmitted--we 
had one woman, for example, who was the spouse of a severe case 
who developed a mild cough herself and some fever, and 
literally walked into an emergency room, talked to some 
emergency room admitting clerks, two other people in a period 
of 20 minutes, and transmitted SARS to everybody that she had 
contact with. And she was mildly ill at the time. So we are 
going to have a problem with that and there is no easy answer. 
So I think that is part of it right there. That we have got a 
problem of diagnosing these patients, and that is going to be a 
key one.
    I think the second piece of it is, you asked about how can 
we--what can we do with doctors and so forth? We provide 
literally no support in this country for the concept of 
infection control. It is a nonrevenue generating activity in a 
hospital. Medicare or Medicaid, nobody is going to sit there 
and cover infection control practices. So when health care 
delivery systems get into tougher economic times, what is the 
first thing you look at as nonrevenue generating activities? 
Well, I think most health care administrators understand the 
importance of infection control. Today we have gnawed that down 
to the bone. And we, as a Nation, need to reinvest in the 
concept of a nonrevenue generating infection control as a 
classic first line of public health. Just those things would 
make a big difference for health care facilities attacking this 
problem.
    Senator Coleman. Do you want to add to that, Commissioner?
    Ms. Mandernach. I think another aspect of this, as the 
first cases begin to emerge, I would go back to the CDC as the 
clearing house for information. To have very quick, 
communicated information when a situation presents itself that 
can be dispersed throughout the country, so that the heightened 
recognition is on everyone's radar screen. Just as Dr. 
Osterholm was talking, by the time the person comes in today in 
Minnesota, it wouldn't be the first thing on your mind. But if 
there is a case, and then that is communicated, the recognition 
does come on to the radar screen. And so I think that is the 
role of the CDC, that real-time communication that can then 
move throughout the country.
    Senator Coleman. I got a sense in listening to the GAO and 
the CDC in my two hearings that there certainly is the capacity 
today with technology to get the information to smaller 
communities. I was a little more confident with that. But yet I 
would ask for your assessments, Commissioner and Doctor, as to 
how small communities are doing in terms of the resources to 
identify and treat possible cases of SARS.
    Ms. Mandernach. Mr. Chairman, certainly once--and I can 
speak from the small community that I was in. The health alert 
network is huge. When that information comes, and you get it to 
the people who are going to be treating individuals, the front 
line people, they have the information, so that they can then 
look for the symptoms, they can look for the recognition. 
Information is key, because that is going to raise the level of 
awareness.
    As far as resources, I think that is an ongoing issue, and 
that is going to be as particular as the community you are in.
    Senator Coleman. Dr. Osterholm.
    Mr. Osterholm. Yes. First of all, public health has 
appropriately been accused of being a two-footed driver. On one 
foot, we really hit the accelerator and try to get people to 
take action and understand the importance of the situations. 
The other foot was simply putting on the brakes and saying, 
``Wait, wait, wait, you don't need to panic.'' And this is 
something that many of us in public health have to live with. 
It is just one of our birthrights, I guess. But being for the 
public, that two-footed driving is a very important activity, 
so we make sure we don't create panic and fear where none 
should be. And at the same time, make sure that we get that 
information out. None of us have that answer down. But I would 
say that in the experience of last spring, I thought that as a 
whole, the news media handled the story quite responsibly. Some 
of the very best reporting I have seen on public health issues 
came out during that time in terms of trying to cover it. And 
so one of the other areas the CDC is working closely with is 
national news media sources to be sure, should something else 
happen, that there is access to accurate and very thoughtful, 
comprehensive information.
    Senator Coleman. OK. Commissioner, maybe I would ask you to 
grade yourself here, but we are in a school setting. What kind 
of grade would you give Minnesota and communities in terms of 
their level of preparedness today to deal with potential cases 
of SARS?
    Ms. Mandernach. Mr. Chairman, I would give them a B. I 
would give them a B at this point, because I believe that there 
has been a great deal of work that has been done. There has 
been planning with partnerships that are new partnerships. And 
that is how this is going to be handled. We are going to work 
together on this, and with nontraditional partners, so that 
public health and the acute care system are working closer than 
they ever have. That is good. We begin to look at our first 
responders, we begin to look at our law enforcement. They all 
have a role to play in this. And I would definitely feel that 
we are in a much better place than what we were. There is a 
great deal of concentration on SARS; that is the immediate 
issue. But what we have learned, and are learning as we go 
through, prepares us for the next infectious disease or public 
health issue, whatever it happens to be. And so we are well on 
the track. We are not at an A, but we are moving down the path.
    Senator Coleman. Dr. Osterholm, I would like you to 
respond. I will give you another aspect; on the national level. 
The Commissioner talked about things like stockpiling supplies 
and things. I don't believe we are at the state of readiness 
that we should be. Can you give me your assessment and grade on 
the national level in terms of helping those at the local 
level, and also your assessment of Minnesota as you see it.
    Mr. Osterholm. Mr. Chairman, let me just start by saying in 
Minnesota, I am glad my family lives here. That gives you my 
idea of a grade. I think that Minnesota Department of Health 
and the partners involved with this have done as good a job as 
any place in the country. And that gives me consolation. But 
having said that, I feel like sometimes public health is the 
medical officer on a big sinking ship, and everybody comes 
running to the medical officer and saying, ``Keep this ship 
from sinking.'' Well, what can the medical officer do about it? 
And I think part of what we have to recognize is that if we run 
out of masks in this country because we don't have capacity to 
produce masks, or we don't have any number of other things that 
we just talked about in place, such as the uninsured not going 
in early and making it more difficult--in Canada, that wasn't a 
problem. They didn't have an issue with uninsured people being 
turned away or not going in. Because, in fact, that was a big 
piece. The same thing is true when we talked about quarantine. 
If we can't get people to comply because they look and say I 
have to make a choice here, do I lose my house or family or do 
I for the good of society stay home for 2 weeks? Those are 
issues well beyond what the Department of Health can do 
anything about. And so I think in that sense, nationally we 
have real issues here. We can stockpile some things, but we 
can't stockpile masks. Those are the kinds of things we have to 
deal with.
    You are going to hear from Administrator Spartz, who is 
going to give you, I think, a very good view of one of the very 
best health care facilities in this country and their ability 
to expand quickly to take care of lots of patients. If that is 
not there, again, public health can only do so much. And so I 
think that we just have to recognize, these are the realities 
of where we sit today. And it is going to take a lot more than 
just preparing for SARS to be able to better prepare us for 
many of these oncoming potential catastrophes in our 
communities.
    Senator Coleman. I want to thank both of the witnesses. It 
has been very helpful, and this is a discussion that will 
continue. So thank you very much.
    Mr. Osterholm. Thank you.
    Ms. Mandernach. Thank you.
    Senator Coleman. I would now like to welcome our second 
panel of witnesses at today's hearing. Our second panel of 
witnesses consists of Jeff Spartz, Administrator of Hennepin 
County Medical Center. Mary Quinn Crow, the Vice President of 
Patient Care Services at Northfield Hospital. Ann Hoxie, the 
Student Wellness Administrator of St. Paul Public Schools. And 
I would note Superintendent Pat Harvey is here with us today. 
Superintendent Harvey, thank you for being with us today. Debra 
Herrmann, District Lead Nurse of the Marshall School District. 
And Rob Benson, the Superintendent of the Floodwood School 
District.
    I welcome all of you to today's hearing and look forward to 
hearing your perspective on three questions. What has Minnesota 
done to prepare for a possible outbreak of SARS this year? What 
do we still need to do, and how can the Federal Government 
help? And how should schools, businesses and communities 
respond when someone they know develops a possible case of 
SARS?
    As I noted, we have a panel. Before we begin, pursuant to 
Rule 6, all witnesses who testify before this Subcommittee are 
required to be sworn. At this time I would ask you to please 
stand and raise your right hand.
    [Witnesses sworn.]
    Senator Coleman. All of your written testimony will be 
presented in its entirety in the record. I would ask that you 
limit your oral testimony to 5 minutes. Again, your written 
testimony will be entered into the record. And with that, we 
will start with Mr. Spartz.

