Bioterrorism: Public Health and Medical Preparedness (09-OCT-01, 
GAO-02-141T).							 
								 
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, highlighting weaknesses in
the public health infrastructure that warrant special attention. 
More than 20 federal departments and agencies have a role in	 
preparing for or responding to the public health and medical	 
consequences of a bioterrorist attack. These agencies are	 
participating in a variety of 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-02-141T					        
    ACCNO:   A02223						        
  TITLE:     Bioterrorism: Public Health and Medical Preparedness     
     DATE:   10/09/2001 
  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-02-141T
     
Testimony Before the Subcommittee on Public Health, Committee on Health,
Education, Labor, and Pensions, United States Senate

United States General Accounting Office

GAO For Release on Delivery Expected at 10: 00 a. m. Tuesday, October 9,
2001 BIOTERRORISM

Public Health and Medical Preparedness

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

GAO- 02- 141T

Page 1 GAO- 02- 141T

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, highlighting weaknesses in the public
health infrastructure that we have identified in our ongoing work and which
we believe warrant special attention.

In summary, we identified more than 20 federal departments and agencies as
having a role in preparing for or responding to the public health and
medical consequences of a bioterrorist attack. These agencies are
participating in a variety of 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, a lack of hospital
participation in training on terrorism and emergency response

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). Also, see the list of
related GAO products at the end of this statement.

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.

Page 2 GAO- 02- 141T

planning, the timely availability of medical teams and resources in an
emergency, and inadequacies in the public health infrastructure. The last
includes weaknesses in the training of health care providers, communication
among responsible parties, and capacity of laboratories and hospitals,
including the ability to treat mass casualties.

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. 4 However,
a number of cases involving biological agents, including at least one
completed bioterrorist act and numerous threats and hoaxes, 5 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 were to require federal disaster
assistance, federal departments and agencies would respond according to
responsibilities outlined in the Federal Response Plan. 6 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

4 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.

5 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.

6 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- 141T

to respond to a domestic terrorist incident involving a weapon of mass
destruction (WMD), that is, a chemical, biological, radiological, or nuclear
agent or weapon. 7

While many aspects of an effective response to 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, 8
epidemiologic investigation, 9 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.

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

Page 4 GAO- 02- 141T

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, 10 we summarized funding by
department or agency, but not across the federal government (see apps. I and
II). 11 Reported funding generally shows increases from fiscal year 1998 to
fiscal year 2001. Several agencies received little or no funding in fiscal
year 1998. For example, within the Department of Health and Human Services
(HHS), the Centers for Disease Control and Prevention?s (CDC) Bioterrorism
Preparedness and Response Program was established and first received funding
in fiscal year 1999 (see app. I and app. II). Its funding has increased from
approximately $121 million at that time to approximately $194 million in
fiscal year 2001.

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

10 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.?

11 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- 141T

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, HHS, Department of Justice (DOJ), Department of the
Treasury, and the Environmental Protection Agency (EPA) have all sponsored
or conducted 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 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 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 Preparedness
Efforts

Include Multiple Actions

Page 6 GAO- 02- 141T

Superbowl. 12 Appendix II contains information on total reported funding for
all the departments and agencies with bioterrorism preparedness activities,
along with examples of these activities.

Several federal departments and agencies, such as the Federal Emergency
Management Agency (FEMA) and 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 the
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.

12 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.

Page 7 GAO- 02- 141T

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 agent. 13
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.

13 In addition to simulating a bioterrorism attack in Denver, the exercise
also simulated 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.

Page 8 GAO- 02- 141T

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 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 Fragmentation

Remains Despite Efforts to Coordinate Federal Programs

Departments and Agencies Use a Variety of Methods to Coordinate Activities

Page 9 GAO- 02- 141T

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 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.
14 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 several factors, including the compartmentalization or
security classification of some research efforts. 15 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. 16

The multiplicity of federal assistance programs requires focus and attention
to minimize redundancy of effort. 17 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

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

17 See also Combating Terrorism: Issues in Managing Counterterrorist
Programs (GAO/ T- NSIAD- 00- 145, Apr. 6, 2000), p. 8. Coordination Remains

Fragmented Within the Federal Government

Page 10 GAO- 02- 141T

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. 18

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. 19 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.

18 See GAO- 01- 822, Sept. 20, 2001, pp. 104- 106. 19 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- 141T

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 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. These lists of agents, only
some of which are capable of making both animals and humans sick, were
developed through an international process. 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 is also apparent in the composition of groups of federal
agencies involved in bioterrorism- related planning and policy. Officials at
the Department of Transportation (DOT) told us that that even though the
nation?s transportation centers account for a significant percentage of the
nation?s potential terrorist targets, the department 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
the TOPOFF 2000 exercise, which simulated a release of a biological agent.

Page 12 GAO- 02- 141T

In May 2001, the President asked the Vice President to oversee the
development of a coordinated national effort dealing with WMDs. 20 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 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. Our recent report highlighted 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. 21

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, a lack of hospital
participation in training on terrorism and emergency response planning,
questions regarding the timely availability of medical teams and resources
in an emergency, and inadequacies in the public health infrastructure. In
our view, there are weaknesses in three key areas of the public health
infrastructure: training of health care providers, communication among
responsible parties, and capacity of laboratories and hospitals, including
the ability to treat mass casualties.

