[House Hearing, 109 Congress]
[From the U.S. Government Printing Office]



 
   MITIGATING CATASTROPHIC EVENTS THROUGH EFFECTIVE MEDICAL RESPONSE

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

                                HEARING

                               before the

                       SUBCOMMITTEE ON PREVENTION
                       OF NUCLEAR AND BIOLOGICAL
                                 ATTACK

                                 of the

                     COMMITTEE ON HOMELAND SECURITY
                        HOUSE OF REPRESENTATIVES

                       ONE HUNDRED NINTH CONGRESS

                             FIRST SESSION

                               __________

                            OCTOBER 20, 2005

                               __________

                           Serial No. 109-48

                               __________

       Printed for the use of the Committee on Homeland Security
                                     
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

                                     

  Available via the World Wide Web: http://www.gpoaccess.gov/congress/
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                     COMMITTEE ON HOMELAND SECURITY

                   Peter T. King, New York, Chairman

Don Young, Alaska                    Bennie G. Thompson, Mississippi
Lamar S. Smith, Texas                Loretta Sanchez, California
Curt Weldon, Pennsylvania            Edward J. Markey, Massachusetts
Christopher Shays, Connecticut       Norman D. Dicks, Washington
John Linder, Georgia                 Jane Harman, California
Mark E. Souder, Indiana              Peter A. DeFazio, Oregon
Tom Davis, Virginia                  Nita M. Lowey, New York
Daniel E. Lungren, California        Eleanor Holmes Norton, District of 
Jim Gibbons, Nevada                  Columbia
Rob Simmons, Connecticut             Zoe Lofgren, California
Mike Rogers, Alabama                 Sheila Jackson-Lee, Texas
Stevan Pearce, New Mexico            Bill Pascrell, Jr., New Jersey
Katherine Harris, Florida            Donna M. Christensen, U.S. Virgin 
Bobby Jindal, Louisiana              Islands
Dave G. Reichert, Washington         Bob Etheridge, North Carolina
Michael McCaul, Texas                James R. Langevin, Rhode Island
Charlie Dent, Pennsylvania           Kendrick B. Meek, Florida
Ginny Brown-Waite, Florida

                                 ______

      SUBCOMMITTEE ON PREVENTION OF NUCLEAR AND BIOLOGICAL ATTACK

                     John Linder, Georgia, Chairman

Don Young, Alaska                    James R. Langevin, Rhode Island, 
Christopher Shays, Connecticut       Ranking Member
Daniel E. Lungren, California        EdwarD J. Markey, Massachusetts
Jim Gibbons, Nevada                  Norman D. Dicks, Washington
Rob Simmons, Connecticut             Jane Harman, California
Bobby Jindal, Louisiana              Eleanor Holmes Norton, District of 
Charlie Dent, Pennsylvania           Columbia
Peter T. King, New York (Ex          Donna M. Christensen, U.S. Virgin 
Officio)                             Islands
                                     Bennie G. Thompson, Mississippi 
                                     (Ex Officio)

                                  (II)












                            C O N T E N T S

                              ----------                              
                                                                   Page

                               STATEMENTS

The Honorable John Linder, a Representative in Congress From the 
  State of Georgia and Chairman, Subcommittee on Prevention of 
  Nuclear and Biological Attack:
  Oral Statement.................................................     1
  Prepared Statement.............................................     2
The Honorable James R. Langevin, a Representative in Congress 
  From the State of Rhode Island, and Ranking Member, 
  Subcommittee on Prevention of Nuclear and Biological Attack....     3
The Honorable Bennie G. Thompson, a Representative in Congress 
  From the State of Mississippi, and Ranking Member, Committee on 
  Committee on Homeland Security.................................    41

                               WITNESSES

Dr. Roy L. Alson, PhD, MD, FACEP, FAAEM, Associate Professor, 
  Emergency Medicine, Wake Forest University School of Medicine:
  Oral Statement.................................................     9
  Prepared Statement.............................................    11
Richard Bradley, MD, Medical Director, Emergency Center--LBJ 
  General Hospital, University of Texas Health Science Center at 
  Houston:
  Oral Statement.................................................    18
  Prepared Statement.............................................    19
Jenny E. Freemen, MD, President and CEO, Hypermed, INC:
  Oral Statement.................................................    28
  Prepared Statement.............................................    31
Donald F. Thompson, MD, MPH&TM, Senior Research Fellow, Center 
  for Technology and National Security Policy, National Defense 
  University:
  Oral Statement.................................................    23
  Prepared Statement.............................................    24











   MITIGATING CATASTROPHIC EVENTS THROUGH EFFECTIVE MEDICAL RESPONSE

                              ----------                              


                       Thursday, October 20, 2005

                     U.S. House of Representatives,
                    Committee on Homeland Security,
      Subcommittee on Prevention of Nuclear and Biological 
                                                    Attack,
                                                    Washington, DC.
    The subcommittee met, pursuant to call, at 1:03 p.m., in 
Room 1310, Longworth House Office Building, Hon. John Linder 
[chairman of the subcommittee] presiding.
    Present: Representatives Linder, Dent, Langevin, and 
Thompson, ex officio.
    Mr. Linder. The hearing will come to order. We are going to 
be very short on this end of the bench, because we finished 
voting an hour ago and everybody is on airplanes already, I 
suspect.
    I would like to welcome and thank our witnesses for 
appearing before this subcommittee today.
    There is an inordinate amount of attention focused on what 
went wrong during Hurricane Katrina. Today, instead, we are 
here to discuss what we must get right to prevent, mitigate and 
respond to a catastrophic biological or nuclear incident.
    As tragic as the loss of life was during the Katrina storm, 
imagine for a minute the consequence of a nuclear or 
bioterrorism event. The Atlantic Storm exercise showed us that 
a covert attack on key transportation hubs with smallpox can 
result in possibly 660,000 cases worldwide in just 30 days. A 
10-kiloton nuclear device detonated near the U.S. Capitol can 
result in 15,000 instant deaths and another 15,000 injured.
    Can our current medical response capabilities meet this 
challenge?
    In 1979, President Carter established FEMA to centralize 
Federal emergency functions. Five years later, the National 
Disaster Medical System was created within HHS to provide 
medical and related services in the event that a disaster 
overwhelms the local medical emergency capabilities.
    In the Homeland Security Act of 2002, NDMS was transferred 
to DHS and at present functions under the management of FEMA. 
Twenty years since their creation, both of these entities 
played a significant and crucial role in response to Hurricane 
Katrina.
    In December 2004, the Department of Homeland Security 
launched its National Response Plan, designed to coordinate the 
Federal Government's efforts to prepare for and respond to a 
catastrophic event. Under the NRP, DES would take the overall 
lead for responding to such events, with HHS tasked with 
coordinating the response of the public health and medical 
sectors. As the events of Katrina also highlighted, the 
Department of Defense played a vital role in providing both 
logistical and medical asset support for the victims.
    We have rearranged the deck chairs, come up with new plans, 
and Congress has committed substantial financial support to 
both Federal and local agencies. My question to you is very 
simple: Are our medical responders better prepared to mitigate 
a truly catastrophic terrorist event?
    I can assure you that while Mother Nature often gives us 
warning, we will not receive fair warning from terrorists. We 
will not have the luxury of ``predeploying'' our medical assets 
and personnel.
    It is often said we have to use an all-hazards approach to 
any catastrophic event. I do not buy into this notion. There 
are unique requirements for both mitigating and responding to a 
nuclear or biological event. We cannot continue to rely on 
lessons learned because terrorists continue to plot and plan 
against us. It was my impression that the lessons learned 
occurred almost 4 years ago on September 11th.
    I look forward to your testimony, because each of you 
represents boots on the ground and not the bureaucratic 
apparatus. Your insights will be valuable to members of the 
subcommittee in constructing legislation to fix problems.
    I recognize the ranking member of the subcommittee,
    Mr. Langevin of Rhode Island, for the purpose of making an 
opening statement.

                 Prepared Statement of Hon. John Linder

    I would like to welcome and thank our witnesses for appearing 
before this Subcommittee today.
    There is an inordinate amount of attention focused on what went 
wrong during hurricane Katrina. Instead, we are here today to discuss 
what we must get right to prevent, mitigate and respond to a 
catastrophic biological or nuclear incident.
    As tragic as the loss of life was during the Katrina storm, imagine 
for a minute the consequence of a nuclear or bioterrorism event. The 
Atlantic Storm exercise showed us that a covert attack on key 
transportation hubs with smallpox can result in possibly 660,000 cases 
worldwide in just 30 days. A 10 kiloton nuclear device detonated near 
the U.S. Capitol can result in 15,000 instant deaths and another 15,000 
injured.
    Can our current medical response capabilities meet this challenge?
    In 1979, President Carter established FEMA to centralize Federal 
emergency functions. Five years later, the National Disaster Medical 
System was created within HHS to provide medical and related services 
in the event that a disaster overwhelms the local medical emergency 
capabilities.
    In the Homeland Security Act of 2002, NDMS was transferred to DHS 
and at present functions under the management of FEMA. Twenty years 
since their creation, both of these entities played a significant and 
crucial role in the response to Hurricane Katrina.
    In December 2004, the Department of Homeland Security launched its 
National Response Plan, designed to coordinate the Federal government's 
efforts to prepare for and respond to a catastrophic event. Under the 
NRP, DHS would take the overall lead for responding to such events, 
with HHS tasked with coordinating the response of the public health and 
medical sectors. As the events of Katrina also highlighted, the 
Department of Defense played a vital role in providing both logistical 
and medical asset support for the victims.
    We have rearranged the deck chairs, come up with new plans, and 
Congress has committed substantial financial support to both federal 
and local agencies. My question to you is very simple: Are our medical 
responders better prepared to mitigate a truly catastrophic terrorist 
event?
    I can assure you that while Mother Nature often gives us warning, 
we will not receive fair warning from terrorists. We will not have the 
luxury of ``pre-deploying'' our medical assets and personnel.
    It is often said that we have to use an all hazards approach to any 
catastrophic event. I do not buy into this notion. There are unique 
requirements for both mitigating and responding to a nuclear or 
biological event. We can not continue to rely on lessons learned, 
because terrorists continue to plot and plan against us. It was my 
impression that the lessons learned occurred almost four years ago on 
September 11th.
    I look forward to your testimony, because each of you represent 
boots on the ground and not the bureaucratic apparatus. Your insights 
will be valuable to members of the subcommittee in constructing 
legislation to fix the problems.
    I now recognize the Ranking Member of the Subcommittee, Mr. 
Langevin of Rhode Island, for the purpose of making an opening 
statement.

    Mr. Langevin. Thank you, Mr. Chairman.
    I would like to thank our witnesses for being here and for 
your service to our Nation. We are all truly grateful. You all 
have a wealth of experience in providing medical care during 
catastrophes, and we welcome your testimony here today.
    In our country, medical responders come from all sectors of 
society, from local hospitals and public health agencies, 
private care facilities, local first responder departments, 
State and Federal agencies, the military and volunteer 
organizations.
    As the recent hurricanes in the gulf coast have shown us, 
coordination of all these different entities is very 
complicated, but the failure to do so leads to confusion and 
ineffectiveness, and in some cases can be the difference 
between life and death. One of the responsibilities of this 
committee is to provide oversight of programs such as the 
National Disaster Medical System to ensure that it functions 
correctly.
    Members of this committee have heard many accounts from 
members of DMAT teams that organization and mission assignments 
in various situations have been confused and, in some cases, 
nearly absent. Dr. Freeman's testimony tells the story of her 
colleague and fellow Massachusetts DMAT member, Dr. Tim 
Crowley, who was so frustrated and disturbed by the failure of 
the leadership of his team while deployed to Louisiana for 
Hurricane Katrina, he resigned upon returning to Massachusetts.
    Dr. Freeman recounts her own experience with a similar lack 
of leadership, sense of mission and logistical support during a 
DMAT deployment when she volunteered to provide medical 
response capabilities to the G8 Summit last year.
    I have also been asked by my colleague, Representative 
DeFazio of Oregon, to submit for the record a letter that he 
received from the team leader of the Oregon disaster medical 
team. The letter details many problems the team faced during 
its deployment after Hurricane Katrina.
    Mr. Chairman, I would ask unanimous consent that it be 
placed in the record.
    Mr. Linder. Without objection.
    [The information follows:]

                                                                                    NDMS AFTER ACTION REPORT



Team:                                                                                                                            Mission:                                        Mission Dates:
IMSURT E                                                                                                                Hurricane Katrina                                       9/3/05--9/18/05
Submitted by:                                                                                            E-mail: [email protected]                                   Phone: 978-443-0808
Timothy Crowley

Date Submitted: 10/5/05......................                                                                                Reviewed by:                                        Date Reviewed:

                                                                                                                            Instructions:
                                               Please include both constructive criticism and positive feedback where appropriate. Do not include security-sensitive issues or personal
                                                                                                                                                           comments.
                                                   ``Impact'' refers to ``how did this impact your mission'': 1-none, 2-minor, 3-moderate, 4-significant, 5-critical.
                                                   ``Effect'' refers to ``how effectively was this topic/issue handled'': 1-very well, 2-good, 3-acceptable, 4-poor, 5-failure.
                                                   Under ``Discussion/Description'', please include any meaningful comments for the corresponding topic or issue. What worked well, what didn't,
                                                                                                      etc. Recommendations are strongly encouraged but not required.
                                                   If you have additional feedback, feel free to duplicate the form or attach additional pages or documents as required; refer to the number of
                                                                                                              the Topic/Issue (e.g., 2a) in your attached documents.
                                                   Using the ``Save As'' command, title the document with the mission name and team identifier (e.g., IVAN-CA1, Katrina-VMAT2, etc.). Secondary
                                                                                        deployments to the same mission should also be identified (e.g., IVAN-CA1b).

                                                                                                                             Once completed, please email copies to:
                                                                                                                                                Team Program Manager
                                                                                                                                                    Team Regional EC
                                                                                                                                           [email protected]



