[Senate Hearing 109-612]
[From the U.S. Government Publishing Office]
S. Hrg. 109-612
ALL-HAZARDS MEDICAL PREPAREDNESS
AND RESPONSE
=======================================================================
HEARING
OF THE
SUBCOMMITTEE ON BIOTERRORISM AND PUBLIC HEALTH PREPAREDNESS
OF THE
COMMITTEE ON HEALTH, EDUCATION,
LABOR, AND PENSIONS
UNITED STATES SENATE
ONE HUNDRED NINTH CONGRESS
SECOND SESSION
ON
EXAMINING ALL-HAZARDS MEDICAL PREPAREDNESS AND RESPONSE
__________
APRIL 5, 2006
__________
Printed for the use of the Committee on Health, Education, Labor, and
Pensions
Available via the World Wide Web: http://www.access.gpo.gov/congress/
senate
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COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS
MICHAEL B. ENZI, Wyoming, Chairman
JUDD GREGG, New Hampshire EDWARD M. KENNEDY, Massachusetts
BILL FRIST, Tennessee CHRISTOPHER J. DODD, Connecticut
LAMAR ALEXANDER, Tennessee TOM HARKIN, Iowa
RICHARD BURR, North Carolina BARBARA A. MIKULSKI, Maryland
JOHNNY ISAKSON, Georgia JAMES M. JEFFORDS (I), Vermont
MIKE DeWINE, Ohio JEFF BINGAMAN, New Mexico
JOHN ENSIGN, Nevada PATTY MURRAY, Washington
ORRIN G. HATCH, Utah JACK REED, Rhode Island
JEFF SESSIONS, Alabama HILLARY RODHAM CLINTON, New York
PAT ROBERTS, Kansas
Katherine Brunett McGuire, Staff Director
J. Michael Myers, Minority Staff Director and Chief Counsel
__________
Subcommittee on Bioterrorism and Public Health Preparedness
RICHARD BURR, North Carolina, Chairman
JUDD GREGG, New Hampshire EDWARD M. KENNEDY, Massachusetts
BILL FRIST, Tennessee CHRISTOPHER J. DODD, Connecticut
LAMAR ALEXANDER, Tennessee TOM HARKIN, Iowa
MIKE DeWINE, Ohio BARBARA A. MIKULSKI, Maryland
JOHN ENSIGN, Nevada JEFF BINGAMAN, New Mexico
ORRIN G. HATCH, Utah PATTY MURRAY, Washington
PAT ROBERTS, Kansas JACK REED, Rhode Island
MICHAEL B. ENZI, Wyoming (ex
officio)
Robert Kadlec, Staff Director
David C. Bowen, Minority Staff Director
(ii)
C O N T E N T S
__________
STATEMENTS
WEDNESDAY, APRIL 5, 2006
Page
Burr, Hon. Richard, Chairman, Subcommittee on Bioterrorism and
Public Health Preparedness, opening statement.................. 1
Agwunobi, John, M.D., assistant secretary for health, U.S.
Department of Health and Human Services; Ellen Embrey, deputy
assistant secretary of Defense for Force Health Protection and
Readiness, director, Deployment Health Support, U.S. Department
of Defense; and Lawrence Deyton, M.D., chief public health and
environmental hazards officer, U.S. Department of Veterans
Affairs........................................................ 3
Inglesby, Thomas V., M.D., chief operating officer and deputy
director, Center for Biosecurity, University of Pittsburgh
Medical Center; Richard Serino, chief of department, Boston
Emergency Medical Services; Eddy A. Bresnitz, M.D., deputy
commissioner and state epidemiologist, Public Health Services
Branch, New Jersey Department of Health and Senior Services, on
behalf of the Council of State and Territorial Epidemiologists;
and Rob Gougelet, M.D., director of emergency preparedness,
Dartmouth-Hitchcock Medical Center............................. 22
Prepared statements of:
Dr. Inglesby............................................. 22
Dr. Bresnitz............................................. 31
Dr. Gougelet............................................. 33
ADDITIONAL MATERIAL
Statements, articles, publications, letters, etc.:
Response to Questions of Senator Burr by:
Dr. Serino............................................... 43
Ms. Embrey............................................... 45
(iii)
ALL-HAZARDS MEDICAL PREPAREDNESS
AND RESPONSE
----------
WEDNESDAY, APRIL 5, 2006
U.S. Senate,
Subcommittee on Bioterrorism and Public Health
Preparedness, Committee on Health, Education,
Labor, and Pensions,
Washington, DC.
The subcommittee met, pursuant to notice, at 10:06 a.m., in
Room SD-430, Dirksen Senate Office Building, Hon. Richard Burr,
chairman of the subcommittee, presiding.
Present: Senators Burr, Hatch, and Harkin.
Opening Statement of Senator Burr
Senator Burr. Good morning. I know we are going to be
joined periodically by other members of the subcommittee, but I
do want to go ahead and get started for the sake of everybody's
time.
I want to thank all of our witnesses, both panels, for
taking the time to come here to share valuable information as
we attempt to reauthorize the bioterrorism and public
preparedness bill. I want to acknowledge the incredible support
that Senator Enzi and Senator Kennedy have shown to the effort,
and I think this is truly bipartisan at every level as we begin
to wade through where we are today, and more importantly, where
we need to go tomorrow.
This roundtable continues to advance our discussions
concerning the reauthorization of the Public Health, Security,
and Bioterrorism Preparedness and Response Act of 2002. This
legislation moved the country in the right direction and
improved our public health and medical preparedness. However,
because of the growing diversity of threats, we need to
continue the progress to increase the momentum and refine our
effort.
An effective medical response to disasters requiring
Federal medical assets relies on a preestablished partnership,
coordination at Federal, State, and local levels. This
partnership must be adaptable enough to respond to all-hazard
medical disasters with well-trained, well-equipped, and rapidly
deployable assets.
As you all know firsthand, the response to disasters begins
at the local level. It is our responsibility at the Federal
level to support local and State medical capabilities by
providing integrated additional personnel, logistics support,
and operational proficiencies to assist in caring for victims
of a disaster, particularly in cases where the local resources
have been overwhelmed. State and local government responders
should know who to call at the Federal Government to get help.
Right now, it is not clear who is in charge. That is something
we definitely plan on addressing in this reauthorization.
Finally, we need to think systematically and collectively
about how best to develop surge capacity within the U.S. health
care delivery system.
I look forward to hearing from each one of our witnesses
today regarding the experiences they have. I know all bring a
different perspective to the table and this will not be the
last hearing or roundtable that the committee has, but I
believe that from a time line standpoint, we have got to begin
to firm up some draft legislation and we will do that in a
bipartisan fashion with the full and open knowledge of the
agencies that are affected in hopes that we can, at the end of
the day, find consensus not just in direction, but in details.
It is my belief that that is one of the single most important
things that this Congress will deal with as we conclude the
109th Congress.
At this time, I would like to introduce our first panel.
Our first panelist today is Assistant Secretary for Health at
the Department of Health and Human Services, Dr. Agwunobi. As
many times as I have said that, you wouldn't think I would get
tripped up. Until recently, he was Florida's Secretary of
Health and brings invaluable operational experience to an
important job at HHS. Doctor, we welcome you today.
In addition, Ms. Ellen Embrey is the Deputy Assistant
Secretary of Defense for Force Health Protection and Readiness
at the Department of Defense. She leads the Defense department-
wide efforts to develop and implement policies, programs, and
activities relating to force health protection, national
disaster support, and medical readiness. Ellen, welcome.
And last but not least, Dr. Lawrence Deyton is the Chief
Public Health and Environmental Hazards Officer at the Veterans
Health Administration within the Department of Veterans
Affairs. Before accepting his present position, he worked at
the National Institute of Allergy and Infectious Disease at NIH
and we certainly welcome you, as well.
I will go in the order that I introduced and make available
to you any opening statement you would like to make. I would
also at this time ask unanimous consent that all members be
allowed to submit opening statements for the record and
questions to the witnesses and would ask all our panelists
today to make themselves available for those written questions,
as well. Without objection, so ordered.
Doctor.
