[Senate Hearing 111-574]
[From the U.S. Government Publishing Office]


                                                        S. Hrg. 111-574
 
                    NOMINATION OF ALEXANDER G. GARZA 

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

                                HEARING

                               before the

                              COMMITTEE ON
               HOMELAND SECURITY AND GOVERNMENTAL AFFAIRS
                          UNITED STATES SENATE


                                 of the

                     ONE HUNDRED ELEVENTH CONGRESS

                             FIRST SESSION

                               __________

 NOMINATION OF ALEXANDER G. GARZA TO BE ASSISTANT SECRETARY AND CHIEF 
         MEDICAL OFFICER, U.S. DEPARTMENT OF HOMELAND SECURITY

                             JULY 28, 2009

                               __________

       Available via http://www.gpoaccess.gov/congress/index.html

                       Printed for the use of the
        Committee on Homeland Security and Governmental Affairs

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        COMMITTEE ON HOMELAND SECURITY AND GOVERNMENTAL AFFAIRS

               JOSEPH I. LIEBERMAN, Connecticut, Chairman
CARL LEVIN, Michigan                 SUSAN M. COLLINS, Maine
DANIEL K. AKAKA, Hawaii              TOM COBURN, Oklahoma
THOMAS R. CARPER, Delaware           JOHN McCAIN, Arizona
MARK L. PRYOR, Arkansas              GEORGE V. VOINOVICH, Ohio
MARY L. LANDRIEU, Louisiana          JOHN ENSIGN, Nevada
CLAIRE McCASKILL, Missouri           LINDSEY GRAHAM, South Carolina
JON TESTER, Montana
ROLAND W. BURRIS, Illinois
MICHAEL F. BENNET, Colorado

                  Michael L. Alexander, Staff Director
               Kristine V. Lam, Professional Staff Member
     Brandon L. Milhorn, Minority Staff Director and Chief Counsel
                   Jennifer L. Tarr, Minority Counsel
                  Trina Driessnack Tyrer, Chief Clerk
         Patricia R. Hogan, Publications Clerk and GPO Detailee
                    Laura W. Kilbride, Hearing Clerk












                            C O N T E N T S

                                 ------                                
Opening statements:
                                                                   Page
    Senator Lieberman............................................     1
    Senator McCaskill............................................     1
    Senator Collins..............................................     4
    Senator Akaka................................................    11
Prepared statements:
    Senator Lieberman............................................    19
    Senator Collins..............................................    20
    Senator McCaskill............................................    21

                                WITNESS
                         Tuesday, July 28, 2009

Alexander G. Garza, M.D., to be Assistant Secretary and Chief 
  Medical Officer, U.S. Department of Homeland Security:
    Testimony....................................................     5
    Prepared statement...........................................    23
    Biographical and financial information.......................    26
    Responses to pre-hearing questions...........................    45
    Letter from the Office of Government Ethics..................    79
    Letters of support...........................................    80
    Responses to post-hearing questions for the Record...........    89


                    NOMINATION OF ALEXANDER G. GARZA

                              ----------                              


                         TUESDAY, JULY 28, 2009

                                     U.S. Senate,  
                       Committee on Homeland Security and  
                                      Governmental Affairs,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 10:02 a.m., in 
room SD-342, Dirksen Senate Office Building, Hon. Joseph I. 
Lieberman, Chairman of the Committee, presiding.
    Present: Senators Lieberman, Akaka, McCaskill, and Collins.

            OPENING STATEMENT OF CHAIRMAN LIEBERMAN

    Chairman Lieberman. Good morning and welcome to this 
hearing at which the Committee will consider the nomination of 
Dr. Alexander Garza to be Assistant Secretary and Chief Medical 
Officer of the Department of Homeland Security.
    Senator McCaskill, if you have other matters to go to, I 
think not only out of respect for you as a fellow Senator, but 
as a fellow honored Member of this Committee, we would welcome 
you to do your introduction first and then we can give our 
opening statements.