----------------------------------------------------------------------------------------------------------------
                                                                                         Recommendation/
         Topic/Issue             Impact      Effect         Discussion/Description           Action         FWG
----------------------------------------------------------------------------------------------------------------
1. Situation Deployed as:              0           0   We were supposedly deployed as    ...............
a. Full team of 37                                      a specialty team to set up a
b. Strike/Augmentation team                             field hospital similar to our
 of 11                                                  mission in Bam, Iran. It
c. Individual                                           turned out much different. We
d. Describe mission                                     ended up either sitting in
 assignment                                             Baton rouge waiting for a
                                                        mission for several days
                                                        (while teams in the field, we
                                                        later learned were begging MST
                                                        for help) We were then finally
                                                        deplyoed to the Airport and
                                                        ultimately divided into strike
                                                        teams to assist the DMORTs,
                                                        cruise ship and West Jeff.
                                                        Hospital sites. Some were left
                                                        at the airport (after all
                                                        evacuations were shut down and
                                                        there was NO BUSINESS for us
                                                        to be there.
----------------------------------------------------------------------------------------------------------------
2. Alert & Notification                5           5   We were notified ONE WEEK after   ...............
a. Initial alert or                                     the hurricane and after the
 organization                                           most critical events where we
b. Notification Process                                 could have made an impact, had
                                                        already transpired-(the
                                                        disasters at the convention
                                                        center and the airport and the
                                                        Superdome.
----------------------------------------------------------------------------------------------------------------
3. Deployment                          5           5   We were sent to Houston in        ...............
a. Timeliness                                           several groups over an
b. Method                                               extended period of time which,
c. Preparedness                                         by the time everyone was there
                                                        and accounted for, required an
                                                        overnight in a hotel, thus
                                                        wasting another day and money.
                                                        We then had to travel 250
                                                        miles in a convoy which took
                                                        up the next day.
----------------------------------------------------------------------------------------------------------------
4. Response                            5           5   As noted above, when we got to    ...............
a. Mission execution                                    Baton Rouge there was no
b. Local staging execution                              organization and no mission
                                                        for the multiple teams waiting
                                                        there despite what we learned
                                                        later, that teams in the field
                                                        such as the teams at the
                                                        Airport and West Jeff were
                                                        pleading for help. I confirmed
                                                        this myself when I was tasked
                                                        to demobilze 190 DMAT
                                                        personell myself at the
                                                        ariport on 9/8/05.
                                                       Everyone told the same story.
                                                        This was repeated when we
                                                        arrived at our strike team
                                                        missions and repeated again
                                                        when we called for help and
                                                        were told by MST that there
                                                        were no assets to send us.
                                                        When out relief finally came
                                                        we learned, again, not to our
                                                        surprise, that the teams
                                                        relieving us had been sitting
                                                        on their butts for days
                                                        wiating and asking for
                                                        missions. This was a TOTAL
                                                        FAILURE in the MST system and
                                                        NDMS to deliver the assets and
                                                        resources to the areas of need.
----------------------------------------------------------------------------------------------------------------
5. Incident Command                    5           5   This is a complicated question    ...............
a. Unified command (JMT)                                to answer since we had so many
b. Group Supervisor (a.k.a.                             locations and interactions
 DMAT liaison or LNO)                                   with leadership personell at
c. Local interface (e.g.,                               various levels. The best
 local govt or hospital                                 experience I had was at West
 command & control)                                     Jeff. where Tom Lowe (?sp) the
d. Your team/unit command)                              team commander of NY-
e. Establishment of                                     Minnesota, also performed at
 priorities                                             the highest level. The other
                                                        outstanding performance to be
                                                        commended was the JIOC under
                                                        the command of Col. Petrenko
                                                        which I was privileged to be
                                                        part of when I was made
                                                        Medical Director of the
                                                        Airport. (I previously had
                                                        been made Supervising Medical
                                                        Officer for Imsurt East when
                                                        Dr. Briggs was brought up to
                                                        the MST due to illness of that
                                                        director. I ultimately was
                                                        made Acting Medical Director
                                                        for the whole 3 state region
                                                        when Briggs returned to
                                                        Boston, although I remained at
                                                        West Jeff due to lack of
                                                        coverage for the night shift.
                                                        I mention this not to blow my
                                                        own horn but to explain that I
                                                        may have had a unique exposure
                                                        to the deployment because of
                                                        all the various posts held and
                                                        the demobilization of several
                                                        of the DMAT teams who were
                                                        able to relay their stories to
                                                        me. The rest is pretty ugly.
                                                        As Medical Director at the
                                                        Airport, I had the unfortunate
                                                        experience to be under the
                                                        command of H. James Young. His
                                                        judgement, knowledge and
                                                        overall command decisions wre
                                                        nothing short of abysmal.
                                                        Example--As anyone whoever
                                                        worked in such a deployment
                                                        knows, different teams members
                                                        have different skills, Some do
                                                        logistics, some commo, etc.
                                                        Rather than ASKING the staff
                                                        at the airport who did what,
                                                        he just named people randomly
                                                        to positions with the expected
                                                        results. He also kept several
                                                        people on our team manning a
                                                        medical clinic long after the
                                                        airport had any need and while
                                                        the military had set up a full
                                                        medical facility and despite
                                                        pleas from myself and our team
                                                        commander to release the team
                                                        members to where the need was.
                                                        Finally, there was a mission
                                                        at the cruise ship which was
                                                        also closed and despite this,
                                                        MST in Baton Rouge refused to
                                                        release the docs there to help
                                                        at West Jeff where the teams
                                                        were getting slammed and
                                                        asking for help. I never
                                                        learned what sort of politcal
                                                        agenda or just plain
                                                        incompetance or stupidity was
                                                        behind these decisions, but
                                                        they were disgraceful.
----------------------------------------------------------------------------------------------------------------
6. Communications                      4           4   First, our intra-team commo.      ...............
a. Within your response unit                            was excellent. Commo to MST
b. Within the incident scene                            (for whatever good it did) was
c. Interagency                                          poor. The communications under
d. Standardization &                                    the auspices of the JIOC at
 compatibility with local                               the airport was superb. The
 resources                                              morning briefings were crisp,
                                                        to the point and very
                                                        efficient. The JIOC was the
                                                        quintessential example of
                                                        Interagency cooperation and
                                                        effectiveness and should serve
                                                        as the ``model'' for future
                                                        national responses to
                                                        disasters, in my opinion.
----------------------------------------------------------------------------------------------------------------
7. Logistics                          31           1   Supply and housing all were       ...............
a. Identifying logistics                                quite acceptable. The U.S.
 needs                                                  Forest Service did a fantastic
b. Resupply process                                     job at the airport with their
c. Staff housing, feeding,                              meal and shower units.
 etc.
----------------------------------------------------------------------------------------------------------------
8. Personnel                           1           1   My team experience on this        ...............
a. Staffing and shift                                   account was excellent. I will
 procedures                                             relate that accountability on
b. Personnel accountability                             some of the demobilizing teams
c. Stress management                                    I interviewed at the airport
d. Life safety                                          was, in some cases,
                                                        nonexistant. I can't recall
                                                        which teams were lacking in
                                                        this regard unfortunately--
                                                        they all kind of ran together.
----------------------------------------------------------------------------------------------------------------
9. Plans/Training/                     5           5   Strong feeling about this area.   ...............
 Preparedness                                           In my view all teams should
a. Adequacy of plans                                    have their caches and
b. Execution of plans                                   equipment loaded on trucks or
c. Adequacy of training                                 pallatized in a form that
 program for the mission                                allows for roll-on deplyoment
d. Adequacy of pre-planned                              to a military aircraft- C-130,
 equipment (e.g., basic load)                           C-17 or C-5, if necessary and
 for the mission                                        be flown point to point ASAP
                                                        when the need arises. They
                                                        sould have a small contingent
                                                        of military units deployed
                                                        along side for security. Sites
                                                        for DMAT units and field
                                                        hospitals should be
                                                        preselected across the country
                                                        as part of national
                                                        contingency planning OR the
                                                        local field commanders should
                                                        be given the authority to set
                                                        up shop at sites selected in
                                                        conjunction with local
                                                        authorities. Disaster teams,
                                                        in that scenario could deploy
                                                        within 6 hours and be anywhere
                                                        in the country in 12 hours and
                                                        be up and running within 24
                                                        hours, at most, from the time
                                                        of activation.
----------------------------------------------------------------------------------------------------------------
10. Demobilization                     5           5   This was one of the most          ...............
a. Notice                                               annoying parts of the
b. Team member travel                                   deplyoment. At the end, our
c. Transportation of cache                              whole teams was AT AN AIRPORT.
d. Cache inspection/resupply                            We were in New Orleans and
e. Financial concerns                                   were made to go to Baton
 including reimbursements                               Rouge, in a convoy, to HAND IN
 payroll, etc.                                          PAPERS. Nothing else was done
                                                        there. The physcial exams and
                                                        mental health checks were
                                                        DONE. We were then sent to
                                                        Houston to stay over night at
                                                        the expense of the taxpayer
                                                        and had flights arranged to
                                                        Ohio and then on to Boston to
                                                        arrive on the 15th day of the
                                                        deployment at midnight.
                                                       There were 27 openings on the
                                                        flight to Boston from New
                                                        Orleans Airport hat Saturday
                                                        at 9 AM and 40 opening on the
                                                        flight at 12:30. The whole
                                                        National Travel service scam
                                                        should be abandoned and the
                                                        teams should be allowed to
                                                        book their own flights and
                                                        send the damn paperwork in
                                                        later. The main problemn with
                                                        this agency is that it is too
                                                        concerned with politics and
                                                        bureaucracy and too little
                                                        with getting the medical
                                                        resources to the areas of need
                                                        expeditiously.
----------------------------------------------------------------------------------------------------------------
Conclusion:                    The whole NDMS concept needs to be rethought. The current management team and
                               disaster response, as I stated above, is completely dysfunctional. What is more
                               worrisome is that this was a response to a disaster that we had fair warning of.
                               I believe it has exposed a significant vulnerability to a sudden mass casualty
                               event such as an earthquake or terrorist attack with NBC agents. Competant
                               contingency planning and refocusing the efforts of the agency on getting the
                               resources to the areas of need are essential to success of its overall mission
                                          and to the security of the nation.
----------------------------------------------------------------------------------------------------------------


    Mr. Langevin. I feel strongly that the National Disaster 
Medical System can and should be an important asset to help 
treat injuries and provide aid in times of crisis. We must 
ensure that this incredible resource is not squandered. The 
members of the medical community who volunteer to be a part of 
this effort are highly motivated and highly skilled. We must 
ensure that those skills and that motivation are harnessed to 
the maximum possible effect.
    Now, I am disturbed by the numerous reports of botched 
leadership, lack of a defined mission and an emphasis on 
bureaucratic functions, such as filling out paperwork when 
citizens are in distress and time is of the essence.
    I am further concerned that in close analogy to the stories 
we heard about our troops in Iraq not being properly equipped, 
the members of these teams were not provided with the equipment 
that they needed to do their jobs.
    Now we have a lot of ground to cover here, and I am anxious 
to explore these issues with our witnesses. I do want to thank 
you all for being here, and I certainly look forward to your 
testimony.
    Thank you, Mr. Chairman, and I yield back.
    Mr. Linder. We will now turn to our witnesses. Dr. Alson is 
Associate Professor of Emergency Medicine at Wake Forest 
University School of Medicine. He was also the commanding 
officer of North Carolina's DMAT team that was deployed during 
Hurricane Katrina.
    Dr. Richard Bradley is Medical Director of the Emergency 
Center at Lyndon B. Johnson General Hospital in Houston and is 
a member of the Texas Urban Search and Rescue Team. He was 
deployed during both Hurricanes Katrina and Rita.
    Dr. Donald Thompson is a colonel in the U.S. Air Force and 
is a Senior Research Fellow at the National Defense University.
    Dr. Jenny Freeman is President and CEO of Hypermed, Inc., 
and a member of the Massachusetts DMAT team.
    Thank you all for being here.
    Mr. Linder. Dr. Alson.
    I would ask you to keep your comments as close to 5 minutes 
as you can.

           STATEMENT OF ROY L. ALSON, PhD, MD, FACEP

    Dr. Alson. Thank you, Chairman Linder and members of the 
committee. Good afternoon, and I appreciate the opportunity to 
speak.
    My name is Dr. Roy Alson. I am an Associate Professor of 
Emergency Medicine at Wake Forest University School of 
Medicine, and I am here representing the American College of 
Emergency Physicians, the specialty of emergency medicine and 
the personnel disaster medical assistance teams of the National 
Disaster Medical System.
    I currently serve as the commander of DMAT NC-1. I have 
been in the NDMS since 1989. I have had the privilege of 
leading an extraordinary group of people on multiple responses, 
including, recently, Hurricane Katrina.
    We have been extremely lucky in this country. We have yet 
to face a truly catastrophic medical event. This is not to 
diminish 9/11, Rita or Katrina to those who were involved 
victims; they are catastrophes. But compared to the casualties 
suffered in the recent earthquake in Pakistan, the 1976 
Tangshan earthquake or the tsunami, we have not had the number 
of victims. Our events that we have had have taxed our medical 
systems because of disruptions of infrastructure, but our 
response systems at the local, State and national level have 
eventually met those needs.
    Was our response perfect? No, it may never be. Can we do 
better? Yes. And many lessons have been learned.
    It remains only a matter of time before we face a truly 
catastrophic event in this Nation. It may come in the form of a 
terrorist attack, using biologic or radiologic weapons; it may 
be a natural disaster or even the looming pandemic from avian 
flu that now faces us.
    To deal with the consequences of a medical disaster, there 
are certain requirements that need to be in place. There must 
be facilities to give care, there must be personnel to provide 
that care, and there must be supplies for those personnel to 
use. All of these items can be greatly affected by the event 
that has taken place, and it may take additional time to bring 
in replacements.
    Also, we have to have the ability to move injured and other 
victims from the impact area to other portions of our country, 
where they can receive definitive care.
    Consequently, at a time when a community has increased 
demands for medical care, the ability of that community to 
provide care is compromised by the very event that caused it. 
Complicating this picture is the current nature of medical care 
in our country.
    All of us practice in competitive environments. Emphasis is 
on cost containment and efficiency. Many facilities operate 
near capacity. Supplies depend on just-in-time delivery. Thus 
our ability to surge in the presence of large numbers of 
casualties is compromised.
    We have, in the past, since September 11th, funded heavily 
the decontamination capabilities, the first responders. We may 
have saturated that market in funding. We need to look at where 
we are going to send the people they have deconned. Do we have 
that surge capacity? Currently, it is limited. Options for 
providing that definitive care remain bringing in more beds, 
such as portable field hospitals, setting up alternate care 
facilities or evacuation of victims. These are not mutually 
exclusive, but are part of a coordinated approach.
    Catastrophic events rapidly overwhelm the local system and 
produce casualties that exceed their capacity. We have to 
harden the locals to handle the first period of time after that 
disaster. This is something that was apparent in most recent 
disasters. We have to give them the capability, as it will hold 
the fort until outside support comes.
    The other thing we have to realize is that the mission of 
bringing these facilities in and distributing patients around 
the country has been the very mission that the NDMS was created 
for in the 1980s. Katrina was the first time we tested the 
evacuation piece; we have learned a lot of lessons. That 
portion needs additional support. It needs to be more robust, 
because such evacuations are resource-intensive.
    We also, as I said, have to have the ability to bring in 
medical support. We currently have the DMATs and the NDMS; HHS 
has other assets, and there are many other local and other 
agencies that have come in. We need to look at the continued 
development of things such as the Federal Medical Contingency 
Stations originally proposed by NDMS and DHS. We have to expand 
the capabilities of recruiting volunteers when they offer their 
services. We saw large numbers in this event with many people 
complaining about the red tape.
    ESAR-VHP, the Emergency System for Advance Registration of 
Volunteer Health Care Personnel, is there to handle the 
registration. We need to also train them in responding.
    In my summary then, our catastrophic medical response must 
include hardening the local infrastructure, a coordinated 
Federal response, ideally under a single agency with committed 
medical logistic support. We also have to make the process of 
bringing the Federal assets in easier. We depend now, through 
the National Response Plan and the Stafford Act, on the request 
of the State to bring the assets. For certain types of 
catastrophic events, the Federal Government needs the ability 
to launch those assets and put them in place before we get the 
request from the State.
    Lastly, the programs must be sustained. Equipment and 
personnel have been gathered and put in place, but it takes 
time, and we must maintain them, and that takes additional 
funding.
    It is not ``if'' we have a catastrophic event, but 
``when.'' I again thank you for the opportunity to speak. I 
want to assure the American people and this committee that when 
such an event happens, the medical and response communities 
will do our best for our fellow citizens.
    Thank you very much.
    Mr. Linder. Thank you, Dr. Alson.
    [The statement of Dr. Alson follows:]

           Prepared Statement of Roy L. Alson, PhD, MD FACEP

    Chairman King and Members of the Committee; good afternoon and 
thank you for inviting me to speak before the committee. My name is Dr. 
Roy Alson. I am an Associate Professor of Emergency Medicine at Wake 
Forest University School of Medicine. I am very pleased to be here 
representing the American College of Emergency Physicians, the 
specialty of Emergency Medicine and the response personnel of the 
Disaster Medical Assistance Teams (DMATs) of the National Disaster 
Medical System (NDMS) which is part of FEMA. I currently serve as the 
Commander of DMAT NC-1 and have been active in the NDMS since NC-1 was 
formed from our local team Special Operations Response Team, in 1989. I 
have also previously served as the executive officer of the NMRT-E 
which is a chem-bio response team for the NDMS. I have had the 
privilege of leading the DMAT on numerous responses beginning with 
Hurricane Andrew and most recently with Hurricane Katrina.

Background
    We have been extremely lucky in this country. We have yet to face, 
in recent memory, a truly catastrophic event, from a medical point of 
view. This is not to diminish events such as 9/11 or even Katrina and 
Rita. For those who suffered from these, they are catastrophes. 
Thousands died and hundreds more injured. But when compared to events 
such as the 2004 Tsunami or the recent Pakistani earthquake or the 
Tangshan earthquake of 1976 which killed 240,000 and left another 
200,000+ injured in just one city, our recent major disasters have not 
generated the massive numbers of victims needing acute and long term 
medical care. Our events have taxed our medical systems because of the 
disruptions to infrastructure, but our response systems at the local, 
state and national level have met those needs. Was our response 
perfect? No, but it never will be. Can we do it better? Yes and many 
lessons have been learned and continue to be studied from both this 
year's storms, the 2004 season in Florida and Hurricane Allison in 
2001.
    The fact remains that it is only a matter of time until we face a 
truly catastrophic medical event in this nation. It may come in the 
form of a terrorist attack, using biological or radiological weapons; 
it may be a natural disaster such as a massive earthquake in the 
central US or Pacific Coast or it may be the threat now looming in 
front of us of a pandemic such as Avian Flu.
    To deal with the medical consequences of a disaster, certain things 
are needed. Some are common to all events and some are specific and 
determined by the type of event. These needs are identified and 
categorized as the Emergency Support Functions (ESF's) as listed in the 
National Response Plan. ESF 8 is the Health and Medical Component of 
the Plan, but it does not stand alone, as appropriate shelter, and food 
and water all have significant impact upon the public health following 
a disaster.
    In order to provide this medical care after a disaster there are 
certain absolute requirements:
         There must be facilities to give care. However during 
        a disaster these sites may be damaged or destroyed, as we saw 
        after Katrina and Allison, where flooding shut many hospitals. 
        Much of day to day medical care is provided in physician's 
        offices and clinics. These too are often rendered inoperable 
        after disasters.
         There must be personnel to provide the care. In the 
        affected community, medical and response personnel can become 
        victims themselves. They may not be able to reach the 
        facilities that remain operational or they may have chosen to 
        evacuate the area.
         There must be supplies and medications for the care 
        givers to treat patients with. These may be destroyed by the 
        event and after the event; it can take time to bring them in.
         The ability to move victims from the impact area to 
        other non affected areas of the country, thus reducing the 
        burden on the medical infrastructure also needs to be a 
        consideration.
    Consequently, at a time when a community has increased demands for 
medical care, the ability of that community to provide care is 
compromised by the event that created the demand. Complicating this 
picture is the nature of medical care in the US today. All of us 
practice in a highly competitive environment, with an emphasis on cost 
containment and ``efficiency''. As a result many medical facilities 
operate at near capacity and supply inventories are kept as low as 
practical, depending on ``just in time delivery systems''. Our ability 
to ``surge'' in response to disasters or epidemics is thus further 
hampered.
    Furthermore, cooperation between hospitals and other components of 
the healthcare system is needed for locally based disaster response to 
work. Such groups are often reluctant to share information, such as bed 
availability, for fear of providing competitors with key information. 
We hear over and over in disasters about the importance of information 
exchange and cooperation. We have begun the process of addressing the 
need for Surge Capacity and Capability through various initiatives such 
as grants from the Health Resources and Services Administration. This 
support is essential if we are to be successful. It is also primarily a 
local and regional responsibility to develop and operate these 
``surge'' programs.

WMD versus Natural Disasters
    September 11 provided us as a nation with the impetus to begin to 
address many disaster medical issues. We have committed large amounts 
of funds to train and equip local communities and ``First Responders'' 
and more recently the hospitals as ``First Receivers''. A condition of 
receiving these funds the adoption of Incident Command, which places 
all responders at the same table and we have supported the acquisition 
of interoperable communications. The emphasis has been on equipping 
Fire and other responders to deal with WMD events and we have purchased 
large quantities of decon supplies and stockpiled necessary medications 
to treat exposures to WMD agents. As an aside, portions of the 
Strategic National Stockpile were activated for Hurricane Katrina and 
were a valuable asset in supporting both Federal and State Response 
assets in the impact area. The SNS lacks many of the day to day 
medications and supplies needed by healthcare facilities and this needs 
to be rectified.
    While we have heavily funded decon and rescue I do wonder whether 
we have ``saturated the market'' regarding the ``decon'' portions of 
our response. Once we have decontaminated or rescued victims, we still 
need to move them to medical facilities, yet last year only 4% of the 
Homeland Security funds went to ready EMS agencies (per the Advocates 
for EMS group sponsored by NAEMSP and NASEMSD). We need to be certain 
we have the assets in place to move the patients. Additionally, as 
mentioned above, we need to put in place the ability to provide 
definitive medical care for the victims of an attack. After victims 
have been decontaminated following a nuclear attack, where do they go?
    As previously stated, the ability of most medical systems to surge 
is limited by the existing economic pressures of medicine. Options for 
definitive care are thus to bring in more ``beds'', such as field 
hospitals (equipped with negative pressure capability for pandemics or 
biologics), establish alternate care and outpatient facilities for 
those whose conditions allow and arrange for evacuation of those 
victims who can travel. These are not mutually exclusive, but rather 
are part of a coordinated abpproach. The evacuation of victims with 
medical issues from Katrina was the first time we have really tested 
this portion of the system. It was challenging, but it did id give us 
the opportunity to see the strengths and weaknesses of the concept 
which will help guide improvements in the system.
    Hospitals and other medical facilities need support to be able to 
expand capacity on short notice. Retrofitting facilities to increase 
the available number of negative pressure rooms, which decreases the 
risk of spread of biologic agents is an expensive proposition and one 
which the medical facility is not able to recoup from patient charges. 
Hospitals will also need increased staff to care for these additional 
patients as well as staff to man ``alternate care facilities'' in the 
community. Medical personnel from outside the impact area will be 
needed and plans for credentialing and moving these personnel must be 
in place and coordinated between the various Federal, State and Local 
agencies. Recent events to which we have responded show that there is a 
need for better coordination of many types of response assets.
    We need to take an ``All Hazards'', approach to disasters and as we 
identify needs, fund the necessary programs to correct those needs. For 
example funding needs to be directed to ``hardening'' the local 
responses. This works for both natural and WMD events, as Federal and 
other outside help still require time to arrive after a major disaster. 
In fact, it can take several days for certain types of assets to be 
setup and running. This is not because of ineptitude, but simply that 
it takes time to move assets, identify needs and get the personnel and 
equipment in place, often in an environment were movement is restricted 
due to damaged or blocked roads and limited helicopter and other 
resources. Lastly under current rules, Federal assets, for the most 
part, can only be committed upon request of the local or state 
authorities. Maybe it is time to review how we commit these assets.
    It is crucial that local medical assets to have the capability to 
begin caring for the immediate victims and to have the necessary 
supplies in storage to support operations for the first several days. 
This includes medical supplies, equipment to expand the number of 
available beds, establish alternate care facilities and maintain 
existing medical care. This concept has long been advocated by Dr. Carl 
Schultz, at U Cal Irvine, as part of the local planning for the ``big'' 
earthquake, based upon the experiences with earthquakes along the San 
Andreas.
    We must also remember that a response to a Catastrophic event is a 
long term response. For natural disasters, many of the injuries happen 
during or in the immediate post event period. Long term medical needs 
are the result of the regularly occurring problems in the community, 
often exacerbated by lack of access to care. In a Biological or Nuclear 
event, the medical demands arising from the event can actually grow 
with time, given the time course of radiation illness or the continuing 
spread of the biologic agent. Thus Catastrophic medical response must 
also be scaleable and flexible in design.
    In addition, we must also look to the psychological aspects of a 
nuclear or biological attack. Natural disasters produce many such 
issues, primarily in the immediate victims and responders. A terrorist 
attack can impact not only those in the immediate area but also at 
great distances. All across our nation, people were affected by the 
events of 9/11. Another such event will have the same or perhaps 
greater effects. Response capability for this issue exists within 
present day response systems, but the needs after such an attack must 
be estimated and the assets developed to meet that need.