STATEMENTS OF JOHN AGWUNOBI, M.D., ASSISTANT SECRETARY FOR
HEALTH, U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES; ELLEN
EMBREY, DEPUTY ASSISTANT SECRETARY OF DEFENSE FOR FORCE HEALTH
PROTECTION AND READINESS, DIRECTOR, DEPLOYMENT HEALTH SUPPORT,
U.S. DEPARTMENT OF DEFENSE; AND LAWRENCE DEYTON, M.D., CHIEF
PUBLIC HEALTH AND ENVIRONMENTAL HAZARDS OFFICER, U.S.
DEPARTMENT OF VETERANS AFFAIRS
Dr. Agwunobi. Thank you, Senator. To save time, I will keep
my comments very short. I will start by thanking you, sir, for
this opportunity, this honor that you present us here today to
have this discussion. I should also state that your leadership
in this particular area is very clear and very well known and I
thank you.
Secretary Michael Leavitt and I have talked often and
frequently on this subject and have traveled the Nation in
recent days visiting almost every State as we talk about
pandemic influenza preparedness. But in each of those settings,
we have focused on some of the same things that you have just
mentioned, sir, related to the fact that it needs to be an all-
hazards approach, that although local and State governments
must always be a focus of preparedness for emergencies and all-
hazard-type events, that the Federal Government does play a
very critical and clear role as we move forward.
I thank you for this opportunity, sir, and look forward to
the conversation.
Senator Burr. Ellen.
Ms. Embrey. Thank you again for the opportunity to be here.
I have a written statement, overview statement that was
prepared, and I would like to submit that for the record to
save time so we can actually have a dialogue in the areas of
your interest.
Senator Burr. Great. Thank you.
Dr. Deyton.
Dr. Deyton. Senator, thank you for asking us here. I will
start out just with two personal comments. I thank you for
pronouncing my last name correctly. My daddy's family is from
Yancy County, North Carolina, and you are the only person who
has said it right the first time, and thank you for that, sir.
Senator Burr. It is a shame I messed his name up right from
the beginning, isn't it?
[Laughter.]
Dr. Deyton. Second, sir, the table situation is
uncomfortable for those of us on the administration side. We
wanted to be at the same table, so we apologize for not sitting
together.
I will dispense with my remarks, too, and just look forward
to your questions, sir.
Senator Burr. Great. I thank all of you.
Let me just say, we have got a huge task. I referred to
this in the staff meeting, that the task before us is somewhat
like herding cats because everybody has a specific area of
responsibility, and expertise within the Federal Government. I
think it is safe to say that as we have gone through this
process for now almost a year and a half on different pieces
that we feel need to be in place, the one question that always
comes up is, who is in charge? Who needs to be designated as
the individual, area, agency?
It is the plan of the subcommittee that in the next 60
days, we will go to the Gulf Coast to explore the health
infrastructure, and try to talk more in-depth about lessons
learned. What worked? What didn't work? Why was the DOD's role
in Katrina so important? Had it ever been planned for from the
standpoint of local response? If not, why not? If it was
crucial in the aftermath of that natural disaster, then how
should we, in the future, plan for it? What were the
differences that existed between Mississippi and Louisiana? Why
could you have two States side by side with what I perceive to
be totally different outcomes from a standpoint of the response
to this disaster?
I have tried to keep everybody focused on the fact that we
would make a true mistake here if our effort was not an all-
hazards approach. I think we naturally sometimes get stovepiped
within government. We get focused on the threat du jour and our
imagination isn't great enough to realize that there is another
threat around the corner. We just don't know the name of it and
we don't know the impact of it.
I truly believe that it is time that we design a model that
not only handles today's threats that we know about, but begins
to address a blueprint that can handle tomorrow's threats
without requesting that the experts come back to the Hill and
we legislatively contort ourselves to try to accommodate what,
in fact, is around the corner.
I think it is safe to say that as it relates to avian flu,
though none of us know the eventual effects, we certainly know
the threat is great enough that we have reexamined our
capabilities and one glaring deficiency was that we were
unprepared or ill prepared to produce countermeasures to offset
the degree of the threat. I believe we have sufficiently, for
the short-term, addressed the needs, but only the needs for
that one threat.
My hope is, as we reauthorize this piece of legislation,
that we will let our imaginations be a little more creative,
that we will look across the scope of the world that is
affected regardless of the artificial boundaries of agencies,
and that at the end of the day, all will agree that as we move
the deck chairs, that we are moving them so that the overall
response capabilities are, in fact, better. So, I guess we are
here today to discuss in more detail which chairs move and
where those chairs move and what our capacity is and what our
capacity should be.
Dr. Agwunobi, a proposal being discussed which was also
included in the White House's report on the response to
Hurricane Katrina is the direct command and control of NDMS and
all Federal medical response elements to HHS. If this is done,
what plans would HHS implement to assure rapid, flexible, and
sustainable Federal medical response? I guess I should ask
first, do you agree with the report from the White House and--
--
Dr. Agwunobi. Sir, I believe a lot of hard work went into
the development of that report. It was very insightful. It
reached out to all of the participants in the response to
Katrina. It was a very deliberative process, and sir, I do
concur with its recommendations.
I know for a fact that the agencies that would be
responsible for following through on the NDMS part of those
recommendations, DHS and NHHS, are currently in deliberation.
We are working very closely with them as we discuss not only
how best to potentially come through on that recommendation,
but also to assure that in going through, we don't threaten
NDMS's ability to deliver on its mission in upcoming hurricane
seasons.
So, I know that a lot of work is ongoing, as we speak, as
to trying to figure out the minute details. Should we change
the format when it is moved? If it is moved, how best would it
be to--in terms of how can we protect its ability to deliver
our services this year and in future years?
Senator Burr. Well, as a member of the Senate that
represents a State that has a coastline and that has an annual
opportunity to not just prepare but to actually practice
response, this year is very important to me. Having said that,
you know exactly what our capabilities are because you came
from a State that had an annual opportunity to not only
prepare, but to practice it, as well, and I think both of our
States rate extremely well from a standpoint of their ability
to handle up to a given point.
Dr. Agwunobi. North Carolina is one of the best, sir.
Senator Burr. Do you envision that there is any gauge that
we can use of the degree of disaster before there is an
automatic default to the Federal Government to be in charge
versus local, State, and then a Federal request?
Dr. Agwunobi. Sir, I believe strongly, and this doesn't
just relate to the fact that I am a part of a team that
supports this philosophy with Secretary Leavitt and the
President, it actually relates back to my experience at the
State level. I believe strongly that our focus should always be
on local preparedness and local response, especially if our
notion is all-hazards, because each community has different
sets of assets and each community is going to respond
differently.
So I believe that as we go about improving our system over
time, we should always have a focus on local public health,
local preparedness, local emergency response, local National
Guard and others, and then build on that. In other words, in
this constant effort to improve preparedness at the local
level, we should then assess what the role of the Federal
Government should be in filling in the gaps or in backing up
the system. I agree completely that we should always be there
as a safety net should that system fail, but I always believe,
sir, that local is better than----
Senator Burr. I agree with you totally. I would ask you
this question: Is it true that not all public health entities
mirror each other?
Dr. Agwunobi. Sure.
Senator Burr. The difficulty that we found is that a
community can have a public health infrastructure that truly
can address anything they are thrown, and 30 miles down the
road can be a public health entity that has, by default or by
choice, become the vaccination point for low-income children
and that is the extent of what they provide. Can we
legitimately go through this reauthorization without defining
what the face of public health is going to look like in the
future and set a goal that that face be replicated in every
community that we feel a public health infrastructure should
address?
Dr. Agwunobi. Sir, you bring up an excellent point. If you
have seen one local community, you have really only seen one.
There are no two that have exactly the same characteristics.
Over the last--since 2001, sir, Congress and the President,
that partnership has invested, I think, upwards of almost $8
billion through CDC and HRSA grants into preparedness at the
local level and that probably doesn't include the dollars that
have come through DHS. Those dollars are focused not only on
strengthening the individual strengths of each public health or
each emergency preparedness entity within a community, but I
think a lot of it has gone toward trying to set certain
standards across each community while allowing each community
the ability to figure its own way in terms of how it gets to
that standard based on its unique characteristics.