             OPENING STATEMENT OF SENATOR MCCASKILL

    Senator McCaskill. That is very kind. Thank you, Mr. 
Chairman and Senator Collins, not only for the hearing this 
morning, but for your really special leadership of this 
Committee. You are both role models of how this should be done, 
and I would say that even if I were not on the Committee.
    Chairman Lieberman. Thank you.
    Senator McCaskill. You work together closely, and you get 
past some of the food fights that go on around here over turf 
and who gets credit and all of that stuff, and it is 
remarkable. I am honored to serve on the Committee because of 
your leadership.
    It is a special morning for me. People ask sometimes when 
you are having a rough week, because of the nature of our work 
and being in the public eye and being accountable for 
everything we say and do, why do you put up with it if you have 
to go through some of these things? Mornings like this morning 
are why you put up with it because you have the opportunity to 
meet and get to know people in your life who are the essence of 
public service and you have the opportunity to come into a room 
like this in the halls of the most deliberative body in the 
world and advocate for a man like Alex Garza.
    I am proud to be here to introduce him this morning. I have 
to give a confession before I read my formal introduction, and 
that is that his family is very close to me. His wife has 
worked for me for a number of years in a number of different 
jobs over my public life, and I remember when they met. I 
remember when they fell in love. I remember their wedding, 
mostly because I was a lot younger and a lot thinner----
    Chairman Lieberman. You do not have to go too far with this 
confession. [Laughter.]
    Senator McCaskill. I remember the birth of all three 
children, who are here today. They are gorgeous boys. I 
remember the anxiousness and the anxiety that Melissa had when 
he was serving in Iraq. I remember all of it, and there is no 
man who is better equipped to step into these shoes today than 
Dr. Alex Garza.
    I have known him for over 15 years and I am confident in 
saying there could not be a more qualified person for this 
position.
    I first came to know Dr. Garza when he volunteered as a 
medical expert on the methamphetamine task force I directed as 
Jackson County Prosecuting Attorney. In recognition of his 
work, he was awarded the Presidential Citation by the Office of 
National Drug Control Policy.
    But his story of service and dedication to the medical 
community did not start here. Dr. Garza grew up as one of five 
brothers in a Maryland Heights, Missouri, middle-class suburb 
of St. Louis. Being one of five children, he learned the 
valuable art of negotiation at an early age. But more 
importantly, his mother, who worked the night shift as a nurse 
in the local emergency department, taught him the value of hard 
work and serving his community, skills that will serve him well 
as Assistant Secretary, if confirmed.
    While attending college, he decided he wanted not to just 
learn from the books, but to experience medicine from the 
ground up. He delayed attending medical school to work as a 
paramedic in Kansas City so he could learn from the front 
lines. He continued his work as a first respondent as a flight 
medic all through medical school, working weekends and holidays 
to put himself through school.
    He graduated from the University of Missouri School of 
Medicine and began the next stage of his emergency medical 
training at Truman Medical Center in Kansas City, Missouri. On 
top of all this, he also heeded his mother's example to serve 
by joining the United States Army Reserves Medical Corps.
    He ultimately chose to make his career in medicine about 
public service when he accepted a position as a member of the 
faculty at the Truman Medical Center. He tenure was interrupted 
when he was called into active duty in service of Operation 
Iraqi Freedom, leaving behind his wife, who was in law school 
at the time, and his then two small children.
    Dr. Garza and his team were responsible for rebuilding 
health care in Iraq. What he found were medical schools with 
out-of-date textbooks and decades-old journals. True to his 
form, he orchestrated a textbook donation program that led to 
medical schools from across the United States sending texts to 
fill the library shelves of schools throughout Iraq. Because of 
Dr. Garza's tireless work rebuilding hospitals and clinics, he 
became a trusted member of the Iraqi medical community and 
developed important strategic relationships. In addition, he 
also cared for an occasional Iraqi sheik, the soldiers in his 
unit, took turns at his post, and cleared buildings when 
needed.
    When his tour was extended for an additional 6 months, I 
consoled Dr. Garza's wife, Melissa, a longtime member of my 
staff, who came to me in tears after learning her husband would 
be spending Christmas in a bombed-out shell of a building where 
he had volunteered to assist the forward surgical team during a 
full-scale offensive operation in Samarra. He finally made it 
home to his family and was awarded the Bronze Star as well as 
the Combat Action Badge.
    His career in academics and public service immediately 
resumed when he returned to direct emergency medical services 
for the City of Kansas City and also returned to the faculty at 
Truman Medical Center. During this time, Dr. Garza recognized 
that outcomes for cardiac arrest patients could be improved, 
and he created a new cardiopulmonary resuscitation protocol 
that challenged conventional dogma. His ability to think 
outside the box led to a doubling of the survival time for 
cardiac arrest patients in Kansas City. For his work, he was 
awarded the Young Investigator Award by the American Heart 
Association. Because of his work, health care workers around 
the world are now changing the protocols and the way they 
resuscitate patients.
    Dr. Garza is one of those rare individuals who, through 
hard work and sacrifice, has improved the lives of those around 
him. He has saved the lives of his patients, working in the 
emergency room, taught compassion and clinical skills to 
medical students and residents, furthered medical science by 
publishing numerous articles in peer-reviewed scientific 
journals, served his country at war, and improved the way pre-
hospital care is rendered across the globe.
    It is with great pleasure and it is an honor that I have 
the opportunity to introduce Dr. Alex Garza to the Committee. I 
have every confidence that under his leadership, the Office of 
Health Affairs will serve the Secretary and the President and 
the Department of Homeland Security in an effective and 
meaningful way.
    Thank you, Mr. Chairman.
    Chairman Lieberman. Thank you, Senator McCaskill, for a 
very impressive and, I would say, obviously heartfelt, and for 
us moving, introduction. I would say that Dr. Garza deserves it 
all. I thank you for taking the time to come and deliver it.
    I don't know when we have last had an introducing Senator 
kiss the nominee. [Laughter.]
    It is a good way to go.
    Senator McCaskill. It is progress. [Laughter.]
    Chairman Lieberman. Thank you very much, Senator McCaskill.
    There is not much I can add to that really extraordinary 
and very compelling introduction. I will just say a few words 
about the position for which you have been nominated.
    The position of Chief Medical Officer at the Department of 
Homeland Security was created by the Post-Katrina Emergency 
Management Reform Act of 2006 that was authored, I am proud to 
say, by Senator Collins and me, following this Committee's 8-
month investigation into why the response of our Government to 
Hurricane Katrina was so poor. The Post-Katrina Reform Act 
reconfigured the Federal Emergency Management Agency (FEMA) so 
that it could, for the first time in history, respond really in 
an excellent way to natural disasters and also beyond that to 
catastrophic disasters equivalent to the swamping of New 
Orleans in 2005.
    Among the new positions created to achieve that end, which 
was better protection of the American people in crisis, was the 
position of Chief Medical Officer to be the chief and principal 
advisor to the Secretary of Homeland Security and to the 
Director of FEMA on both medical and public health issues.
    Among the responsibilities of the Chief Medical Officer is 
coordinating the Department's response not just to natural 
disasters, but to terrorism, including particularly 
bioterrorism, which is a special focus of this Committee in 
this session, ensuring coordination of all medical preparedness 
and response activities at the Department, and coordinating the 
Department's workforce health protection. In short, the Chief 
Medical Officer is responsible for ensuring that the Federal 
Government is ready, ready to carry out a quick, comprehensive, 
and effective medical response to disasters, both natural and 
unnatural.
    I would say that it is especially important, and I know the 
Secretary feels this, that we fill this position right away.
    As chief medical advisor, Dr. Garza, should you be 
confirmed, you will play a vital role in our Nation's response 
to the H1N1 outbreak, which is continuing. Though many 
Americans and a lot of the news media have turned to other 
matters, this epidemic has continued to spread. Cases now 
number over 1 million in this country, and the flu has not 
subsided, as expected, this summer. It has not surged up in 
numbers, but it has continued at pretty much the same pace, 
which is not what most public health experts predicted. It 
continues to be most problematic for children and young adults, 
and unfortunately, there is every indication that it will 
spread more rapidly in the fall when the traditional flu season 
returns. Obviously, it is imperative that we be ready for that 
and we get the public ready for that, and I want to ask you 
about that during the question and answer period.
    The next section of my prepared statement was a recitation 
of your really quite extraordinary, patriotic biography,\1\ but 
Senator McCaskill did such a great job, I will just express in 
closing here my admiration and gratitude for your experience 
and your service to your country and how much I look forward to 
hearing your opening statement and then questioning you as you 
go forward on this nomination. Thank you.
---------------------------------------------------------------------------
    \1\ The prepared statement of Chairman Lieberman appears in the 
Appendix on page 19.
---------------------------------------------------------------------------
    Senator Collins.