  TESTIMONY OF JEFF SPARTZ,\1\ ADMINISTRATOR, HENNEPIN COUNTY 
             MEDICAL CENTER, MINNEAPOLIS, MINNESOTA

    Mr. Spartz. Mr. Chairman, briefly, I will respond to your 
questions. The first one is what has Minnesota done to prepare 
for a possible outbreak of SARS this year. We start with 
Hennepin County Medical Center being the Center for Disease 
Control Global Migration and Quarantine facility for the State 
of Minnesota. We got the honor of handling the first case of a 
suspected infectious disease. Second, through the Minnesota 
Hospital Association, which has 130 or so hospital members in 
this State, we have put together what is called the 
Minneapolis-St. Paul Metropolitan Hospital Compact. That is a 
group of 27 hospitals. One of the few nationally that has been 
put together having a preexisting regional plan for dealing 
with infectious disease emergencies. The hospital compact is 
also working with local public health and emergency management 
agencies to explore other possible options, such as using 
facilities like the Minneapolis Convention Center, if you had a 
large number of infected individuals. We have also done a 
number of tabletop and functional exercises over the past 
several years, including one last December, Operation Snowball, 
which looked at a biological scenario called ``Very Bad 
Disease.'' We have learned a great deal from that with 350 
individuals involved from around the State and region, and we 
are learning what issues have to be dealt with and how they 
handle these kinds of problems.
---------------------------------------------------------------------------
    \1\ The prepared statement of Mr. Spartz appears in the Appendix on 
page 43.
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    And the Minnesota Department of Health is also using 
something called the Electronic Health Network to immediately 
inform the public and hospital contacts about critically 
important public health issues. MDH is also applying for a 
grant to conduct surveillance that basically goes on the model 
of preparing the home line. It is designed to follow health 
care workers who are suspected of being infected to make sure 
that they do not end up spreading the disease.
    Representatives from around the area have also been 
indoctrinated in the use of the Hospital Incident Command 
System, which is a way of handling major emergencies. 
Individual hospitals have also had the opportunity to test 
their infection control systems to look for areas of 
vulnerability. We have also identified those hospitals, as has 
been mentioned previously, that have negative air flow rooms so 
we can successfully isolate individuals who have SARS, or are 
suspected of having SARS. Twenty-three hospitals in the 
metropolitan area have such facilities, and they will be 
available.
    One of the critical areas that will fail in the event of a 
massive outbreak is our laboratory facilities, like our ICU 
units. They will be overwhelmed, and we as yet do not have a 
good answer of how to handle that.
    Second, the question is, what do we need to do and how can 
the Federal Government help? One of the problems we face in 
Minnesota is that one-third of the hospitals operated in the 
red last year. We don't have a lot of financial reserves or 
stockpile capacity to prepare for events that may or may not 
happen. In the event of a massive SARS outbreak, because people 
will be told to stay home, people would avoid elective 
procedures. Many hospitals can go insolvent in a short period 
of time. The current Stafford Act provides for reimbursement in 
times of tragedies, or disasters, but it would be impossible to 
accommodate the needs of hospitals which are in desperate 
financial condition. Most of the clinics and hospitals in the 
State that provide patient care for SARS patients would be 
private entities, and thus, their responsibilities during a 
public health emergency would be voluntary. We need better 
mechanisms that involve all hospitals in planning for and 
responding to public health needs and emergencies.
    Hospital responsibilities and liabilities regarding 
quarantine are not well-defined and vary widely from State to 
State. We need more uniform Federal guidance in this area.
    Attention has been focused both by Commissioner Mandernach 
and Dr. Osterholm on surge capacity. We don't have much surge 
capacity available in this metropolitan area, probably not in 
any metropolitan area in the country. The cost of having an ICU 
room available is very large, and it is impossible for 
hospitals to sustain if it is not used. Stockpiling ICU units 
somewhere, even if they are portable, is not the answer either, 
because the other component that we need is highly skilled 
people to manage those ICU units for patients.
    We have to have a Federal dialogue regarding how you best 
triage people in the event of a massive outbreak of a disease. 
Neither the public or the government at that point can expect 
the normal standard of care that we expect at times of 
nonviolent disasters.
    We also need better public health plans to manage public 
health care workers. Cases can cross city, county and State 
jurisdictions. We need to understand these plans have to go 
beyond the walls of any given health care facility, and we need 
to better coordinate with State and county public health 
systems.
    We should learn from the Toronto experience to determine 
the most appropriate way to monitor and manage exposed health 
care workers, when to quarantine them, and how else to handle 
them. We are pretty vulnerable in this area, and not much 
formal work has been done.
    The third question is how should schools, businesses, and 
communities respond when someone they know develops a possible 
case of SARS. We have to have better education of the public 
and professionals, and that needs to come from local media and 
our public health entities. We have to have appropriate 
guidelines and guidance of who should seek medical care and 
evaluation, and we should educate the public in advance, 
because they will cooperate better and respond better in the 
event of an outbreak.
    Senator Coleman. I would ask if you could sum up your 
testimony, and the entire testimony will be on the record.
    Mr. Spartz. OK. In summary, Mr. Chairman, I see this is 
really a three-legged stool. You have hospitals and their 
ability to respond for acute care. You have public health 
demanding to control the outbreak. And ultimately, though it is 
going to depend upon the response of individual citizens; do 
they follow the advice given to them by public health 
authorities, do they respond appropriately, and do they avoid 
panic? If we avoid that, we may have outbreaks, but we will not 
have massive outbreaks. Thank you for the opportunity to 
testify, Mr. Chairman.
    Senator Coleman. Thank you very much. Ms. Crow.