So, although I would concur, sir, that we do need to have
expectations of each community and each local government, I
would wager that their citizens have high expectations, as
well. But, I think we should always seek to find local
solutions as opposed to trying to apply a single cookie cutter
approach across each community.
Senator Burr. I certainly understand your answer. I am not
sure how there can be a national framework if, in fact, the
capabilities community by community have the ability to differ
to a great degree, and I think this is what this subcommittee
is struggling with right now, that if we limit this to the 12
targeted cities for chemical, biologic, radiological threats,
that is one thing. But when you begin to try to model the
country for an H5N1 threat without the consistency of knowing
what capability exists community by community, it is impossible
to put together a response--a Federal response that is in
total.
I know we are not going to find the solution out today, but
I guess my follow-up would be, is HHS open to the discussion as
to what the face of public health should look like in the
future and committed to try to achieve whatever we collectively
decide that should be?
Dr. Agwunobi. Absolutely, sir. I can say that without
hesitation, that I have heard the Secretary himself ask his
team to reach out to partners across the community to do just
that. What should the future look like? As we design a path to
that future and make that available to each community so that
they can begin figuring it out, how they are going to get
there, our role absolutely should be to help define that
future.
Senator Burr. Regardless of the community in America, who
do you perceive in that community is in charge of a natural,
deliberative, or intentional disaster? I mean, who would we
look to in a given community to be in charge?
Dr. Agwunobi. Sir, I think a natural way to look at this
is, who does the community look to when there is trouble, when
there is an emergency, when there is a crisis, and all too
often, my experience in Florida, and indeed now as I walk
around the Nation, has been that they look to their elected
leaders. They look to their Congressional representatives,
their governors, their mayors. I think Rudy Giuliani, as he
stood on that podium at 9/11, is an example of what communities
expect----
Senator Burr. I agree with you, but Mayor Giuliani was not
the one that determined where the debris went. He wasn't the
one that determined how many assets needed to come in to
support what may have been casualties that needed medical care.
He was the mouthpiece, and I think we all know if there were a
national disaster, we would look to the President for that
ability to communicate with the American people.
I am more concerned with who we default to on the ground in
charge. Who is the one that we see, regardless of the
community, that is the traffic cop deciding where the surge
capabilities are, which hospitals receive which patients? In
the event that there were contamination, who maintains the
protection of a contamination line without a decision to move
people outside of it?
Dr. Agwunobi. Sir, North Carolina has a wonderful example
of this in Leah Devlin, a great public health official, a great
officer, and she offers great leadership on issues related to
health and medical emergencies. But because emergencies like
Katrina can be so much bigger than just health and medical
issues, there needs to be someone above that level who is
coordinating all of the activities of the different functions
underneath, and so typically that is the Homeland Security
Director or the Emergency Preparedness Director--they are
called different names in different communities, but they all
serve a very common function. They help coordinate and,
therefore, lead across the individual areas.
If it is health and medical, I am pretty clear in my mind
that it needs to be at the Federal level, the Secretary of the
Department of Health and Human Services. If it is health and
medical at the State level, I am pretty clear in my mind that
it needs to be the State health officer or the Commissioner or
Secretary of Health. And then, of course, if it is at the local
level, typically, local communities have a designated health
and medical, usually a county health department officer or
director.
Senator Burr. Just out of curiosity, today, do we have a
point of contact in all the States? Do we know who they have
designated to be that person?
Dr. Agwunobi. Yes, sir. On the health and medical side,
very clearly. I can only imagine the Department of Homeland
Security, who aren't here today, also have designated or at
least contacted people in each State.
Senator Burr. In all likelihood, is that person the same
regardless of which agency is looking at it?
Dr. Agwunobi. Yes, I think it has been. There is pretty
good consensus, I think, across the Nation as to who leads the
health and medical response.
Senator Burr. So, is it safe to say that our plan, Federal
plan, identifies an individual within that State designated by
the State, regardless of the title, and then assume that they
have put together a plan for that State to respond to whatever?
Dr. Agwunobi. Yes, sir.
Senator Burr. If you had to guess today, how many States
have that plan?
Dr. Agwunobi. An emergency preparedness plan that addresses
health and medical needs?
Senator Burr. That could respond to an all-hazard threat.
Dr. Agwunobi. In fact, I think one of the requirements of
the cooperative agreement, the funding that Congress provided
through CDC and HRSA, one of the requirements was that each
State, in order to benefit from those funds, needed to show
that they had a plan to expend those funds in an efficient
manner and in a way that changes the public health and the
preparedness of their State, and I think all of the States have
actually shown that they have that ability.
Senator Burr. Ms. Embrey, some believe that DOD and the
capabilities it controls is the only Federal agency that
possesses the ability to effectively and rapidly respond to
medical events of national significance. Because of this, they
feel that DOD should take the lead in response. What are your
thoughts on how the DOD assets should be utilized, integrated
into a domestic Federal medical response?
Ms. Embrey. Well, DOD has the advantage of command and
control over its particular assets. For that reason, we are
perceived as having good coordination and the ability to
execute the assets under our control. But we are organized and
our assets are trained and equipped to function in our
warfighting missions and our peacekeeping missions, and we,
with the global war on terrorism, are engaged pretty heavily in
those activities with those assets. So the structure that
exists today in the medical community is focused on those
requirements and there is very little additional assets that
have been organized to provide domestic support.
We do have a commitment to planning. We have public health
emergency officers at all of our DOD installations whose job is
to work with the public health infrastructure outside the gates
to make sure we have an integrated response here at home. We
have an immediate response policy that authorizes all of our
installations and our assets of all types, even medical, to
provide immediate assistance where lives or property are at
stake for a short time until other assets can be brought to
bear.
DOD has strength in planning and exercising those plans,
and I believe that our biggest contribution to the readiness
for response in this country would be to participate with our
partners in establishing those kinds of training and standards
and planning that we know how to do very well and share that
with our lead agency partners.
Senator Burr. In fact, DOD participated in Determined
Promise in 2004, which was--it sort of tested DOD's ability to
assist civilian authorities in a coordinated response to
simulated chemical, radiological, and explosive hazards.
Clearly, that coordination was lacking as it related to
Katrina. As a result of that, what specific plans does DOD have
that would improve that integration when the time comes? I
guess, what did you learn?
Ms. Embrey. Oh, we learned a lot of things. We learned a
lot of things in the broad context of the response, more than
just health and medical. From a health and medical perspective,
I think we were fairly well coordinated.
I think the challenge is that for the Federal agencies
represented here, the VA and the Department of Defense have
physical assets and people around the country and it is
important that, in addition to having a national framework to
understand how we integrate with each other through the
National Incident Management System and through the various
other capabilities that we have set up to provide surge
capacity to a locality, more importantly, though, is we have
these places and people in communities and it is important that
we look at ourselves as part of that community and to plan with
that community and to plan with that public health
infrastructure and to plan with that State on how these assets
could be brought to bear immediately, not waiting for a much
larger coordinated surge.
I think the real focus here is that we need to engage our
State, local, and corporate partners, and private industry, in
creating a community by community awareness of what our
vulnerabil-
ities are and quantifying them and looking at the community as
the entirety of all of the assets in that community, whether
they are the FBI or, you know, any part of the Federal
community. If we are there, we should be part of the planning
process and agree to preestablished arrangements for roles and
responsibilities of how that community would respond and be
prepared and to identify specific gaps in capability so that
that community could work with nearby communities to fill those
gaps initially and expanding there.
My belief is, and I believe the Federal Government is
working toward a regional response model, where communities
form a region within a State, perhaps, and a region of States
becomes a region of communities, and that region of States
becomes a plan in and of itself that recognizes the core reason
why we have communities. There is some economic basis for those
communities. It is either an academic center or a corporate
town or a major government center or a financial center or
maybe a combination of all of those things.
Military bases, again, are sometimes the reason for the
existence of an entity. And so it is important for us to allow
those communities to define what is important to them and to
define and set out in a common framework what they are capable
of doing based on their population at risk, and that would have
to involve the corporate partners who have an economic
incentive to keep that city or area functioning effectively.