Federal Medical Disaster Response
    Let us now turn to the Federal Medical Response to disasters. While 
many agencies play roles in this and Health and Human Services is the 
Lead Agency for ESF-8 under the NRP, the National Disaster Medical 
System has been and remains the Federal Government's primary rapid 
civilian medical response to disasters. Begun in the mid-80 the mission 
of the agency is (taken from the web site) . .''to design, develop, and 
maintain a national capability to deliver quality medical care to the 
victims of--and responders to--a domestic disaster. NDMS provides state 
of the art medical care under any conditions at a disaster site, in 
transit from the impacted area, and into participating definitive care 
facilities.''
    The teams are composed of medical and support personnel who on 
notice as short as 6 hours, leave their primary jobs or close their 
medical practices and respond to provide medical care in disasters. We 
at the NDMS are the ``tip of the spear'' for Federal Medical Response. 
There are approximately 9000 of these responders all over the US (A 
list of teams and assets is Attachment 3) and while there are many 
issues and problems with how the system works, it is important to note 
that it does work. 19 NDMS DMAT's and other NDMS teams were pre-staged 
for Katrina, and as the storm passed, they along with the USAR Task 
Forces, began moving, into the impact areas. By the day after the 
storm, teams were providing medical care and continue to do so today. 
The mission is still ongoing, with personnel staffing hospitals and 
clinics destroyed or rendered inoperable by the storms as we speak. 
(Attachment 2 lists patient services by NDMS personnel as of As of 10/
13/05).
    Like many issues in response, much of the NDMS problems are related 
to funding and support. Full time NDMS staff numbers about 50. They are 
stretched thin on a daily basis and during a disaster deployment; I am 
amazed they do not snap. Much of the problems in the field, for us as 
teams, stems from agency's lack of an intrinsic medical logistics 
support system. FEMA logistics has shown on the last 3 deployments a 
great inability to deliver medical supplies in a timely manner.
    The emphasis and design of the team equipment and operations is 
heavily geared towards acute care, yet many of the missions, including 
those ongoing, have a strong primary care component. Often what is 
needed after the acute phase (often handled by local and state 
response) is to back fill and replace local medical assets destroyed by 
the disaster. Many of the physicians involved in this program, 
including myself, feel that a stronger medical presence in the 
operation of the agency will help correct some of these issues and 
balance the current emphasis on ``rescue'' type activities with the 
provision of ``medical care''.
    I believe the public and much of Congress thinks of dramatic 
rescues and surgery taking place in ``MASH'' like tents, when they 
think of Disaster Medicine. That is but one component of the entire 
picture. This early phase acute care is an important one and I must 
again stress the importance of having local communities and regional 
assets trained and equipped to deal with this in the first few days 
post event as well as the importance of having rapidly deployable 
medical elements to get onsite and begin care. This must be followed by 
a rapid response of outside help to relieve the locals and expand the 
capabilities. The other portion of the Disaster Medicine equation is 
the replacement of the community's medical infrastructure to handle the 
``day to day'' needs that are no longer met. People still have heart 
attacks and babies still get born. Not perhaps as exciting as the other 
aspect, but just as important.

CATASTROPHIC EVENTS
    These are events that rapidly overwhelm the system and in terms of 
medical issues produce casualties that exceed the ability of local and 
state resources to provide care. When local and state assets cannot 
handle the demands, the role of the Federal Government's response is to 
provide them the support and personnel to manage the problem. The 
mechanism by which this happens either after the event or in 
anticipation of certain high risk types of events is outlined in the 
NRP and I will not review these in detail. There is also a Catastrophic 
Incident Annex to the Plan, which further defines assets and Federal 
Capabilities involved in the response.
    To deal with the medical needs, as was said earlier, one needs to 
have facilities, personnel and equipment, all of which can be adversely 
impacted by the event. In addition, once stabilized, patients will 
likely need to be moved from the impact are to definitive care at 
medical facilities elsewhere. This mission: of bringing in medical 
facilities and personnel and distributing injured to medical facilities 
around the country is the mission which the NDMS was created in the 
1980's. Besides developing medical response teams, the NDMS recruited 
hospitals around the nation, who would make beds available to care for 
victims of disasters or soldiers returning stateside for further care.
    As was said above, ``excess'' bed capacity in the US is low. For 
most of our disasters, the number of victims was relatively low and the 
transfer of patients to open more bed space or provide definitive care 
has not been needed. It was however needed during Katrina. The movement 
of patients requires the support of NDMS partners including DOD and VA 
and does require time to ramp up. Katrina showed that it can and does 
work and this program requires continued support.
    During a true catastrophic event the number of patients to be moved 
can easily number in the thousands, since one way to increase surge 
capacity in a community is to move existing patients out of the area 
for continued care. But moving or evacuating patients may be much more 
difficulty than it first appears. Such evacuations are resource 
intensive and the air frames available for such activities are limited 
and may be committed to military operations. Similar limitations on 
availability of ambulances may result from the response demands to the 
disaster. Funding for additional transport assets must be included in 
catastrophic medic planning.
    The other arm of post catastrophic event care is to bring in 
additional, portable medical facilities. I have been serving as one of 
many subject matter experts on a working group that is developing this 
type of facility, the ``Federal Medical Contingency Station-Type I''. 
This project has been designed by Dr. Lew Stringer and Capt Gary 
Sermones, USPHS (ret), at NDMS. As proposed, the:
    ``FMCS (I) provides hospital care capability during an emergency 
response by augmenting the local or community health care system with 
additional or replacement hospital facilities. In addition to declared 
national emergencies, FMCS (I) can support a continuum of state public 
health missions. One such mission would be to replace a local hospital 
if it becomes non functional due to contamination or destruction. Based 
on this scenario the hospital unit can be deployed to support the 
community hospital needs by providing up to 250 patient ED visits/24 
hours, 12 ICU and 252 medical/surgical inpatients as well as up to 25 
operative procedures/24 hours. The units will be fully staffed with 
NDMS healthcare professionals.''
    The prototype and project development for this unit was funded in 
FY 2005. The funding of $10 M to receive, equip the facility and carry 
out training, evaluation and design revision, as well as maintain the 
units was removed from the FY 2006 budget by the Senate. While I have a 
bias as to the importance of the project, since I volunteer my time to 
help with it, I believe that it is important for this to go forward. It 
allows us to rapidly bring into the affected those 3 key things I 
mentioned as essential to disaster medical care: Facilities, Personnel 
and Supplies.
    Personnel issues must also be addressed. We have about 9000 
personnel in the NDMS and in the ongoing response to Katrina; this 
resource was taxed to the maximum. Our day to day employers have been 
supportive and USERRA status for the NDMS has helped greatly, but it 
does become hard on the personnel's primary agency or hospital or 
private practice to be without them for long periods. During major 
disasters large numbers of medical professionals of all levels step 
forward to help, as we saw in the recent Hurricanes. It will be the 
same with any other catastrophic event. We will need these personnel 
and must find a way to effectively tap this resource should we have a 
true catastrophic, Biologic or Nuclear event.
    Licensure and liability concerns have always been an issue with 
these volunteers and these hurricanes were no exception. There was much 
complaining about the ``red tape''. Emergency System for Advance 
Registration of Volunteer Health Care Personnel (ESAR-VHP) will help 
reduce some of this. However, ESAR-VHP only credentials personnel. . . 
it does not train them. Just because someone has a license or 
credential as a medical provider does not mean they are able to 
function in an environment they have never been in and which is very 
different from their day to day practice. I believe that ESAR-VHP needs 
additional funding to provide some basic disaster medical response 
training to those participants, especially to deal with infectious and 
communicable disease issues seen with biological agents. We will need 
the manpower.
    This same type of training needs to be made available to Medical 
Reserve Corp volunteers as well. An excellent opportunity to provide 
this type of training in a realistic setting is to use these Medical 
Volunteers to assist with patient care in the continuing portions of a 
response to natural disasters such as NDMS has ongoing now in Jefferson 
and St. Bernard's Parishes in Louisiana. In a pandemic event, the 
demands for primary care, health screenings and similar services will 
rise dramatically. The ability to feed in additional medical personnel 
is important to maintain quality of care. The process must be worked 
out in advance.
    This brings up the topic of coordination of medical response 
efforts at the Federal level, as MRC and ESAR-VHP are under the 
umbrella of HHS. Many agencies are involved in preparing for and 
responding to disasters and their medical consequences. FEMA and the 
NDMS have such programs, as does HHS and Public Health, to name a few. 
In order to reduce wastage and duplication of effort, as well as 
improve coordination before the event and in the field, I believe that 
all of these should reside under a ``single roof''. To be honest, I do 
not know whose roof that should be but I do feel that the purpose of 
this agency is to coordinate and provide the Federal Medical Response 
to disasters. I also believe that as we are talking about the provision 
of medical care, there must be active medical oversight and input as a 
key component of the process.
    Furthermore, the agency that oversees these programs must have some 
flexibility to deal with response and other issues. Many of us in the 
medical community find the inflexibility and slavish devotion to rules 
and regulations we encounter with FEMA to be counterproductive to 
disaster response. Personnel tasked with specific responsibilities 
should not have to worry whether their decisions made during events 
will be second guessed afterwards, in the comfort and safety of 
headquarters by accounting and legal personnel. In addition, the 
response must have a dedicated medical logistical group, solely tasked 
with supporting the medical assets, both in the field and during the 
planning and preparation phase. Under current FEMA and NDMS operations, 
support of team medical needs has been less than stellar.
    Lastly I must ask this body and the American public to be realistic 
in their expectations of what will happen after a major disaster. 
Federal medical assets will be coming. We are not going to be there as 
soon as the smoke clears. Personnel must be mobilized and they and 
equipment moved. Assessments of needs must be done to determine what is 
needed and where and then those assets sent in and setup. That is not 
going to happen in just a few hours, but realistically may take several 
days.
    To summarize my remarks, recent natural disasters, which are as 
close to a catastrophic event as our system has faced, severely taxed 
our capabilities. Our existing disaster medical response assets at 
Federal, State and Local levels did meet the challenge. We have learned 
much from these events and can apply those lessons to dealing with the 
medical aspects of a future Biological or Nuclear related attacks or a 
catastrophic natural disaster.

    Our catastrophic medical response plan must include:
        1. Equipping, training and hardening local medical 
        infrastructure and rescue assets so that they remain functional 
        after the event, with adequate supplies to operate in the 
        immediate post event period.
                a. Provide the funding and support to enable surge 
                capacity at the local level to deal with the influx of 
                victims following such catastrophic events.
                b. Provide adequate decontamination capability
                c. Provide adequate medical supplies and 
                pharmaceuticals in storage to support the initial 
                ``local'' phase.
        2. The Federal Catastrophic Medical Response must be scaleable, 
        flexible and rapidly deployable, with trained personnel. This 
        response must have its own dedicated supply chain that can 
        support the operation consistently.
                a. The Federal response must be coordinated such that 
                multiple agencies are not duplicating the efforts in 
                advance and during the event and the there is 
                consistency in how the program and response is run.
                b. While a number of options exist to accomplish this, 
                the NDMS is currently the best positioned of the 
                Federal medical response agencies to carry out this 
                mission and needs to be supported.
                c. The Federal Response to an event must be ``long 
                term'' as Biological and Nuclear events have long term 
                medical consequences
        3. During a Catastrophic Event such as a terrorist attack with 
        an IND or, if we have advance warning, such as in a Category 5 
        Hurricane, the Federal Government must have the authority to 
        mobilize and engage assets, without waiting for the request 
        from the local officials.
                a. Eliminate the requirement, during Catastrophic 
                Events, which under the Stafford Act, has the states 
                paying for up to 25% of the response cost for Federal 
                Assets. The question of how the state can come up with 
                the funds may serve as an impediment to asking for 
                Federal help.
                b. Federal Response assets of all types need the 
                authority to engage and carry out their respective 
                missions during a Catastrophic Event, without waiting 
                for local or state requests. This will shorten Federal 
                Response times and bring more assets to bear on the 
                event. This is a major change from the current National 
                Response Plan and Stafford Act.
        4. Federal Disaster Medical Response for all types of events 
        needs to be under a single agency umbrella, to eliminate 
        duplication of effort and improve communication
        5. Lastly, our response programs MUST be sustained. We have 
        bought large amounts of equipment and supplies and distributed 
        them or stockpiled them. These items require maintenance and 
        even periodic replacement. Personnel must be trained and 
        retrained. Otherwise they and the equipment lose their 
        effectiveness. The Civil Defense Packaged Disaster Hospitals of 
        the 1950'-60's all rotted in storage, for lack of support 
        money. Congress must continue to support these efforts, not 
        only today, but in the future.
    It is not if we will have a catastrophic event, but when. I again 
thank you for the opportunity to speak and I assure you and the 
American people that when such an event happens, and we pray it does 
not, the Medical and Response communities will be there and will do our 
best for our fellow Citizens. Thank you
    Attachment 1: Summary of Federal Medical Contingency Station
    Department of Homeland Security/Federal Emergency Management Agency 
(DHS/FEMA) is developing two Prototype Field hospitals which will be 
called Federal Medical Contingency Stations (FMCS) type I in 
2005.Sec. ne will have its own sheltering and support system and the 
second will require a building to be placed in. Both will have a one 
hundred forty (140) bed capacity, Emergency room, Lab, X-ray, Pharmacy, 
Central Supply/Processing, Operating rooms, Post Operative Unit, Labor 
and delivery and intensive care units. The two Split field hospitals 
could be combined as a single fixed or mobile 270 bed facility.
    These two facilities will be staffed by the National Disaster 
Medical System (NDMS), now under DHS/FEMA. These Medical response teams 
will begin training and exercising with the FMCS Type I units in 2006 
after the units are packaged. . .The exact locations that the two 
medical units will be stored and maintained have not been determined at 
this time. Funding to maintain, train and evaluate the units is in the 
requested FEMA 06 budget under Medical Surge Capacity.
    DHS and HHS have been collaborating closely for many months on the 
design and operational issues for the Type I units.

 Attachment 2: Listing Patient contacts since start of operations and 
       current personnel deployed by NDMS, based upon FEMA Region

                           HURRICANE KATRINA

                      NDMS RESOURCE STATUS REPORT

                         Updated: 10/14/05-0700

    REGION IV: Through Reported Operational Period: 10/13/05: 0700-1900
        --Total Patients Treated = 16,477
        --Total Number of Personnel in the Field = 75

    REGION VI: Through Reported Operational Period: 10/13/05: 0700-1900
        --Total Patients Treated = 40,995
        --Total Individuals Immunized = 59,917Total Number of Personnel 
        in the Field = 383

                             HURRICANE RITA

                      NDMS RESOURCE STATUS REPORT

    Updated: 10/14/05--0700

    REGION VI: Through Reported Operational Period: 10/13/05: 0700-1900
        --Total Patients Treated = 9,074
        Total Number of Personnel in the Field = 49

                             Attachment 3:

National Disaster Medical System Response Teams
        22 Disaster Medical Assistance Teams
         (Fully Operational/Operational)
        33 Disaster Medical Assistance Teams
         (Augmentation/Developmental)
        4 National Medical Response Teams / WMD
        5 Burn Teams
        2 Pediatric Teams
        1 Crush Medicine Team
        3 International Medical / Surgical Teams *
        3 Mental Health Teams
        3 Veterinary Medical Assistance Teams
          11 Disaster Mortuary Operational Response Teams (1 WMD)
          10 National Pharmacist Response Teams
        10 National Nurse Response Teams
          1 Joint Management Team
                        * Includes 1 under development

    Dr. Bradley.