TESTIMONY OF MARY QUINN CROW,\1\ VICE PRESIDENT OF PATIENT CARE 
      SERVICES, NORTHFIELD HOSPITAL, NORTHFIELD, MINNESOTA

    Ms. Crow. Thank you for inviting me to speak today. I think 
that I am here more to tell a story that I hope will address 
the questions that you have asked.
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    \1\ The prepared statement of Ms. Crow appears in the Appendix on 
page 48.
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    I am from Northfield, Minnesota, which is a community of 
about 18,000, about 40 miles south of the metro area. Our 
community is the home of two prestigious colleges in the 
State--St. Olaf and Carlton.
    And in March of this past year, as we were beginning to 
train our physician staff and our medical staff about SARS and 
the emerging infection and what things that the Department of 
Health was telling us we needed to know, we started to pay 
close attention to this. Simultaneously, our respiratory staff 
at the hospital began a fairly time-consuming process of 
testing our staff with N-95 masks, which we have heard about 
today. These are filtered masks that protect health care 
workers. We had to stop the training, because we ran out of 
masks and because they were back ordered, and 3M was our only 
supplier at that time. I am happy that we didn't know that they 
were back ordered for years. We thought we were looking at 
about 9 weeks.
    However, in mid April, we received a call from the Wellness 
Center at one of the colleges that told us that 30 students who 
were traveling in China were being returned to campus because 
of the SARS outbreak in China, and that they were being 
returned because they had been visiting several areas where 
SARS was fairly epidemic. The college Wellness Center went to 
the hospital, requesting assistance for the management of these 
students. We were given approximately 5 days to develop a plan 
before the students would be back home in Northfield. Well, 
many meetings took place, as you can imagine, and we involved 
hospital leadership, hospital staff, ambulance staff, Wellness 
Centers and nurse practitioners and public health. And planning 
discussions included many, many issues. But I will give you the 
top of those. We looked at protocols, what we were going to 
teach these students when they returned in terms of how they 
needed to monitor themselves and protect the public. The 
Wellness Center was very concerned about their lack of ability 
to actually assess these patients, and the safety issues around 
bringing them into a small health center that did not have 
negative pressure. Hospital and triage and treatment of the ill 
students was also addressed. At that time, we were in a 
building that had no negative pressure availability, no 
ventilator availability, and we immediately needed to complete 
the N-95 fit testing for our emergency department staff or 
essential staff and get a supply of N-95 masks, so that we 
could at least triage these patients, should they come to the 
hospital. There was also a need to provide 24-hour medical 
direction to the college during that time, and that was done 
through the hospital emergency staff.
    There were transport issues we needed to consider. If one 
of these students did become ill and needed to be transported 
to the Metro, how were we going to protect our ambulance staff 
who would be in very close quarters with a potentially very 
infectious patient. And then we needed to develop a network 
with HCMC so that we understood what patients they would take, 
and how they would coordinate that transport to safely bring 
the patient into the exam system. Finally, we talked about 
isolation and quarantine. And this was perhaps our stickiest 
issue, surprisingly perhaps, but understand that in these 
colleges, we have to have some of the best thinkers in the 
State, and they clearly addressed the human rights issues of 
students to return to campus and to be able to come fully back 
into the community that they lived in. At that time, the only 
guidance from the CDC and the Department of Health was that 
unless you were symptomatic, you did not need to be isolated. 
However, we did realize we were bringing a high-risk group back 
to our community. So in the last week of April, ten students 
actually returned. Twenty students chose to return to their own 
communities, which I am uncertain as to how those communities 
dealt with that issue. They returned to the college campus from 
Beijing. The college had decided not to isolate these students. 
However, they did cohort them for sleeping and eating. But they 
were allowed to be completely involved in campus and community 
activities. They were also told, actually, at the airport where 
they were met by one of their deans, they were all given 
thermometers and told they needed to daily monitor their 
temperatures for 10 days, that they needed to report those 
daily temperatures to the Wellness Center by phone, and that 
they needed to report upper respiratory symptoms immediately, 
should they occur. Within about 48 hours, the first student 
reported a fever of 101 and upper respiratory symptoms. This 
was a patient that you asked about earlier--how do we know this 
isn't a cold. This is the Kennedy person. They had been there. 
We really did have to consider that these were high-risk SARS 
patients.
    We decided that we would not bring the patient to health 
care. We did not have negative pressure in our hospital. The 
Wellness Center also did not have negative pressure available, 
and we felt that the safest thing to do was to assess this 
patient in his home. So our ambulance staff, which had been 
well-trained and now having protective equipment, was sent to 
the home of the patient where they did assess the patient to be 
indeed feverish with a upper respiratory infection, but not in 
respiratory distress. At that time, they communicated with our 
emergency department physician, who communicated with HCMC. And 
the decision was made to take the patient directly to HCMC to 
be evaluated for the potential of carrying SARS. The patient 
was kept at HCMC for about 12 hours, and determined to be a 
suspect SARS case, and at that point discharged back to the 
community. He was at that time isolated for 2 weeks, and kept 
apart from everyone. Food was delivered to his door, where he 
picked it up and brought it in. And the only visitors he had 
were actually from the County Public Health Department to 
assess him.
    Senator Coleman. Could you summarize?
    Ms. Crow. Sure. I will. There were a number of issues, as I 
have talked about; supplies and equipment, training, the 
protective equipment for medical staff and ambulance staff, 
contingency planning, and then I guess high-level discussions 
that I believe need to occur around the ethics of isolation and 
quarantine. These are things I think we will face in the 
future.
    Senator Coleman. Thank you very much. Ms. Hoxie.

