3 October 1998
Source: http://www.hhs.gov/progorg/asl/testify/t981002c.txt

See also FBI testimony: http://jya.com/fbi100298.htm

    1998/10/02; OPHS Testimony; Anti-Terrorism Measures

    STATEMENT OF
    ROBERT F. KNOUSS, M.D.
    DIRECTOR, OFFICE OF EMERGENCY PREPAREDNESS
    U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
    BEFORE THE
    HOUSE SUBCOMMITTEE ON NATIONAL SECURITY,
    INTERNATIONAL AFFAIRS, AND CRIMINAL JUSTICE
    COMMITTEE ON GOVERNMENT REFORM AND
    OVERSIGHT

    October 2, 1998

    Mr. Chairman and Members of the Committee,

         Thank you for inviting me to appear before you today to
    discuss activities of the 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 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.

    [Congressional Record: October 2, 1998 (Digest)]
    [Page D1088-D1091]
    From the Congressional Record Online via GPO Access [wais.access.gpo.gov]
    [DOCID:cr02oc98-2]

                            House of Representatives

    COMBATING TERRORISM

    Committee on Government Reform and Oversight: Subcommittee on National
    Security, International Affairs, and Criminal Justice held a hearing on
    Combating Terrorism: The Status of the Defense Department Domestic
    Preparedness Program. Testimony was heard from the following officials
    of the National Security and International Affairs Division, GAO:
    Richard Davis, Director, National Security Analysis; and Davi
    D'Agostino, Assistant Director, National Security Analysis; the
    following officials of the Department of Justice: Robert M. Blitzer,
    Section Chief, Domestic Terrorism/Counterterrorism Planning Section,
    National Security Division, FBI; and Michael J. Dalich, Chief of Staff,
    Office of Justice Programs; the following officials of the Department
    of Defense: Charles L. Cragin, Principal Deputy Assistant Secretary,
    Reserve Affairs; and James Q. Roberts, Principal Director, Policy and
    Missions, Office of the Assistant Secretary, Special Operations and
    Low-Intensity Conflict; and Robert Knouss, Director, Office of
    Emergency Preparedness, Department of Health and Human Services.