              OPENING STATEMENT OF SENATOR COLLINS

    Senator Collins. Thank you, Mr. Chairman.
    I join you in welcoming Dr. Garza to our Committee today. 
As is so often the case, the Chairman and I have written 
opening statements that are virtually identical. I, too, went 
through the history of the creation of the Chief Medical 
Officer in response to our investigation into the failed 
response to Hurricane Katrina. I, too, outlined the 
responsibilities and duties of the Chief Medical Officer. I, 
too, talked about the threat of H1N1 and the fear that experts 
have that it is going to return in the fall and winter with 
even higher rates of infection and increased severity.
    So rather than repeat what the Chairman has just said, let 
me just wrap up my comments by saying that I am particularly 
interested in hearing Dr. Garza's thoughts on our ability to 
surge medical resources to respond to major medical events, 
whether caused by a pandemic flu, the intentional release of a 
deadly biological agent, or the detonation of a dirty bomb.
    Last year, our Committee held a series of hearings on our 
preparedness for the detonation of a nuclear device in a large 
urban area, and we found many troubling gaps in our medical 
surge capabilities. I contrasted that to what I saw in Israel, 
where there is such preparedness to surge medical resources. I 
think we have a long way to go.
    In that area, Dr. Garza, having served as an emergency 
doctor in both military and civilian settings, can help us 
improve. I look forward to hearing his testimony today.
    Thank you, Mr. Chairman, and I would ask that my full 
statement be inserted in the record.\1\
---------------------------------------------------------------------------
    \1\ The prepared statement of Senator Collins appears in the 
Appendix on page 20.
---------------------------------------------------------------------------
    Chairman Lieberman. Without objection, so ordered. Thank 
you, Senator Collins.
    That was actually a very good and different point that you 
made at the end. I was thinking as you were saying what you did 
that I remember saying when we switched roles and I became 
Chairman and you Ranking Member that nothing would change 
except our titles, and I realize that one thing has changed, 
which is that I get to give our speech first.
    Senator Collins. That is so true. [Laughter.]
    Chairman Lieberman. Dr. Garza has filed responses to a 
biographical and financial questionnaire, answered pre-hearing 
questions submitted by the Committee, and had his financial 
statements reviewed by the Office of Government Ethics. Without 
objection, this information will be made part of the record, 
with the exception of the financial data, which are on file and 
available for public inspection in the Committee offices.
    Dr. Garza, our Committee rules require that all witnesses 
at nomination hearings give their testimony under oath, so I 
would ask you to please stand and raise your right hand.
    Do you swear that the testimony you are about to give to 
the Committee will be the truth, the whole truth, and nothing 
but the truth, so help you, God?
    Dr. Garza. I do.
    Chairman Lieberman. Thank you. Please be seated and please 
proceed with your statement and feel free to introduce your 
family.

   TESTIMONY OF ALEXANDER G. GARZA, M.D.,\2\ TO BE ASSISTANT 
    SECRETARY AND CHIEF MEDICAL OFFICER, U.S. DEPARTMENT OF 
                       HOMELAND SECURITY