And once we have done that, with all of us working together
even at the local level, then bringing those together into a
framework for a national response, using the National Incident
Management System, I think is the proper way to go, and DOD is
fully prepared to participate in that way and to provide
support when needed with whatever resources we have that isn't
otherwise engaged in our DOD missions.
Senator Burr. I am going to ask one more quick question and
then I am going to allow Senator Hatch to make whatever
comments and questions that he would like.
From a standpoint of the constant use of the Guard relative
to deployment, should any of us be worried that their assets
have been depleted to a degree that any State should be alarmed
on our own capabilities to respond to disasters?
Ms. Embrey. It is a very good question, Senator. I used to
work in Reserve Affairs in the Department of Defense for a
number of years, so I feel particularly aware of the demand
that we are now placing on the National Guard. The National
Guard is somewhat schizophrenic, and I don't mean that in a
negative way. But the National Guard is a State asset to the
Governor and the legislature in each State has the authority to
assign that Guard under the authority of the Governor to
perform State missions. They may employ National Guardsmen in
that capacity that are not federally recognized to perform
those State missions underwritten by the State legislature and
the funding that comes from the State.
In addition, the National Guard has federally recognized
State employees that perform military missions. The Department
of Defense takes those federally recognized assets and assigns
specific military missions for them. In the past, it had been
less and less of a--it was primarily for combat operations and
it was primarily for surge for long-term operations. We are in
a global war on terrorism which is a long-term, but maybe not
highly intense, but it is a long-term commitment, and the way
in which we now use the National Guard is for short tours over
a period of time, which is different than it used to be.
So there is a conflict between what the Federal Government
and the military uses the National Guard for and for its
evolving State mission role under the control and command of
the Governor and the adjutant general in the States,
particularly since the adjutant general in many States is also
the emergency response coordinator in many States. This puts a
triple burden, if you will, or a double burden, at least, on
the National Guard, and we are quite sensitive to that. There
are some legislative changes that have occurred in the last
couple of years that have put even more burden on the National
Guard to perform domestic response missions underwritten by the
Department of Defense in terms of emergency response. So that
came following the anthrax attacks and the 9/11 attack.
Senator Burr. I am going to defer to Senator Hatch now. I
will come back to you, and my concern probably deals more with
equipment that is being left in theater that might have been
equipment that was assigned to the Guard, used by the Guard,
multiuse because it would be used for a State response, it is
used in the war on terror. Leaving it there, they don't have
that asset. Does that hurt us at all? But I will come back to
that.
Senator Hatch.
Senator Hatch. Thank you, Mr. Chairman. To all three of
you, if you care to answer any of these, welcome. We are proud
of you and very pleased to have you here today. We want to work
as closely with you as we possibly can.
In organizing a response to an emergency, many of the
suggestions that we have heard today or will hear today have a
top-down focus. Create a new HHS office and make HHS the
responsible agency, etc., etc. These are important concerns,
but most biohazards are likely to be regional or local and
local groups, agencies, and leaders direct and carry out the
initial efforts, as you have been pointing out. The interface
between local efforts and the engagement of broader national
assistance is a critical control point where things can go very
well or they can go very much wrong. This was an issue with the
Katrina hurricane and the flooding that occurred there.
Now, who should be the regional or local decision maker to
initiate a decision to engage broader assistance? That is
question number one. How do we assure that all regions and
localities understand the process of rules for asking for,
approving, and receiving this support? And are there Federal or
State regulations that would hinder this process? If you could
answer those.
Dr. Agwunobi. Thank you, sir. Sir, if I understand your
question correctly, I think I will respond as follows, and that
is that the National Response Plan, and indeed most State
plans, contemplate the fact that local-elected officials for
particular sovereign areas have a primary responsibility for
organizing within their teams of experts whether that be
emergency preparedness or public health, and embedded in that
responsibility is, I think in most plans, a clear process and
expectation that those individuals will call for help if they
need some.
I know that at the State level, every governor sees as a
part of their responsibility not only the maintenance of their
executive branch agencies, including emergency preparedness and
public health and their ability to respond locally, but also
this notion that they have to, on an ongoing basis, assess when
they are overwhelmed and when they need help from the Federal
Government.
Now, I also concur that the Federal Government has a
distinct role in situational awareness. We have to constantly
be aware of what the strengths and weaknesses of any given
State are, as perceived by perhaps our measurements through the
cooperative agreements for HRSA and CDC. As we invest, we have
to be sure that we know how States are doing with that
investment. But I do think that we also have to maintain the
ability to come to the assistance as soon as we sense that a
State is overwhelmed. But I still think that it should be
something that is called for by State and local communities as
opposed to something that is pushed upon them.
I am not sure if I understood your question correctly, sir.
I hope I----
Senator Hatch. You have covered part of it, that is for
sure.
Ms. Embrey, do you care to add anything to that?
Ms. Embrey. Yes, sir. I think I will address the question
relating to the last question you asked in terms of regulations
and what suggestions that we might take to improve our ability
to do this.
I think one of our challenges in medical response is how we
are organized nationally. The States have responsibility for
public health and safety and they reserve the right for
credentialing. They reserve the right for formulary. They
reserve the right for how we declare the cause and management
of deaths in the States.
During disasters, if there is a Federal response,
credentialing issues always become a problem, especially for
volunteers surging into the State. What can be brought to bear
based on the formulary in those States becomes an issue that
gets routinely waived, but it would be better if we were doing
something about it in advance.
And third, by having the capability to identify and surge
needed personnel, because each State retains its own authority
on that and it is a source of funding for the States,
especially in credentialing. I think we need to examine a
national framework that recognizes the authority and
responsibility of the State, perhaps through validation and
fund collection, but still has a national credentialing
capability. I believe that is very important for us to have an
effective national capacity. It is important for the Department
of Defense as we live everywhere. Our doctors move all the time
and they are routinely engaging in different credentialing
efforts as they move from State to State. We should have a
national standard that we all agree to across the States, but
still give the States the authority to validate that credential
as they move from State to State.
Dr. Agwunobi. If I could just add to that, over the last
few years, Congress has actually been moving in that direction
as they have helped HRSA, one of the agencies within the
Department of Health and Human Services, as it tries to develop
and disseminate standards, an emergency credentialing-type
standard across the States by investing in States, allowing
them to build credentialing systems at each State level.
Now, this year in the President's budget, there is a
request to try and link all of that activity together into a
national portal where--national is probably not the best
description, nationwide portal, a portal that States can use in
one State to check on the verification of credentials of
practitioners coming from another State rapidly because they
have been pre-credentialed in this system. We call it ESAR-VHP,
which is a number of letters that mean a very long phrase of
words, but basically it is an emergency credential verification
system that allows people ahead of time--and by the way, sir,
that is the best way to have a standing army to surge up to
health and medical needs is to have them register ahead of time
so we can do the due diligence, credential them appropriately,
and put them in a database that, in an emergency, is readily
available to everyone.
Senator Hatch. Dr. Deyton.
Dr. Deyton. Senator Hatch, several answers to your
questions. Certainly the Department of Veterans Affairs is an
extraordinarily well-endowed system to respond to local needs
or national needs and it is one of our four articulated
missions.
In terms of a national response, obviously, sir, you know
that we back up the Department of Defense for whatever medical
needs that they have in a time of declared emergency or
disaster or war. We also are obligated to work with State and
local communities in terms of responding to what their needs
are, and we do that in the context of the National Response
Plan. So we stand ready to do that whenever that is needed.
I am very glad that we are focusing on this as local issues
and local responses because that is where any action will be
required. The VA, again, is very well positioned because we are
in every community in the Nation. We have got doctors, nurses,
pharmacists, and psychologists everywhere. They are fully
engaged in taking care of veterans, but when there are
disasters or emergencies, we do ongoing planning both
nationally within the VA system as well as in communication
with State and local health departments at the lead with those
Federal agencies. We have named contacts with every State
health department to work directly with the VA.
