Bioterrorism: Coordination and Preparedness (05-OCT-01, 	 
GAO-02-129T).							 
								 
Preparing to respond to the public health and medical		 
consequences of a bioterrorist attack poses some challenges that 
are different from those in other types of terrorist attacks,	 
such as bombings. This testimony discusses findings from a	 
September 2001 GAO report on the activities of federal agencies  
to prepare the nation to respond to the public and medical	 
consequences of a bioterrorist attack. Federal departments and	 
agencies are participating in a variety of research and 	 
preparedness activities, from improving the detection of	 
biological agents to developing a national stockpile of 	 
pharmaceuticals to treat victims of disasters. Federal		 
departments and agencies have engaged in a number of efforts to  
coordinate these activities on a formal and informal basis, such 
as interagency work groups. Despite these efforts, coordination  
between departments and agencies is fragmented. However, there	 
have been recent efforts to improve coordination across federal  
departments and agencies. GAO also found emerging concerns about 
the preparedness of state and local jurisdictions, including	 
insufficient state and local planning for response to terrorist  
events, inadequacies in the public health infrastructure, a lack 
of hospital participation in training on terrorism and emergency 
response planning, insufficient capabilities for treating mass	 
casualties, and the timely availability of medical teams and	 
resources in an emergency.					 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-02-129T					        
    ACCNO:   A02155						        
  TITLE:     Bioterrorism: Coordination and Preparedness	      
     DATE:   10/05/2001 
  SUBJECT:   Biological warfare 				 
	     Chemical warfare					 
	     Disaster relief aid				 
	     Emergency medical services 			 
	     Emergency preparedness				 
	     Infectious diseases				 
	     Interagency relations				 
	     Terrorism						 
	     FEMA Federal Response Plan 			 
	     HSS Bioterrorism Preparedness and			 
	     Response Program					 
								 

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GAO-02-129T
     
Testimony Before the Subcommittee on Government Efficiency, Financial
Management, and Intergovernmental Relations, Committee on Government Reform,
House of Representatives

United States General Accounting Office

GAO For Release on Delivery Expected at 10: 00 a. m. Friday, October 5, 2001
BIOTERRORISM

Coordination and Preparedness

Statement of Janet Heinrich Director, Health Care- Public Health Issues

GAO- 02- 129T

Page 1 GAO- 02- 129T

Mr. Chairman and Members of the Subcommittee: I appreciate the opportunity
to be here today to discuss our work on the activities of federal agencies
to prepare the nation to respond to the public health and medical
consequences of a bioterrorist attack. 1 Preparing to respond to the public
health and medical consequences of a bioterrorist attack poses some
challenges that are different from those in other types of terrorist
attacks, such as bombings. On September 28, 2001, we released a report 2
that describes (1) the research and preparedness activities being undertaken
by federal departments and agencies to manage the consequences of a
bioterrorist attack, 3 (2) the coordination of these activities, and (3) the
findings of reports on the preparedness of state and local jurisdictions to
respond to a bioterrorist attack. My testimony will summarize the detailed
findings included in our report, which augments our previous work on
combating terrorism. 4

In summary, we found that federal departments and agencies are participating
in a variety of research and preparedness activities, from improving the
detection of biological agents to developing a national stockpile of
pharmaceuticals to treat victims of disasters. Federal departments and
agencies have engaged in a number of efforts to coordinate these activities
on a formal and informal basis, such as interagency work groups. Despite
these efforts, we found evidence that coordination between departments and
agencies is fragmented. We did, however, find recent actions to improve
coordination across federal departments and agencies. In addition, we found
emerging concerns about the preparedness of state and local jurisdictions,
including insufficient state and local planning for response to terrorist
events, inadequacies in the public health infrastructure, a lack of hospital
participation in training

1 Bioterrorism is the threat or intentional release of biological agents
(viruses, bacteria, or their toxins) for the purposes of influencing the
conduct of government or intimidating or coercing a civilian population.

2 See Bioterrorism: Federal Research and Preparedness Activities (GAO- 01-
915, Sept. 28, 2001). This report was mandated by the Public Health
Improvement Act of 2000 (P. L. 106- 505, sec. 102).

3 We conducted interviews with and obtained information from the Departments
of Agriculture, Commerce, Defense, Energy, Health and Human Services,
Justice, Transportation, the Treasury, and Veterans Affairs; the
Environmental Protection Agency; and the Federal Emergency Management
Agency.

4 See the list of related GAO products at the end of this statement.

Page 2 GAO- 02- 129T

on terrorism and emergency response planning, insufficient capabilities for
treating mass casualties, and the timely availability of medical teams and
resources in an emergency.

A domestic bioterrorist attack is considered to be a low- probability event,
in part because of the various difficulties involved in successfully
delivering biological agents to achieve large- scale casualties. 5 However,
a number of cases involving biological agents, including at least one
completed bioterrorist act and numerous threats and hoaxes, 6 have occurred
domestically. In 1984, a group intentionally contaminated salad bars in
restaurants in Oregon with salmonella bacteria. Although no one died, 751
people were diagnosed with foodborne illness. Some experts predict that more
domestic bioterrorist attacks are likely to occur.