              STATEMENT OF RICHARD N. BRADLEY, MD

    Dr. Bradley. Chairman Linder, Ranking Member Langevin, Mr. 
Thompson, thank you very much for the opportunity to address 
you today.
    I do represent the University of Texas Health Science 
Center at Houston, and through a contract with FEMA, I serve as 
the medical team manager on the Texas Task Force One Urban 
Search and Rescue team. I did deploy to Hurricane Katrina and 
several other incidents with them. However, the testimony I am 
providing today is my own, and I am not testifying on behalf of 
FEMA or the Urban Search and Rescue program or Texas Task Force 
One.
    The primary mission of an urban search and rescue team is 
to rescue people from collapsed buildings. Thus, urban search 
and rescue teams would be useful in the medical response to 
mitigate catastrophic events. Specifically, they would have a 
specific role in the medical response to a nuclear attack. 
Since building collapse would be likely, urban search and 
rescue personnel would search for trapped victims and provide 
lifesaving care until the medical team extricated them and 
turned them over to other medical care providers. The teams are 
trained in the medical care of radiation victims, and the 
medical members on the team know how to limit their radiation 
exposure and deal with contamination.
    A terrorist attack involving biological weapons would 
present an entirely different scenario. While it is reasonable 
to consider that such an incident may involve thousands of 
people needing medical care, we would not expect there to be 
any collapsed buildings or anyone in need of rescue.
    While an urban search and rescue task force does have 70 
highly trained members, the general level of medical training 
is that of the emergency medical technician. A full task force 
has only two physicians and four paramedics. Now, while the 
National Disaster Medical System does credential these 
providers as Federal health care providers, the Urban Search 
and Rescue system has neither designed nor equipped their teams 
for handling large numbers of casualties.
    The treatment priorities for Urban Search and Rescue 
medical personnel are, first, injured or ill Urban Search and 
Rescue members; second, trapped victims; third are search dogs; 
and finally other disaster victims at the incident scene. The 
six people on our team are not equipped to operate 
independently. We depend on the rest of our team for command, 
logistical and support functions. Thus, while total activation 
of the Federal Urban Search and Rescue system would provide 
approximately 6,000 highly trained personnel to FEMA, they 
would be of minimal benefit in the medical response to a 
terrorist attack using biological weapons.
    In addition to direct medical care, the impacted community 
would need services such as laboratory detection, quarantine, 
isolation, disease control, disease tracking and mass 
vaccination. It is really hospitals and health departments that 
are the best providers of these services.
    So, Mr. Chairman, to answer your question, we are better 
prepared, the FEMA Urban Search and Rescue team, for handling 
the medical aspects of a biological and nuclear attack, 
specifically a nuclear attack, as long as it is within the 
program that we were designed for, which is rescue and medical 
care of trapped people.
    Beyond the Urban Search and Rescue aspects, there are some 
other things that we could do to improve our preparedness to 
deal with the medical impacts of a catastrophe.
    We know that everything begins locally. It is the local 
emergency manager who is responsible for coordinating the 
disaster response. There are a lot of resources that he or she 
will need and has direct control over, such as fire, police or 
EMS, but there are other resources that he does not have 
correct control over, such as hospitals and doctors. This is a 
significant challenge for him. He is responsible for ensuring 
that hospital care is capable, but has no authority over the 
hospitals to compel them to respond.
    I suggest that we consider developing a template for a 
memorandum of agreement between the emergency manager and the 
hospital, and this agreement could address a number of things, 
including specific response options for each hospital, who 
would have the authority to initiate those response options, 
and then how those response options would be paid for. Then, of 
course, once all the local community assets have been deployed, 
the emergency manager is going to look for help from the State 
and Federal Government.
    We know that the Federal government, the State government 
is not going to respond until the local emergency manager calls 
for it. But I would like to consider the possibility of sending 
in an advisor right away, even before the resources were 
requested, someone who can help the local emergency manager 
understand what Federal resources are available and help him 
tailor his request, because often the emergency manager may not 
know exactly what the details are of each Federal asset that 
could come.
    So we are better prepared now in the Urban Search and 
Rescue realm, but I look at how we can support hospitals and 
support the local emergency manager more fully in terms of 
tailoring his or her requests.
    Mr. Linder. Thank you, Dr. Bradley.
    [The statement of Dr. Bradley follows:]

              Prepared Statement of Dr. Richard N. Bradley

    Chairman Linder, Ranking Member Langevin, and other distinguished 
Subcommittee Members, thank you very much for the opportunity to 
address you today. My name is Dr. Richard Bradley. I am the Medical 
Director of the Emergency Center at Lyndon Baines Johnson General 
Hospital in Houston, Texas, and an Associate Professor of Emergency 
Medicine at The University of Texas Health Science Center at Houston. 
The UT Health Science Center at Houston is the most comprehensive 
academic health science center in the Southwestern United States. We 
are educators, students, physicians, researchers, dreamers, explorers, 
and inventors. We have six schools, several institutes, a psychiatric 
hospital and a multi-specialty group practice--all focused on improving 
health and preventing disease through education, research and clinical 
service. We work for our patients, our community and for humanity. Our 
institution, its faculty, health professionals and staff were heavily 
involved in Katrina recovery and relief efforts both in Louisiana and 
in Houston. We provided health care for evacuees; advised elected and 
appointed officials in all jurisdictions about public health and 
recovery efforts; and assisted people in need in many other areas. I am 
proud to be a member of the faculty because our leadership and my 
colleagues responded quickly and with enormous compassion.
    I also serve the University as the Associate Director for Emergency 
Medical Services Preparedness at our Center for Biosecurity and Public 
Health Preparedness. The center educates the frontline public health 
workforce, medical and emergency responders, key leaders, and other 
professionals to respond to threats such as bioterrorism, emerging 
infectious diseases, and other emergencies affecting our communities.
    Through a contractual relationship between the university and the 
Federal Emergency Management Agency (FEMA), I serve as a Medical Team 
Manager with Texas Task Force One, a FEMA Urban Search and Rescue 
(US&R) team. I have deployed to several incidents with this team, most 
recently to Hurricane Katrina, where our team performed hundreds of 
rescues in New Orleans. Based on my first-hand experience as an 
emergency physician working with the US&R team, along with experience 
from participation in other disaster responses, I have formed several 
opinions regarding the importance of effective medical response in 
mitigating catastrophic events. However, the testimony I am providing 
today is my own--I am not testifying on behalf of the FEMA US&R program 
or Texas Task Force 1.

FEMA US&R Teams are Prepared to Respond to Nuclear Attacks
    US&R involves the location, rescue, and initial medical 
stabilization of victims trapped in confined spaces. Structural 
collapse is the most common cause of victim entrapment. Additionally, 
transportation accidents, mines and collapsed trenches may entrap 
people. US&R is considered a ``multi-hazard'' discipline, as it may be 
needed for a variety of emergencies or disasters, including 
earthquakes, hurricanes, typhoons, storms and tornadoes, floods, dam 
failures, technological accidents, terrorist activities, and hazardous 
materials releases. The events may be slow in developing, as in the 
case of hurricanes, or sudden, as in the case of a nuclear attack.\1\
---------------------------------------------------------------------------
    \1\ FEMA. About US&R. [Online]. 2004 [cited 2005 Oct 13];[1 page]. 
Available from: URL:http://www.fema.gov/usr/about.shtm
---------------------------------------------------------------------------
    There are currently twenty-eight US&R teams in the United States. 
Each team can deploy in either a `heavy' or a `light' configuration. In 
the heavy configuration, the team deploys with seventy people, all 
trained to at least the technician level in their area of specialty. 
These specialties include high angle rope rescue, confined space 
rescue, technical search, weapons of mass destruction (WMD) and 
hazardous materials operations, defensive water rescue, medical care 
and communications. Each task force is capable of operating round-the-
clock, is completely self-sufficient for the first 72 hours, and can 
sustain operations for up to ten days.\2\
---------------------------------------------------------------------------
    \2\ FEMA. Typed resource definitions: search and rescue resources. 
[Online]. 2005 [cited 2005 Oct 13];[41 pages]. Available from: 
URL:http://www.fema.gov/pdf/nims/508-8_search_and_rescue_resources.pdf
---------------------------------------------------------------------------
    A terrorist attack involving nuclear weapons would likely create a 
situation with multiple casualties. Damage to structures may trap 
numbers of people. Responding personnel would need to monitor and 
control exposure to radiation and control contamination.
    The US&R system could be part of the medical response to this 
scenario. In the past few years, all of the members of the system have 
completed training in WMD and hazardous material operations. In 
particular, the medical personnel on the team have training and 
certification in handling these types of casualties. The teams carry 
equipment to detect radiation and monitor personal exposure. They are 
also prepared for contamination avoidance and control.

US&R Teams are Not Appropriate for Response to Biological Attacks
    A terrorist attack involving biological weapons would present an 
entirely different scenario. While it is reasonable to consider that 
there may be thousands of people needing medical care, and a complete 
overload of local medical resources, there would be no collapsed 
buildings and no one in need of rescue.
    While a US&R Task Force does have seventy highly trained members, 
the general level of medical training is that of emergency medical 
technician. A heavy task force has only two physicians and four 
paramedics. While the National Disaster Medical System does credential 
these individuals as federal health care providers, the US&R system has 
neither designed nor equipped these teams for handling large numbers of 
casualties.
    The treatment priorities for US&R medical personnel are first, 
injured or ill US&R team members, second, entrapped victims, third, the 
team's search dogs, and finally, other disaster victims. The six 
medical personnel are not equipped to operate completely independently 
of the remainder of the task force--they depend on other task force 
personnel for support in the logistical, planning and command areas.
    Thus, while total activation of the federal US&R system would 
provide approximately 6,000 highly trained personnel to FEMA, they 
would be of minimal benefit in the medical response to a terrorist 
attack using biological weapons. In addition to direct medical care, 
the impacted community would need services such as laboratory 
detection, quarantine, isolation, disease control, disease tracking and 
mass vaccination. Hospitals and health departments are the best 
providers of these services. If a community needs federal medical 
assistance after a biological attack, Disaster Medical Assistance Teams 
(DMAT's), and assets from organizations such as the Veteran's 
Administration, The United States Public Health Service, the National 
Guard and other Department of Defense medical assets are much more 
appropriate.

Command and Control of the Local Medical Response
    Effective medical response to a disaster begins locally and the 
official ultimately responsible is the emergency manager. This 
individual is usually the mayor or city or county manager, who, as the 
local chief executive officer, is responsible for public safety and 
welfare. He or she directs the response to the disaster by assessing 
the needs and assigning resources to meet those needs. The emergency 
manager must commit all appropriate local resources and mutual aid 
before requesting state, federal or military assistance.3, 4
---------------------------------------------------------------------------
    \3\ U.S. Dept. of Homeland Security. National response plan. 
[Online]. 2004 [cited 2005 Oct 18];[114 pages]. Available from: 
URL:http://www.dhs.gov/interweb/assetlibrary/NRPbaseplan.pdf
    \4\ While the emergency manager is ultimately responsible for all 
disaster response, he or she generally delegates many emergency 
response functions. Most jurisdictions will have a health officer or 
other individual pre-designated to exercise emergency public health 
powers. In many cases, this should be the individual directly 
responsible to the emergency manager for medical and hospital issues.
---------------------------------------------------------------------------
    *ERR13**ERR14*Many of the resources that the emergency manager 
needs to deal with the disaster are those that he or she has direct 
command over, such as fire, police, EMS, public works, waste 
management, etc. There are other resources that he or she needs but 
does not have direct authority over, such as hospitals and doctors. 
These are critical resources because ultimately, the emergency manager 
is responsible to ensure that all victims get the medical care they 
need. This is a significant challenge for the emergency manager: he or 
she is responsible for ensuring hospital care is available but has no 
authority over the hospitals to compel them to respond.
    To complicate this further, even though federal law does require 
hospitals and emergency departments to treat anyone with a medical 
emergency, it does not require them to do anything to augment their 
capacity to respond when a disaster strikes. As a result, many 
hospitals faced with a nearby disaster will manage the overflow as the 
do on any other busy day. This means that when the in-patient beds and 
intensive care units are full, patients will backup in the emergency 
department.
    As local hospitals become overloaded, emergency managers will need 
hospitals outside the immediate disaster zone to accept patients in 
transfer. These hospitals are only required to accept transfer patients 
if they have the capacity to care for them. The issue here is that the 
receiving hospital defines its capacity without external validation. It 
is under no obligation to call-in extra staff to create surge capacity 
during a disaster.
    It is clearly in the public interest to address this problem at a 
national level. One possible solution would be to encourage local 
governments to develop memoranda of agreement (MOA) with the hospitals 
in their area. The MOA should specify several things. First, working 
collaboratively, each hospital and the local government should develop 
a number of specific response options they could invoke in time of 
disaster. Some options would be general, such as agreeing to cancel all 
staff time off and have all available clinical personnel work twelve-
hour days, seven days per week for up to ten days. Other options would 
be specific, such as tasking the hospital to turn its day surgery 
center into a ten-bed intensive care unit. The MOA would give the 
emergency manager the authority to request hospitals to initiate any or 
all of these emergency actions. It should also allow the emergency 
manager to send field observers to each hospital to determine the 
actual situation and workload during a disaster.
    The MOA should also address reimbursement for hospitals and 
physicians. During and after a disaster, they should continue to bill 
patients for care they provide. This is appropriate, since, in many 
cases, third-party payers have financial responsibility for medical 
care. However, many individuals who require medical assistance after 
the disaster will not be able to pay for it. Furthermore, hospitals and 
physicians will experience unusual expenses. Most of these expenses 
will be overtime pay, but they may also include the cost of renting or 
purchasing extra equipment. Government agencies that request hospitals 
and physicians to respond to the disaster should compensate them for a 
potion of these unusual expenses. The MOA should specify the 
reimbursement rate for each response option that the emergency manager 
may request.
    There are many advantages to this proposal. Each hospital and its 
entire staff will be able to plan for and train to the exact requests 
they may receive during a disaster. Emergency managers will gain an 
understanding of the extent of the emergency medical resources 
available in their community and will know when all of these resources 
have been committed. This is a critical step in understanding when it 
is time to ask for state or federal assistance. Finally, the MOA will 
create a process to track and validate requests for reimbursement. 
Government officials will be able to know the cost of the medical 
response in real time. I urge our national leaders to consider 
requiring the existence of such an MOA as a pre-requisite to full 
federal reimbursement for disaster medical expenses.

Defining Health and Medical Resources
    As hospitals and communities respond to meet the needs of the 
disaster, they may need to request additional medical resources. 
Medical response will be more effective when there is consistent use of 
standard resource definitions. Whether the need is for a cardiac 
monitor or a disease control team, everyone who deals with resource 
requests must share the same definition of the resource. The solution 
is to include hospitals and other medical personnel and teams into the 
national resource typing system. Resource typing is designed to enhance 
emergency readiness and response at all levels of government through a 
comprehensive and integrated system that allows jurisdictions to 
augment their response resources during an incident. Specifically, it 
allows emergency management personnel to identify, locate, request, 
order, and track outside resources quickly and effectively and 
facilitate the response of these resources to the requesting 
jurisdiction.\5\ The National Incident Management System (NIMS) has 
already developed specific definitions of 120 different types of 
resources, covering assets as diverse as `small animal sheltering team' 
and `crawler cranes.' The typed resource definitions already include 
some health and medical resources, but these are currently limited to 
the response teams that have performed so well during past disasters, 
such as DMAT's and Disaster Mortuary Assistance Teams.\6\
---------------------------------------------------------------------------
    \5\ The NIMS Integration Center. Resource typing. [Online]. 2005 
[cited 2005 Oct 16];[2 pages]. Available from: URL:http://www.fema.gov/
pdf/nims/resource_typing_qadoc.pdf
    \6\ FEMA. Typed resource definitions: health and medical resources. 
[Online]. 2005 [cited 2005 Oct 17];[13 pages]. Available from: 
URL:http://www.fema.gov/doc/nims/508-5_health_medical_resources.doc
---------------------------------------------------------------------------
    I would like to commend the leadership at FEMA for their foresight 
in establishing these resource definitions. They are continuing to 
refine and expand them and are inviting input from the emergency 
response community as they proceed. I strongly encourage my health and 
medical colleagues from around the country to provide expert 
suggestions and comments to FEMA during this process.

Requesting State and Federal Medical Assistance
    As the Emergency Manager determines that local and mutual aid 
medical resources are fully committed, he or she will begin to request 
resources from the next higher political authority, usually the state. 
The state, in turn, fills resource requests as best it can, and then 
requests assistance from the federal government.
    Officials at the state and federal level may face the temptation to 
question some resource requests coming from the local emergency 
manager. It is clearly possible that some requests may not be 
practical, and others might be unreasonable. However, state and federal 
officials should not spend an unreasonable amount of time to approve 
reasonable requests simply because independent verification of the need 
is not available.
    I have personally seen what a good job our federal disaster 
officials can do with these requests. After Tropical Storm Allison hit 
Houston in 2001, I was assigned to the Emergency Medical Services desk 
in the City of Houston's Emergency Operations Center. We were beginning 
to understand the significant impact that losing six major hospitals 
would have on our city. Due to the nature of the storm, the rest of the 
country did not yet have any idea of its severity. Our initial request 
for medical support was for four DMAT teams and twenty ambulances. Soon 
after I submitted this request through channels, I was on a conference 
call with the senior leadership of the National Disaster Medical System 
(NDMS). I recall one of the federal participants on the call 
questioning the severity of the situation in Houston, and suggesting 
that it would be a good idea to wait and send a federal representative 
to Houston to validate the need before sending assistance. The NDMS 
leader on the call responded, ``No. If Houston says they need it, that 
is good enough for me. We will send them what they are asking for.'' 
Any local official who deals with the medical consequences of a 
disaster expects and appreciates responses like this.
    Under the National Response Plan, federal officials do not send 
resources to a disaster until requested by local officials.\3\ However, 
this should not prevent federal disaster officials from sending 
advisors in to the disaster area immediately after the incident has 
occurred. These advisors could work with teams that perform rapid needs 
assessments. They could then assist the local and state officials with 
determining exactly what the needs are. The advisor could also counsel 
the emergency manager and his or her staff to help them determine what 
state or federal resources would best meet their needs.

Conclusion
    We can mitigate disasters through effective medical response. In 
relation to a nuclear attack, US&R teams are clearly a vital part of 
the nation's response capability. In contrast with this, the US&R 
system would probably not be a key part of our medical response to a 
biological attack.
    Looking beyond the US&R system, effective medical response will 
require efforts to develop new resource definitions in the hospital and 
medical area. Using these definitions, each hospital should work with 
local government to determine a list of actions that it could take to 
expand its ability to care for patients during a disaster. They should 
formalize this with a written agreement that has provisions for 
assigning activation authority to the emergency manager while 
guaranteeing reimbursement for some of the unusual expenses that they 
would incur.
    As emergency managers are deciding what to request from their 
hospitals, they must also decide what to request from state and federal 
government. Since, in many cases they may not have a complete picture 
of their current medical needs, and they may be unfamiliar with all of 
the federal medical resources available, federal advisors should be 
available early after a disaster occurs to guide them in making the 
correct decisions.
    Thank you very much for this opportunity to speak with you 
regarding such an important topic.

    Mr. Linder. Colonel Thompson.