TESTIMONY OF ANN HOXIE,\1\ STUDENT WELLNESS ADMINISTRATOR, ST. 
            PAUL PUBLIC SCHOOLS, ST. PAUL, MINNESOTA

    Ms. Hoxie. Thank you, Senator Coleman. Our story in St. 
Paul is quite opposite. We did have a staff member whose child 
was hospitalized with a probable case of SARS following the 
child's trip to Toronto. And so for us, it was really just a 
practice run, but we saw the issues that will arise. We looked 
at, what is our responsibility to 44,000 students and 600 
staff, while continuing to run our business? How not to 
overreact, or what is the appropriate reaction in this sort of 
case? And then all of the worry and concern of the co-workers 
of the father and the need to protect the privacy of this 
family. We went into it with some baseline knowledge, because 
of all of the CDC communication we had. And we checked the 
Toronto school's website to give us some other baseline 
information. Our superintendent, Dr. Patricia Harvey, spoke 
with Dr. Harry Hull, the State epidemiologist, to get 
information specific for a St. Paul response. And what we 
really felt is that we had information needs at that point. So 
we included a notice to all our administrators in the 
superintendents' weekly bulletin that laid out what SARS is, 
what the symptoms are, and what's appropriate attendance 
criteria for staff and students. But still, we got lots of 
questions. Despite giving lots of resources, putting a page on 
our website, with links to all of the right people. And then we 
did mention hand washing. We continued to stress that.
---------------------------------------------------------------------------
    \1\ The prepared statement of Ms. Hoxie appears in the Appendix on 
page 51.
---------------------------------------------------------------------------
    So that situation was quickly resolved, but it does leave 
us better prepared to come here today and talk of what the 
future might hold. So I am trying to continue to stay informed, 
so that I can support our administrative decisions. We are 
going to offer flu shots to all our staff this fall, hoping 
that will help in the differential diagnosis kinds of things. 
We are continuing to stress the hand washing. But mainly, we 
are just educating our students. So, we look at what might be a 
specific response that we might need to do with students' 
quarantine. And that was kind of one of our first things, how 
do you provide education to quarantined students. We know 
technology provides the potential and the opportunity to help 
us do that, but we are not ready for that at all. That is a 
possibility, but we have not developed that. What is our surge 
capacity in the schools to respond to educating kids at home? 
We can educate a few kids that are homebound, but we don't have 
surge capacity to do that, either. We know that our parents 
have a pretty good degree of access to the internet, but much 
of that for our parents in St. Paul will be at the work place 
or in libraries, not at home. So that is not a good resource 
for us.
    The Federal Government can help us by continuing to support 
local public health. That is who we turn to for infectious 
disease help. We need strong leadership at the local level to 
help us respond to what occurs in our communities. And that 
professional health leadership is also going to need support 
from public safety officials. And then we need the Federal 
laws, rules, or policies in the State in support of the 
activities that need to be done.
    We also need real clear guidelines for schools. Isolation 
in a school setting is very difficult. I tried to picture 
exactly how we are going to do that, and we are quite a bit 
different than Carlton or St. Olaf in that we have much younger 
children, and we have lots of different languages, so that 
presents us with space issues. I don't know exactly--and we 
have no supplies. Clearly, no surge capacity there for 
isolation.
    We need accurate messages in the media. That will be highly 
important to us. Accurate messages which are simple and 
consistent--in a way that our many second language households 
can understand. And you know, for a school district such as St. 
Paul, an urban district, where many of our families live in 
crowded homes, the disease can spread quite rapidly. Forty-one 
percent of our students come from homes where English is a 
second language, so the communication challenges are enormous. 
And while we have good interpreter support for education, we 
would be highly challenged to get our educational interpreters 
to understand these health issues, and to convey them.
    Many of our students--at times we estimate up to 20 percent 
of our students in some buildings do not have health coverage. 
So that issue we heard about earlier, about early access, is a 
real concern for us. Where do they get the medication, and 
where do they get diagnosis. And we know that will result in a 
burden on emergency rooms and neighborhood clinics.
    But directly, many of our families use the school nurse as 
the front line health care provider. We provide safety net 
services to meet the gaps in the health care delivery system, 
and we would anticipate that SARS would be a situation where 
many parents might call us, but many others might send their 
child to school to see the school nurse. And then we are going 
to sort out which of these are a cold and which are SARS. It is 
a huge challenge, when I begin to think about it.
    I think the Federal Government could help by recognizing 
the amount of front line health care that is provided, and not 
funded in schools. Take a look at that, and help us be 
available to provide those safety net services to kids. Schools 
are accountable to the educational standards in Leave No Child 
Behind, and we don't have resources to put into health care and 
health education. And that is something we need. We need a 
comprehensive and coordinated school health program that can be 
ready to respond and can teach the kids about concepts of 
health prevention.
    Many of our students are from cultures that don't have 
experience with Western medicine. We can't give them 
thermometers and say, ``Take your temperature twice a day.'' 
There is no experience with that.
    In St. Paul, 67 percent of our students are eligible for 
free or reduced meals. That means that many of them rely on the 
two meals they receive at school. So feeding these kids at home 
when quarantined or in isolation situations is a challenge for 
the community.
    I think we have got to think about the data privacy issues, 
and certainly there are ways around that, but that is always an 
issue between systems.
    I might be remiss coming from schools if I didn't mention 
that Leave No Child Behind has very high standards for us. If 
we went through a winter of a lot of absenteeism, quarantine, 
isolation, problems like these, what would happen to our 
accountability to that system?
    The question of how we respond, I think we do----
    Senator Coleman. I would ask you if you could summarize.
    Ms. Hoxie. OK. We would respond by sending people home so 
they could be assessed. But that would be real challenging for 
us. We would be worried about kids being at home and not having 
anyone supervising them. Thank you.
    Senator Coleman. Thank you very much. Ms. Herrmann.