The burden of responding to such an attack would fall initially on personnel
in state and local emergency response agencies. These ?first

responders? include firefighters, emergency medical service personnel, law
enforcement officers, public health officials, health care workers
(including doctors, nurses, and other medical professionals), and public
works personnel. If the emergency required federal disaster assistance,
federal departments and agencies would respond according to responsibilities
outlined in the Federal Response Plan. 7 Several groups, including the
Advisory Panel to Assess Domestic Response Capabilities for Terrorism
Involving Weapons of Mass Destruction (known as the Gilmore Panel), have
assessed the capabilities at the federal, state, and local levels to respond
to a domestic terrorist incident involving a weapon of mass

5 See Combating Terrorism: Need for Comprehensive Threat and Risk
Assessments of Chemical and Biological Attacks (GAO/ NSIAD- 99- 163, Sept.
14, 1999), pp. 10- 15, for a discussion of the ease or difficulty for a
terrorist to create mass casualties by making or using chemical or
biological agents without the assistance of a state- sponsored program.

6 For example, in January 2000, threatening letters were sent to a variety
of recipients, including the Planned Parenthood office in Naples, Florida,
warning of the release of anthrax. Federal authorities found no signs of
anthrax or any other traces of harmful substances and determined these
incidences to be hoaxes.

7 The Federal Response Plan, originally drafted in 1992 and updated in 1999,
is authorized under the Robert T. Stafford Disaster Relief and Emergency
Assistance Act (Stafford Act; P. L. 93- 288 as amended). The plan outlines
the planning assumptions, policies, concept of operations, organizational
structures, and specific assignment of responsibilities to lead departments
and agencies in providing federal assistance once the President has declared
an emergency requiring federal assistance. Background

Page 3 GAO- 02- 129T

destruction (WMD), that is, a chemical, biological, radiological, or nuclear
agent or weapon. 8

While many aspects of an effective response to a bioterrorism are the same
as those for any disaster, there are some unique features. For example, if a
biological agent is released covertly, it may not be recognized for a week
or more because symptoms may not appear for several days after the initial
exposure and may be misdiagnosed at first. In addition, some biological
agents, such as smallpox, are communicable and can spread to others who were
not initially exposed. These differences require a type of response that is
unique to bioterrorism, including infectious disease surveillance, 9
epidemiologic investigation, 10 laboratory identification of biological
agents, and distribution of antibiotics to large segments of the population
to prevent the spread of an infectious disease. However, some aspects of an
effective response to bioterrorism are also important in responding to any
type of large- scale disaster, such as providing emergency medical services,
continuing health care services delivery, and managing mass fatalities.

8 Some agencies define WMDs to include large conventional explosives as
well. 9 Disease surveillance systems provide for the ongoing collection,
analysis, and dissemination of data to prevent and control disease. 10
Epidemiological investigation is the study of patterns of health or disease
and the factors that influence these patterns.

Page 4 GAO- 02- 129T

Federal spending on domestic preparedness for terrorist attacks involving
WMDs has risen 310 percent since fiscal year 1998, to approximately $1.7
billion in fiscal year 2001, and may increase significantly after the events
of September 11, 2001. However, only a portion of these funds were used to
conduct a variety of activities related to research on and preparedness for
the public health and medical consequences of a bioterrorist attack. We
cannot measure the total investment in such activities because departments
and agencies provided funding information in various forms- as
appropriations, obligations, or expenditures. Because the funding
information provided is not equivalent, 11 we summarized funding by
department or agency, but not across the federal government (see apps. I and
II). 12

Research is currently being done to enable the rapid identification of
biological agents in a variety of settings; develop new or improved
vaccines, antibiotics, and antivirals to improve treatment and vaccination
for infectious diseases caused by biological agents; and develop and test
emergency response equipment such as respiratory and other personal
protective equipment. Appendix I provides information on the total reported
funding for all the departments and agencies carrying out research, along
with examples of this research.

The Department of Agriculture (USDA), Department of Defense (DOD),
Department of Energy, Department of Health and Human Services (HHS),
Department of Justice (DOJ), Department of the Treasury, and the
Environmental Protection Agency (EPA) have all sponsored or conducted

11 For example, an agency providing appropriations is not necessarily
indicating the level of its commitments (that is, obligations) or
expenditures for that year- only the amount of budget authority made
available to it by the Congress, some of which may be unspent. Similarly, an
agency that provided expenditure information for fiscal year 2000 may have
obligated the funds in fiscal year 1999 based on an appropriation for fiscal
year 1998. To simplify presentation, we generally refer to all the budget
data we received from agencies as ?reported funding.?

12 Although there are generally no specific appropriations for activities on
bioterrorism, some departments and agencies did provide estimates of the
funds they were devoting to activities on bioterrorism. Other departments
and agencies provided estimates for overall terrorism activities but were
unable to provide funding amounts for activities on bioterrorism
specifically. Still others stated that their activities were relevant for
bioterrorism, but they were unable to specify the funding amounts. Funding
levels for activities on terrorism, including bioterrorism, were reported
for activities prior to the 2001 Emergency Supplemental Appropriations Act
for Recovery From and Response to Terrorist Attacks on the United States (P.
L. 107- 38). Federal Departments

and Agencies Reported a Variety of Research and Preparedness Activities

Research Activities Focus on Detection, Treatment, Vaccination, and
Equipment

Page 5 GAO- 02- 129T

projects to improve the detection and characterization of biological agents
in a variety of different settings, from water to clinical samples (such as
blood). For example, EPA is sponsoring research to improve its ability to
detect biological agents in the water supply. Some of these projects, such
as those conducted or sponsored by the DOD and DOJ, are not primarily for
the public health and medical consequences of a bioterrorist attack against
the civilian population, but could eventually benefit research for those
purposes.

