Mr. Chairman and Members of the Committee,
Thank you for inviting me to appear before you today to
discuss activities of the U.S. Department of Health and Human Services
(DHHS) in responding to the health and medical effects of
terrorism. I am Dr. Robert Knouss, Director of the DHHS Office of
Emergency Preparedness (OEP).
The first link in the response chain to any terrorist incident
in the United States will be local in nature and will be
supplemented by state and federal assistance. This is why local
capability and capacity building is absolutely crucial to reducing
preventable mortality and morbidity caused by terrorist attacks.
The critical issues are the level of preparedness, rapidity of
response, and the integration of all levels of government that will
result in either the success or failure of our nation's ability to
respond to a major terrorist attack.
My remarks today are organized in the following manner:
First, OEP's role and the role of the National Disaster Medical
System; second, the Department's role in implementing the
Domestic Preparedness Program with emphasis on our "bottom up"
strategy and the development of local Metropolitan Medical
Response Systems; third, the unique challenge of biological attacks;
and fourth, some comments on two recent GAO reports, one of
which is still in draft.
OEP coordinates the health and medical emergency
preparedness activities within DHHS, and is the lead DHHS
organization to coordinate disaster and emergency activities with
other federal agencies, including the FBI and DOD. DHHS is the
primary agency that provides the health and medical response under
the Federal Emergency Management Agency (FEMA) Federal
Response Plan. We also manage the National Disaster Medical
System (NDMS). NDMS is a partnership between DHHS, the
Departments of Defense and Veterans Affairs, FEMA, 7,000 private
citizens across the country who volunteer their time and expertise as
members of response teams to provide medical and support care to
disaster victims, and more than 2,000 participating non-federal
hospitals.
Disaster Response Teams
Our primary response capability is organized in teams such
as Disaster Medical Assistance Teams (DMATs), specialty medical
teams (such as burn and pediatric) and Disaster Mortuary Teams
(DMORTs). Our 24 level-1 DMATs can be federalized and ready
to deploy within hours and can be self sufficient on-the-scene for 72
hours. This means that they carry their own water, portable
generators, pharmaceuticals and medical supplies, cots, tents,
communications and other mission essential equipment. These
teams have been sent to many areas in the aftermath of disasters in
support of FEMA-coordinated relief activities.
In addition, staff from OEP and our regional emergency
coordinators also go to the disaster sites to manage the team
activities and ensure that they can operate effectively. Within the
last week alone, we have deployed to the Virgin Islands, Puerto
Rico, Florida, Mississippi and Alabama to assist with relief efforts
after Hurricane Georges.
Our mortuary teams can assist local medical examiner
offices during disasters, or in the aftermath of airline and other
transportation accidents, when called in by the National
Transportation Safety Board.
To make maximum use of our resources, we also allow state
governments to activate our teams as state resources, if necessary.
Special National Medical Response Teams for Weapons of Mass
Destruction
Last year, we provided additional training and specialized
equipment to three of our DMATs, to develop a specialized
capability known as National Medical Response Teams (NMRTs).
These teams, in North Carolina, Colorado, and California, are
capable of providing medical treatment after a chemical or
biological terrorist event. They are fully deployable to incident
sites anywhere in the country with a cache of specialized
pharmaceuticals to treat up to 1,000 patients. They also have
specialized personal protective equipment, detection devices and
patient decontamination capability. A fourth NMRT is located in
the National Capital Area and remains locally to respond in our
nation's capital.
Metropolitan Medical Strike Team Systems
Several years prior to initiation of the Domestic
Preparedness Program, DHHS realized that the nation was not
prepared to deal with the health effects of terrorism, and that should
a chemical, nuclear or bombing terrorist event occur, our cities and
local metropolitan areas would bear the brunt of coping with its
effects. In addition, we realized that the local medical
communities would be faced with severe problems, including
overload of hospital emergency rooms, medical personnel injured
while responding, and potential contamination of emergency rooms
or entire hospitals.
Consequently, in FY 1995, HHS began developing the first
prototype Metropolitan Medical Strike Team in partnership with the
Metropolitan Washington Council of Governments and their 18
local member jurisdictions in and around Washington, D.C. This
system became the prototype for the team that we developed in
Atlanta in 1996 to prepare for the Centennial Olympic Games, and
for the 25 systems that we began in 1997 as part of the Domestic
Preparedness Program. The FY 1999 budget currently before
Congress includes a total of $14 million to begin additional local Metropolitan Medical
Response Systems and to supplement systems already begun with a
bioterrorism component. We hope to begin development of 24
additional local systems in the coming fiscal year.
Systems Approach to Preparedness
To put this system in perspective, this chart (Chart 1)
depicts the systems approach to preparedness during a chemical
incident. As you can see, once the incident occurs, the local first
responders - police, fire, emergency medical services - would
respond. HAZMAT teams would be called in to provide agent
identification and hot zone management. These first two actions
have been the focus of DOD, FEMA, and the Department of Justice
(DOJ) under the Domestic Preparedness Program.