  TESTIMONY OF DEBRA HERRMANN, RN, PHN, LSN,\1\ DISTRICT LEAD 
      NURSE, MARSHALL SCHOOL DISTRICT, MARSHALL, MINNESOTA

    Ms. Herrmann. Thank you for allowing me to be here and 
inviting us from Greater Minnesota. I represent the southwest 
portion of the State.
---------------------------------------------------------------------------
    \1\ The prepared statement of Ms. Herrmann appears in the Appendix 
on page 56.
---------------------------------------------------------------------------
    For what has Minnesota done to prepare for the possible 
outbreak of SARS this year, for us in our area of the State, we 
have received a lot of the information from the Department of 
Health, and the CDC websites. There is also lots of information 
and classes available. Many of the resources have been very 
medically-oriented for the hospitals, health care settings. So 
there has been limited information available to the schools and 
the procedures that we would actually have to follow, should 
there be an outbreak.
    In November this year, the School Nurses of Minnesota 
(SNOM) is holding a workshop, and SARS is one of the topics. So 
hopefully that will relate to some of the school issues. Many 
of the information educational opportunities are held in the 
metro area, and the time and the travel for those types of 
workshops at some times are very difficult. Although with a lot 
of technology, we are able to tap in and get a lot of those 
resources.
    In seeking out information regarding this prior to coming 
here, many of the things that I was told from our county 
emergency system, our public health system and our hospital and 
health care systems is they are still awaiting more 
information. They would be getting that to me, or to the 
schools. We do have a very good rapport with all of those 
agencies within our community and within the area communities.
    What do we still need to do, and how can the Federal 
Government help? We really need to be better prepared for 
identification and education to the public. Education and 
communication to our public is going to be a major problem, as 
you have seen here. We do have English language learners in our 
area, also. Our school district has--even just with the issues 
of pertussis--the education and the scare factor of many of the 
people in the community was huge with that. So the safety and 
the needs for that--the communication of correct and legitimate 
information is going to be of great need.
    We do have, like I say, the language and communication 
barriers in the school and the community. We also have many 
students that have no insurance. They also use the school 
nurses--the families will send their children to school and 
say, ``I am going to the school nurse,'' and they say, ``if she 
thinks you need to go home, they will make that availability to 
them.'' So we often times are a good health care resource for 
these kids who are seeking care or information--or families are 
sending them to us. We are the resources that these families 
use, due to the financial burden on them at other clinics.
    Another concern is the possible quarantine issue, while 
still providing the educational services. The reimbursement of 
the facility--the faculty and the staff--that need to be under 
quarantine is a major question. Or should a larger outbreak 
occur, how would we even educate the students that we have in 
the schools, let alone the students that might be put on 
tutoring at home. And, again, with the No Child Left Behind 
law, the added burdens of that would be to the districts; that 
we would be able to adequately reach the students not in 
school.
    Again, we do have some of the technology and computer 
availability in our area, but the lower income population--as 
you know, many of these people do not have access to that at 
home, so it would be a burden on our areas.
    There are many unanswered questions at this time. We have 
limited financial resources. There has been additional funding 
cuts to the schools, so this does not allow a vast amount of 
time or manpower for us to be committed to the procedural 
development and research that needs to take place. So we are 
awaiting further information and recommendations from the 
Department of Health, the Department of Education, and CDC 
regarding policies that we could possibly adopt and use within 
our area. So additional funding or procedures that we could 
easily merge into our area would be of great advantage. The 
dollars for the proper medical equipment--and speaking of the 
hospital--we have two rooms in Marshall that would have the 
proper air exchange, and three in Willmar, Minnesota. So you 
are talking about the southwest portion of the State--five 
rooms that would have the equipment necessary. They are also 
having trouble getting the proper air flow masks that need to 
be available for them to use. And that is just for the county 
emergency management and the hospitals. That does not include 
covering the schools.
    How should schools, businesses, communities respond when 
someone they know develops a possible case of SARS? Really, a 
comprehensive plan needs to be developed and available to all 
of the agencies. It needs to address the health care 
facilities, as well as the schools, the businesses, and all 
agencies within the community. We do have a population that 
travels extensively, and so these types of outbreaks could be 
expected at any time.
    The Marshall Public School District, our health program is 
working in conjunction with the other local emergency 
management agencies, community health, and other local health 
care facilities to be a part of a workable plan on how to 
identify and educate our community regarding SARS if there were 
an outbreak. All of the agencies that I have listed are 
currently discussing policy and procedural development, but I 
cannot at this time find one agency that had a fully 
operational procedure that they could follow at this time, if 
there were to be a case of SARS. Again, we are awaiting further 
information.
    We, as a school, have no actual procedure or plan in place 
with a SARS outbreak. We would handle this under our 
communicable disease protocol and policy, as we handle any 
communicable disease, and we would be contacting and using our 
local public health agency tremendously, as well as our 
hospital, clinic and emergency management services to try to 
help get us through. Thank you very much.
    Senator Coleman. Thank you. It was very helpful. Mr. 
Benson.