Departments and agencies are also conducting or sponsoring studies to
improve treatment and vaccination for diseases caused by biological agents.
For example, HHS? projects include basic research sponsored by the National
Institutes of Health to develop drugs and diagnostics and applied research
sponsored by the Agency for Healthcare Research and Quality to improve
health care delivery systems by studying the use of information systems and
decision support systems to enhance preparedness for the delivery of medical
care in an emergency.

In addition, several agencies, including the Department of Commerce?s
National Institute of Standards and Technology and the DOJ?s National
Institute of Justice are conducting research that focuses on developing
performance standards and methods for testing the performance of emergency
response equipment, such as respirators and personal protective equipment.

Federal departments? and agencies? preparedness efforts have included
efforts to increase federal, state, and local response capabilities, develop
response teams of medical professionals, increase availability of medical
treatments, participate in and sponsor terrorism response exercises, plan to
aid victims, and provide support during special events such as presidential
inaugurations, major political party conventions, and the Superbowl. 13
Appendix II contains information on total reported funding for all the
departments and agencies with bioterrorism preparedness activities, along
with examples of these activities.

13 Presidential Decision Directive 62, issued May 22, 1998, created a
category of special events called National Security Special Events, which
are events of such significance that they warrant greater federal planning
and protection than other special events. Preparedness Efforts

Include Multiple Actions

Page 6 GAO- 02- 129T

Several federal departments and agencies, such as the Federal Emergency
Management Agency (FEMA) and the Centers for Disease Control and Prevention
(CDC), have programs to increase the ability of state and local authorities
to successfully respond to an emergency, including a bioterrorist attack.
These departments and agencies contribute to state and local jurisdictions
by helping them pay for equipment and develop emergency response plans,
providing technical assistance, increasing communications capabilities, and
conducting training courses.

Federal departments and agencies have also been increasing their own
capacity to identify and deal with a bioterrorist incident. For example,
CDC, USDA, and the Food and Drug Administration (FDA) are improving
surveillance methods for detecting disease outbreaks in humans and animals.
They have also established laboratory response networks to maintain state-
of- the- art capabilities for biological agent identification and
characterization of human clinical samples.

Some federal departments and agencies have developed teams to directly
respond to terrorist events and other emergencies. For example, HHS? Office
of Emergency Preparedness (OEP) created Disaster Medical Assistance Teams to
provide medical treatment and assistance in the event of an emergency. Four
of these teams, known as National Medical Response Teams, are specially
trained and equipped to provide medical care to victims of WMD events, such
as bioterrorist attacks.

Several agencies are involved in increasing the availability of medical
supplies that could be used in an emergency, including a bioterrorist
attack. CDC?s National Pharmaceutical Stockpile contains pharmaceuticals,
antidotes, and medical supplies that can be delivered anywhere in the United
States within 12 hours of the decision to deploy. The stockpile was deployed
for the first time on September 11, 2001, in response to the terrorist
attacks on New York City.

Federally initiated bioterrorism response exercises have been conducted
across the country. For example, in May 2000, many departments and agencies
took part in the Top Officials 2000 exercise (TOPOFF 2000) in Denver,
Colorado, which featured the simulated release of a biological

Page 7 GAO- 02- 129T

agent. 14 Participants included local fire departments, police, hospitals,
the Colorado Department of Public Health and the Environment, the Colorado
Office of Emergency Management, the Colorado National Guard, the American
Red Cross, the Salvation Army, HHS, DOD, FEMA, the Federal Bureau of
Investigation (FBI), and EPA.

Several agencies also provide assistance to victims of terrorism. FEMA can
provide supplemental funds to state and local mental health agencies for
crisis counseling to eligible survivors of presidentially declared
emergencies. In the aftermath of the recent terrorist attacks, HHS released
$1 million in funding to New York State to support mental health services
and strategic planning for comprehensive and long- term support to address
the mental health needs of the community. DOJ?s Office of Justice Programs
(OJP) also manages a program that provides funds for victims of terrorist
attacks that can be used to provide a variety of services, including mental
health treatment and financial assistance to attend related criminal
proceedings.

Federal departments and agencies also provide support at special events to
improve response in case of an emergency. For example, CDC has deployed a
system to provide increased surveillance and epidemiological capacity
before, during, and after special events. Besides improving emergency
response at the events, participation by departments and agencies gives them
valuable experience working together to develop and practice plans to combat
terrorism.

Federal departments and agencies are using a variety of interagency plans,
work groups, and agreements to coordinate their activities to combat
terrorism. However, we found evidence that coordination remains fragmented.
For example, several different agencies are responsible for various
coordination functions, which limits accountability and hinders unity of
effort; several key agencies have not been included in bioterrorism- related
policy and response planning; and the programs that agencies have developed
to provide assistance to state and local governments are similar and
potentially duplicative. The President

14 In addition to simulating a bioterrorism attack in Denver, the exercise
also portrayed a chemical weapons incident in Portsmouth, New Hampshire. A
concurrent exercise, referred to as National Capital Region 2000, simulated
a radiological event in the greater Washington, D. C., area. Fragmentation

Remains Despite Efforts to Coordinate Federal Programs

Page 8 GAO- 02- 129T

recently took steps to improve oversight and coordination, including the
creation of the Office of Homeland Security.