Our focus has been on the development of Metropolitan
Medical Response Systems, which are components of local, city
systems that would be called in to provide triage, medical treatment
and patient decontamination. The city systems that we have been
developing would then be able to transport "clean patients" to
hospitals or other medical facilities for continued care. The
hospitals are developing procedures to ensure that patients coming
in would be decontaminated before entering the facility where they
would be treated for their exposures. They are also developing
procedures to determine which patients should remain in the
hospital, and which patients can and should be moved to facilities
elsewhere in the city or in other cities for care, if necessary.
Through NDMS, DOD can evacuate these patients to VA and
DOD-managed NDMS Federal Coordinating Center areas across
the country where participating non-federal hospitals have NDMS
beds available should patients need to be relocated out of an
affected area. In addition, our response team doctors, nurses and
support staff can help relieve or augment overburdened hospital
staff.
Domestic Preparedness Program
As legislated, DHHS'role in the Domestic Preparedness
Program was the development of Metropolitan Medical Strike
Team systems. The purpose of these systems is to ensure that a
city's health system is able to cope with the injuries and chaos that
results from a terrorist act. DHHS has contracted with 27 cities to
date. Because each city has a public safety and public health
system with unique characteristics, the contracts specify that each
city will develop an enhanced health and medical response system,
within their current emergency response structure. These Systems
provide an integrated pre-hospital, hospital and public health
response capability to local metropolitan areas. Each system must
ensure that health workers be able to recognize a chemical injury,
know the proper treatments (or know where to get the information),
be able to ensure that medical facilities do not become
contaminated, and that the local system is integrated with state
plans. Our goal is to develop 120 of these medical response
systems across the country.
The DHHS program is a health systems development
program, not an equipment or training program. If a city identifies
equipment as one of its cost elements under the contract, DHHS
requests that DOD, FEMA, VA, FBI, DOE and EPA review the list
and comment on it, to eliminate any duplicate equipment purchases
by the federal government. Training is not usually one of the cost
elements under our contracts. In fact, training requirements which
are identified are referred to our interagency partners.
Biological Incident
However, these activities to date have primarily dealt with
the consequences of a chemical or nuclear attack, or a bombing. A
different response is needed should biological attack occur. We
may not know for days that a biological event has occurred, until
local health departments have reported clusters of unexplained
symptoms or deaths. This second chart
(Chart 2) shows the necessary actions to effectively respond to an
attack with a biological weapon.
Local and state health departments must have effective
surveillance programs in place to be able to detect that a biological
event has occurred, and then must be able to identify the bacteria,
virus, toxin or other organism being used. Appropriate treatment
(such as antibiotics, antivirals and vaccines) must rapidly be made
available to prevent those exposed from becoming ill and to treat
those who are already symptomatic. Today, in many cases, the
specific drugs needed are not available in sufficient quantity to treat
large number of unexpected patients at multiple sites across the
U.S. This is why DHHS has proposed a national pharmaceutical
stockpile of antibiotics and other medications to treat victims of
biological agents such as anthrax, plague, tularemia and botulism.
Mass patient care, mass fatality management, and
environmental clean up may also be required. The NDMS would
mobilize to help assure that patients can access needed services.
It may be used to agument local medical resources, including
pharmaceuticals, or it may assist in assuring safe transportation of
patients to other regions where the hospital systems have unused
capacity.
General Accounting Office Reports
After this brief description, I would like to offer a few
comments about GAO's recent draft report on "Combating
Terrorism: Opportunities Exist to Gain Focus and Efficiencies in
the Nunn-Lugar-Domenici Domestic Preparedness Program"
(September 1998).
The report made reference to the lack of a "sound
assessment process, such as a threat and risk assessment" for the
120 cities included in the program. I am concerned that threats are evanescent -- what may be valid today may not be valid in the
future. We believe that population density continues to be a valid
basis for measuring risk. Within the funds available for
preparedness activities, this interagency approach has focused on
population centers of our nation in their descending order of size.
The report mentions that the training subcommittee formed
by the interagency group made little progress in compiling a list of
terrorism related courses. DHHS' Public Health Service (PHS)
was represented on this DOD lead training subcommittee and
through substantial effort, the subcommittee did, in fact, generate a
rather comprehensive compendium of existing courses.
The report also recommended consolidating training and
equipment delivery locations on a regional basis. In a chemical
response, it is important to note that capabilities/assets are almost
immediately required. A regional approach could prolong response
time for local jurisdictions. The time factor in a chemical response
is crucial.
Summary
The U.S. Department of Health and Human Services through the
Public Health Service is committed to assuring the health and
medical care of our citizens. We are prepared to quickly mobilize
the professionals required to respond to a disaster anywhere in the
U.S. and its territories and to assist local medical response systems
in dealing with extraordinary situations, including meeting the
challenge of responding to the health and medical effects of
terrorism.
Mr. Chairman, that concludes my remarks. I would be
pleased to answer any questions you may have.