Senator Hatch, I think another important concept that we
are just beginning to explore is the idea of Federal facility-
based deployable emergency response teams, and that is we have
Federal endowments around the Nation, largely VA but also DOD
and Public Health Service endowments, with Federal employees
who are health care workers--doctors, nurses, pharmacists, etc.
The four departments, DOD, HHS, Homeland Security, and VA, are
exploring together the concept of would it be feasible to have
established teams of health care providers at facilities who
are trained and ready to be deployed in response to an
emergency, an all-hazards emergency, to help with the surge
capacity kinds of issues.
Ms. Embrey, myself, Dr. Knable, sitting behind the
Assistant Secretary here, and Dr. Waters from Homeland Security
are all leading this effort at exploring the feasibility of
this, and I think that that is a very exciting potential to
consider. Obviously, we are working on it and we are moving
ahead with that concept.
Dr. Agwunobi. If I could just add to that, it is an analogy
of something Congress has investigated in the last few years,
the Medical Reserve Corps, which are teams of private
physicians and nurses and nurse practitioners in communities
that have come together to form teams that could be deployed
either locally or within the region, and so that would be an
analogy, where we might do the same thing over in the Federal
medical agencies and medical facilities.
Senator Hatch. With that reserve corps, I think we have
provided some language that protects the reserve corps from
liability, haven't we, or should there be language?
Dr. Agwunobi. I am not sure if we have specific language,
but clearly, they are, for the purposes of deployment, they are
part of a Federal deployment----
Senator Hatch. These are volunteers----
Dr. Agwunobi. These are volunteers, that is correct.
Senator Hatch. These are doctors who are willing to give of
their time and effort----
Dr. Agwunobi. Yes, sir. Yes, sir.
Senator Hatch. We have got to provide some means whereby
they are protected from liability should----
Dr. Agwunobi. We do need to remove every barrier we
identify.
Senator Hatch. That is something we need to work on.
Senator Burr. Is it my understanding that when those teams
are deployed, they are Federal--they are designated as Federal
assets?
Dr. Agwunobi. Yes, sir. That was my point, that if they are
a part of our response to an event, they come under our Federal
protections.
Senator Hatch. Out in Utah, we have found that that has
really helped us in rural Utah and other areas, not necessarily
in disaster situations, but just in everyday life. So we are
really excited. I am really excited about that, and that may be
a way of helping to bring down health care costs, as well. But
one of the problems that exists is that we are going to have to
provide some means whereby these people who are volunteers, who
are totally capable of serving, who are experts in their field
and who are qualified, have some degree of protection from
medical liability concerns. So it is something I think we have
to worry about on this committee and I hope that both sides,
Democrats and Republicans, will recognize the importance of
that corps that may be very helpful.
Dr. Agwunobi. Four-hundred-and-eight. I mean, the response
to this has been dramatic. Four-hundred-and-eight Medical
Reserve Corps have stood up in recent years in 49 States. I
think only North Dakota at this point, and they continue to
work on building theirs. So it has been dramatic. The
volunteerism in the health and medical providers with the
private sector across our Nation stimulated by Congress has
been absolutely dramatic.
Senator Hatch. Mr. Chairman, the reason I bring this up and
the reason I get excited about it is because there are a lot of
doctors who are going out of the profession just because of
medical liability concerns and the high cost of malpractice
insurance. But they are willing to give their time free of
charge as volunteers in our respective communities and
elsewhere. We are going to have to find some way of protecting
them and the Government is going to have to, it seems to me,
provide that. Over the long run, it would be a very efficient
cost for us.
Senator Burr. I think it is safe to say, Senator Hatch,
that there were some glitches as it related specifically to the
response of Katrina where there were some assets that were
asked to leave, where there was a delay because of the lack of
one agency or another being the one to assume the liability. I
am hopeful that internally, those glitches have worked out so
there is not a delay in the future and I feel fairly confident
in those national assets.
Senator Hatch. I am going to count on Senator Harkin and
others to assist in resolving this difficulty, because the more
we can get qualified doctors to volunteer in the local
communities--this isn't just for biohazards purposes but to
help people who otherwise would not have medical care, we are
going to have to find some way of, since they can't afford
medical liability insurance, we are going to have to find some
way where the Government backs this up. Hopefully, it will be a
wonderful combination that will help us provide medical care at
a much lower cost than what we are currently doing.
I have other questions, but I feel like I have taken enough
time.
Senator Burr. Senator Harkin.
Senator Harkin. I agree with that. I want to pick up on
what we have just been talking about since I came in. I
apologize, Mr. Chairman, for being late. Someone interrupted my
schedule. But in talking about this reserve corps and health
corps, that is all right as far as it goes, but consider what
would happen, and I want to focus on a broader theme, what
happens if we get hit with pandemic flu? We have got to have a
broader pool than what is in the reserve corps right now.
I would just say, Orrin, that I introduced a bill last
year, S. 2112, the Seasonal Flu and Pandemic Preparedness Act,
and then what we did there, the idea was to set up a pre-
cleared, pre-trained volunteer force all over America, not just
doctors or nurse practitioners but other people that--there are
a lot of nurses in this country, by the way, who went to
nursing school. They may have been a nurse for a while. They
got married, raised families. They are in our small towns and
communities all over America. I discovered this in my State of
Iowa. They have some background. They could be a great
volunteer force. But they need to be trained and prepared and,
in terms of the liability protection, what I did in my bill,
Orrin, is I just said, cover them just like a Federal employee.
Senator Hatch. Torts claims.
Senator Harkin. But it seems to me that, and Dr. Agwunobi,
it is probably more in your bailiwick than anywhere, but again,
thinking ahead about a disaster of the nature of pandemic flu,
I mean, people can say, ``Well, it may not hit here'' and all
that kind of stuff, but just about every health professional I
talk to says, ``Look, and we have had NIH here, we have had CDC
here, we have had everybody up here saying it is not a question
of if. The only question is when.''
Never in the history of mankind since we have been studying
viruses have we known a virus not to mutate. They all do.
Viruses tend to become virulent, HIV being one that we
recognize as being very virulent. This pandemic flu also seems
to be one that is very virulent, and if it starts going from
human to human--we have one case that I know of where it went
from human to human. The CDC has documented one case. It seems
to me that if we are going to get ready for this, we have some,
in that Health Reserve Corps you were talking about, we sort of
have a template of how this could be done. It just needs to be
bigger and broader.
Now, again, I am thinking of DOD, I am thinking of our
National Guard forces that are out there also that could also--
these are civilians that are out there that could also be
utilized and trained or maybe people that served in the
National Guard, maybe they are out now but they still want to
contribute some way. Find these people. But establish a pool of
trained, identified people who are--you were talking about
credentialing. Somehow, we have got to get these national
credentials that every State recognizes, and that is why you do
it now. You start doing it now so that the States buy in, they
do get credentialed, scope of practice, what can they do. That
varies by State to State, also, what can they do. Liability, we
talked about that. Workers' comp issues, all these other
things.
So again, in that, what I guess is called the Emergency
System for the Advanced Registration of Volunteer Health
Profess-
ionals----
Dr. Agwunobi. ESAR-VHP, sorry about that, sir.
[Laughter.]
Senator Harkin. So we have got a system there that kind of
gives us a way to go.
Dr. Agwunobi. Yes, sir.
Senator Harkin. But it is just not robust enough to cover
something like this, and so again, I don't know if I have so
much a question as just a discussion about how we might do
this. I left the VA out, but obviously we have VA in every
State, too, and we have got nurses there and we have got other
health-type professionals that may not be doctors, but they can
sure give it a shot, because my vision of this is that if
pandemic flu ever hits, it is not going to be enough to have
people go to doctors' offices to get shots. You are going to
have to do it at Wal-Mart, you are going to have to do it at
churches on Sunday, you are going to have to do it at
synagogues on Friday night, you are going to have to do it all
over the place--shopping malls, sports arenas where people
come. You are going to have to have systems set up where people
can get these free flu vaccinations, or anti-virals, if that is
the case.