    Dr. Garza. Thank you for those remarks. Good morning, 
Chairman Lieberman, Ranking Member Collins, and distinguished 
Members of the Committee. I am humbled and honored to be a 
nominee of President Obama and to seek your support today for 
my nomination to be Assistant Secretary for Health Affairs and 
Chief Medical Officer of the U.S. Department of Homeland 
Security (DHS).
---------------------------------------------------------------------------
    \2\ The prepared statement of Dr. Garza appears in the Appendix on 
page 23.
---------------------------------------------------------------------------
    If I may, Mr. Chairman, I would like to thank my wife, 
Melissa, and my three sons. This is Alex----
    Chairman Lieberman. Good morning, Alex.
    Dr. Garza [continuing]. Samuel, and young Danny.
    Chairman Lieberman. Good morning.
    Dr. Garza. They have supported me here today as well as 
throughout my career.
    I am grateful for the leadership of this Committee for 
ensuring the Nation is prepared to respond to all hazards and 
all threats. The position for which I am nominated was 
authorized by the Post-Katrina Emergency Management Reform Act 
of 2006. Therefore, it is because of the work of this Committee 
investigating the government's response to Hurricane Katrina 
and the important legislation that all of you championed as a 
result that I stand before you today. I want to thank you again 
for your leadership.
    I believe the role of the Chief Medical Officer is one of 
the most challenging and rewarding roles for a physician in the 
Federal workforce. The position not only requires experience 
and knowledge in medical preparedness and response, but also 
demands an understanding and awareness of intelligence and 
security issues. My background as a local and State public 
health official, coupled with my military service, makes me 
uniquely qualified for this position.
    My career has been dedicated to public service. I appear 
before you today asking that you support my nomination so that 
I may continue serving our country.
    If confirmed, my priorities will be as follows. To continue 
to build and strengthen the relationships between the Office of 
Health Affairs (OHA) and its partners in DHS. The foundation 
established by these relationships will permit OHA to deliver 
the best possible advice and guidance to the Secretary, the 
Administrator of FEMA, and our other component services.
    Two, to continue building OHA's capacity. OHA must continue 
to expand on its ability to respond to the various threats and 
challenges of the DHS. The Office must adopt an all-hazards and 
all-threats approach in order to prepare for a constantly 
changing landscape of natural and manmade disasters and 
catastrophic events. The office must be able to quickly assess 
and adapt to the circumstances and to deliver rapid, yet sound, 
response.
    Third, protecting the DHS workforce. Those protecting the 
homeland are absolutely vital to the mission of the Department. 
OHA must continue to offer appropriate guidance to the DHS's 
components in order to protect those who protect us.
    If confirmed, I will pursue these three priorities. I would 
build and strengthen OHA's relationships with all its component 
services, expand its capacity to respond to all hazards and all 
threats, and I will work with OHA's efforts on protecting the 
health of the DHS workforce.
    In closing, I am honored by the President's and Secretary 
Napolitano's faith in my ability to effectively lead this 
office and would like to put my knowledge and experience to use 
in continued service of my country. I look forward to working 
with this Committee, if confirmed, and I am glad to answer any 
questions that you may have. Thank you.
    Chairman Lieberman. Thank you, Dr. Garza.
    I am going to start my questions with the three standard 
ones that we ask of all nominees. First, is there anything you 
are aware of in your background that might present a conflict 
of interest with the duties of the office to which you have 
been nominated?
    Dr. Garza. No, sir.
    Chairman Lieberman. Second, do you know of anything, 
personal or otherwise, that would in any way prevent you from 
fully and honorably discharging the responsibilities of the 
office to which you have been nominated?
    Dr. Garza. No, sir.
    Chairman Lieberman. And third, do you agree without 
reservation to respond to any reasonable summons to appear and 
testify before any duly constituted Committee of Congress if 
you are confirmed?
    Dr. Garza. Yes, sir.
    Chairman Lieberman. Thank you.
    We will start with a first round of questions of 7 minutes 
per Senator.
    As I indicated in my opening statement, in a relatively 
young Department of Homeland Security, the Office of Health 
Affairs is itself a relatively young office. The position of 
Chief Medical Officer was not formally authorized until 2006. 
Since then, the office, OHA, has grown to over 100 in staff and 
a budget of approximately $150 million, but in many respects, 
it is still young and still in its formative stages.
    I want to ask you, because you are coming in to manage at 
this point--you will be more than just a singular advisor to 
the Secretary, you have got an office there--to just develop a 
little bit more of what your priorities and vision is for the 
future of OHA.
    Dr. Garza. I understand and I can fully appreciate the 
relative newness of the office and what challenges it brings 
with it.
    The priorities that I envision for the office, if 
confirmed, are as outlined in my opening statement. When I met 
with the staff over the last couple of weeks to try to get a 
better handle on what the office was doing, I asked each 
program manager at the end of our session, what was their 
biggest challenge. Without any hesitation and overwhelmingly, 
the program managers said the biggest challenge was integration 
and cooperation with other agencies. So I believe that should 
be at the very top of my list, trying to build relationships 
with our Federal agencies, Department of Health and Human 
Services (HHS) in particular, but as well as our other agencies 
since the Department of Homeland Security spans a greater 
breadth and depth than just medical issues.
    So we would do this, what I described as both vertically 
and horizontally. We would go across our components. The office 
would reach out to its other agencies and other partners. But 
the office should go up and down, as well, and by that I mean 
we should be able to cooperate and work with State, local, 
tribal, public health providers, first responders, law 
enforcement, emergency management, as well as critical 
infrastructure and key resources.
    So that would be one of my priorities, and the second would 
be making sure that the workforce is protected. I know that 
there are challenges that have been identified by this 
Committee. I know it is the Secretary's priority to make sure 
that the workforce is getting clear guidance, that they are 
operating with the best equipment, with the best training, with 
the best knowledge so that they can execute their duties.
    I have particular interest in this because of my military 
background as a battalion surgeon, where I fulfilled this role 
in making sure our soldiers were medically prepared to go to 
war, including vaccinations, and that included smallpox and 
anthrax, taking care of them while they were deployed, as well 
as doing post-deployment medical-related issues. So I fully 
understand, comprehend, and am passionate about that, as well.
    One of my other priorities is to build capacity within the 
office. I realize that the office spans a great many things. 
However, we must continue to build on a foundation of 
excellence, and that sort of fits in with building our 
relationships, as well. We have to build that capacity in order 
to get better information, in order to work collaboratively in 
building that capacity so that when we are advising the 
Secretary, the FEMA Administrator, and whoever else our 
customers are, be it the other Federal agencies, this 
Committee, State or local governments, that we are able to give 
them the very best product, the very best advice that we can.
    Chairman Lieberman. Are there particular areas in which you 
want to build the capacity of the office, where you think it is 
short now?
    Dr. Garza. Yes, sir. One of the areas that is of particular 
interest to me is in the area of biosurveillance. I do have 
some experience in this in the civilian world. I have worked 
with various emegency medical service (EMS) providers. During 
my time as a Medical Director in Kansas City, we made it a 
point to develop syndromic surveillance using emergency data.
    Chairman Lieberman. And this biosurveillance is to set up a 
system where you would have as close to immediate notice as 
possible of a potential biological attack?
    Dr. Garza. Absolutely, sir. And so with the syndromic 
surveillance, what we were doing is we were looking for any 
patterns that were out of the normal for the community.
    Chairman Lieberman. Please say a little more about what 
syndromic is, as in syndrome.
    Dr. Garza. Yes. And so what we tried to develop for the 
City of Kansas City was looking at all of the calls that came 
into 911. Now, the dispatch center for the EMS service uses 
computer algorithms to arrive at what we call presumptive 