Over 40 federal departments and agencies have some role in combating
terrorism, and coordinating their activities is a significant challenge. We
identified over 20 departments and agencies as having a role in preparing
for or responding to the public health and medical consequences of a
bioterrorist attack. Appendix III, which is based on the framework given in
the Terrorism Incident Annex of the Federal Response Plan, shows a sample of
the coordination efforts by federal departments and agencies with
responsibilities for the public health and medical consequences of a
bioterrorist attack, as they existed prior to the recent creation of the
Office of Homeland Security. This figure illustrates the complex
relationships among the many federal departments and agencies involved.

Departments and agencies use several approaches to coordinate their
activities on terrorism, including interagency response plans, work groups,
and formal agreements. Interagency plans for responding to a terrorist
incident help outline agency responsibilities and identify resources that
could be used during a response. For example, the Federal Response Plan
provides a broad framework for coordinating the delivery of federal disaster
assistance to state and local governments when an emergency overwhelms their
ability to respond effectively. The Federal Response Plan also designates
primary and supporting federal agencies for a variety of emergency support
operations. For example, HHS is the primary agency for coordinating federal
assistance in response to public health and medical care needs in an
emergency. HHS could receive support from other agencies and organizations,
such as DOD, USDA, and FEMA, to assist state and local jurisdictions.

Interagency work groups are being used to minimize duplication of funding
and effort in federal activities to combat terrorism. For example, the
Technical Support Working Group is chartered to coordinate interagency
research and development requirements across the federal government in order
to prevent duplication of effort between agencies. The Technical Support
Working Group, among other projects, helped to identify research needs and
fund a project to detect biological agents in food that can be used by both
DOD and USDA.

Formal agreements between departments and agencies are being used to share
resources and knowledge. For example, CDC contracts with the Department of
Veterans Affairs (VA) to purchase drugs and medical Departments and Agencies

Use a Variety of Methods to Coordinate Activities

Page 9 GAO- 02- 129T

supplies for the National Pharmaceutical Stockpile because of VA?s
purchasing power and ability to negotiate large discounts.

Overall coordination of federal programs to combat terrorism is fragmented.
15 For example, several agencies have coordination functions, including DOJ,
the FBI, FEMA, and the Office of Management and Budget. Officials from a
number of the agencies that combat terrorism told us that the coordination
roles of these various agencies are not always clear and sometimes overlap,
leading to a fragmented approach. We have found that the overall
coordination of federal research and development efforts to combat terrorism
is still limited by a number of factors, including the compartmentalization
or security classification of some research efforts. 16 The Gilmore Panel
also concluded that the current coordination structure does not provide for
the requisite authority or accountability to impose the discipline necessary
among the federal agencies involved. 17

The multiplicity of federal assistance programs requires focus and attention
to minimize redundancy of effort. 18 Table 1 shows some of the federal
programs providing assistance to state and local governments for emergency
planning that would be relevant to responding to a bioterrorist attack.
While the programs vary somewhat in their target audiences, the potential
redundancy of these federal efforts highlights the need for scrutiny. In our
report on combating terrorism, issued on September 20, 2001, we recommended
that the President, working closely with the Congress, consolidate some of
the activities of DOJ?s OJP under FEMA. 19

15 See also Combating Terrorism: Comments on Counterterrorism Leadership and
National Strategy (GAO- 01- 556T, Mar. 27, 2001), p. 1. 16 See Combating
Terrorism: Selected Challenges and Related Recommendations (GAO- 01- 822,
Sept. 20, 2001), pp. 79, 84. 17 Advisory Panel to Assess Domestic Response
Capabilities for Terrorism Involving Weapons of Mass Destruction, Toward a
National Strategy for Combating Terrorism, Second Annual Report (Arlington,
Va.: RAND, Dec. 15, 2000), p. 7.

18 See also Combating Terrorism: Issues in Managing Counterterrorist
Programs (GAO/ T- NSIAD- 00- 145, Apr. 6, 2000), p. 8. 19 See GAO- 01- 822,
Sept. 20, 2001, pp. 104- 106. Coordination Remains

Fragmented Within the Federal Government

Page 10 GAO- 02- 129T

Table 1: Selected Federal Activities Providing Assistance to State and Local
Governments for Emergency Planning Relevant to a Bioterrorist Attack

Department or agency Activities Target audience

HHS- CDC Provides grants, technical support, and performance standards to
support bioterrorism preparedness and response planning.

State and local health agencies

HHS- OEP Enters into contracts to enhance medical response capability. The
program includes a focus on response to bioterrorism, including early
recognition, mass postexposure treatment, mass casualty care, and mass
fatality management.

Local jurisdictions (for fire, police, and emergency medical services;
hospitals; public health agencies; and other services) DOJ- OJP Assists
states in developing strategic plans.

Includes funding for training, equipment acquisition, technical assistance,
and exercise planning and execution to enhance state and local capabilities
to respond to terrorist incidents.

States (for fire, law enforcement, emergency medical, and hazardous
materials response services; hospitals; public health departments; and other
services) FEMA Provides grant assistance to support state

and local consequence management planning, training, and exercises for all
types of terrorism, including bioterrorism.