And so how do we go about doing that now? How do we start
setting up a preparedness system that gets these people
trained, give them periodic refresher courses. Obviously, if
people die or something like that, you have got to have them
replaced. How many people would it take? I don't know that I
have a number in my mind, how many it would take. I don't know
the answer to that question. But can we take that template and
make it bigger for something like pandemic flu? I guess that
is----
Dr. Agwunobi. Yes, we can, sir. Congress and yourself as
one of the leaders have helped us design the path, as you
state, things like this Emergency Advanced Credentialing System
that we have in place, and in the President's budget this
request to add to that a portal that links all of the State
credentialing systems together and makes the information that
is in each of those systems available to each of those States
and to the Federal Government, this notion that the providers
in Federal facilities through VA and, of course, in DOD and at
the National Guard level be roped into this concept.
In addition to that, sir, I wear a uniform very proudly of
the U.S. Public Health Service Commissioned Corps. Each of us
are officers trained to lead others into health and medical
battle. The opportunity to link our commissioned corps and its
current ongoing transformation--we are adding a few officers
and a few competencies in terms of building teams--allows us to
now become the officers that lead those larger medical reserve
corps into the fray, so to speak. We have all the pieces. We
need a little bit of time to continue building upon them. And
with the ongoing support that is already being exhibited by
Congress, I am pretty certain that we will incrementally begin
to grow.
As I stated, 408 of these Medical Reserve Corps have stood
up around the Nation. Each community recognizes their value. I
think it is true, sir, that we have started with physicians and
nurses, but we should add to them nonphysician and medical
providers and have them grow into a larger team.
Senator Harkin. And you would admit that that is not enough
to handle a pandemic flu.
Dr. Agwunobi. Sir, in a pandemic, it is going to take an
awful lot more than licensed physicians and nurses to provide
the care that is needed.
Senator Harkin. They can provide the core of it, the
leadership, as I said, the template of it, but we need--we
talked about this----
Dr. Agwunobi. Extenders, yes.
Senator Harkin. How do we start doing that? I mean, we
can't keep waiting and waiting and waiting and waiting. I mean,
we have to find these people, identify them, get them trained,
get them credentialed, work with the States. I mean, this takes
time.
Dr. Agwunobi. As we travel the States, the pandemic summits
that we have been holding in each of the States, we are
actually quite comforted to find that many States have actually
gotten way out in front of this and have begun to do just what
you are suggesting, sir.
Senator Burr. Let me drill a little bit deeper than what
Senator Harkin has, and I am confident that each agency that is
represented here has a model for pandemic. Have you modeled it
with 40 percent of the individuals not able to fulfill the
commitment that you have got them designed in your model? I
think that it is a conservative estimate, at any given point
over the affected period of the pandemic, that 40 percent of
health care workers won't be able to come to work. It is 40
percent of law enforcement. It is 40 percent of truck drivers.
It is 40 percent of the military that is down, that can't
respond. Is there worst-case modeling that is currently going
on and do we have the capabilities to overcome that type of
challenge?
Dr. Agwunobi. I think it is important that we state that we
don't know for certain in a pandemic. We do know that there is
going to be a pandemic in the future. What we are not clear on
is whether or not it is going to be a 1918-like pandemic or a
1968-like pandemic, which had a lot less impact on our
communities. But we are using, for what we call our planning
assumptions, 40 percent--people staying home for 2 to 3 weeks
at a rate of about 40 percent of the workforce, either because
they are sick or they are scared or they are caring for a loved
one at home.
The truth of the matter is, that is the challenge and that
is why we have been reaching out into every community, every
local community and saying, ``Listen, the truth of the matter
is''--and I quote almost my Secretary when I say this--``if you
fail to respond and develop a plan and try to prepare at your
own local level because you expect that the Federal Government
will come in and rescue you, you probably don't fully
understand the concept of a pandemic, which is that every
community is facing this simultaneously, and it is not that we
won't have the will or the money, it is that we really don't
have the way to get to every community simultaneously across
the Nation in a pandemic.''
So we are using 40 percent, sir. It is a model, meaning
that there isn't a lot of science behind that particular
number, and there is some variation across entities as to
whether they use 45 or 35, but I think, on average, most people
are using 40 percent as their model.
Senator Burr. I know I will get into it with the second
panel, but we are a just-in-time society now. Our economy is
driven on just-in-time inventory. Should we be concerned--do
you need to----
Senator Harkin. Just one other----
Senator Burr. Go ahead.
Senator Harkin. Again, listening to this, you are right
about the pandemic. I mean, if it happens, you are going to
have to rely upon people in those local areas to take charge.
It is that whole idea of pre-training. How do you get them
trained? How do you integrate training of these people into the
planning of this?
Dr. Agwunobi. Sir, we haven't focused enough on that in our
funding, cooperative agreements, and technical guidance. We
have offered what we can to States and we have relied on States
and local communities to figure out what their needs are
locally and, therefore, what their training needs are going to
be going forward. And we might offer more advice and more
direction as we move forward over time. I know the Department
looks forward to seeking input anywhere we can find it, in that
regard. But we are listening to communities as we speak, and
where we find communities who have a special need for training
or a particular profession or a particular group, we are
providing it.
Senator Burr. Where typically we have said in the case of a
disaster, be prepared to have 3 days of water, 3 days of food,
the supply chain will be there to accommodate you, do we have
to change that as it relates to the pandemic? Can we believe
that that supply chain is going to be there? Should we be
concerned if hospitals haven't rethought the degree of
inventory they had because of just-in-time inventory and
potentially 40 percent of truck drivers are out? This
potentially means that that resupply line is affected in a
significant way and that DOD is even more important from the
logistics standpoint than envisioned in the current modeling.
Ms. Embrey. DOD is well aware that the infrastructure and
our ability to sustain economic commerce during a pandemic is
very important. The commander at NORTHCOM is considering that
and does believe that there is a possibility that the
Department may be asked to provide support to the Nation in
various places to ensure that commodities get to where they
need to be. But DOD would do that in the context of support
with other Federal agencies like the Department of
Transportation and others to ensure that we sustain our
economic--our commerce.
Another idea that we believe is very important is to engage
our corporate partners in their own campaign to educate and
have a coordinator for their communities on what to do in this
kind of crisis, how to sustain their operations and their
supply chain and their distribution system, because they are
going to be affected in the same way. So they need to come up
with their plans and their contingencies and have a point of
contact for us to talk to when they feel like they are going to
be running south on that.
So, yes, I think it is very important that the Department,
the Federal, State, and local and private sector all work
together on contingency planning for a loss--a potential loss
of our capability during this pandemic, and it is truly an
environment, it is not an event. It will happen over time. Some
parts of the country will be perfectly fine, perhaps. Other
parts will not. So it will really depend on how we coordinate
and have the ability--pre-established alerts to say, ``You
know, we are running a little short here. We need assistance.''
And so doing the pre-planning, having that coordination well
understood in advance is the most important piece, and DOD
understands that we may be asked and we are preparing in
several areas to make sure that we can provide that support if
asked.
Senator Burr. Dr. Deyton, you have highlighted the fact
that VA has a presence everywhere around the country. Operating
medical facilities. They also are geared toward what the
private sector utilities--which is just-in-time inventory. You
have got the largest prescription drug availability in the
country. So I think day in and day out, VA is challenged on a
logistics standpoint. Give us VA's insight and expertise and
experience so far as it relates to the logistics challenge that
we might be faced with.
Dr. Deyton. First, the good news is that we are all
thinking about pandemic flu as a great model, and so for that
one, we already have gotten guidance out to our facilities to
begin to think through what are going to be our needs for
sustaining care for veterans and for helping communities in a
situation of a pandemic influenza. And so, we have given them
actually lists and recommendations about the kinds of supplies
that they may want to have more of available.
In addition, we are working through our National
Acquisition Center, which, you are right, sir, is probably the
largest single purchaser of health care equipment and drugs in
the Nation, and we have our National Acquisition Center that is
working with the various distributors and contractors on
language that will deal with these kinds of emergencies to make
sure that they are doing exactly what Ms. Embrey said, putting
in place whatever kind of continuity of operations that they
need for their own distribution and supply so that they can
maintain the supply that we all need.
Now, VA also purchases through its National Acquisition
Center supplies for other Federal agencies in response to
disasters and emergencies, so that is why we take that very
seriously and we are talking to our various distributors
through the National Acquisition Center on what they need to do
to keep the supply flowing.