conditions. So by interrogating the caller on a series of 
questions, we arrive at what we think is the most likely 
diagnosis or complaint. Those are all coded on computer. It is 
all in real time.
    One of the beauties of 911 data, which sets it apart from 
emergency department data, which I have written papers on, is 
all these calls are geocoded, and so we know exactly where the 
caller is calling from, so we know where the incidents will be 
coming from, as well.
    So we collect this data, and we do a continuous sweep of 
the computer, and we plot it up against what we know our 
normals are for that time of day, for that time of year, things 
like this.
    Chairman Lieberman. That is a very good idea. I was 
thinking you were going to talk about detection devices around 
areas, in other words, technological devices----
    Dr. Garza. Sure.
    Chairman Lieberman [continuing]. But what you are really 
talking about is taking advantage of an existing flow of 
information and trying to draw from it quickly----
    Dr. Garza. Exactly.
    Chairman Lieberman [continuing]. A warning sign that 
something is happening.
    Dr. Garza. Exactly. And the way we reasoned it is that we 
can analyze this data much quicker than waiting for the 
emergency department to pull the data together from multiple 
different sources. One of the beauties of emergency dispatch 
data, as well, is that it is a single center. Everyone who 
calls 911 calls to the center. So you are not pulling data from 
different emergency departments to try to bring all that data 
together. You have a single source. You have a single 
algorithm. You have a single pattern that you can look at in 
order to decide if this is something that is out of the 
ordinary.
    Chairman Lieberman. So what are you thinking of, trying 
from the Chief Medical Officer's position to advocate that at 
least the major urban areas in the country do similar ongoing 
screening of 911 calls?
    Dr. Garza. Sure. Presently, there are quite a number of 
communities that do this. That was in reaction to what we had 
done.
    Chairman Lieberman. Right.
    Dr. Garza. So currently, this monitoring is done in over 80 
cities around the country, including Canada. So it does seem to 
be a fairly robust and equitable system.
    I think the point of me bringing that up, though, is to 
explain that we need to start thinking a little bit more 
globally on where we can look for syndromic surveillance and 
for other data bits in order to give us a complete picture of 
what is going on out in the community.
    Chairman Lieberman. My time is up. I want to say I hope 
that, if you are confirmed, and I sense that you understand 
this already, you will not simply be there waiting for the 
Secretary to ask you for advice or the FEMA Director, but that 
in the areas of readiness, public health, medical, you will be 
a very aggressive advocate and initiator of policy.
    Dr. Garza. Absolutely, sir.
    Chairman Lieberman. Thank you.
    Dr. Garza. Thank you.
    Chairman Lieberman. Senator Collins.
    Senator Collins. Thank you, Mr. Chairman.
    Dr. Garza, I was very pleased to hear you say that 
workforce protection is a high priority for you. The Department 
is going to have to make a decision on whether or not Customs 
and Border Protection officials, for example, should receive 
priority for vaccination against the H1N1 virus once the 
vaccine is fully developed. In addition, the Department needs 
to develop more complete protocols for the FEMA Emergency 
Response Teams that are deployed to disaster areas so that they 
are protected from hazards that they face.
    Your predecessor made it a priority that OHA would create a 
uniform set of policies for workforce protection. Yet in 
response to questions from the Committee, you seem to see your 
role more as advising the Chief Administrative Officer. I would 
tell you that is not what we envisioned. You are supposed to be 
the direct and principal advisor to the Secretary on a whole 
host of issues, including workforce protection.
    I am going to ask you again what role you think that your 
office should play when it comes to DHS workforce protection.
    Dr. Garza. Yes, ma'am. I share in your concerns for 
workforce protection, and I know it is one of the top issues on 
the Secretary's list, as well. So let me try to assuage your 
fears of us abdicating our role.
    OHA has a very strong presence with the Secretary. I view 
the role of the Chief Medical Officer and the Office of Health 
Affairs as being intimately involved in whatever posture that 
the border takes, that our workforce takes, and giving the 
Secretary the very best advice that we can, as well as 
assisting in developing policy.
    I do have some experience in this, I think as is evidenced 
by my biography, while working with the military. I was the 
chief advisor to the battalion as the battalion surgeon and as 
well as to the division staff on civil military operations. And 
so I do have some familiarity with that.
    Now, as the battalion surgeon, you assume a lot of roles, 
and so one of those is what sort of posture should your 
soldiers take while operating in a hostile environment, and 
that includes chemical protection, protection against known 
biological threats, and things like this. So I am completely 
comfortable with that role.
    As far as developing policy and procedures for our 
workforce, let me emphasize that our workforce is the most 
important asset of our organization, and there are no doubts 
that I, as well as my staff and the Secretary, take that role 
very seriously.
    Senator Collins. I just want to make very clear that we 
look to you to develop those protocols and provide that advice. 
It is not the job of the Chief Administrative Officer or the 
Under Secretary for Management. It is the job of your office, 
and I am confident from your response, in contrast to your 
response to the pre-hearing questions, that you do understand 
that.
    I want to go on to two other issues in the time that I 
have. Last year, the Commission on the Prevention of Weapons of 
Mass Destruction (WMD) Proliferation and Terrorism found that a 
biological attack was ``more likely than not'' to occur 
somewhere in the world by the year 2013. Seven years ago, we 
authorized the Select Agent Program in the wake of the anthrax 
attacks on our Capitol and on the Postal Service. I believe 
that DHS needs to play a stronger role in evaluating the 
security of labs that are working with the most dangerous 
pathogens.
    I, for one, was surprised and alarmed to realize how weak a 
regulatory structure we have and how dispersed these pathogens 
are in labs all over the country, many in academic or medical 
settings, with very low levels of security.
    Do you believe that we need to reexamine and strengthen the 
regulation of labs that are housing these very dangerous 
pathogens?
    Dr. Garza. Yes, Senator. I, as well, share your concern 
about biological agents with a potential to do harm to the 
community. As far as the biosafety level (BSL) labs and issues 
like that are concerned, I know that the Office of Health 
Affairs will work collaboratively with the Office of Science 
and Technology, which is, I believe, mostly charged with 
biosecurity instruction and things like that.
    So where I believe, as Chief Medical Officer--if 
confirmed--the Office of Health Affairs can be of assistance 
is, once again, getting all of the best science available to 
advise the Secretary on the threats that this would pose to the 
community as well as working with our component services and 
the Office of Science and Technology in developing plans to 
make sure that if there were such an event, we would have a 
robust response, as well as discussing any security issues and/
or things of that nature. As a physician and as a community 
provider, I think it is important that we get the best 
available evidence for the Secretary to make those decisions.
    Senator Collins. I hope that you will also work with the 
Members of this Committee.
    Dr. Garza. Absolutely, ma'am.
    Senator Collins. I personally think that we need to 
strengthen the law in this area and come up with a risk-based 
security scheme where greater level of scrutiny and regulation 
would be applied to labs with the most dangerous pathogens and 
that we come up with that kind of approach, similar to the 
approach that we took with chemical facilities security.
    Dr. Garza. Yes, ma'am.
    Senator Collins. I see my time has expired, so I will wait 
for the next round. Thank you.
    Chairman Lieberman. Thanks, Senator Collins.
    I just wanted to echo what Senator Collins has said. This 
will be one of our legislative priorities this year, which is 
to legislatively beef up the oversight and protection that we 
provide to the American people from bioterrorist attack. I 
mean, you are now moving into a position, if you are confirmed, 
which we live with. We are all about defense. We are all about 
defense of the homeland in the post-September 11, 2001, period, 
and in some ways we spend a lot of time imagining worst case 
scenarios. But after September 11, 2001, that is what we have 
got to do. And this is one, particularly coming off of the 
Graham-Talent WMD Commission report, that I think we really 
want to focus on, and I will come back with one or two 
questions afterward.
    Senator Akaka, good morning. Thanks for being here.