  STATEMENT OF COLONEL DONALD F. THOMPSON, MD, MPH&TM, SENIOR 
                        RESEARCH FELLOW

    Colonel Thompson. Mr. Chairman and members of the 
committee, thank you for the opportunity to discuss how to 
improve our domestic response capabilities.
    I am a physician at the Center for Technology and National 
Security Policy at the National Defense University, and I am 
working on several studies examining terrorism, public health 
emergencies such as SARS and pandemic influenza, and natural 
disasters such as hurricanes and earthquakes.
    Katrina exposed systemic problems in local, State, Federal 
and military response coordination. For an effective response, 
there must be coordinated planning between these levels of 
government that incorporates the private sector, volunteer and 
faith-based organizations and academic institutions. Each 
agency must understand its roles and responsibilities, its 
capabilities and limitations, and from whom it will obtain 
additional resources when its capabilities have been 
overwhelmed. We are destined to continued haphazard responses 
until we get this right.
    There are three broad areas that are essential to improved 
national preparedness: first, requirements-based mass casualty 
planning; second, working across institutional cultures of 
response agencies; and third, learning coordinated crisis 
management decision-making. A significant deficiency lies in 
resolving problems that are too big for or beyond the 
jurisdiction of State and local agencies and are beyond clear 
Federal control. My written statement describes these areas in 
detail.
    The Federal Government has a leadership role in developing 
preparedness principles, implementation strategies, and 
opportunities to test and exercise local plans. Perhaps most 
critical, though, is that funds should be provided with strings 
attached to cajole local and State agencies to develop 
interconnected regional plans. To paraphrase General George 
Patton, The best plan is useless if executed too late. 
Successful decision-making must be demonstrated in staged 
crisis management exercises that proceed to the point of 
failure, so all deficiencies can be identified and corrected.
    Opportunities for senior leaders to learn about crisis 
decision-making in such realistic environments are almost 
nonexistent. Some are suggesting that the Defense Department 
assume more responsibility in the case of domestic disasters, 
but a more appropriate role might be more proactive engagement 
in the planning process. As Katrina lessons are analyzed, we 
must identify the mechanism by which military medical, 
logistics and response planners may engage in planning at the 
appropriate Federal, State and local levels. Such a forum 
should be cosponsored by the Departments of Homeland Security, 
Health and Human Services and Defense. If these agencies work 
together to develop effective plans that incorporate public, 
private and volunteer resources, the risk of terrorism and the 
impact of natural disasters will be reduced and the homeland 
security will indeed be more secure.
    Mr. Chairman, I request my complete statement be included 
in the record.
    Mr. Linder. Without objection.
    Colonel Thompson. I thank you for the opportunity to appear 
before you, and will be happy to answer your questions.
    Mr. Linder. Thank you, Colonel Thompson.
    [The statement of Colonel Thompson follows:]

            Prepared Statement of Colonel Donald F. Thompson

    Mr. Chairman and members of the committee, I thank you for the 
opportunity to appear before you and discuss ways to improve domestic 
medical response capabilities within the United States. I am a 
physician and a Senior Research Fellow in the Center for Technology and 
National Security Policy at the National Defense University, and am 
working on several studies examining preparedness for and response to 
terrorism, public health emergencies such as Severe Acute Respiratory 
Syndrome (SARS) and pandemic influenza, and natural disasters such as 
hurricanes and earthquakes. I would like to share with you some common 
themes I have identified that suggest opportunities for improving our 
nation's ability to respond to such catastrophes.
    Katrina exposed systemic problems in local, state, federal, and 
military response coordination, problems that will be much more severe 
and have much more negative outcomes in the event of a terrorist attack 
in multiple cities. The strained medical response when there were only 
a few dozen serious injuries as a direct result of the hurricane shows 
that there is much to be done to prepare for a terrorist incident that 
suddenly produces hundreds or thousands of casualties in multiple 
locations. This underscores the importance of coordinated preparedness 
planning between these levels of government that incorporates the 
private sector, volunteer and faith-based organizations, and academic 
institutions. It is crucial for response agencies at each level to 
understand their roles and responsibilities, their capabilities and 
limitations, and from whom they will obtain additional resources when 
their capabilities have been overwhelmed. We are destined to continued 
haphazard responses until we get this right. While this discussion 
focuses on mass casualties, the principles apply in the law 
enforcement, logistics, evacuation, recovery, and communications areas 
as well.
    Difficulties in responding to a catastrophic event are particularly 
apparent and challenging in the medical and public health areas, when a 
coordinated civil-military response will likely be needed for an 
incident that produces significant casualties. There is no health care 
``system'' in the United States; there is instead a vast collection of 
public and private institutions, agencies, and individuals that deliver 
healthcare services, only a small portion of which are provided by 
local, state, and Federal authorities. Civilian referral hospitals are 
largely unprepared to handle the large patient load from a catastrophic 
event. Hospitals are often filled to capacity, have few isolation beds 
for contagious infections, and have insufficient staff to handle a 
large influx of patients. If an attack involved the real or perceived 
threat of biological or chemical weapons, civilian hospitals might 
refuse to take contaminated or contagious casualties altogether.

Needs to Improve National Preparedness
    There are three broad areas that are essential to improve national 
preparedness: requirements-based mass casualty planning, learning to 
work across institutional cultures of response agencies, and learning 
coordinated crisis management decision-making. In the coming weeks, 
analysis of the local, state, and federal response to Katrina will 
yield details about--and insights into improving--these elements, so 
only a brief description of them is necessary at this point.
    T3Requirements: Comprehensive planning for a mass casualty response 
must start with defining requirements, identifying capabilities needed 
to meet them, and then linking particular units or personnel to 
particular needs in specific locations. Policies and procedures must be 
developed to task particular resources for an actual mission, reimburse 
all associated costs, and backfill the unit or personnel for whatever 
it was involved in when tasked.
    It is difficult to predict the types and numbers of casualties from 
a conventional explosion, a communicable biological weapons attack, 
release of a chemical agent, a nuclear weapon detonation, or a 
radiological dispersion device where a conventional explosive has been 
contaminated with radioactive material. Numbers of casualties would 
depend on whether the explosion or release takes place indoors or 
outdoors, in a densely populated area, in or near a mass transit 
system, or at the busiest time on a weekday. These complexities are the 
first order effects of the attack--the victims directly injured, 
exposed, or contaminated by the event.
    Complexities increase exponentially through second and third order 
effects, the unintended consequences of the event. People exposed to 
radiological material or anthrax spores will track the material on 
their shoes and clothes, endangering more. Those fleeing an incident 
area may move into a more hazardous zone. Persons exposed to a covert 
release of a communicable biological agent such as smallpox, plague, or 
influenza will depart the initial area of exposure and travel to their 
homes, school, work, or around the world on commercial air flights 
while incubating an infection. They become a risk to others and cause 
secondary cases as person-to-person transmission takes place.
    These types of complexities, especially those that deal with how 
people might respond in a crisis, cause many officials to move such 
requirements planning into the ``too hard to do'' box. In actuality, 
however, much supportive work has been done in social network analysis 
and adaptive response that sheds light on likely human behaviors. Well 
worded, timely messages from appropriate opinion leaders often lead to 
desired behaviors. The challenge that faces the nation, though, is who 
should identify this supportive work, develop and test solutions, and 
integrate strategies into response plans at all levels? From the local, 
state, federal, and military perspective, this is indeed too hard to 
do, because so much complex coordination is required. All-inclusive 
answers to these and additional questions must be developed in a 
setting that mirrors the likely response to an incident.
    Capabilities: Capabilities that are available at each level of 
response must be identified and compared with the likely requirements. 
Since mass casualty response begins with local emergency medical 
response, hospital emergency departments, and emergency management 
agencies, the capabilities in each of these local sectors must be 
clearly described. Next, response capabilities at the state level must 
be identified. These are often limited to National Guard resources 
under control of the Governor, as well as state law enforcement 
resources. Few states have significant medical response resources, 
though public health laboratories are essential in supporting a 
response to a natural pandemic or a biological terrorism agent. 
Finally, capabilities of various federal agencies must be defined. 
Dangerous assumptions are often made that because a particular local, 
state, or federal agency has a specific capability in its day-to-day 
mission, that agency could provide the same capability in the event of 
a national disaster.
    Close Capability Gaps: As capability shortfalls are identified, 
responsible authorities in response agencies at all levels must develop 
plans for closing these gaps. Comprehensive plans include the required 
capability, the point in the evolution of the crisis when it is 
required, where the resource to meet this capability can be obtained, 
who must authorize the request, who must approve its fulfillment, who 
will reimburse associated costs, how the capability will be replaced 
when it goes to the requesting location, and when it will be released 
to return home. The most efficient surge capacity plans consist of 
obtaining capabilities from neighboring areas through mutual aid 
compacts. These agreements are used every day as police and fire 
response units move across jurisdictional boundaries to meet short-term 
surge needs.
    Coordinated procedures and protocols for closing gaps beyond fire 
and emergency medical services are rarely in place for regional and 
multistate mass casualty incidents because few jurisdictions have had 
to develop them. The hurricane-prone Atlantic and Gulf Coasts and 
earthquake-prone California are usually exceptions, but by and large 
the United States is not ready for a national mass casualty response to 
a major incident.

Planning Deficiencies
    National all-hazard mass casualty planning for acts of terrorism, 
natural disasters, and public health emergencies includes three primary 
components, of which only the first two are being addressed. The first 
component is local and state response planning, which varies in quality 
according to the local community's experience and resources. For a 
terrorist attack such as the 2001 anthrax letters on the East Coast, an 
efficient response must consist of integrated, coordinated planning 
between all response sectors: public health, emergency medical 
services, fire, law enforcement, hospital-based emergency departments, 
private sector healthcare delivery, local emergency management 
agencies, local elected officials, military installations, public and 
private sector businesses who would provide food, water, utilities, 
communications, and transportation, local volunteer organizations, 
schools, faith-based organizations, and the news media. Such 
comprehensive local planning is rare. Furthermore, Katrina showed that 
even when plans are in place, they must be promptly executed. Local 
leaders cannot afford to wait for the Federal Government to provide an 
initial response.
    The second component is planning for a Federal response, when 
states may approach the Federal Government through the Department of 
Homeland Security seeking Federal financial aid and response assets. 
Real Federal medical resources are limited, though, and primarily 
consist of small deployable medical teams from the National Disaster 
Medical System. Planning for Federal alternate hospital facilities is 
underway, but integration with actual local and state response 
capabilities has yet to be accomplished. These facilities will provide 
bed space to care for non-emergency hospitalized patients, so existing 
hospital space can be reserved for new, more seriously injured 
casualties. Katrina showed that staffing requirements for these 
facilities cannot be met from Federal sources. A senior National 
Disaster Medical System official underscored this deficiency when he 
reported in a 2004 Institute of Medicine workshop that a catastrophic 
disaster would require an additional 20,000 healthcare professionals 
beyond what could be provided by the Federal government. Catastrophic 
mass casualty planning is beginning at the federal level, but more 
important is the need to build interoperable state, regional, and 
federal response plans for smaller, more likely events.
    The third component, not currently being addressed, is planning for 
a national response where problems are addressed that are too big for, 
or beyond the jurisdiction of, state and local agencies, and beyond 
clear Federal control. This type of planning often includes working 
with organizations and institutions that operate at the border between 
state and society, such as private sector businesses, volunteer 
organizations, faith-based organizations, national professional 
societies, and academic institutions. Such groups are not part of any 
formal governmental structure, but play a crucial role in society, 
providing essential support and cohesion. As Katrina demonstrated, 
involvement of these groups is essential to disseminate information via 
trusted local opinion leaders, to identify volunteers to assist in a 
mass casualty response and to maintain trust in local, state, and 
Federal authorities.

The Federal Role in Mass Casualty Planning
    The Federal Government has a leadership role in all three of these 
planning components. Federal agencies must support local and state 
agencies by providing principles for preparedness, goals and 
objectives, strategies for implementation, and opportunities for 
testing and exercising local plans. Perhaps most critical is the 
provision of funding with strings attached to cajole local and state 
agencies to develop interconnected regional plans.
    Federal agencies must identify resources that are likely to make a 
difference in a local or regional terrorist or mass casualty incident 
response. A chemical, nuclear, radiological, or biological attack may 
call for the immediate deployment of capabilities that no local or 
state government can afford to maintain. National sources of hospital 
beds and medical equipment may be necessary, but identifying sufficient 
healthcare professionals and providing them and the hospitals in which 
they deliver emergency care with licensure and credentialing standards 
and liability protection is a much more crucial federal task. Prompt 
response actions are often hindered by built-in delays as requests for 
assistance flow from local to state to federal officials, so action 
thresholds for requesting additional help should be established in 
advance.
    The Federal Government must create an environment in which best 
practices can be developed and tested. Alternative models for national 
solutions should be prototyped and fine tuned in a multistate region, 
then provided to state and local governments for adaptation to local 
needs. These models should include sources, organization, and 
management of healthcare professionals; credentialing, training, and 
personal protective equipment; and liability protection and 
reimbursement. Tools should be provided to maximize existing hospital 
bed space and to create alternate facilities, transport casualties to 
regions with excess capacity, and identify funding sources for local 
hospital preparedness. National professional medical and legal 
societies should be engaged to discuss mechanisms of triage and the 
graceful degradation of the quality of emergency care that will take 
place in the face of mass casualties.

Organizational Barriers to Coordinated Planning
    The rate-limiting step in coordinated planning is the requirement 
to work across bureaucratic, organizational, and professional barriers. 
Communication and coordination barriers thwart communication 
horizontally, with like agencies at the same levels of government, and 
vertically, when proceeding up or down the chain of command. 
Organizational cultures become barriers when moving across agencies or 
business sectors; the resulting bureaucratic obstacles and 
inefficiencies seem to be ubiquitous and can be overcome only with 
sustained effort.

Crisis Decisionmaking
    To paraphrase General George S. Patton, the best plan is useless if 
executed too late. The best confirmation that planning and preparedness 
efforts are adequate is to demonstrate successful decisionmaking as a 
plan is executed in a staged crisis management exercise. Such tests 
must intentionally focus on cross-jurisdictional crisis communication.
    None of these steps can happen, however, until the basic 
coordinated planning described above takes place. For Katrina, a 
massive Federal response in less than 72 hours was widely criticized 
due to a lack of understanding that the first response is necessarily a 
state and local responsibility.

Current Deficiencies
    Much positive work has been accomplished in the four years since 
September 11 and the subsequent anthrax attacks, but much remains to be 
done. For example, planning and training efforts are largely intra-
agency rather than interagency. Federal funding supports this stove-
piped approach rather than requiring cross-sector planning. Exercising 
of plans is rare, and the few that are exercises usually stop well 
before the point of failure, so true capabilities and limitations are 
rarely identified and corrected. Opportunities for senior leaders to 
learn about crisis decision-making in a realistic environment are 
almost nonexistent. There is little evidence of integration between 
local-state planning and federal planning. Catastrophic mass casualty 
planning certainly needs to be done at the federal level, but more 
important is the need to build interoperable response plans between the 
state, regional, and federal levels.
    A national target for preparedness for combating terrorism has been 
proposed by the Gilmore Commission and applies equally to any domestic 
emergency:
    Preparedness for combating terrorism requires measurable 
demonstrated capacity by communities, states, and private-sector 
entities throughout the United States to respond to acute threats with 
well-planned, well-coordinated, and effective efforts by all of the 
essential participants, including elected officials, police, fire, 
medical, public health, emergency managers, intelligence, community 
organizations, the media, and the public at large.
    The tangible need for the United States is integrated, coordinated, 
all-hazard response planning. All requirements, capabilities, and 
potential sources must be considered and courses of action developed to 
close gaps. Plans need to be developed and realistically exercised, 
then improved, and exercised again. Training then must be developed 
that supports integration of these plans into day-to-day actions at 
every level.
    Some are suggesting that the Defense Department should assume a 
greater role in responding to such domestic disasters, but a more 
realistic role might be proactive engagement in this planning process. 
The military possesses several core competencies that directly support 
mass casualty planning. These were brought out in the Defense Science 
Board 2003 Summer Study on DOD Roles and Missions in Homeland Security 
and include training, experimentation, and operational-level planning 
and execution. The need persists, though, as Katrina lessons are 
analyzed, to identify the mechanism in which military medical, 
logistics, and response planners may engage at the appropriate Federal, 
state, and local levels. Military planning for civil support will be 
ineffective if it is not carried out with all the agencies involved in 
a response. Engagement at the Federal interagency level is important 
but insufficient. It is incumbent on leadership to create the national 
forum in which functional, effective mass casualty preparedness 
planning can occur across artificial bureaucratic barriers.
    Such a mass casualty planning forum should be cosponsored by the 
Departments of Homeland Security, Health and Human Services, and 
Defense, but must address local and state needs first. Its charter 
should be to support the development by states of local, state, and 
regional mass casualty preparedness and response plans, rather than 
simply Federal response plans. It must include private sector and 
volunteer capabilities, and must engage local and national medical 
associations. In the wake of Hurricane Katrina, this forum could 
initially focus on the various tasks associated with evacuation of the 
Gulf Coast, alternatives available when local resources and 
infrastructure are completely overwhelmed, and the preparedness and 
response steps necessary to minimize the consequences of a future 
natural disaster or terrorist attack in this region. If an earnest 
effort is made to develop effective plans that incorporate public, 
private, and volunteer resources, the risk of terrorism and the impact 
of natural disasters will be reduced and the homeland will indeed 
become more secure.
    Mr. Chairman, this concludes my prepared statement. With the 
Committee's permission, I request my formal statement be submitted for 
the record. Mr. Chairman and members of the committee, I thank you for 
the opportunity to appear before you and I will be happy to answer any 
questions that you may have.

    Mr. Linder. Dr. Freeman.