Senator Burr. I desperately need to move to this second
panel so that we are not going to run out of time, but I do
want to ask one last question of you, if I may. The VA, in
briefings with us, have estimated that were there the need,
they could free up 4,500 beds within VA facilities to meet a
surge capacity, and I would only ask you, have you attempted to
practice that, to know whether this is something that we can
actually accomplish or that it is just a goal that we have set.
Dr. Deyton. We do that all the time, because that is the
support we give to the Department of Defense, and we on a
regular basis do, in fact, assess the beds that we have
available and how we would be able to staff them up, how we
would discharge patients to free up those beds. Have we
actually physically done a disaster drill to do that? No, sir,
we haven't, but it is an annual--it is more frequent than
annual, it is a regular counting thing that we do so that we
can--we are obligated to make sure and get that information to
DOD.
Senator Burr. I lied. I am going to ask one last question,
Doctor.
[Laughter.]
I don't want this to be associated with any of my
colleagues up here. I will take the blame if, in fact, this is
portrayed incorrectly. One could look at the worst case
scenario for pandemic and say, ``if 40 percent of your health
care providers are unable to perform their duties, a surge plan
is sort of useless.'' Should we spend a tremendous amount of
time as it relates to that surge capacity specifically as it
relates to pandemic, or is that the reality, that if we have a
1918 scenario, that we are more on the model that Senator
Harkin mentioned and that every available outlet that we have
got, we are trying to tap into, but the realities are that even
if we had the 4,500 beds, if you haven't got the health care
professionals to show up, that we have done no additional good
other than move somebody from a bed at home to a bed at a
facility?
Dr. Agwunobi. Sir, you hit on a very important point here.
In a pandemic, I think it is pretty clear that there are going
to be a number of different things that we have to do as a
Federal Government and as a Nation. One, we have to protect
critical infrastructure, critical health care infrastructure.
If there is only one producer of insulin in the Nation, a
particular kind of insulin, we need to protect that
manufacturer. If you are a vaccine producer, we need to protect
your employees and your ability to develop vaccine. If you are
the only specialist of your kind and you offer a particular
kind of life-saving intervention, we need to find ways to
protect you and your team.
But I do think that when all is said and done, like in
1918, we are going to have to adapt to many of those standards
and many of those customs and norms that we apply in our health
care setting today. We are going to have to adapt to this
massive increase in demand.
I do want to just state, if I may, the obvious, which is
that although 40 percent of our folks will be out sick,
fortunately, not 40 percent of our Nation will be in hospitals
seeking health care. We expect that gradually, over time, there
will be a surge-up in demand, and clearly, our approach is
going to be how we manage that demand for services over time.
So skills such as using anti-virals to shorten the length of
stay will be a critical skill. Social distancing to
particularly protect health care providers, I think, will be
important. And then when the availability of the vaccine
becomes ready, that they be a priority group in terms of
protecting them for the rest of the pandemic.
Senator Burr. One last question. After Katrina, health care
providers provided aid through several distinct government
agencies and programs. The responders on the ground worked hard
to help Americans trapped on the Gulf Coast. But we have heard
the stories of people that didn't get help for days or weeks.
Were the medical treatment and patient evacuation problems
caused by a lack of trained personnel, a breakdown of
communications, inappropriate structure to the Federal
response, or something else?
Ms. Embrey. Yes.
[Laughter.]
Senator Burr. Is that all of the above?
Ms. Embrey. I think Katrina was a conflagration of many,
many different things. Geographically, it was quite widespread.
It shut down what connectivity did exist between authorities to
render a response. And many of the folks who were available to
provide support had lost their homes or their families had been
evacuated. And so I believe that the situation of the pandemic
is different. Homes will be intact. Electronic systems and
coordination systems will be intact. We will have individuals
who will be sick, but if we plan properly and we set those
connections and coordination points in advance, we will have
the ability, particularly through surveillance.
I think surveillance is another big area where we have a
responsibility to come to some common agreement on how we
communicate with each other across the States. Surveillance is
not a standard in this country. It is an imperative and we all
do it, but we all do it differently. It may be time to come to
a common denominator on what is surveillance, how do we
identify it across the Nation, how do we report and alert who,
when, and that is another big area of opportunity here. I think
we are working very hard to make sure that, right now, the
differences become less so in our preparation.
Senator Burr. We had some very good insight from the
panelists that we had 2 weeks ago as it related to surveillance
and some of it highlighted current directions and some of it
suggested that we needed to rethink it, and I think it was
beneficial to all of us.
I want to thank all of you for coming. As one who
represents a State where a mobile hospital was delayed for a
few days from being deployed in Katrina because we hadn't quite
figured out who was going to assume the liability, it is my
hope that we won't have that problem again. From a conversation
I had with a soon-to-be-former Governor yesterday who deployed
medical assets, medical teams to Louisiana only for those
medical teams to sit in Louisiana and not be able to perform
their duties because the credentialing was not done at probably
the most crucial time where lives could have been affected, it
is disturbing to see the outpouring that existed within the
country and the way people responded only to look back and find
that we have a tremendous amount of work to do before we are
able to sufficiently address something of that magnitude again
and to look back on it and highlight the successes. But I am
convinced that we are well on the road to doing that.
At this time, I will dismiss the first panel and call up
the second panel.
Let me welcome the second panel, and my apologies because
we did run over just slightly with the first one. My hope is
that we will be able to conclude on time for the purposes of
your schedule.
Let me welcome Dr. Tom Inglesby, who is the Chief Operating
Officer and Deputy Director of the Center for BioSecurity at
UPMC. Previously, he was a member of the Johns Hopkins School
of Medicine faculty and one of the founding members of the
Center. Doctor, welcome.
Richard Serino is the Chief of the Boston EMS Department.
Mr. Serino also serves as the bureau chief for the city of
Boston's Health Commission, where he assists in establishing
public health goals and guides policy development. Richard,
welcome. I also understand that you were intricately involved
in the planning leading up to the Democratic National
Convention, which I think can provide us a tremendous amount of
insight in that planning and preparation.
Dr. Eddy Bresnitz is the Deputy Commissioner of the New
Jersey Department of Health and Senior Services. He is also the
Secretary of the Council of State and Territorial
Epidemiologists, who he represents here today.
Dr. Rob Gougelet is an assistant professor of emergency
medicine at Dartmouth Medical School and the Medical Director
for Emergency Response at Dartmouth-Hitchcock Medical Center.
His current duties also include the directorship for the New
England Center for Emergency Preparedness and Medical Director
for Emergency Response for the Vermont Department of Health.
Welcome, Doctor.
I am going to go in the order of introduction and you are
open for whatever opening statement you would like to make and
then we will move to questions.
STATEMENTS OF THOMAS V. INGLESBY, M.D., CHIEF OPERATING OFFICER
AND DEPUTY DIRECTOR, CENTER FOR BIOSECURITY, UNIVERSITY OF
PITTSBURGH MEDICAL CENTER; RICHARD SERINO, CHIEF OF DEPARTMENT,
BOSTON EMERGENCY MEDICAL SERVICES; EDDY A. BRESNITZ, M.D.,
DEPUTY COMMISSIONER AND STATE EPIDEMIOLOGIST, PUBLIC HEALTH
SERVICES BRANCH, NEW JERSEY DEPARTMENT OF HEALTH AND SENIOR
SERVICES, ON BEHALF OF THE COUNCIL OF STATE AND TERRITORIAL
EPIDEMIOLOGISTS; AND ROB GOUGELET, M.D., DIRECTOR OF EMERGENCY
PREPAREDNESS, DARTMOUTH-HITCHCOCK MEDICAL CENTER
Dr. Inglesby. Senator Burr, thank you for the opportunity
to address you and the committee on this very important issue.
I think your committee is to be commended for taking this on so
directly.
I have written comments, which I will submit for the
record, but let me just pour out a couple of comments,
especially after listening to the first panel.