State emergency management agencies

Source: Information obtained from departments and agencies.

We have also recommended that the federal government conduct
multidisciplinary and analytically sound threat and risk assessments to
define and prioritize requirements and properly focus programs and
investments in combating terrorism. 20 Such assessments would be useful in
addressing the fragmentation that is evident in the different threat lists
of biological agents developed by federal departments and agencies.
Understanding which biological agents are considered most likely to be used
in an act of domestic terrorism is necessary to focus the investment in new
technologies, equipment, training, and planning. Several different agencies
have or are in the process of developing biological agent threat lists,
which differ based on the agencies? focus. For example, CDC collaborated
with law enforcement, intelligence, and defense agencies to

20 See Combating Terrorism: Threat and Risk Assessments Can Help Prioritize
and Target Program Investments (GAO/ NSIAD- 98- 74, Apr. 9, 1998) and GAO/
NSIAD- 99- 163, Sept. 14, 1999.

Page 11 GAO- 02- 129T

develop a critical agent list that focuses on the biological agents that
would have the greatest impact on public health. The FBI, the National
Institute of Justice, and the Technical Support Working Group are completing
a report that lists biological agents that may be more likely to be used by
a terrorist group working in the United States that is not sponsored by a
foreign government. In addition, an official at USDA?s Animal and Plant
Health Inspection Service told us that it uses two lists of agents of
concern for a potential bioterrorist attack developed through an
international process (although only some of these agents are capable of
making both animals and humans sick). According to agency officials,
separate threat lists are appropriate because of the different focuses of
these agencies. In our view, the existence of competing lists makes the
assignment of priorities difficult for state and local officials.

Fragmentation has also hindered unity of effort. Officials at the Department
of Transportation (DOT) told us that the department has been overlooked in
bioterrorism- related planning and policy. DOT officials noted that even
though the nation?s transportation centers account for a significant
percentage of the nation?s potential terrorist targets, DOT was not part of
the founding group of agencies that worked on bioterrorism issues and has
not been included in bioterrorism response plans. DOT officials also told us
that the department is supposed to deliver supplies for FEMA under the
Federal Response Plan, but it was not brought into the planning early enough
to understand the extent of its responsibilities in the transportation
process. The department learned what its responsibilities would be during
TOPOFF 2000.

In May 2001, the President asked the Vice President to oversee the
development of a coordinated national effort dealing with WMDs. 21 At the
same time, the President asked the Director of FEMA to establish an Office
of National Preparedness to implement the results of the Vice President?s
effort that relate to programs within federal agencies that address
consequence management resulting from the use of WMDs. The purpose of this
effort is to better focus policies and ensure that programs and activities
are fully coordinated in support of building the needed preparedness and
response capabilities. In addition, on September 20, 2001, the President
announced the creation of the Office of Homeland

21 According to the Office of the Vice President, as of June 2001, details
on the Vice President?s efforts had not yet been determined. Recent Actions
Seek to

Improve Coordination Across Federal Departments and Agencies

Page 12 GAO- 02- 129T

Security to lead, oversee, and coordinate a comprehensive national strategy
to protect the country from terrorism and respond to any attacks that may
occur. These actions represent potentially significant steps toward improved
coordination of federal activities. In a recent report, we listed a number
of important characteristics and responsibilities necessary for a single
focal point, such as the proposed Office of Homeland Security, to improve
coordination and accountability. 22

Nonprofit research organizations, congressionally chartered advisory panels,
government documents, and articles in peer- reviewed literature have
identified concerns about the preparedness of states and local areas to
respond to a bioterrorist attack. These concerns include insufficient state
and local planning for response to terrorist events, inadequacies in the
public health infrastructure, a lack of hospital participation in training
on terrorism and emergency response planning, insufficient capacity for
treating mass casualties from a terrorist act, and questions regarding the
timely availability of medical teams and resources in an emergency.

Questions exist regarding how effectively federal programs have prepared
state and local governments to respond to terrorism. All 50 states and
approximately 255 local jurisdictions have received or are scheduled to
receive at least some federal assistance, including training and equipment
grants, to help them prepare for a terrorist WMD incident. In 1997, FEMA
identified planning and equipment for response to nuclear, biological, and
chemical incidents as an area in need of significant improvement at the
state level. However, an October 2000 report concluded that even those
cities receiving federal aid are still not adequately prepared to respond to
a bioterrorist attack. 23

Components of the nation?s infectious disease surveillance system are also
not well prepared to detect or respond to a bioterrorist attack. Reductions
in public health laboratory staffing and training have affected the ability
of state and local authorities to identify biological agents. Even the
initial West Nile virus outbreak in 1999, which was relatively small and
occurred in an area with one of the nation?s largest local public health
agencies,

22 See GAO- 01- 822, Sept. 20, 2001, pp. 41- 42. 23 A. E. Smithson and L.-
A. Levy, Ataxia: The Chemical and Biological Terrorism Threat and the U. S.
Response (Washington, D. C.: The Henry L. Stimson Center, Oct. 2000), p.
271. Despite Federal

Efforts, Concerns Exist Regarding Preparedness at State and Local Levels

Page 13 GAO- 02- 129T

taxed the federal, state, and local laboratory resources. 24 Both the New
York State and the CDC laboratories were inundated with requests for tests,
and the CDC laboratory handled the bulk of the testing because of the
limited capacity at the New York laboratories. Officials indicated that the
CDC laboratory would have been unable to respond to another outbreak, had
one occurred at the same time. In fiscal year 2000, CDC awarded
approximately $11 million to 48 states and four major urban health
departments to improve and upgrade their surveillance and epidemiological
capabilities.