               OPENING STATEMENT OF SENATOR AKAKA

    Senator Akaka. Thank you. Good morning.
    Let me congratulate you, Dr. Garza, for being the nominee 
and welcome you and your beautiful and handsome family. It is 
good to see Melissa here and also--is that Alexander Junior?
    Dr. Garza. He has a different middle name, sir. I would not 
want to burden him with my name.
    Senator Akaka. I also welcome Samuel, Daniel, and the rest 
of your family here, and also friends and supporters, as well. 
Thank you for being here.
    Dr. Garza. Thank you.
    Senator Akaka. As you know, Dr. Garza, the Office of Health 
Affairs is tasked with protecting our country from bioterrorism 
as well as natural agents that threaten our health. Given the 
increasingly difficult challenge of protecting our Nation, I 
urge you to focus on working collaboratively and communicating 
effectively with partner agencies and other stakeholders. It 
was good to hear your priorities about strengthening 
relationships with other agencies. There are a lot of agencies 
and departments where the relationships have to be 
strengthened.
    Like you, I believe that our workforce is our most valuable 
asset, and I understand that one of your priorities is to 
protect and help build the morale of that workforce. I hope in 
particular that you will focus on the growing shortage of the 
Federal veterinarian workforce and how it will affect our 
public health and food safety.
    Dr. Garza, your wide-ranging experience in emergency 
medicine, academia, and the military gives me confidence that 
you will bring a valuable perspective to the office. Again, I 
congratulate you on your nomination and look forward to working 
with you and again commend you for your priorities.
    As I mentioned in my opening remarks, I am concerned about 
the Federal veterinarian workforce and its shortages. I 
requested that the Government Accountability Office (GAO) 
conduct a comprehensive review of the Federal veterinarian 
workforce and held a hearing in February of this year, which 
focused on the challenges facing this workforce. GAO found that 
within the next 3 years, more than one-fourth of the 
veterinarians at key agencies for public health, homeland 
security, and food safety will be eligible to retire.
    As you know, OHA veterinarian agro-defense personnel 
provide advice on zoonotic diseases and agricultural security 
related to food and water. Keeping in mind that most Federal 
veterinarians work outside DHS, what steps would you take to 
address this critical workforce challenge so that Federal 
veterinarians are able to help address the Nation's 
vulnerabilities in these areas?
    Dr. Garza. Senator, I share your concern about our 
veterinarians and their declining numbers in the workforce.
    If I may, I would like to discuss how the Office of Health 
Affairs intersects with veterinarian medicine. Now, as with 
almost the whole of DHS, it is multi-ingrained with many 
different aspects and partners and things like that, and the 
same is true of the Office of Health Affairs. The Office of 
Health Affairs does not necessarily just deal with human 
disease. We value the all-hazards, 360-degree situational 
awareness, and that includes zoonotic disease as well as 
agricultural issues, as well.
    If we take a look at the big picture, we would understand 
how important the surveillance, the response, and the handling 
of zoonotic disease is to the importance of human health. So I 
share in your concerns that we must keep a robust, a very 
active and involved participation with our veterinarian 
colleagues, who, by the way, are some of the smartest people 
that I have ever met.
    So as a role of the Chief Medical Officer and the Office of 
Health Affairs, I believe it is important that we support our 
veterinarians and that we enhance their capabilities, as well 
as interacting with partners in other agencies, such as the FDA 
and the Department of Agriculture, in order to leverage our 
abilities with them and also to showcase the importance and the 
value that they bring to the table, as well as push this down 
to the State and local agricultural partners and our veterinary 
partners.
    So I value their input. They are an important part of the 
Office of Health Affairs, and if confirmed, I would further 
continue to try to improve our relationship with them and 
improve their standing in the Federal workforce.
    Senator Akaka. Dr. Garza, until recently, the Department of 
Health and Human Services operated immigrant health services 
while working with Immigration and Customs Enforcement (ICE) 
under a Memorandum of Understanding. Now, the Division of 
Immigration Health Services operates within ICE. In recent 
years, ICE's medical services have come under great scrutiny 
due to the numerous reported deaths.
    What role do you expect OHA will play in guiding the 
decisions and policies to improve the oversight and quality of 
medical care for immigrant detainees?
    Dr. Garza. Yes, Senator. Again, I think we share the 
concern for detainee health. I have read the same articles in 
the newspaper that you have. I know that this is a priority for 
the Secretary, so much so that she has a special advisor 
particularly on detainee health.
    I have spoken with her, and she has shared with me her 
assessment as well as some issues that she sees going forward. 
During the conversation, I implied to her that, if confirmed 
and if I assume this office, the Office of Health Affairs will 
be more than happy to assist her in whatever medical issues she 
would need guidance on as well as giving her the best science 
and policy advice available.
    Senator Akaka. Thank you very much.
    Dr. Garza. Thank you, Senator.
    Senator Akaka. Mr. Chairman, my time has expired.
    Chairman Lieberman. Thanks, Senator Akaka. Perhaps we will 
just do a few more questions if my colleagues have them.
    Dr. Garza, under Section 516 of the Homeland Security Act, 
as I read it, the Chief Medical Officer is actually responsible 
for coordinating all the biodefense activities of the 
Department. So you would play a very important role, and that 
is why, if you are confirmed, we will want to work with you----
    Dr. Garza. Yes, sir.
    Chairman Lieberman [continuing]. On the legislation that we 
are going to introduce.
    The WMD Commission, Senators Graham and Talent, recommended 
that we do everything we could to ensure that we had a much 
more robust response capacity to a biological attack. And I 
understand you are just going into this, so these are 
preliminary thoughts, but beyond the upgrading of the 
biosurveillance that you talked about earlier, what thoughts do 
you have--this does tie into what Senator Collins mentioned in 
her opening statement--about our concern, which we share, about 
the relative lack of capacity to surge our public health 
infrastructure in case of a biological or pandemic attack that 
takes off?
    Dr. Garza. Yes, sir. The Office of Health Affairs is the 
primary biodefense office within the Department of Homeland 
Security and so the way that I envision in response to a 