 TESTIMONY OF ROB BENSON,\1\ SUPERINTENDENT, FLOODWOOD SCHOOL 
                DISTRICT, FLOODWATER, MINNESOTA

    Mr. Benson. I would like to thank Senator Coleman for 
inviting me to be a part of this panel. It is indeed an honor.
---------------------------------------------------------------------------
    \1\ The prepared statement of Mr. Benson appears in the Appendix on 
page 58.
---------------------------------------------------------------------------
    I would like to start my presentation with some of my 
personal background and information on disease control. My 
earliest memory of disease control was when my older sister 
came home from school in Deer River with a case of the measles. 
So the disease would not spread to the little two-room school 
that my middle sister and I attended, we were quarantined. We 
could not go out in the public, so for 2 weeks, I helped my 
father in the logging operation. When I became sick with the 
measles, the disease had to run its course before I was allowed 
back in school.
    The second incident I would like to relate is my mother's 
1928 teaching contract. My mother, like many young girls of the 
day, went to 8 weeks of summer school after high school 
graduation. That qualified her to teach in a rural elementary 
school. About 10 years ago, while cleaning out the attic, I 
found her 1928 teaching contract. The thing that interested me 
in the contract was that it stated, ``If said teacher married 
before or during the school year, it would void the contract.'' 
I told my mother what a different world she lived in in 1928, 
than we live in today. I told her that if I put that into a 
teacher's contract today, it would be discrimination, and would 
be taken out of the contract. To my surprise, my mother told me 
that that was not discrimination. She explained that in 1928, 
when people got married, they usually started a family. There 
was a fear that young, married women would be exposed to German 
measles, and the results would be children with birth defects. 
According to my mother, the reason that women of child-bearing 
age could not be in that environment, was to protect the unborn 
children from birth defects.
    The last incident I would like to relate is when I was a 
student at the University of Minnesota. Senator Humphrey gave a 
presentation at Coffman Memorial Union. Senator Humphrey's 
presentation was on the advances in medicine, and what we could 
expect in the future. He talked about how smallpox would be 
eradicated worldwide. It was new at that time--polio vaccine, 
and how polio would soon be a thing of the past. He stated that 
by the year 2000, viruses would be no more. The common cold 
would be a thing of the past. Having a friend that had died 
from polio, and having several friends that were permanently 
paralyzed from polio, Senator Humphrey's talk had an impact on 
them. I also remember that in 1946, Minnesota cancelled the 
State Fair, for fear of spreading polio.
    The reason that we are here today is that school is a place 
where young people come together, and spread disease.
    We are here today addressing SARS, because disease is not a 
thing of the past. We realize that disease will never be a 
thing of the past. I represent a small school, 431 students. 
That is our kindergarten through 12 population. The town of 
Floodwood has a population of 502 people. Floodwood is 
virtually 40 miles away from services; be it Duluth, Grand 
Rapids, Hibbing, Cloquet or Moose Lake. Floodwood is 40 miles 
away from a hospital. Floodwood has a medical clinic in town 
that is staffed by a doctor and a nurse practitioner. The 
doctor is the first full-time doctor that has practiced in 
Floodwood for nearly 50 years. The school has a licensed public 
health nurse that is on staff 12 hours a week. This is an 
increased time from last year, when the nurse was on duty just 
7\1/2\ hours a week, and that is thanks to a grant from the 
Northland Foundation.
    What are our plans in case of a SARS outbreak? Well, we 
depend on our school nurse. The problem is, like many other 
small, rural schools, or larger schools that assign a nurse to 
several buildings, the funding is not available to employ a 
full-time nurse to each building. Since ours is a part-time 
position, we have a difficult time keeping that position 
filled, and this puts our students at an additional risk on 
many days the nurse is not in the building.
    I have handed out an article that our nurse is publishing 
in our Bear Facts, our monthly school newspaper. She gleaned 
this information from the internet at WWW.CDC.GOV.\1\
---------------------------------------------------------------------------
    \1\ Article by Lisa K. Carsrud, RN, BSN, PHN, School Nurse, 
entitled ``What You Need To Know About Severe Acute Respiratory 
Syndrome (SARS),'' appears in the Appendix on page 60.
---------------------------------------------------------------------------
    Senator Coleman. I will have that article placed into the 
record.
    Mr. Benson. It is the Centers for Disease Control. Every 
month she writes that article for the school newspaper.
    I was asked to address how the government could help with 
disease control in schools. In our situation, the government 
could help by assuring funding so the communities could have a 
full-time public health nurse in all school buildings. SARS is 
not the only concern that schools face today. We have children 
that are diabetic, children that are allergic to foods, 
children that are on various medication, and a list that goes 
on and on. A full-time nurse is an essential addition to our 
schools. We now live in a global economy. Schools now need a 
full-time person in each building that can address the health 
problems of students in that building, as they arise. The 
problems are not diminishing, as Senator Humphrey said they 
would. Even with the advances in medicine, the medical problems 
that schools must address are growing and becoming more 
complex.
    The U.S. Senate can help by assuring funding for a full-
time school nurse in each and every building.
    Thank you, Senator Coleman.
    Senator Coleman. Thank you, Superintendent Benson. And 
thank you all, by the way. This has been very helpful to me and 
I hope, by the way, to the other health care professionals, Dr. 
Hull and Commissioner Mandernach's operation. We have certainly 
had a wide perspective, here--Hennepin County and St. Paul 
Public Schools to the rural communities.
    I have passed along--I am raising my family here. I think 
we do a great job in Minnesota; we pride ourselves on a great 
job. But by virtue of what I have listened to today, the 
challenges still are enormous. It is the nature of the world in 
which we live.
    One of the issues you raised, Commissioner Spartz, you 
talked about three things we need to focus on, in large part 
ties into the reaction of individual citizens. There are 
different experiences with that and different challenges. One 
of the challenges is to get information to the citizens by 
virtue of language or location. But I would like an assessment 
of where we are today, and if SARS were to hit our communities, 
do you think people would be prepared? And if not, on the 
communication side, can you help me get a sense of what else it 
is we have to do, other than school nurses checking with CDC 
bulletins? I will open it up to the entire panel. I am really 
interested in your assessment of your universes, the kind of 
reaction you think if cold season hits this week, all of a 
sudden there is a case of SARS somewhere in your communities. I 
want to touch on Mr. Spartz's point, because he said the 
reaction of citizens is going to play a key role in how we are 
able to respond. Ms. Hoxie.
    Ms. Hoxie. I think that we really need the media to provide 
consistent messages. And that starts with what the CDC can do, 
and what the health department can do, but I will go to the 
communications people in my district--that CDC guidance for 
schools last year was very helpful--a one-page guidance that 
said these people should stay home and these people can come to 
school. And that kind of very clear and consistent message can 
be conveyed in the media, as well as what we can do and more 
direct.
    Senator Coleman. I can assure you that I will ask my staff 
to go through the record to make sure we communicate that to 
the CDC, that they get the message that comes out of this 
hearing.
    Addressing other responses to the question. Mr. Spartz, you 
raised the issue, your assessment for us today. Where do you 
think things are at?
    Mr. Spartz. At this point, Mr. Chairman, I fear we would 
have a panic set in if we had a moderate to major outbreak. Ms. 
Hoxie is right. We need to do education, we need to do it now, 
in advance, so that people have some of the fundamental 
concepts in mind before an event happens. And then you need the 
messages to be gotten out, in the event that happens which 
reinforces the education that was done in advance. I think that 
is the most valuable thing we can do, because if we get a sense 
of panic in the community, public health in the hospitals will 
not be able to control the problem.
    Senator Coleman. I would like to note the presence of Jim 
Rhodes, a State Representative in this area. And I am sure as 
we go back and look at this record, I know he is very concerned 
about these issues. Certainly the State needs to be a full part 
of the legislature. Ms. Crow.
    Ms. Crow. I would just like to comment with regard to the 
mind-set of health care workers around this subject. We are at 
least a full generation away from an outbreak of polio or 
measles, and really having to look at that. Health care workers 
today won't have some of the same altruism that perhaps was 
there 25 years ago. And as we look at this in Northfield, I can 