Inadequate training and planning for bioterrorism response by hospitals is a
major problem. The Gilmore Panel concluded that the level of expertise in
recognizing and dealing with a terrorist attack involving a biological or
chemical agent is problematic in many hospitals. 25 A recent research report
concluded that hospitals need to improve their preparedness for mass
casualty incidents. 26 Local officials told us that it has been difficult to
get hospitals and medical personnel to participate in local training,
planning, and exercises to improve their preparedness.

Several federal and local officials reported that there is little excess
capacity in the health care system for treating mass casualty patients.
Studies have reported that emergency rooms in some areas are routinely
filled and unable to accept patients in need of urgent care. 27 According to
one local official, the health care system might not be able to handle the
aftermath of a disaster because of the problems caused by overcrowding and
the lack of excess capacity.

Local officials are also concerned about whether the federal government
could quickly deliver enough medical teams and resources to help after a

24 See West Nile Virus Outbreak: Lessons for Public Health Preparedness
(GAO/ HEHS- 00- 180, Sept. 11, 2000), p. 21. 25 Advisory Panel to Assess
Domestic Response Capabilities for Terrorism Involving Weapons of Mass
Destruction, p. 32. 26 D. C. Wetter, W. E. Daniell, and C. D. Treser,
?Hospital Preparedness for Victims of Chemical or Biological Terrorism,?
American Journal of Public Health, Vol. 91, No. 5 (May 2001), pp. 710- 16.

27 J. R. Richards, M. L. Navarro, and R. W. Derlet, ?Survey of Directors of
Emergency Departments in California on Overcrowding,? Western Journal of
Medicine, Vol. 172 (June 2000), pp. 385- 88.

Page 14 GAO- 02- 129T

biological attack. 28 Agency officials say that federal response teams, such
as Disaster Medical Assistance Teams, could be on site within 12 to 24
hours. However, local officials who have deployed with such teams say that
the federal assistance probably would not arrive for 24 to 72 hours. Local
officials also told us that they were concerned about the time and resources
required to prepare and distribute drugs from the National Pharmaceutical
Stockpile during an emergency. Partially in response to these concerns, CDC
has developed training for state and local officials on using the stockpile
and will deploy a small staff with the supplies to assist the local
jurisdiction with distribution.

We found that federal departments and agencies are participating in a
variety of research and preparedness activities that are important steps in
improving our readiness. Although federal departments and agencies have
engaged in a number of efforts to coordinate these activities on a formal
and informal basis, we found that coordination between departments and
agencies is fragmented, as illustrated by the many and complex relationships
between federal departments and agencies shown in Appendix III. In addition,
we found concerns about the preparedness of state and local jurisdictions,
including the level of state and local planning for response to terrorist
events, inadequacies in the public health infrastructure, a lack of hospital
participation in training on terrorism and emergency response planning,
capabilities for treating mass casualties, and the timely availability of
medical teams and resources in an emergency.

Mr. Chairman, this completes my prepared statement. I would be happy to
respond to any questions you or other Members of the Subcommittee may have
at this time.

28 Smithson and Levy, p. 227. Concluding

Observations

Page 15 GAO- 02- 129T

For further information about this testimony, please contact me at (202)
512- 7118. Barbara Chapman, Robert Copeland, Marcia Crosse, Greg Ferrante,
Deborah Miller, and Roseanne Price also made key contributions to this
statement. Contact and

Acknowledgments

Page 16 GAO- 02- 129T

Total Reported Funding for Research on Bioterrorism and Terrorism by Federal
Departments and Agencies, Fiscal Year 2000 and Fiscal Year 2001

Dollars in millions Department or agency Fiscal year

2000 funding Fiscal year 2001 funding Sample activities

U. S. Department of Agriculture (USDA)- Agricultural Research Service

0 $0.5 Improving detection of biological agents Department of Energy $35.5
$39.6 Developing technologies for detecting and responding to

a bioterrorist attack Developing models of the spread of and exposure to a
biological agent after release Department of Health and Human Services
(HHS)- Agency for Healthcare Research and Quality

$5.0 0 Examining clinical training and ability of frontline medical staff to
detect and respond to a bioterrorist threat Studying use of information
systems and decision support systems to enhance preparedness for medical
care in the event of a bioterrorist event HHS- Centers for Disease Control
and Prevention (CDC) $48.2 $46.6 Developing equipment performance standards

Conducting research on smallpox and anthrax viruses and therapeutics HHS-
Food and Drug Administration (FDA) $8.8 $9.1 Licensing of vaccines for
anthrax and smallpox

Determining procedures for allowing use of not- yetapproved drugs and
specifying data needed for approval and labeling HHS- National Institutes of
Health $43.0 $49.7 Developing new therapies for smallpox virus

Developing smallpox and bacterial antigen detection system HHS- Office of
Emergency Preparedness (OEP) 0 $4.6 Overseeing a study on response systems
Department of Justice (DOJ)- Office of Justice Programs (OJP) $0.7 $4.6
Developing a biological agent detector DOJ- Federal Bureau of Investigation
0 $1.1 Conducting work on detection and characterization of

biological materials Department of the Treasury- Secret Service 0 $0.5
Developing a biological agent detector Environmental Protection Agency (EPA)
0 $0.5 Improving detection of biological agents

Note: Total reported funding refers to budget data we received from
agencies. Agencies reported appropriations, actual or estimated obligations,
or actual or estimated expenditures. An agency providing appropriations is
not necessarily indicating the level of its obligations or expenditures for
that year- only the amount of budget authority made available to it by the
Congress. Similarly, an agency that provided expenditure information for
fiscal year 2000 may have obligated the funds in fiscal year 1999 based on
an appropriation for fiscal year 1998.