biodefense or a biological event is, I think, in my priority 
with building capacity. And so in building capacity, I do not 
feel that the office should purely focus on surveillance 
activities and data acquisition and things like this. I believe 
that the office must take an almost holistic view for all 
threats, all hazards, as well as working with our component 
services, such as the Centers for Disease Control and 
Prevention (CDC) and the Office of the Assistant Secretary for 
Preparedness and Response (ASPR), in the response capabilities, 
as well.
    One part where we are particularly effective is in working 
with our first responders, with our emergency managers, and 
with law enforcement. Should I be confirmed, I would put 
emphasis on this office, as well, to get information and 
guidance, policy directive, down to these individuals, as well, 
who are going to, frankly, be where the rubber hits the road 
and the first folks on the scene. They deserve this sort of 
support from our office.
    So I am trying to take more of a systematic approach to our 
biodefense capabilities with building the structure so that no 
matter what the threat, whether it is manmade or natural, 
whether it is a weather-related event or infectious disease or 
other issues, we would be able to appropriately detect, 
appropriately respond, and appropriately recover from that 
event.
    Chairman Lieberman. Let me focus finally on H1N1, which we 
talked about. I think that Secretary Napolitano along with 
Secretary Sebelius have done an admirable job in both 
responding and, as importantly--maybe more importantly--keeping 
the focus on preparing for the flu season to come in the fall. 
But everybody agrees, we have a lot of work to do, and there 
are very critical questions about whether, for instance, 
vaccines will be ready in time.
    So I wanted to ask you, assuming you are confirmed, what do 
you see are the major challenges that we face as a Nation or 
the Department faces over the next couple of months as we head 
into the fall and the more traditional flu season to get ready 
for a possible rapid spread of H1N1?
    Dr. Garza. Yes. I believe everyone on the Committee as well 
as Secretary Napolitano and myself and the office shares your 
concerns with H1N1. I know it is a priority of hers. I am 
familiar with her meeting with Secretary Sebelius and the 
Department of Education.
    So the issues that need to be coordinated before our 
presumed second surge of the virus are multi-faceted and multi-
pronged. And so the issue that we have with OHA, which sort of 
separates us from the rest of the field, is we have to have 
better interaction with our partners over at HHS.
    I have met with Dr. Lurie at ASPR, talked with the CDC, and 
sat down and had discussions with Craig Fugate at FEMA, as 
well, and this seems to be on the top of their list, as well.
    So the issue for the Office of Health Affairs would be 
coordinating with these folks to strengthen our relationships. 
I know that we have a physician in our office who is 
particularly involved with vaccine as well as distribution of 
vaccine, prioritizing, protecting our workforce, which is on 
the top of our list, as well as disseminating information down 
to our critical infrastructure and key resources, as well as 
our emergency responders, first responders down at the front 
level, as well as providing guidance to the American people. So 
all of these issues, I think, put together are issues that the 
Office of Health Affairs really needs to focus on to get us 
prepared for the presumed second wave of H1N1.
    Chairman Lieberman. Would you say that in the meetings you 
have had with people at DHS and HHS, for instance, the 
presumption is that we will have a serious problem with H1N1 
this fall and winter, obviously hoping that is not so, but 
people are going forward acting as if this is going to be a 
genuine public health crisis?
    Dr. Garza. Thank you, sir. In my meetings with these 
individuals, they did express to me their concern for the 
coming fall.
    Chairman Lieberman. Right.
    Dr. Garza. They did not expressly say whether they felt it 
was going to be worse than our spring. Of course, the big fear 
is that the virus will mutate and assume some sort of different 
form and then we will be in a lot of trouble. But they did not 
express with any confidence whether they felt it was going to 
be worse. So when I was discussing these issues with them, we 
mostly discussed our needs to better collaborate and work 
together on H1N1 issues.
    Chairman Lieberman. Thank you.
    Dr. Garza. Thank you.
    Chairman Lieberman. Senator Collins.
    Senator Collins. Thank you, Mr. Chairman.
    Dr. Garza, earlier this year when we held a hearing with 
the Secretary to look at the Federal response to the flu 
pandemic, we found that there was a great debate over whether 
our border with Mexico should have been closed and also whether 
there should have been more rigorous screening at the border. 
Now, I, for one, accept the medical advice we heard that 
closing the border was not the answer. For one thing, the virus 
was already in our country.
    Dr. Garza. Yes.
    Senator Collins. However, I am concerned that the 
Department seems to be very hesitant to use technology more 
fully to try to identify travelers who may be carrying H1N1 or 
some other new communicable disease. Other countries have 
successfully used technology that is able to scan travelers to 
identify fever. This was used back when the severe acute 
respiratory syndrome (SARS) epidemic was in full force, and 
some countries, including Japan and Singapore, have been using 
it during the flu pandemic.
    What are your views on the use of technology to better 
screen travelers at the border? After all, I think we have to 
remember that while our Customs and Border Protection officials 
and our immigration agents are highly trained, they are not 
physicians. They are not nurses. They are not health officials.
    Dr. Garza. Yes, Senator. I understand your concerns, and I 
appreciate them, and I would like to work further with the 
Committee in order to help with this issue. I know the 
Secretary keeps this on the top of her list, as well.
    So in regard to the border protection, this is of prime 
importance to the Secretary. It is her responsibility for the 
protection of the border. I know that she values good, active, 
actionable intelligence and information in order to decide what 
actions and what posture she is going to take at the border.
    With that being said, I also appreciate the tremendous 
strain that our Customs and Border Protection agents were under 
during this event. You are correct, they are not medically 
trained personnel, and so quite frankly, I think it makes them 
a little uneasy to be performing duties such as these since 
they are not medically trained.
    So as far as the technology is concerned, I am somewhat 
familiar with the technology. I cannot say that I am an expert 
at the technology. But from what I have understood is that it 
still is not where it needs to be.