tell you that people looked at themselves and said, ``I don't 
want to risk my health or my family's health to take care of 
what may be a major incident here.'' We do have to take care of 
our health care workers. We do have to give them the protection 
they need to be able to do the work. If that doesn't happen, I 
can tell you that we won't get the health care workers to come 
to work. And that would be a very big issue.
    Senator Coleman. And I would anticipate then, the same 
holds true for teachers and school settings, who are probably 
less familiar with some of these things, than the health care 
workers. So I would suspect that concern would be amplified in 
a school setting.
    Ms. Herrmann. I think very much so, as well as the school 
teachers. We wouldn't have any protection. I can just tell you 
now from preliminarily putting out information on influenza, 
that I have had a much larger response this year already than 
we have in past years. And should there be a SARS case anywhere 
in the area, it is going to be huge as to whether they will be 
coming to school or not. Because many of our kids do come to 
school sick. They don't have any place to stay home and be 
watched, so they are at school spreading everything.
    Senator Coleman. Ms. Crow, I was interested in your 
discussion of the students, 10 were kept together and 20 went 
somewhere else?
    Ms. Crow. Right.
    Senator Coleman. So in spite of whatever we do with 10, 
there were 20 others that we presumably had no knowledge of. 
The other thing that you have--the issue that you mentioned was 
the philosophical discussion of the rights of individuals. If 
the same situation were to come about today, how would your 
response be different?
    Ms. Crow. I would look for more guidance from the 
Department of Health and CDC. We are not sure at what point of 
an infectious process this disease is spread. Is it prior to 
when you become really symptomatic? Can you actually spread 
prior to that? We looked for that guidance last spring, and 
clearly the faculty, the deans, the leadership at the college 
said we don't need to isolate these students. We were looking 
at the health of the community and saying, you don't want to 
have to isolate your campus--and that could happen. And 
certainly you don't want to have to isolate this whole 
community--and that could happen. How that would be handled 
differently, I think we are not there yet. We still need to 
have these discussions, to say, ``let's think about how we can 
do some simple things to protect the common good.'' In that 
case, my idea would have been to take the 10 students and 
simply take them camping for 10 days or do something with them, 
where they were really truly isolated and yet not be punished. 
But those discussions seem to occur. We need to get creative 
about that.
    Senator Coleman. Was legal counsel involved in these 
discussions?
    Ms. Crow. We did seek legal counsel, and legal counsel went 
back to the guidelines of CDC and Minnesota Department of 
Health and said, there is no legal stand to isolate these 
students at this point.
    Senator Coleman. I believe Commissioner Mandernach talked 
about State quarantine which sunsets in 2004. So I would 
suspect that issue will be reviewed in the next session to make 
sure that we have the place where it is needed to adequately 
deal with these situations.
    Ms. Crow. I think that would be helpful. I think also we do 
need to think about the logistics of that. And I know the 
Commissioner referred to that, as well as Dr. Osterholm. But 
the logistics of quarantine. And that was one of these kinds 
of--understand what you are asking. To logistically isolate 10 
students for 10 days. And first of all, I have to deal with the 
parents of these students who are going to look to me to say 
why. And second, there is just the logistics of making this--so 
that is only 10.
    Senator Coleman. Turning to the school personnel, what I am 
listening to is mostly a look into the health care 
professionals and having a school nurse as someone who is in 
contact with CDC. Is there benefit in training school personnel 
to identify symptoms, or would that simply be too costly, and 
take away from the main focus on education? How far do we go in 
training staff as to what to look for in issues like SARS? I am 
interested in a response. You all represent different 
perspectives. Dr. Benson.
    Mr. Benson. I think there are teachers that are just 
overwhelmed right now with the No Child Left Behind, and all of 
those things. I think they look towards the school nurse as the 
professional person to do this.
    Senator Coleman. Ms. Herrmann.
    Ms. Herrmann. I would say also that our teachers are so 
ingrained in meeting the guidelines of the No Child Left 
Behind, and all of the other issues, that they do come to the 
school nurses as a what am I going to do here, this child is 
coughing, what could this be. We, a lot of times, are the 
medical help or information area, they are coming to us. And it 
is a matter, a lot of times, taking time to be able to deal 
with all of that information and give them accurate data.
    Senator Coleman. Ms. Hoxie.
    Ms. Hoxie. I would agree. We have undertaken a big effort 
to educate our teachers about asthma. And they have so much 
else to be thinking about. They really need our expertise. 
Clearly, I think we would need to reinforce the information to 
them, mainly so they won't have to panic about these kind of 
things. And part of the information is saying these are the 
symptoms. But, again, I don't know how I am going to educate my 
nurses to sort out the symptoms.
    Senator Coleman. That is my next question. I would be very 
interested in your assessment of how do you educate your 
nurses, who has that responsibility, what role does the CDC 
play, and what role does the State play?
    Ms. Hoxie. Well, I think that would be my responsibility to 
start with. And what I have done so far is to try to keep them 
apprised. I don't know how we are going to sort out what's 
SARS. There is no good way to do it. A child comes in and says, 
my mom says to see if my ankle is broken. I have a response. No 
one can tell without an X-ray, and I don't have an X-ray at 
school. But we don't have a good response like that for SARS. 
An X-ray maybe yes, but what we really need is a quick test or 
something, and so they are going to have to leave school and 
get some kind of evaluation, or going to need some time to see 
how the symptoms happen. None of that can be done easily, 
quickly, or efficiently in schools. Because it won't be one 
child, it will be 15, 30, or 50. Often in the winter, health 
offices in the St. Paul schools, have 75 or 80 kids in a day. 
We have to sort out how we are going to sort that out.
    Senator Coleman. Ms. Herrmann.
    Ms. Herrmann. It is going to be a challenge, because even 
just to identify, is it influenza, is it just a cold, or is it 
another type of respiratory infection? As soon as we get the 
information, we spread it out to the other nurses. Our 
infection control nurse at the hospital is excellent about 
getting out any new information that she receives, so we can 
keep on top of that. But it is difficult to keep everybody 
trained on the same page. And not everyone is full-time. So we 
don't always have somebody there to deal with it. So then we 
are trying to educate secretaries and staff on what to 
recognize, and who is important to be seen or sent home.
    Senator Coleman. This has been a fascinating discussion. In 
many ways, we are asking folks to think the unthinkable. 
Hopefully it doesn't happen. And even after thinking, if it 
does happen, what I am hearing is that there are some very 
practical, logistical time-issues like Ms. Hoxie talked about. 
Supplies, capacity, that even under the best of circumstances, 
if SARS were to break out, we would be challenged to respond 
effectively. I was tempted in the school setting to ask about 
grades. But I think under the best of circumstances, we are 
clearly going to be challenged.
    I will certainly go back and carry the message about the 
resource issue, the information issue, and certainly about some 
longer-term issues. I do know that Dr. Osterholm wanted to go 
through short-term and long-term. Long-term is access to health 
care. Short-term is how many masks do you have, what's the 
surge capacity? And I think we have to be thinking in those 
terms, break that up. Clearly, the burden is on folks at the 
local level. We can discuss this in Washington. I am impressed 
with CDC, with the work that they are doing in regard to folks 
at the local level, the information that has been made 
available. They had a checklist that they put together at my 
last hearing that they kind of laid out, and I would hope that 
checklist--and I presume it is going to the health care 
professionals, probably not going to the schools, but should be 
going to the mayors and others for each community, a list of 
those things that you need to do. Certainly when I get back, I 
will do my best to see that the checklist of what needs to be 
done is circulated more extensively. I think we all need to 
kind of measure where we are right now.
    I do want to thank St. Louis Park High School for hosting 
this hearing. It has been really an extraordinary session. Very 
helpful. I am an optimist. If bad things happen, I think we 
have folks in this community who are certainly geared to do the 
best they can. Hopefully that will be enough, and hopefully we 
will get smarter as time goes on. So I want to thank you all.
    The record of this hearing is open for an additional 10 
days, if there are others here who wish to submit statements or 
other information for the record, I will make sure that that 
takes place. So with that, this hearing is now adjourned.
    [Whereupon, at 11:40 a.m., the Subcommittee was adjourned.]