Source: Information obtained from departments and agencies.

Appendix I: Funding for Research

Page 17 GAO- 02- 129T

Total Reported Funding for Preparedness Activities on Bioterrorism and
Terrorism by Federal Departments and Agencies, Fiscal Year 2000 and Fiscal
Year 2001

Dollars in millions Department or agency Fiscal year

2000 funding Fiscal year 2001 funding Sample activities

USDA- Animal and Plant Health Inspection Service

0 $0.2 Developing educational materials and training programs specifically
dealing with bioterrorism Department of Defense (DOD)- Joint Task Force for
Civil Support

$3.4 $8.7 Planning, and when directed, commanding and controlling DOD?s WMD
and high- yield explosive consequence management capabilities in support of
FEMA

DOD- National Guard $70.0 $93.3 Managing response teams that would enter a
contaminated area to gather samples for on- site evaluation DOD- U. S. Army
$29.5 $11.7 Maintaining a repository of information about chemical and

biological weapons and agents, detectors, and protection and decontamination
equipment HHS- CDC $124.9 $147.3 Awarding planning grants to state and local
health departments to

prepare bioterrorism response plans Improving surveillance methods for
detecting disease outbreaks Increasing communication capabilities in order
to improve the gathering and exchanging of information related to
bioterrorist incidents HHS- FDA $0.1 $2.1 Improving capabilities to identify
and characterize foodborne

pathogens Identifying biological agents using animal studies and
microbiological surveillance HHS- OEP $35.3 $46.1 Providing contracts to
increase local emergency response

capabilities Developing and managing response teams that can provide support
at the site of a disaster DOJ- OJP $7.6 $5.3 Helping prepare state and local
emergency responders through

training, exercises, technical assistance, and equipment programs Developing
a data collection tool to assist states in conducting their threat, risk,
and needs assessments, and in developing their preparedness strategy for
terrorism, including bioterrorism EPA $0.1 $2.0 Providing technical
assistance in identifying and decontaminating

biological agents Conducting assessments of water supply vulnerability to
terrorism, including contamination with biological agents Federal Emergency
Management Agency

$25.1 $30.3 Providing grant assistance and guidance to states for planning
and training Maintaining databases of safety precautions for biological,
chemical, and nuclear agents

Note: Total reported funding refers to budget data we received from
agencies. Agencies reported appropriations, actual or estimated obligations,
or actual or estimated expenditures. An agency providing appropriations is
not necessarily indicating the level of its obligations or expenditures for
that year- only the amount of budget authority made available to it by the
Congress. Similarly, an agency that provided expenditure information for
fiscal year 2000 may have obligated the funds in fiscal year 1999 based on
an appropriation for fiscal year 1998.

Source: Information obtained from departments and agencies.

Appendix II: Funding for Preparedness Activities

Page 18 GAO- 02- 129T

We identified the following federal departments and agencies as having
responsibilities related to the public health and medical consequences of a
bioterrorist attack:

 USDA - U. S. Department of Agriculture

 APHIS - Animal and Plant Health Inspection Service

 ARS - Agricultural Research Service

 FSIS - Food Safety Inspection Service

 OCPM - Office of Crisis Planning and Management

 DOC - Department of Commerce

 NIST - National Institute of Standards and Technology

 DOD - Department of Defense

 DARPA - Defense Advanced Research Projects Agency

 JTFCS - Joint Task Force for Civil Support

 National Guard

 U. S. Army

 DOE - Department of Energy

 HHS - Department of Health and Human Services

 AHRQ - Agency for Healthcare Research and Quality

 CDC - Centers for Disease Control and Prevention

 FDA - Food and Drug Administration

 NIH - National Institutes of Health

 OEP - Office of Emergency Preparedness

 DOJ - Department of Justice

 FBI - Federal Bureau of Investigation

 OJP - Office of Justice Programs

 DOT - Department of Transportation

 USCG - U. S. Coast Guard

 Treasury - Department of the Treasury

 USSS - U. S. Secret Service

 VA - Department of Veterans Affairs

 EPA - Environmental Protection Agency

 FEMA - Federal Emergency Management Agency Figure 1, which is based on the
framework given in the Terrorism Incident Annex of the Federal Response
Plan, shows a sample of the coordination activities by these federal
departments and agencies, as they existed prior to the recent creation of
the Office of Homeland Security. This figure illustrates the complex
relationships among the many federal departments Appendix III: Examples of
Coordination

Activities on Bioterrorism Among Federal Departments and Agencies

Page 19 GAO- 02- 129T

and agencies involved. The following coordination activities are represented
on the figure:

 OMB Oversight of Terrorism Funding. The Office of Management and Budget
established a reporting system on the budgeting and expenditure of funds to
combat terrorism, with goals to reduce overlap and improve coordination as
part of the annual budget cycle.