    Given that, though, I believe the OHA mission should be 
taking all available resources in order to screen or identify 
or protect the country from infectious agents and other things 
coming into the country, and that, of course, includes new 
technology such as what you were talking about with the thermal 
scanners. I believe the Office of Health Affairs as well as 
Science and Technology, we do have a duty to look at, evaluate, 
and understand all these technologies. It is on the forefront 
of our agenda every day to protect the people, and it is a 
priority of the office to make sure that we are using all 
available resources.
    With that being said, I think we should also rely on best 
science, as well, to dictate what our priorities should be and 
what equipment we should use and what sort of posture we should 
take at the border.
    Senator Collins. The thermal scanners are not perfect, that 
is certainly true, but they are a tool----
    Dr. Garza. Absolutely.
    Senator Collins [continuing]. That can be used to screen. 
It does not mean that you allow that tool to make the decision, 
and there are, I believe, five developed nations, 
industrialized nations, using them----
    Dr. Garza. Yes.
    Senator Collins [continuing]. So clearly there is some 
value. If they were so inaccurate or unproven----
    Dr. Garza. Right.
    Senator Collins [continuing]. I doubt very much Japan would 
be using them. So I really urge you to take a look at this. We 
need to be willing to use all the tools that we have. 
Technology should not be used to make the decision, but it can 
be helpful in assisting individuals who do not have medical 
training in making the first cut, if you will, in making the 
preliminary screening more effective.
    Similarly, last year, there was a case where a Mexican 
citizen with a contagious form of resistant tuberculosis was 
able to cross the border, back and forth, 21 times despite the 
fact that the Department of Homeland Security had his name and 
his date of birth. This was an example where the left hand of 
government did not talk to the right hand of government. The 
CDC had identified the individual as having this kind of 
contagious tuberculosis. It was known to the government that, 
for business reasons, he frequently crossed the border. And yet 
there was a failure of communication between the CDC and DHS.
    First of all, are you familiar with this case?
    Dr. Garza. I am somewhat familiar. I cannot say I know the 
intimate details, but yes.
    Senator Collins. What will you do to make sure that we do 
not have these egregious gaps in communication? Here, we have 
an individual who has specifically been identified by the CDC, 
and there is just poor communication.
    Dr. Garza. Yes. I understand the concern of the Committee 
with this, and I believe it would be on OHA's priority list to 
do, as well. But I think what you have brilliantly illustrated 
is what I was trying to put forth in my opening statement and 
answers to other questions, and that is capacity and systems 
building as well as developing relationships with our component 
services.
    So, if confirmed, one of the priorities in my office would 
be to make sure that those relationships and those systems are 
robust enough to not let this issue happen again. And if 
confirmed, I look forward to working with the Border Patrol, 
CDC, and DHS as a whole so that these sorts of issues would not 
occur again.
    Senator Collins. Finally, our Committee held 24 hearings 
looking at the failed response to Hurricane Katrina. Of all 
those hearings, the one that stands out most in my mind because 
it was so tragic and so preventable was the hearing that looked 
at the number of homebound individuals and elderly, sick 
individuals in nursing homes who died because of a failure to 
evacuate them. It was so tragic and so outrageous that it 
happened.
    After that hearing, I had a number of home health care 
groups with whom I have worked closely come to me and say, we 
know where the homebound elderly are because we serve them. We 
visit their homes. But we have never been asked to be involved 
in evacuation planning.
    What will you do to ensure that all resources are brought 
to bear by States, by local governments, and by the Federal 
Government to ensure that we never again see homebound elderly 
individuals who are incapable of evacuating themselves, or 
people who are in a nursing home who, again, cannot evacuate 
themselves, become victims of a disaster due to a failure of 
planning and a failure to mobilize all possible resources?
    Dr. Garza. Yes, Senator. I think that question absolutely 
goes back to my previous answers of capacity building. And so 
for us to effectively deal with the entire population, we must 
make sure that we are cooperating and connected with the entire 
population, and so that includes populations that you 
mentioned.
    Now, I am not sure if you had a meeting with the FEMA 
Director right before I did, but that was on the top of his 
list, as well, when I met with him. And so I do want to assure 
you that it is on a lot of people's minds. And in particular, 
Mr. Fugate's direct question to me was, we need better planning 
on at-risk populations, and I consider the homebound and 
nursing home population an at-risk population.
    I believe that also speaks to the Office of Health Affairs 
having to think outside the box. We cannot just simply accept 
the normal response to an event which is very well contained, 
such as a small event. We have to be prepared for all hazards, 
all threats, and all people in response to a catastrophic 
event.
    Senator Collins. Thank you. I look forward to working with 
you.
    Dr. Garza. Thank you.
    Senator Collins. Thank you, Mr. Chairman.
    Chairman Lieberman. Thank you very much, Senator Collins.
    I thank you, Dr. Garza. I do not have any further 
questions, and I think we have reached the limits of the 
impressive patience of your sons. They have really been very 
well behaved today. I do not think we should ask more than this 
of them. [Laughter.]
    Dr. Garza. He almost made it.
    Senator Collins. A good period on that.
    Chairman Lieberman. He expressed a sentiment often felt by 
people who sit in this room but rarely expressed. [Laughter.]
    Without objection, the record will be kept open until noon 
tomorrow for the submission of any written questions or 
statements for the record.
    It would be the intention of our Committee to have, as we 
call it, an off-the-floor markup sometime soon of your 
nomination and hopefully get you confirmed before we break for 
August recess on August 7.
    But I thank you for your willingness to serve. I thank your 
family for their willingness to back you up as you serve. As 
Senator Collins said, we really look forward to working with 
you on these urgent matters of homeland defense. Thanks very 
much.
    Dr. Garza. Thank you.
    Chairman Lieberman. The hearing is adjourned.
    [Whereupon, at 11:04 a.m., the Committee was adjourned.]
















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