               STATEMENT OF JENNY E. FREEMAN, MD

    Dr. Freeman. Good afternoon. Thank you, Chairman Linder, 
Ranking Member Langevin and members of the committee.
    My name is Jenny Freeman. I am here today to discuss an 
issue which is important to me and, I believe, affects every 
American, that of the ability of the government to respond 
appropriately to protect our citizens in a time of disaster.
    My comments come today not only as those of a concerned 
citizen or as one who has trained and been part of the mission 
and preparedness process of the NDMS, but more importantly, as 
one who has actually served on a real deployment. I believe 
that this provides me with a perspective I could not have 
obtained either by listening to the experiences of others or by 
participating in a mythical demonstration or a training 
exercise.
    I am a pediatric cardiac surgeon by original training. In 
that process, I was trained by physicians who stress both 
medicine and systems analysis. I understand how important it is 
to develop a system that is automatic so that in a critical 
situation, the system would have a strong foundation for work 
and provide the best patient care.
    I have started several surgical programs, run a surgical 
practice and founded three businesses, two medical device 
companies and a Wall Street health care research analysis firm. 
I continue today to practice medicine, supporting two 
understaffed area hospitals. I have included my biosketch and 
CV in the record.
    Relevant to my input here, I have provided charity services 
in Nigeria and the Philippines, served on the Defense Science 
Board Task Force on Defense Against Biological Weapons, chaired 
by George Poste and Michael Hopmeier in 2000, and became a 
member of the International Medical and Surgical Response Team 
East in 2003.
    Under the auspices of that team, I was deployed to help 
fill out physician requirements for the Georgia-3 DMAT team in 
the G8 Summit in June of 2004. My written testimony revolves 
around what I personally observed during the G8 deployment. I 
have included excerpts from the journal that I kept there, as 
well as the after-action report of Tim Crowley, which Mr. 
Langevin mentioned in his opening remarks and I don't need to 
repeat here.
    I remain on the team, unlike Mr. Crowley--Dr. Crowley, 
although after this testimony, I may never be chosen to deploy 
again. To date, I have trained with the team for 2 years, have 
been part of the ready team for missions including Pakistan, 
Katrina and Bam, Iran, and actually deployed for support of the 
G8 mission in Georgia in 2004. I believe that this direct 
experience allows me to draw a number of conclusions based on 
real observation, given my previous experiences. This may 
provide input different from what you may receive from those 
who have merely studied, but never been part of a real event.
    I was concerned from the time I received predeployment 
briefing materials to the G8 and I began a journal my first 
night. The first paragraph reads, June 6, 2004: ``Based on my 
first night at the MACC sick call station, it became apparent 
that it would be useful if I had a better understanding of the 
mission of this particular facility, a specified set of goals 
and objectives,'' and it goes on from there. Four days later I 
left with no better information or understanding. I believe 
that this represents a microcosm of the bigger picture, 
unfortunately.
    First and foremost, from what I have seen, I believe that 
there was a nearly complete lack of understanding of the role 
of the DMAT in the natural disaster process, and that stems 
from an even greater problem at the very highest policy levels 
as to the role of the Federal Government in responding to 
disaster.
    While I admit that my observation comes from one who is not 
at the policy level, it has sadly been borne out by the abject 
failure of our Nation at almost all levels to effectively 
respond to the recent events surrounding Katrina, to the Chiron 
influenza vaccine debacle last year, and to what I see as the 
obvious lack of preparedness for the possible emergence of 
avian flu that we should be addressing now. In my mind, we are 
still sorely underprepared for the H5N1 flu strain despite 
long-standing predictions and even the Chiron wake-up call.
    These flus and hurricanes that I mentioned are examples of 
known cyclic events that we could be well prepared for, yet we 
have not been able to develop a proactive plan to mitigate the 
events of such expected disasters. In my mind, this bodes 
extremely poorly for the greater unknowns we might face in a 
bioterrorism scenario.
    Due to this fundamental lack of clear mission and set of 
goals, the medical response system was unable to effectively 
plan and execute even a scheduled mission such as the G8. I am 
not sure that any NDMS mission has ever been optimally 
conducted. I wish to note most strenuously, this is not due to 
the failing of dedication or professionalism at the operational 
level, but primarily due to a lack of direction and guidance 
from the very highest levels of Homeland Security and medical 
preparedness. My colleagues and I have dedicated considerable 
time and effort, taking tolls on both professional and personal 
lives in order to support this truly laudable mission; however, 
we have been let down and not supported by these efforts.
    I believe, based on my discussion and discussion with 
colleagues, that many of the following are fundamental issues 
that must be addressed. There is a genuine need and role for 
the NDMS in responding to a disaster, and it is the role of the 
Federal Government to provide the guidance, support and impetus 
for this mission to occur.
    Number two, any response to a disaster is not just a 
medical response, but is instead a combination of many factors, 
including logistics, management, training, transport, security, 
many things. To respond effectively, it is necessary that all 
of these factors be considered systemically, not as isolated 
bits and pieces. In my opinion, such an important system must 
be tightly structured and staffed, at least in greater measure 
by professionals and not relegated solely to a volunteer-based 
organization or volunteer fire department.
    Until we have a clear, rational and accurate guidance as to 
what we as medical professionals will be required to prepare 
and train for, we will all act as individuals doing the best 
that we can in an extremely suboptimal manner. The result will 
continue to be significant injury and death to the people that, 
as a physician, it is my job to treat.
    The recent focus on standardization of medical care through 
evidence-based medicine has helped physicians transcend the 
responses of individuals acting on isolated experiences, and 
this has dramatically improved the outcomes. Similar structure 
and standardization will be required to improve our track 
record at disaster management.
    Four, while the political one-upmanship considering the 
result of Katrina and past disasters is certainly entertaining 
and results in higher viewership on the nightly news, until a 
realistic objective and undoubtedly painful review at all 
levels of our national response to disaster is done, this is 
nothing more than a sideshow, circuses for the masses.
    If my last comments seem frustrated, they are, I have 
dedicated my life from the time I first took the Hippocratic 
Oath until today to saving lives, as has probably everyone here 
on this panel. I see here the potential to save very many lives 
thwarted by an inadequate and failing system.
    I wish to close with a personal note. I have two children. 
They will someday, I hope, have the opportunity to start 
families and raise children of their own. I hope they never 
have to face a disaster such as the poor victims of Katrina or 
the people of Pakistan, if they are involved in a disaster. 
However, I sincerely hope that our Nation is better prepared to 
face it and protect them than it has been to date. I, as a 
mother, physician and citizen, charge you with the 
responsibility of leading us to a better state of preparedness.
    Again, thank you for the opportunity to testify. I am 
prepared to take any questions.
    Mr. Linder. Thank you, Dr. Freeman.
    [The statement of Dr. Freeman follows:]

          Prepared Statement of Jenny Freeman, MD, FACS, FACC

    Good afternoon. Thank you Chairman Linder, Ranking Member Langevin, 
and members of the committee. My name is Jenny Freeman and I am here 
today to discuss an issue which is important to me, and affects every 
American: that of the ability of the government to respond 
appropriately to protect our citizens, in time of disaster. My comments 
today come, not just as those of a concerned citizen, or as one who has 
trained and been part of the mission and preparedness process of the 
National Disaster Medical System, but most importantly, as one who has 
actually served as part of a real deployment. I believe this provides 
me a perspective I could not have attained either by listening to the 
experiences of others or by participating in mythical demonstration or 
training exercises.
    I am a pediatric cardiac surgeon by original training. In that 
process, I was trained by physicians who stressed both medicine and 
systems analysis. I understand how important it is to develop a system 
that is ``automatic'' so that in a critical situation, the system would 
have a strong foundation to work and provide the best patient care. I 
have started several surgical programs, run a surgical practice, and 
founded three businesses, two medical device companies and a Wall 
Street healthcare research analysis firm. I continue today to practice 
medicine supporting two understaffed area hospitals. I have included my 
biosketch and CV in the record.
    Relevant to my input here, I provided services in charity settings 
in Nigeria and the Philippines, served on the ``Defense Science Board 
Task Force on Defense against Biological Weapons chaired by George 
Poste and Michael Hopmeier in 2000 and became a member of the 
International Medical and Surgical Response Team East in 2003. Under 
the auspices of that team, I was deployed to help fill out physician 
requirements associated with the deployment of the Georgia-3 DMAT team 
to the G-8 summit in June of 2004.
    My testimony revolves around what I personally observed during the 
G-8 deployment. I have also included in written testimony excerpts from 
a journal that I kept there as well as the after action report of Tim 
Crowley, a respected physician colleague, who described his 
experiences, during his deployment in the aftermath of hurricane 
Katrina. As a thoughtful and competent physician who wound up in a 
command position, the disorganization that prevented him from providing 
useful patient care was highly problematic. Over and over again he saw 
physician and medical resources squandered--his team remained in Baton 
Rouge being told there was no mission while the staff at the key West 
Jefferson location were crying for help. When they finally got to West 
Jeff and in turn asked for assistance the same sad story was repeated 
with other teams and team members being held at irrelevant locations 
with nothing to do. I should note that, upon Dr. Crowley's return from 
the Katrina operation, he resigned from the ImSURT/DMAT team in disgust 
at the lack of preparation, organization and mission knowledge 
demonstrated by the management structure of the NDMS system.
    I remain on the team, although after this testimony I may never be 
chosen to deploy again. To date, I have trained with the team for two 
years, been part of the ready team for missions including Pakistan, 
Katrina and Bam, Iran and actually deployed for support of the G8 
meeting in Georgia, June, 2004. I believe that this direct experience 
allows me to draw a number of conclusions which are based on real 
observation. This may provide input different from that many of you may 
receive from those who have merely studied, but never been part of, a 
real event.
    I was concerned from the time I received briefing materials before 
we even left for the G8 and I began a journal my first night. The first 
paragraph reads as follows: June 6, 2004: ``Based on my first night at 
the MACC sick call station, it became apparent that it would be useful 
if I had a better understanding of the mission of this particular 
facility, a specified set of goals and objectives, a clearer 
understanding of protocols under which to operate, a list containing 
primary and secondary contact information, a better understanding of 
available resources and as much of a secondary action plan as could be 
disclosed. If I had these things, I believe that I would be able to be 
a better resource to FEMA/NDMS.'' Four days later I left with no better 
information or understanding. I believe that this represents a 
microcosm of the bigger picture.
    First and foremost, from what I have seen, I believe that there is 
a nearly complete lack of understanding of the role of the DMAT in a 
national disaster and that this stems from the even greater problem at 
the very highest policy levels as to the role of the Federal Government 
in responding to disaster. While I admit that my observation comes from 
one who is not at the policy level, it has sadly been born out by the 
abject failure of our nation, at almost all levels, to effectively 
respond to the recent events surrounding Katrina, to the Chiron debacle 
surrounding influenza vaccine last year, and what I see as the obvious 
lack of preparedness surrounding the possible emergence of avian 
influenza that we should be addressing now. In my mind we are still 
sorely under-prepared for the H5N1 flue strain despite longstanding 
predictions and even the Chiron wake up call. These flues and 
hurricanes that I mentioned are examples of known cyclic events that 
could be well prepared for yet we have not been able to develop a 
proactive plan to mitigate the effects of even such expected disasters. 
In my mind this bodes extremely poorly for the greater unknowns we 
might face in a bioterrorism scenario.
    Due to this fundamental lack of a clear mission and set of goals 
the medical response system was unable to effectively plan and execute 
even a scheduled mission such as the G8. In my mind, it is unlikely 
that ANY NDMS mission has ever been optimally conducted. I wish to 
note, most strenuously, that this is not due to a failing of dedication 
or professionalism at the operational level, but primarily due to a 
lack of direction and guidance from the very highest levels of homeland 
security and medical preparedness. My colleagues and I have dedicated 
considerable time and effort, taking tolls on both our personal and 
professional lives, to volunteer to support this truly laudable 
mission; however we have been let down and not supported in these 
efforts.
    I believe, based on my experience, and discussion with colleagues 
that of many that the following are fundamental issues that must be 
addressed;
    1. There is a genuine need, and role, for NDMS in responding to a 
disaster, and it is the role of the Federal Government to provide the 
guidance, support & impetus for this mission to occur.
    2. Any response to a disaster is not just a medical response, but 
is instead a combination of many factors, including logistics, 
management, training, transportation, security, etc. To respond 
effectively, it is necessary that all of the factors be considered 
systemically, not as a variety of isolated bits and pieces. In my 
opinion, such an important system must be tightly structured and 
staffed at least in greater proportion by professionals and not 
relegated solely to a volunteer based organization.
    3. Until we have clear, rational and accurate guidance as to what 
we, as medical professionals, will be required to train and prepare 
for, we will all act as individuals, doing the best we can in an 
extremely suboptimal manner, and the result will continue to be 
significant injury and death to the people as a physician it is my job 
to treat. The recent focus on standardization of medical care through 
evidence based medicine has helped physicians transcend the responses 
of individuals acting on isolated experiences and this has dramatically 
improved outcomes. Similar structure and standardization will be 
required to improve our track record at disaster management.
    4. While the political one-ups-man-ship concerning the results of 
Katrina and past disasters is certainly entertaining and results in 
higher viewer ship on the nightly news, until a realistic, objective, 
and undoubtedly painful review of all levels of our nation's response 
to disaster is done, this is nothing more than a sideshow providing 
circuses for the masses.
    If my last comments seem frustrated, they are. I have dedicated my 
life, from the time I first took the Hippocratic oath, until today to 
saving lives. I see here the potential to save very many lives thwarted 
by an inadequate and failing system
    I wish to close with a personal note; I have two children. They 
will, some day I hope, have the opportunity to start families and raise 
children of their own. I hope they never have to face a disaster such 
as the poor victims of Katrina, or the people of Pakistan, must today. 
If they are involved in a disaster, however, I sincerely hope that our 
nation is better prepared to face it, and protect them, than it has 
been to date. I, as a mother, physician and citizen, charge you with 
the responsibility of leading us to a better state of preparedness.
    Again, thank you very much for this opportunity to testify and I am 
prepared to take any questions you may have.

    Memo, June 6
    Based on my first night at the MACC sick call station, it became 
apparent that it would be useful if I had a better understanding of the 
mission of this particular facility, a specified set of goals and 
objectives, a clearer understanding of protocols under which to 
operate, a list containing primary and secondary contact information, a 
better understanding of available resources and as much of a secondary 
action plan as could be disclosed. If I had these things, I believe 
that I would be able to be a better resource to FEMA/NDMS.
    On arriving at the MACC sick call station, we noted that there were 
no drugs at all and some discrepancy with supplies. Over the course of 
the night we received drugs which were ``left over'' from the Epworth 
facility. We initially noted a very significant shortfall between what 
was here and what would be necessary to implement effectively the level 
of care that we could provide with the other equipment we had, such as 
intubation equipment. We had drugs that could be used to paralyze a 
patient but no sedation to make it tolerable, we had a lidocaine drip, 
but no injectable lidocaine with which to primarily treat an 
arrhythmia, etc. We certainly were not fully equipped to perform as a 
unit providing ALS level care,.
    It soon became apparent, however, that there were deeper issues 
relative to understanding what the actual mission of this clinic was 
and what level of care that we were expected to be able to provide, 
either now or under other potentially adverse circumstances. It also 
became clear that we did not have adequate information as to what 
protocols we were supposed to follow. We had little contact 
information. There were numbers given out in the briefing, but I had 
written those on the map that was handed out at the meeting, which I 
had left in the car presuming incorrectly that any important numbers 
that I needed would be provided in the sick call area or be in our 
packets. We had the Brunswick Hospital address and driving instructions 
to tell patients how to get there, but no telephone number or protocol 
as to how to get patients into the Emergency Room or potentially out--
patient clinic environment.
    Some other questions that arose here and in discussions with other 
physicians at Epworth included:

    Who exactly do I call and for what? Is there a back up number if 
the original one is unreachable?
    How do I transport out patients that require further or more 
extensive care from the clinic?
    How hard will it be to get ambulance services? now? later in the 
week?
    What are the criteria for strike team mobilization?
    What are the criteria for the strike team to take care of patients 
on site, vs bring back to strike team facilities vs send to hospital?
    If the strike teams have supplies to care for one or two people is 
that sufficient?
    Over night, we did speak with Ron from MST who was helpful in 
sending over additional drugs, and asked us to take an inventory and 
find out what we needed in terms of drugs or supplies that were not 
there. I said we could do that, but really I needed to know what level 
of care we were expected to provide first in order to do that 
adequately. He deferred the system related questions until the morning. 
Shortly thereafter Stanley Krol of NDMS came in to introduce himself 
and we discussed this with him as well.
    I presume that is the intention for the Medical Strike Teams to 
provide ALS level care, but it seems not to be so for the sick call 
clinic. Clearly a full list of medications and supplies required for us 
to do our job will depend on the expectation set and mission of each 
facility or each team. If standard ALS level care is expected, we are 
including a list of drugs that should be available. Please excuse the 
formatting, but it was copied from an adobe file and I cannot correct 
easily tonight. Supplies as found on a standard EMS truck would be 
adequate should the mission be to either provide now or have the 
capability to provide ALS level services. Such would include emergent 
chest decompression equipment, large bore IVs, saline flush materials, 
a burn kit, burn medications, trauma dressings, more than the 2 bags of 
saline that we have now etc.
    After discussion with Mr. Krol, we are going under the interim 
guidelines of serving merely as a triage facility and not actually 
attempting to treat any patients that require more than what could be 
undertaken at a doctors office. Unfortunately, however, we still do not 
have prescription pads either, so even though there is a licensed 
physician here, unless we have a way to call in prescriptions that has 
yet to be described we are unable to provide that function either.
    Please understand that I clearly appreciate the complex nature of 
this entire event and that this is really only a very tiny part of the 
whole picture, but also please understand that I am trying to fulfill 
my responsibility to my potential patients and need to ask for further 
guidance in order to do so.

    Addendum
    June 10
    On the morning of June 6, I passed this letter on through the 
``Chain of Command''. I thought that I would jot down some further 
comments from the next few days to describe the follow through and 
consolidate my thoughts. Essentially, nothing changed, we never learned 
our mission, we got a few random drugs and supplies. I discussed this 
with Dr. Stringer on June 8 when he came over to make sure a form was 
filled out properly and e-mailed the letter to him at his request that 
night. I never heard back from him. On June 9, I met Gary Sirmons who 
asked that I forward it to him as well. I also made copies of the 
packet of information that was provided in a manila envelope for the 
MACC sick call clinic (which included the preliminary materials 
furnished to us over the web before we were deployed), a list of what 
the Georgia 3 team was told to bring and what they actually did bring 
and whatever random papers that were sent to give us instructions and 
had been taped on the wall. I also wrote a somewhat rambling set of 
journal type observations of the occurrences and my impressions..
    Fortunately, we only saw a dozen patients or so the whole time, and 
the most complex problems treated were hypertension and headache for a 
week which we sent to a local hospital for evaluation and prescription 
of antihypertensive medication and helicopter pilot with an infection 
around the finger nail that I drained by using an 18 gauge needle to 
slice the skin instead of the scalpel that we did not have. We had no 
packing material (would have liked 1/4 inch gauze) so made a small wick 
from the sterile covering of an eyepad which had approximately the 
right dimensions and characteristics). I only did this because given 
his demeanor, I did not believe that he would go elsewhere to get this 
done.
    Throughout this experience I was treated on more that a few 
occasions like I was an idiot or like I was being refractory and not 
cooperative. Or that I wasn't a real Emergency, EMS, FEMA, NDMS kind of 
person, but more like a silly ivory tower surgeon that wanted 
everything handed to them on a silver platter or like a stupid blonde 
who couldn't figure out what to do or like someone who was just not 
trying to be cooperative; or that I was not of ``the right stuff''; or 
that I didn't know how to `` ``rough it'' '' and ``just do what has to 
be done''. As it turns out, I have quite a bit of experience making do 
at Bellevue in NYC in the 70s and 80s, in Nigeria, in the Philippines 
and at new cardiac programs that I had started--and I have seen the 
deficiencies in patient care and outcome in those environments (see my 
attached CV). But it did not seem necessary in this kind of situation 
to have to improvise or to settle for a substandard environment, with 
months of planning and millions of dollars spent in preparation and in 
the United States of America, optimizing the care of the support staff 
assembled at a high risk event and also being available for an unlikely 
but possible critical situation. I have also seen the benefits of `` 
''institutional knowledge as developed by John Kirlkin in the 1960s-
1980s as he built the University of Alabama at Birmingham from scratch 
into one of the premier cardiac surgical programs in the world at that 
time, or second hand in talking to the Israeli's about the system they 
have developed of conducting well orchestrated medical operations and 
of training physicians to have the operational and leadership 
experience to handle both missions and medical infrastructure 
necessities.
    In all of this I have no personal interest, no axe to grind, no 
program to promote. I am merely a volunteer deployed for the first time 
on such a mission with the opportunity to provide some (nearly) 
external review. I believe from what I saw, that the system is severely 
inadequate to meet even simple challenges adequately let alone 
potential WMD scenarios. Despite what I thought to be completely 
inadequate oversight and delivery of a functional operational plan by 
Dr. Stringer, I believe that the system that permitted this level of 
performance to exist without correction is far more worrisome.. As a 
single unknown voice, I realize that it is highly likely that my input 
will be discarded, but I believe also that it is my obligation and 
responsibility to at least express my opinion in case it can provide 
insight that might effect positive change. If it would be of any use, I 
would be happy to provide further information.