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

20 According to the Office of the Vice President, as of June 2001, details
on the Vice President?s efforts had not yet been determined. 21 See GAO- 01-
822, Sept. 20, 2001, pp. 41- 42. Recent Actions Seek to

Improve Coordination Across Federal Departments and Agencies

Despite Federal Efforts, Concerns Exist Regarding Preparedness at State and
Local Levels

Page 13 GAO- 02- 141T

identified planning and equipment for response to nuclear, biological, and
chemical incidents as areas in need of significant improvement at the state
level. However, an October 2000 research report concluded that even those
cities receiving federal aid are still not adequately prepared to respond to
a bioterrorist attack. 22

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. 23 A recent research report
concluded that hospitals need to improve their preparedness for mass
casualty incidents. 24 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.

Local officials are also concerned about whether the federal government
could quickly deliver enough medical teams and resources to help after a
biological attack. 25 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 in using the stockpile
and will deploy a small staff with the supplies to assist the local
jurisdiction with distribution.

Components of the nation?s public health system are also not well prepared
to detect or respond to a bioterrorist attack. In particular, weaknesses
exist in the key areas of training, communication, and hospital and
laboratory capacity. It has been reported that physicians and nurses in

22 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. 23 Advisory Panel to Assess Domestic
Response Capabilities for Terrorism Involving Weapons of Mass Destruction,
p. 32. 24 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.

25 Smithson and Levy, p. 227.

Page 14 GAO- 02- 141T

emergency rooms and private offices, who will most likely be the first
health care workers to see patients following a bioterrorist attack, lack
the needed training to ensure their ability to make observations of unusual
symptoms and patterns. 26 Most physicians and nurses have never seen cases
of certain diseases, such as smallpox or plague, and some biological agents
initially produce symptoms that can be easily confused with influenza or
other, less virulent illnesses, leading to a delay in diagnosis or
identification. Medical laboratory personnel require training because they
also lack experience in identifying biological agents such as anthrax.

Because it could take days to weeks to identify the pathogen used in a
biological attack, good channels of communication among the parties involved
in the response are essential to ensure that the response proceeds as
rapidly as possible. Physicians will need to report their observations to
the infectious disease surveillance system. Once the disease outbreak has
been recognized, local health departments will need to collaborate closely
with personnel across a variety of agencies to bring in the needed expertise
and resources. They will need to obtain the information necessary to conduct
epidemiological investigations to establish the likely site and time of
exposure, the size and location of the exposed population, and the prospects
for secondary transmission. However, past experiences with infectious
disease response have revealed a lack of sufficient and secure channels for
sharing information. Our report last year on the initial West Nile virus
outbreak in New York City found that as the public health investigation
grew, lines of communication were often unclear, and efforts to keep
everyone informed were awkward, such as conference calls that lasted for
hours and involved dozens of people. 27

Adequate laboratory and hospital capacity is also a concern. 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, taxed
the federal, state, and local laboratory resources. 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

26 Smithson and Levy, p. 248. 27 See West Nile Virus Outbreak: Lessons for
Public Health Preparedness (GAO/ HEHS- 00- 180, Sept. 11, 2000), pp. 21- 22.

Page 15 GAO- 02- 141T

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. With regard
to hospitals, several federal and local officials reported that there is
little excess capacity in the health care system in most communities for
accepting and treating mass casualty patients. Research reports have
concluded that the patient load of a regular influenza season in the late
1990s overtaxed primary care facilities and that emergency rooms in major
metropolitan areas are routinely filled and unable to accept patients in
need of urgent care. 28

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. In addition, we remain concerned about weaknesses in
public health preparedness at the state and local levels, a lack of hospital
participation in training on terrorism and emergency response planning, the
timely availability of medical teams and resources in an emergency, and, in
particular, inadequacies in the public health infrastructure. The latter
include weaknesses in the training of health care providers, communication
among responsible parties, and capacity of laboratories and hospitals,
including the ability to treat mass casualties.

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 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. R. Derlet, J. Richards, and R.
Kravitz, ?Frequent Overcrowding in U. S. Emergency Departments,? Academic
Emergency Medicine, Vol. 8, No. 2 (2001), pp. 151- 55. Smithson and Levy, p.
262. Concluding

Observations

Page 16 GAO- 02- 141T

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 17 GAO- 02- 141T

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- yet- approved 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 18 GAO- 02- 141T

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 biological agents and

decontaminating affected areas 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 19 GAO- 02- 141T

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 and agencies involved. The
following coordination activities are represented on the figure: Appendix
III: Examples of Coordination

Activities on Bioterrorism Among Federal Departments and Agencies

Page 20 GAO- 02- 141T

 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 to
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.

 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.

Page 21 GAO- 02- 141T

 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 for 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 22 GAO- 02- 141T

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

Page 23 GAO- 02- 141T

Page 24 GAO- 02- 141T

Bioterrorism: Coordination and Preparedness (GAO- 02- 129T, Oct. 5, 2001).
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 FederalResponse
(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). Related GAO
Products

Page 25 GAO- 02- 141T

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

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).

(290135)
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