                            A P P E N D I X

                              ----------                              


               CLOSING STATEMENT OF SENATOR NORM COLEMAN

    I want to thank all of today's witnesses for participating in 
today's hearing. I know that all of us are working for the same thing, 
to protect the health of Minnesotans, especially our children. We 
cannot control when or where SARS will emerge, but we can make sure 
that we are prepared to recognize it when it does and respond 
appropriately. I know that several international and Federal agencies, 
led by the World Health Organization and the Center for Disease Control 
and Prevention have already done a great deal to get information and 
resources to State and local officials so that they can do their jobs. 
I will work to ensure that these resources continue to be delivered in 
an effective and useful manner. I hope that all of you will feel free 
to notify my office of any needs or concerns you have.
    The main burden of protecting local health will always fall upon 
the local health care officials who are on the scene treating 
individuals. As the first point of contact, it is important that they 
receive the information and resources needed to prevent an outbreak 
from occurring. We must also make sure that they receive adequate 
protection when they treat patients.
    This is an area that I intend to remain involved in. I have 
requested that the General Accounting Office conduct a study of 
national and international surveillance systems for spotting the 
emergence of an infectious disease. GAO is likely to complete this 
study at the end of the year, and I will make sure that the results are 
acted upon.
    I also want to thank St. Louis Park High School for hosting this 
event. Given today's focus on protecting our children, it is very 
fitting that we held this hearing in a school.
    Civilization is possible because human institutions are capable of 
learning from past experiences. I am confident that the lessons from 
last spring will make us better prepared to deal with the continued 
threat of SARS and other highly infectious diseases.
    Thank you.

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