    Events recaptured between June 6 and June 10, 2004
    On June 6, when I arrived I asked if we had gotten any information 
about our mission or any thing else had been provided. I said again 
that we really needed what was on a medic truck if we were supposed to 
function at that level or that we needed to be told at what level we 
were expected to be able to function. The response from the other staff 
was that we just needed to make do with what we had and that it was 
always like that. . . I was told when I asked about mission and 
objectives that we had received some papers which were now taped to the 
wall. There was a paper Entitled G8 Medical Coverage with a variety of 
names and phone numbers and teams different from those that I was 
familiar with, none of which I recognized and no indication of what to 
do with this information ( as of June 10 I still have no clue who they 
are or what I should do with the information despite asking many 
people). On the wall I still could see the MST info I had scribbled on 
the sheet of NDMS coordinators that Stan Krol had given me the night 
before. There was still no information about who to call if a patient 
was to be transferred out emergently and I still had the naive question 
that given the security measures outside if 911 would work the same way 
in this environment or a more problematic scenario. I continued to go 
with my original plan to call 911 if there were any serious problems 
(for lack of any better information). Later that night I was called by 
MST and told to identify the Fire Response person from somewhere inside 
the complex so that if I needed to send someone out I would know how to 
get a hold of him because he would in fact be the one to help me do 
that and arrange things. On the Georgia side of the complex I asked for 
that person and was told that there was no one there in that capacity 
that night, but was referred to the EMS representative. The EMS rep had 
a colleague of his help me who had come from another facility which had 
been evacuated because of a bomb scare. He came back and told me I 
should call 911 and that he had spoken with the local EMS and told them 
where the medical facility was within the complex so they should be 
able to come over. At least I had an answer for that. Later I was told 
that those people (fire and EMS response) should be strictly involved 
in the large logistical process and in no way should be involved in 
individual patient care.
    There was another sheet on the wall labeled ``Response Objectives'' 
I have copied it below verbatim with questions that arose on first 
perusal along side in red.
    Incident Name: G-8 at Epworth Date Prepared: 6/6/200 Time Prepared 
940 what about MACC clinic where I was--
    was it the same mission?
    4. Operational Period (Date/Time) 0800 thru 2200 June 6, 2004--page 
began with 4 no indications of 1-3 were thos important points?
    what about times other than 0800--2200 June 6?

    5. Overall Incident Objectives
        Provide Safe Work Environment for all team members
        Treat all patients as per protocol--What protocol?
        Observe all HIPAA regulations
        Prepare Strike Teams for Immediate response
        Obtain needed Shortfalls from Logistics--Shortfalls from what 
        list and serving what mission?
    6. Objectives for specific Operational Period:
        Team Safety
        Best possible patient care--What is this???
        Maintain team morale during entire period
        Maintain adequate rest periods for all team members
        Maintain inventory--What inventory are we supposed to have?
        Promote communication with team and MST
    Provide ongoing education

    7. Safety Message for Specific Operational Period
        Follow all instructions given--all safety briefings
        Buddy System at all times
        In/Out Board
        Standard Precautions during patient treatment

    8. Weather: See Attached Weather Sheet

    As you might suspect, this is not what I had been hoping for. While 
particular immediate incredulous responses to this paper are noted in 
red above, the big picture remained that there was no indication of 
what level of care we were supposed to provide, expected protocols to 
follow or ways to adjust standard care to this slightly (but 
potentially significantly) unusual environment. We did get several 
other random medications--a vial of morphine, a few doses of injectable 
valium and some vicodin. Some pancuronium to paralyze a patient for a 
longer period of time and propranalol, no longer the beta blocker of 
choice, but better than nothing.
    I did not bother calling again or agitating, or going crazy trying 
to figure out what I might want. I just went by what I had decided for 
myself the first night--to treat this as having no more capacity than 
somewhere between a high-school nurses station and a standard doctor's 
office and to send anything else out to the hospital by either private 
transport or ambulance. So I did not inventory things or try to prepare 
for a variety of circumstances that I might envision occurring. I was 
disconcerted however to hear the others on days talking about 
intubating people if we had to etc, now that we had morphine. I said 
one morning (I think it was the 8th) that I wished we had what was on 
an EMS truck as a nice model if people expected us to provide ALS level 
care. The response from my relief was that we had most of what we 
needed and it was ``always like that'' ``you just gotta make do with 
what ya got''. I asked if there were any large bore IVs if we needed 
them and asked what about anything to decompress the chest if someone 
had a pneumothorax--that there was not a pneumo kit or even a large 
bore IV. I was told that there was a chest tube--I said but no 
pleurivac suction--the response was that there was a chest tube in one 
box with a Heimlich valve (which just lets air go out and not suck back 
in). It was only two days later that I found out that we had no 
scalpels at our place and that there was one at Epworth that they 
wanted to keep for themselves. Hard to put in a chest tube with no 
scalpel!! To me that also meant that I could not paralyze anyone to 
intubate them because I could not perform a tracheotomy if intubation 
was impossible. In one way this is all trivial detail, but it is merely 
meant to demonstrate the cascade that occurs from inadequacies.
    On June 7 I was told that I needed to fill out a full record for 
every patient that came through, including those that just wanted two 
tyelenol because they had left their bottle in the car or cepacol 
throat lozenges because of a sore throat. I said that that was probably 
not what was intended, and perhaps OTC meds could just be dispensed and 
written in the med distribution log. I was told absolutely not. I asked 
if we could question that in the morning and I was told yes, but could 
I please just fill out paperwork on everyone. No other word ever came 
back. Several people left over the next few days without registering, 
saying that they would get meds elsewhere if they had to stay for the 
questions.
    On the evening of June 8, I was asked if I could fax over the 
patient demographic sheet to MST. I said I had never seen such a sheet 
and that we had faxed over the patient log for the full 24 hours the 
night before along with the medications used so the drugs could be 
restocked. I did not collect the information for this new form and it 
was not obvious from the forms that I saw that we had been filling out 
i.e. the patient and medication logs. I said I really didn't know about 
the patients that had been there during the day, but some info was on 
the other forms. I asked if I could fax those forms that had been 
filled out from the day shift instead and they could take what info 
that was needed. That did not seem to be a viable solution. I was told 
to find the new form. I could not. I told MST that they would need to 
fax it to me and that was done. When I got it, it had several 
categories that I did not know how to fill out--one that asked for 
state federal or local--I did not know where to put the air national 
guard (was it federal or state or some of each) and one patient had no 
record of branch of service or any other job description. Also I did 
not know the disposition of the patients from the log (whether they 
were sent out to go to the hospital or just back to work). Perhaps more 
importantly if this was to be used for epidemiological reporting and 
surveillance purposes, there were CDC categories. Because I had not 
seen the patients, I did not know the CDC designation. There was a 
category for cough, but I had URI written down. Did that count or not? 
I said I would do what I could but that I doubted it would be complete. 
I was speaking at first to the MST on duty and then Steve Allen who 
finally said I needed to talk to Dr. Stringer.
    Dr. Stringer called me and started to try to be aggressive about my 
not wanting to fill out the form--I told him all of the above again and 
that I would have no problem doing that for our shift, but for the 
previous one, I would do what I could but I continued to have some 
confusion as described and it would not be complete because I could not 
find some of the data. I also asked if he had gotten my letter and he 
said no he had not--and expressed annoyance that it had not been passed 
along, blaming those who should have done so and saying he did not 
understand why they had not. I told him that there were really some 
issues regarding what our mission was supposed to be, what our 
objectives were aside from providing best possible care and what we had 
to work with. He said he had been struggling all day with the fact that 
he had been working on all of this since September but still none of 
the drugs that he had ordered for the units had been delivered. He said 
that he understood that was a problem but that I should have gotten 
most of what I needed by now and I should list what I was missing. I 
brought it back to not knowing what I needed until I was told what I 
was supposed to be DOING. He said that he had had little rest for a few 
days but all that would get sorted out.
    I then went about the task of filling out the requested form and 
had most of it done except for places where I did not know the actual 
answer I wrote in comments (i.e. 3 Air National Guard and 1 Georgia Air 
National Guard not knowing whether they were in some way different i.e. 
the question of being State or Federal) and URI next to section for 
cough. I was surprised about a half an hour later to see Dr. Stringer 
walk in. He walked in and sat down. He looked tired. He asked how 
everything was. I started again to discuss that we really were kind of 
a mish-mosh--with no mission--and that we had some equipment and 
supplies, but were we supposed to be working at the level of a high-
school nurses station, a BLS ambulance, an ALS EMS vehicle etc. He 
mentioned quite critically, almost angrily, that he had been by during 
the day and no one told him there was a problem at all. I could not 
figure out weather he was being critical of the day people for not 
telling him or me for not just pretending everything was as it should 
be.
    Instead he was focused on the form and started to complain about 
why I had not gotten the form from the day shift. I replied ``You mean 
the form that I had never seen before and didn't know about until I was 
told to find it? I asked how I was supposed to request something that I 
did not know existed and wasn't that a Catch 22. Dr. Stringer 
sheepishly agreed that was a problem, but then rebounded quickly, said 
it was in our packets, and got more aggressive again. I said quite 
firmly that it was not. I handed him the packet. He shuffled through it 
and kept commenting that things weren't stapled and no wonder we 
couldn't find anything. I said we had to undo some of the staples the 
first night to Xerox patient care forms because they were our only 
copies, but that a lot of things had not been stapled to start with. He 
kept looking for the form of interest, but finally gave up when he 
could not find it either. He also said that the designation for all of 
the agencies as federal or state were in there in the briefing he had 
sent out ahead of time, and didn't I get that since I was supposed to 
have gotten that from my POC. I said I had gotten the briefing, but it 
did not have information identifying the acronyms of different branches 
of the service. He said they did but when I handed him the briefing he 
dropped the subject. Again I said they were not--and he could not find 
them either. I said there were no contact numbers for MST or for 
ambulance service or anything either and he said they were only just 
recently available. I said they could have been provided to the clinic 
in a binder on site or some such. I bit my tongue in terms of saying 
that his packet basically had no really useful operational information, 
but rather described things such as how I should not shake hands with 
anyone who did not shake hands with me first. He also mentioned that he 
had put some information as to mass casualty in there so everyone would 
know what to do. I have a copy of the entire packet if anyone is ever 
interested. In my mind it is rambling and sorely insufficient.
    I then went back to the discrepancy about the equipment supplied 
and the drugs provided. I mentioned that really I would have to treat 
this environment like a glorified nurses station because of the lack of 
a full compliment of equipment and supplies to provide a higher level 
of care, and that I was concerned that others might fall into the trap 
of administering medications and performing procedures thinking they 
had the right equipment and supplies and get into trouble when the full 
armamentarium they were used to for that level of care was not present. 
I threw out the example that I certainly would not feel comfortable 
intubating someone, but would wait for the local EMS to arrive with all 
of their equipment, supplies and drugs. In front of me and my co-
worker, Dr. Stringer brought down his voice and said--``Don't tell 
anyone, it would be bad if you did, but the EMS here is very weak--and 
we have people here--secret service people and all--it costs a lot of 
money to train them they are very valuable and I don't want those guys 
to get into trouble--just intubate someone if you have to''. I asked 
``because the local guys can't intubate and it costs a million bucks to 
train a Navy Seal and that kind of thing?'' and he just nodded and said 
``You know, just do the right thing.'' I said that we were not fully 
equipped to do that and he said to do what I could.
    It seemed like his main objective in coming over to our place was 
to fill out this form--he actually sat and reviewed it and made sure it 
was filled out and filled some of it out himself. I said repeatedly 
that more than anything we needed an understanding of the level of care 
that we were supposed to be able to provide and under what 
circumstances, routine, difficulty in transportation because of traffic 
or other similar issues, but that received far less attention. I asked 
also about filling forms for every one that came in--even for OTC meds. 
He was vague but basically said, just do what's right. I mentioned that 
we had been filling out the medication logs faithfully so that we could 
feed into the restocking procedure correctly. He appeared puzzled and 
didn't know what I was talking about. There was no such mechanism to 
restock supplies based on usage. Rather if we ``got low'' or ran out of 
something we should call MST. He asked me to fax the form over. Then he 
left.
    Later that night I was called up by MST and asked if they could fax 
me a form to take to Stan Krol. I said sure. It was a similar form to 
the one Dr. Stringer was so interested in but a summation of all sites 
instead of just ours. I took it to Stan in the main big room on the 
federal side and told him that Dr. Stringer had been by. He asked how 
that went and I merely shrugged and smiled and told him to come by some 
time.
    On June 9, Stan Krol and Gary Sirmons came by the MACC clinic. I 
was reading on a cot and sat up to talk. Stan asked if anything got 
better after Stringer came by. I said no and described Stringer's visit 
and the core problem again in moderate detail. Gary asked me to send a 
copy of the letter I sent to Stringer.
    On June 10 at 8 pm I got called and asked if I had been told by the 
day shift what we were doing. I said no I had heard nothing from them, 
but earlier in the day I was told that the plans had changed and that 
we were going to have to work overnight instead of leaving at 10PM as I 
had heard the previous night. She said no, that we were done at 10, and 
we should pack up, but that Epworth would be staying open. I said that 
I had asked specifically because I had wanted to leave on a 6AM flight 
and had been told that the clinics were open until noon. She said she 
would check. She called back and said that we should leave up one 
station (and leave one of the three cots) but pack up everything else--
once again I ask, one station to do what?
    We were told just to pack everything randomly in the containers 
that we had because the Ga3 team had unpacked their usual tightly 
organized and inventoried boxes to just bring what Dr. Stringer had 
required (with strict instructions to bring no more) so there was no 
organization coming in and none required going out. When the Ga3 team 
came at 3 AM to pick up ``all but one station'', they told us that if 
we needed anything we should call them since MST had been gone since 
10PM and would not be back until the morning.
    Of note, given circumscribed requests, the support people were very 
helpful and responsive in attempting to fulfill them. Under proper 
direction their efforts would have been more productive.