 Federal Response Plan - Health and Medical Services Annex. This annex in
the Federal Response Plan states that HHS is the primary agency for
coordinating federal assistance to supplement state and local resources in
response to public health and medical care needs in an emergency, including
a bioterrorist attack.

 Informal Working Group - Equipment Request Review. This group meets as
necessary to review equipment requests of state and local jurisdictions to
ensure that duplicative funding is not being given for the same activities.

 Agreement on Tracking Diseases in Animals That Can Be Transmitted to
Humans. This group is negotiating an agreement to share information and
expertise on tracking diseases that can be transmitted from animals to
people and could be used in a bioterrorist attack.

 National Medical Response Team Caches. These caches form a stockpile of
drugs for OEP?s National Medical Response Teams.

 Domestic Preparedness Program. This program was formed in response to the
National Defense Authorization Act of Fiscal Year 1997 (P. L. 104- 201) and
required DOD to enhance the capability of federal, state, and local
emergency responders regarding terrorist incidents involving WMDs and high-
yield explosives. As of October 1, 2000, DOD and DOJ share responsibilities
under this program.

 Office of National Preparedness - Consequence Management of WMD Attack. In
May 2001, the President asked the Director of FEMA to establish this office
to coordinate activities of the listed agencies that address consequence
management resulting from the use of WMDs.

 Food Safety Surveillance Systems. These systems are FoodNet and PulseNet,
two surveillance systems for identifying and characterizing contaminated
food.

 National Disaster Medical System. This system, a partnership between
federal agencies, state and local governments, and the private sector, is
intended to ensure that resources are available to provide medical services
following a disaster that overwhelms the local health care resources.

 Collaborative Funding of Smallpox Research. These agencies conduct
research on vaccines for smallpox.

Page 20 GAO- 02- 129T

 National Pharmaceutical Stockpile Program. This program maintains
repositories of life- saving pharmaceuticals, antidotes, and medical
supplies that can be delivered to the site of a biological (or other)
attack.

 National Response Teams. The teams constitute a national planning, policy,
and coordinating body to provide guidance before and assistance during an
incident.

 Interagency Group for Equipment Standards. This group develops and
maintains a standardized equipment list of essential items for responding to
a terrorist WMD attack. (The complete name of this group is the Interagency
Board for Equipment Standardization and Interoperability.)

 Force Packages Response Team. This is a grouping of military units that
are designated to respond to an incident.

 Cooperative Work on Rapid Detection of Biological Agents in Animals,
Plants, and Food. This cooperative group is developing a system to improve
on- site rapid detection of biological agents in animals, plants, and food.

Page 21 GAO- 02- 129T

Figure 1: Examples of Coordination Activities on Bioterrorism Among Federal
Departments and Agencies

Page 22 GAO- 02- 129T

Page 23 GAO- 02- 129T

Bioterrorism: Federal Research and Preparedness Activities (GAO- 01- 915,
Sept. 28, 2001).

Combating Terrorism: Selected Challenges and Related Recommendations (GAO-
01- 822, Sept. 20, 2001).

Combating Terrorism: Comments on H. R. 525 to Create a President?s Council
on Domestic Terrorism Preparedness (GAO- 01- 555T, May 9, 2001).

Combating Terrorism: Accountability Over Medical Supplies Needs Further
Improvement (GAO- 01- 666T, May 1, 2001).

Combating Terrorism: Observations on Options to Improve the Federal Response
(GAO- 01- 660T, Apr. 24, 2001).

Combating Terrorism: Accountability Over Medical Supplies Needs Further
Improvement (GAO- 01- 463, Mar. 30, 2001).

Combating Terrorism: Comments on Counterterrorism Leadership and National
Strategy (GAO- 01- 556T, Mar. 27, 2001).

Combating Terrorism: FEMA Continues to Make Progress in Coordinating
Preparedness and Response (GAO- 01- 15, Mar. 20, 2001).

Combating Terrorism: Federal Response Teams Provide Varied Capabilities;
Opportunities Remain to Improve Coordination (GAO- 01- 14, Nov. 30, 2000).

West Nile Virus Outbreak: Lessons for Public Health Preparedness (GAO/ HEHS-
00- 180, Sept. 11, 2000).

Combating Terrorism: Linking Threats to Strategies and Resources (GAO/ T-
NSIAD- 00- 218, July 26, 2000).

Chemical and Biological Defense: Observations on Nonmedical Chemical and
Biological R& D Programs (GAO/ T- NSIAD- 00- 130, Mar. 22, 2000).

Combating Terrorism: Need to Eliminate Duplicate Federal Weapons of Mass
Destruction Training (GAO/ NSIAD- 00- 64, Mar. 21, 2000).

Combating Terrorism: Chemical and Biological Medical Supplies Are Poorly
Managed (GAO/ T- HEHS/ AIMD- 00- 59, Mar. 8, 2000). Related GAO Products

Page 24 GAO- 02- 129T

Combating Terrorism: Chemical and Biological Medical Supplies Are Poorly
Managed (GAO/ HEHS/ AIMD- 00- 36, Oct. 29, 1999).

Food Safety: Agencies Should Further Test Plans for Responding to Deliberate
Contamination (GAO/ RCED- 00- 3, Oct. 27, 1999).

(290125)
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