    Mr. Linder. Some provocative comments by each of you.
    We had a hearing, I think it was yesterday, of the 
governors who pleaded that we not federalize these things. I am 
hearing here a stream that we can't have an effective system 
unless it is top-down driven.
    Dr. Alson, I think you said the Federal Government needs 
the ability to launch assets before we even hear from the 
State. That is not the way we have operated in the past. Would 
you expand on that?
    Dr. Alson. Yes, sir.
    As was seen in the events in Katrina, often an experience 
in several of the other hurricanes--I will speak to my own 
State; in North Carolina it was Floyd. The event happens in 
your community, and it very quickly overwhelms the 
capabilities. Much of the effort is often devoted to the 
immediate things of rescue, whether it is pulling people out of 
the floods or starting the search and rescue operations before 
USAR arrives.
    In many areas the State, local and emergency management 
officials are not capable of taking the information that comes 
in dribs and drabs and processing it. We have to wait, for 
example, for the request to send Federal help, at which point 
we begin to send in teams to carry out the assessments. We need 
the ability to put them in and begin that process--often when 
needs are identified, being able to go to the folks and say, We 
have these assets here, we are ready to use them for you; or if 
the need is there, even begin to use them.
    Mr. Linder. When Floyd came to North Carolina, were FEMA 
people on the ground in the planning stages of that? Because 
they are routinely--Governor Bush--
    Dr. Alson. Yes, there were FEMA people out in the area. 
There were also State people.
    Our team was deployed as a FEMA asset into the staging, 
into the immediate area, but I ended up in one particular 
county working where, quite frankly, a medical assessment was 
nonexistent. They were concentrating on one, rescue, and two, 
providing food and shelter, and had yet to conduct a medical 
assessment of needs that they had in the community.
    Mr. Linder. Dr. Freeman, you said that DHS should do a 
better job of providing leadership and guidance. Most of the 
medical expertise we have seems to be in HHS rather than DHS. 
Would HHS be more competent to guide these teams than DHS? What 
is your opinion on that?
    Dr. Freeman. I am not at the level to make that decision. I 
mean, I can give you reports from the field. I can give you a 
potential analysis of a system failure. In terms of 
understanding the resources in those difference organizations, 
I am not the one.
    Mr. Linder. Dr. Bradley, you commented that the local 
emergency manager does not have any authority over universities 
or hospitals. Should they?
    Dr. Bradley. Yes, sir.
    I don't think they should have authority over the hospitals 
on a routine basis. However, my recommendation is that the 
hospitals and the local government enter into this MOA--that 
during a time of a locally declared emergency, the emergency 
manager would have agreed-upon authority to direct the hospital 
to implement specific actions that have already been agreed to 
in the MOA.
    One of the advantages of that is that would not only tell 
the hospital what to do, the hospital could train for those, 
knowing exactly what they could ask for. Also, if there was 
reimbursement, that would make tracking the reimbursement a 
much more simple process because hospitals could say, we are 
clearly responding to this task from the local official.
    Mr. Linder. Colonel Thompson, you said that we should have 
requirements-based mass casualty planning. If you don't know 
what kind of casualty is coming, how do you figure out the 
requirements for planning it?
    Colonel Thompson. Sir, the way the Defense Department tends 
to handle these is, they do a worst-case scenario, a best-case 
scenario and then a scenario in between, so that you will have 
a situation where you will have a number of casualties, but 
perhaps not something that is at the catastrophic level. Then 
you will take something at that time catastrophic level and 
plan for all kinds of contingencies there. Then you will go 
down the center and plan for a contingency that is more in 
between those two extremes.
    Mr. Linder. Dr. Alson, you concerned yourself with the fact 
that the evacuation piece needs to be reexamined for getting 
people out. Did the evacuation piece work at all for Katrina?
    Dr. Alson. I have no direct knowledge or involvement of 
that particular portion in my response to Katrina. I was 
running a field hospital in the Gulfport area, and any patients 
we had to move, we moved into the local hospital. But it is my 
understanding, in talking with other individuals, the component 
did work; that it is still going to require some additional 
effort, because this is the first time it was attempted. It 
does involve a partnership of many, many agencies, not just 
DHS.
    Mr. Linder. Thank you. My time has expired.
    Mr. Langevin.
    Mr. Langevin. Thank you, Mr. Chairman.
    Again, I want to thank our witnesses for their testimony 
today.
    Let me start, if I could, with Dr. Freeman, as you and I 
have both mentioned in our opening statements you have had 
members of your team that were deployed to Katrina. At this 
point, I would like to give you the chance to elaborate on 
that.
    Can you give us some examples of what they saw? In 
particular, I would like you to establish a time line of the 
Massachusetts DMAT team deployment. When were they called, and 
what was the sequence of events of their deployment? Put 
simply, where did they go, at what time, and what did they do?
    I will preface my remarks, too, before I turn it over to 
you, Doctor, that I have a good friend who is an emergency room 
physician. He is also part of a DMAT team, was deployed down to 
Louisiana and found everything, in particularSec. n chaos, 
obviously, but they didn't have a place for the docs to go at 
least to the hospital, they really weren't wanted, they were 
kind of in the way. So it was poor utilization of resources.
    That just can't happen. We have to utilize the talents of 
these people who are deployed to the greatest degree possible 
where they are needed and not, obviously, underutilize them.
    I will turn it over to you for your comments.
    Dr. Freeman. With the caveat that I was not at Katrina, 
understanding that I was going to be here today, I did speak 
with some of my colleagues, including Tim Crowley, who is a 
family practice guy in Boston, in the Harvard system, another 
physician, Neel Sunder, who is an anesthesiologist at Mass 
General, and some other folks who did not wish to be 
mentioned--Peter Pillitteri, who was not at Katrina but who was 
involved in passing out medications after the anthrax scare and 
the anthrax exposure for the postal workers in New York.
    But in speaking with Dr. Crowley, Dr. Sunder, et cetera, 
and the other ones who wish to remain unnamed, I really got a 
sense that there was a significant amount of disorganization. I 
can give you a few quotes, if you would like.
    You know--at least talking to Dr. Crowley, I think that, 
you know, his concept was that the physician and medical 
resources were squandered. His team remained in Baton Rouge. He 
had been promoted through a variety of medical illnesses and 
departures, et cetera, higher and higher up the chain, and he 
had never had a command position before.
    But his team remained in Baton Rouge. They were told there 
was no mission, while there was staff at the West Jefferson 
location that was crying for help. When they finally got to 
West Jefferson and, in turn, asked for assistance, the same 
story was repeated with other teams and other team members 
being held at irrelevant locations with nothing to do. I think 
that was part of the things that made Dr. Crowley leave the 
team.
    You know, talking to Dr. Sunder, who is a very mild-
mannered and very gentle kind of physician, he was disturbed, 
you know. He really felt that--think his quote was, There was a 
disconnect at every level. That was one quote. The other was, 
He had never seen such a well-trained group of people--I am 
sorry, never seen such highly talented personnel used so 
poorly.
    If you want to go back to a time line, which I believe I 
have somewhere here, I think that what was--what happened was 
that we were put on alert on the 27th of August and that the 
team was deployed on Friday, September the 2nd. These folks 
said they watched the news with increasing disturbance 
throughout that time period. I knew I couldn't go, so I was in 
a different frame of mind.
    They traveled on Saturday, the 3rd of September. They got 
to Houston on Sunday, the 4th of September. They got to Baton 
Rouge on Monday the 5th of September, and then they stayed 
there for basically 3 to 4 days, being told there was nothing 
to do before they finally deployed out to West Jefferson 
Hospital. I think those were the--again, I wasn't there.
    I can't speak to that from personal experience, but those 
are the conversations I had with my colleagues.
    Mr. Langevin. It sounds like that experience reflects the 
experience of the emergency room I mentioned, that our DMAT 
team and his DMAT team had as well. It is problems that we need 
to correct.
    I know that my time has expired so I will not ask another 
question as yet, but if there is a second round.
    Mr. Linder. I would like to follow up on that point.
    Dr. Alson, you were actually on the ground. Did you have 
the same experience?
    Dr. Alson. Mr. Chairman, I was very fortunate. I had a very 
different experience. I had been the team commander, as I said, 
in NC-1 for several years and before that served as the XO of 
that for a number of responses, including the G8.
    We were predeployed on the Sunday before the storm. We were 
quartered in the Memphis area, along with a number of other 
teams, DMATs, VMATs and DMOG. We were actually deployed into 
the impact area beginning on Tuesday. We had to wait for the 
storm to pass, so we didn't end up with the trucks on the side 
of the road. We staged at Hattiesburg that night.
    Wednesday we were set up at the Memorial Hospital in 
Gulfport, where we operated basically an overflow for their 
emergency department. I believe we saw in the range of 1,200 
patients before that operation was closed.
    In terms of the entire operation, it is my understanding 
that as of the 18th, NDMS has had a total of 126,000 patient 
contacts throughout the system. That includes approximately 
59,000 people that were treated, plus an additional 60,000 
immunizations that are given.
    As I said before, we could probably have gotten our 
responses up faster, and we certainly feel that we need to 
improve that. We are certainly talking to many of our friends, 
stories about issues where teams are assigned and not assigned. 
But part of it is--the term the military uses, ``the fog of 
war.'' There is a lot of information flying, much of it is 
good, much of it is not good. It is a very frustrating thing 
for medical professionals.
    My team members will tell you my blood pressure often goes 
sky high when I deal with some of these. But the ultimate goal 
for all of us is to go out and do the mission.
    As I said, I have been very fortunate. I have not had some 
of those kinds of horrible experiences that some of my 
colleagues have faced.
    Mr. Linder. Thank you.
    Mr. Thompson.
    Mr. Thompson of Mississippi. Thank you very much,
    Mr. Chairman and Ranking Member. I appreciate the testimony 
of the witnesses, as well as the job that all of you do.
    Some have said, rather than having perhaps an all-volunteer 
operation, it might be better if we had a paid system of 
response. Give me your thoughts on that, individually.
    Dr. Alson. Mr. Thompson, thank you.
    I believe that in order to achieve a very rapid response, 
it may be necessary to have some paid, full-time personnel and 
full-time teams prestaged throughout the country so that the 
initial wave can be brought in in a very rapid manner. The 
other advantage you would have in such a group would be the 
ability to maintain the levels of training, as well as 
maintenance of equipment, that is often challenging when 
dealing with a volunteer, part-time group, as we see.
    But I also believe that when faced with a catastrophic 
event, we as a nation cannot afford to employ on a full-time 
basis the number of personnel necessary to respond to such an 
event. We are going to have to utilize our volunteers.
    We have a nation whose history is flush with examples of 
volunteerism, beginning back in our colonial days, and it is 
part of the American character.
    Switching to the fire side of the house, we are really the 
only nation on the planet were the majority of fire services 
are provided by volunteers. This is part of what we do and who 
we are.
    I believe we have to incorporate both segments, make sure 
that they are appropriately equipped with the necessary 
equipment and have the appropriate training under a coordinated 
response plan.
    Mr. Thompson of Mississippi. Dr. Bradley?
    Dr. Bradley. Sir, I am not an expert on the entire Urban 
Search and Rescue system, but speaking about the medical 
component of Urban Search and Rescue, each team deploys with 
six medical professionals. So far in my experience, we have 
done a very good job with the six people we have. Of course, we 
all become paid FEMA employees during the duration of our 
deployment.
    We have been able to make our 6-hour, out-the-door 
deployment every time. I don't know of a single time when our 
team has not made their 6-hour deployment window, so we get 
moving pretty quickly.
    Mr. Thompson of Mississippi. Colonel?
    Colonel Thompson. Sir, I believe--like you, I was a 
volunteer fireman many, many years ago. Our fire department put 
quite a bit of effort into organization and training and 
recruitment. Different disasters call for different kinds of 
logistics, different kinds of communications expertise.
    I think it will be necessary. I think it is appropriate to 
consider that you may need to have some people who are paid to 
do this full time, but I think even more so the need is to 
figure out a system to recruit and train and organize 
volunteers who can then come out for 1 to 2 weeks at a time. I 
am not sure that the Nation can afford to have a vast number of 
people who are paid just to handle this.
    Mr. Thompson of Mississippi. Dr. Freeman?
    Dr. Freeman. I guess I would take it one level further 
back. I think before you start to decide these operational 
kinds of issues, you need to understand what the needs are of 
the system, you know, what really are the scenarios, what is 
the big picture of what the requirements are going to be.
    It was the same thing that I faced at that time, G8. There 
was no obvious definition of the mission. So if you really 
understood or understood the overall requirements, then you 
could take that--what you needed. You could look at what the 
DMAT provided. You could take out of that DMAT-NDMS system what 
was useful. You could discard what was not. You could fill in 
the rest.
    I think that whether it comes out--in my mind, there should 
be a greater infusion of a nonvolunteer staff. But exactly 
where that falls in the spectrum needs to fall out of a real 
systems analysis of the need, not somebody's opinion.
    Mr. Thompson of Mississippi. Thank you.
    One of the other comments I would like to talk about is the 
notion of how do we have a support system.
    Dr. Alson, you made it to Hattiesburg by Tuesday, and down 
on the coast on Wednesday. I talked to a lot of friends who 
were first responders and other people who, by Wednesday still 
could not talk to each other; the communications system was 
still downSec.  number of things you would assume that first 
responders would absolutely have to have in order to do a good 
job.
    Did you hear any of these comments about the lack of assets 
available to first responders?
    Dr. Alson. I did not directly hear any of those issues in 
terms of assets, other than that, as in many disasters, 
communications were indeed a challenge. It has been on most of 
them-- I am afraid for the foreseeable future, will continue to 
be one of those issues that we struggle with. There are 
certainly efforts being made to improve upon it.
    But when you are talking about having to develop a 
communications plan that crosses so many different agencies in 
so many different spectrums, it does present a challenge.
    Our immediate interaction, once we got into the Gulfport 
area, was directly with the hospital. The other interaction I 
had was with the local EMS service, which had been augmented. 
There was a private provider that brought in assets from 
elsewhere in the country. So the two groups I directly dealt 
with did not have major supply issues or asset issues.
    There were some issues dealing with some of the special 
needs populations in the community, and I think some of that 
was related more to the lack of the local EOC being able to 
obtain the assets to support the need that they had across the 
spectrum. It was recognized they were attempting to do it, but 
they did not have them immediately available to them. Those 
eventually did arrive.
    Mr. Thompson of Mississippi. Thank you, Mr. Chairman.
    Mr. Linder. Colonel Thompson, the National Disaster Medical 
System was created in the middle of the Cold War, 1984. Is it 
still applicable? Do they have different challenges to face?
    Colonel Thompson. Sir, I do think that we do indeed have 
different challenges. The National Disaster Medical System was 
developed for two reasons: at the time. It was to provide teams 
that could deploy for natural disasters, and then to provide 
casualty care for military casualties who were coming back from 
a major war in Europe. That assumes 30 to 60 days' advance 
notice, an opportunity to reorganize the--or to build the 
support and distribution system for those casualties here in 
the United States.
    Things have changed significantly in the last 20 years. Not 
only are expectations greater that we will respond to these 
faster, but the number of hospital beds has decreased 
significantly. Just in the last 5 years, I believe in-patient 
beds have decreased another 5 percent, and that is after a very 
large decrease back in the late 1980s and early 1990s.
    So I think that there are certainly components of the 
National Disaster Medical System that make sense, but I think 
it is necessary to look at how they mesh with the needs of 
today.
    Mr. Linder. Dr. Alson, you talked about surge in your 
opening statement, surge capacity. Do we have surge capacity?
    Dr. Alson. It, I think, very much depends on the community 
and the country right now, Mr. Chairman. I also think that 
there are initiatives being put forth, a component, for 
example, of committees receiving funds from HRSA that begin to 
work on a plan.
    I know that in North Carolina we have put together a 
network where we can now track bed availability on a daily 
basis across the entire State, using a computerized system.
    Mr. Linder. Is that voluntary reporting?
    Dr. Alson. It is currently voluntary reporting, but it is 
essentially a component of receiving HRSA funding for the other 
preparedness issues, for WMD and so forth. We have had 
virtually total compliance. It has proved itself very useful in 
some of the recent storms and other issues we have.
    I also know in my portion of the country, South Carolina 
has a similar system. It actually went on line just before G8. 
There are other issues that communities are looking at, 
availabilities--as I said, alternate care facilities being 
established, but it takes assets. The planning is there.
    I don't think we are quite where we need to be with our 
capacity, given the potential for casualty generation in a 
nuclear or major biologic event.
    Mr. Linder. How much training do you do with your team?
    Dr. Alson. The DMAT that I command has a monthly meeting. 
We do several field exercises a year. We also function in a 
number of capacities--not as the DMAT, but as the local 
agency--so we have our ongoing training for that.
    In addition, we function within our State system as what is 
called an SMAT, or State Medical Assistance Team, so we train 
with that as well.
    The other component that is quartered in our community is 
the NMRT, or National Medical Response Team, which is one of 
four national medical biologic teams within the NDMS systems. I 
served actually as the XO of that team up until last year. That 
team train trains and drills on a monthly basis as well.
    Mr. Linder. Thank you.
    Mr. Langevin.
    Mr. Langevin. Thank you, Mr. Chairman.
    Dr. Alson, the chairman raised an issue that I am concerned 
about as well, surge capacity. You said--in your testimony you 
mentioned your concern about lack of surge capacity in our 
health care system, and I certainly share your concern about 
this problem. I also share your analysis that a big part of the 
problem is the economic pressures of a just-in-time economy 
that views inventory as a waste.
    I am concerned not just about beds, but with all kinds of 
medical supplies. The problem seemed so fundamental to the 
system.
    What do you think we can do to build that capacity? You 
touched on a little bit of that. Can you elaborate on that a 
little more?
    Dr. Alson. Thank you, Mr. Langevin. There are a couple of 
ways I think this can be addressed, one of which is at the 
local level. We have to put some additional supplies in to deal 
with the immediate consequences of the event, particularly 
because, depending on the nature of the event, the ability to 
get those supplies in can be hampered.
    I know I was successful at my own institution to get them 
to look at what we keep on hand for disasters and without a 
major expenditure. Given the current environment, they adjusted 
what we maintained, and we have done that as a private agency.
    But I also think that communities need to be looking at how 
they stockpile. As I say in my written testimony, Dr. Carl 
Schultz out on the West Coast for years has advocated the 
concept of hardening communities with stockpiling supplies to 
address that immediate phase.
    I also think that we have to look at the ability to put 
together additional care space, whether it is in fixed 
structures or tents to handle that expansion. This could be a 
role of the DMAT, it could be the role of a State or local 
resource within our State Medical Assistance Teams.
    Each of the trauma systems has put together a SMAT-2 or 
two-level team. Besides doing decon, their major function is 
begin to develop additional surge capacity with the supplies. I 
also think a similar approach has to happen at the Federal 
level that we can bring in these additional materials. Whether 
these supplies are stockpiled in high-risk communities or 
whether they are regionalized, we have to have the assets to 
get into the hands of the response personnel.
    I also believe that one of the issues we have to have is 
that the logistics system that handles it has to be a dedicated 
medical logistics system. Experience from disasters has taught 
us that often medical supplies, being a small portion of what 
is shipped, may get lost in the entire FEMA logistics system.
    Dr. Freeman. Am I allowed to add something to that?
    Mr. Linder. Yes.
    Dr. Freeman. I guess it depends--coming again a little bit 
from the outside, it depends on what you mean by surge 
capacity. If you are talking about a totally different 
scenario, you have 100,000 people or 1 million people having a 
surge capacity that is two- or threefold in your hospital is 
not going to help.
    Mr. Langevin. That is a valid point. On that point, do you 
want to expand on that a little further since you raised it?
    Dr. Freeman. Again, it depends on--it goes back to a 
systems analysis, what do you need to prepare for. You know, 
are we preparing for 1 million people with a really bad flu? 
Are we preparing for 100,000 people with smallpox that we think 
we can keep in one particular part of the country? You know, 
what are we preparing for?
    The analysis needs to be done first, before you decide what 
surge capacity is.
    I mean, everybody gets tied up in these little operational 
details, yes, we need surge capacity, give us more money. But 
the point is, I don't think anybody is looking at it from--I am 
sure people are-- it appears that people are not looking at it 
with a global enough view to really come up with an overarching 
strategy.
    Mr. Linder. Does anybody else care to comment on
    Dr. Freeman's comments?
    Colonel Thompson. Yes, sir. I will echo that completely.
    The need is really to determine the requirements, what you 
need if you have a communicable or biological event; what you 
would need if you have contaminated casualties from a 
radiological or nuclear event, and then where would the 
resources come from to meet those needs; what is the first 
level of resources in the particular geographic area, and then 
what can you surge in. That needs to be developed.
    It needs to be developed with the local, State, regional 
perspective in mind. It needs to be--in my personal opinion, it 
needs to be resourced from the Federal level to figure that 
out, but then it needs to be gamed so you can test the plan, 
see where the deficiencies are, because there will be 
deficiencies; game it again and then prototype it in some 
regional area so that you can get the solution as close to 
fixed as possible before an event happens.
    Mr. Langevin. Dr. Alson, just very quickly, because I know 
my time is about to expire, why was your experienceSec. n your 
estimation, why is your experience with respect to the 
deployment in response to Katrina and the DMAT team in 
Massachusetts and the experience that the DMAT team in Rhode 
Island different? Can you speculate?
    Dr. Alson. I didn't. I am sorry, sir, I didn't hear the 
last part of your question.
    Mr. Langevin. Was it your experience as part of the 
deployment that the response to Katrina was different from the 
experience of the DMAT team from Massachusetts or the DMAT team 
from Rhode Island? Can you speculate as to why that was the 
case?
    Dr. Alson. I really cannot. You know, we were obviously 
working very different environments. It is my understanding 
that there was a lot more--or somewhat--confusion happening in 
the Louisiana area than there was in portions of Mississippi 
where I was working. But I really had no plans.
    We got a mission assignment, and as soon as we got the 
assignment, we deployed into the area, made our contact and 
carried out our mission. But while we may have had some supply 
and support issues, like most of the time, we are adaptable and 
managed to make it through.
    But I have no idea why they ended up in the situation they 
did. I guess we happened to be lucky this trip.
    Mr. Langevin. Thank you.
    Mr. Linder. Thank you. That ends our questioning of these 
four witnesses. We are grateful for your time and your 
expertise, and we thank you for coming.
    The hearing is adjourned.
    [Whereupon, at 2:03 p.m., the subcommittee was adjourned.]