I think one of the things that needs to be clear is the
central role of hospitals in an all-hazards medical response. I
think that one of the things that sometimes gets glossed over
is that a medical response is essentially, by definition, going
to be centrally located in hospitals. That is where people get
health care in America and I think that point is worth
punching. Hospitals have largely been out of the hot water loop
in terms of homeland security and emergency preparedness,
public health preparedness. I know the committee is addressing
that and I commend you for that.
The second point is that I think in the event of a large-
scale catastrophe, even America's strongest and largest
hospitals are at great risk of becoming dysfunctional quite
quickly or perhaps even going offline and not being able to
provide medical care. I think this is a serious risk which I,
again, think you are taking on directly.
I think that there are a number of things the first panel
brought out in terms of the country's commitment to
volunteerism, in some cases, nascent or just developing
programs in HHS are going to be important, but overall, I think
a general theme is that in terms of preparing America's
hospitals to get ready for a pandemic or bioterrorist attack or
large-scale chemical attacks, we are generally at the wrong
order of magnitude and we don't have enough people in
government and out of government working on this problem. I
think the committee is considering a number of remedies for
that and I look forward to talking about that.
But I think those are the points that I would just bring to
your attention at the start.
Senator Burr. Thank you very much.
[The prepared statement of Dr. Inglesby follows:]
Prepared Statement of Thomas V. Inglesby, M.D.
introduction
Ensuring the capacity to provide medical care to mass numbers of
sick Americans in the aftermath of a major regional or national
catastrophe should be a top national security priority. The Public
Health Security and Bioterrorism Preparedness Response Act of 2002
helped the country take a number of important initial steps toward that
goal. But planning for a medical response to mass casualties remains
the most neglected component of public health preparedness and homeland
security.
If an All-Hazards Medical response for hospitals is to be a major
new initiative, there should be clearly articulated top hazards, and
these must include pandemics and bioterrorist attacks. Of the kinds of
catastrophes that could lead to mass numbers of ill persons, pandemic
influenza and large-scale bioterrorist attacks would pose particularly
severe problems given the prolonged duration of the crisis, the
possibility for widespread geographic impact (even national impact in
the event of pandemic), the fear of contagion to health care workers
and their families, and the sudden demands on critical medical and
material resources. Not all hazards should be of equal priority.
A sense of the impact of a catastrophe on the scale of a 1918-like
pandemic on U.S. hospitals can be gained using CDC's FluSurge program.
In a typical city in a pandemic of moderate duration, flu patients, at
epidemic peak, would be predicted to require 191 percent of non-ICU
beds, 461 percent of all of the available ICU beds, and 198 percent of
all available ventilators. Hospitals are in no condition to deal with
this level of catastrophe: 30 percent of U.S. hospitals are currently
losing money; of those that are profitable, operating margins average
1.9 percent; 45 million Americans are uninsured, and hospitals provide
$25 billion per year in uncompensated care. There are shortages of
healthcare workers of all kinds. The numbers of hospitals and Emergency
Departments have all decreased in recent years despite nearly half of
Emergency Departments being over capacity.
The following comments address questions of the subcommittee
regarding the Federal Government's efforts to ensure the country can
provide medical care for mass casualties:
How should the recruiting, credentialing, training of
Federal health providers be accomplished and organized? How should the
Federal Government deploy health care providers in response to a
national emergency?
What is the most effective way to support a Federal
medical response and which agency should take the lead?
What steps should be taken to foster a more coordinated
response built on a strong public-private partnership?
increasing the health care volunteer work force
Recommendations
(1) Create an Office of Citizen Engagement within HHS, presumably
within OPHEP. A clearly designated office should have responsibility
for the training, credentialing, liability, funding efforts of the
Federal Government intended to increase the health care workforce in
crisis.
As top priority, the office should focus on developing
local/state-based systems for recruiting, training, organizing
volunteers to work in their own localities and States. Local volunteers
would have pre-existing knowledge and commitment to their own
communities, would not need to be transported to another region, would
not need to be housed, etc.
The office should also be responsible for the systems that
would allow more efficient sharing, credentialing, movement of
volunteers from region to region, given that some kinds of catastrophes
could not be handled without influx of volunteers from outside the
region.
Will need plans to organize lay volunteers, not just
health care professionals, to help hospitals provide mass medical care.
Many of the things needed to run hospitals could be executed by lay
professionals.
(2) Increase funding and accelerate development of the state-based
Emergency System for Advanced Registration of Volunteer Health
Professionals (ESAR-VHP); ESAR-VHP is intended to allow States to
better utilize their own health care resources. The program should be
expanded and accelerated. Clear public description and discussion of
ESAR-VHP and other community volunteer programs (both health care
worker and lay volunteer) should take place in advance of a crisis.
Many healthcare workers do not yet see themselves as being a crucial
part of public health or community response, but would likely be
willing to engage if the means of participation were clearer. Some
health care professionals have wondered whether signing on to ESAR-VHP
would mean they could be involuntarily drafted in a health emergency--
these kinds of misconceptions should be publicly addressed. One
specific serious improvement would be for ESAR-VHP to induce States to
use uniform credentialing guidelines across the country and to use
databases that are compatible with each other to allow easier movement
of volunteers across State lines should that be necessary.
(3) Consolidate ESAR-VHP efforts and the Medical Reserve Corp (MRC)
(whether or not this occurs in the new office of Citizen Engagement);
Clarify role of MRC teams. Currently HRSA has responsibility for ESAR-
VHP, while the Medical Reserve Corp program office in the Surgeon
General's office has responsibility for the MRC but no budget to fund
the MRC units and offers no provision of liability protection for
volunteers. These efforts should be consolidated. If MRC teams are
meant to provide local augmentation of the health care workforce, then
they should be explicitly training with hospitals where they work. If
MRC teams are meant to provide a source of health care volunteers to
other regions of the country, the MRC program needs a concept of
operations, credentialing and liability process, administrative
systems, processes, etc. to organize such movement of volunteers, and
it should be clarified how the MRC will relate to the NDMS (see below).
(4) Make liability protection in emergencies clear and national in
scope. If health care workers volunteer to work in a mass casualty
catastrophe, they are potentially putting their own lives at some risk
(and their families if the crisis involves a contagious disease). They
should not also be exposed to the potential of being sued. The Federal
Government should pass some form of Good Samaritan legislation that
protects health care volunteers working with a State or federally
sanctioned volunteer program--with the exception being gross
negligence. Absent this kind of liability protection, many potential
volunteers will be dissuaded from participating.
improving organization of the federal medical response
Recommendations
(1) HHS should be the Federal agency responsible for the Federal
Medical Response to large-scale catastrophes. There is significant
confusion in the hospital and medical communities around the country
regarding which agencies and programs are responsible for hospital
preparedness. In the 2002 bill, the ASHPEP was given responsibility for
this work, but he has not had the human resources or budget to
accomplish the wide range of work necessary to prepare hospitals for
the range of terror attacks, pandemics and catastrophes the Nation
could face. Organizationally, matters were subsequently made worse when
NDMS and the DMATS program were transferred to DHS. To fix this,
HHS should be given unequivocal responsibility and
accountability for all Federal medical response programs.
Within HHS, the hospital preparedness program should be
elevated in importance, visibility and resources, and it should be made
quite clear who is the lead Federal official responsible for working
with America's hospitals on hospital preparedness.
(2) HHS hosp prep programs (and preparedness programs overall)
would benefit from a stronger management structure and more senior
managers. HHS should be given an Undersecretary for Preparedness that
would be responsible for coordinating the large number of preparedness
programs residing in HHS within OPHEP, HRSA, AHRQ, CDC, ONCHIT, NIH,
FDA, et al. (It would be logical to include perhaps two or three other
Undersecretaries responsible for the other HHS portfolios.)
An Undersecretary for Preparedness would raise profile,
importance of all HHS public health preparedness programs--including
medical surge; should also improve coordination of these various public
health preparedness programs--most of which do not now report to the
ASHPEP.
Creating the Undersecretary for Preparedness might be best
accomplished by elevating the ASPHEP or by combining the Surgeon
General's position with the new Undersecretary.
Whether or not an Undersecretary for Preparedness is
created, HHS will need to substantially augment its senior management
cadre with persons with extensive experience and contacts with the
private health care system.
(3) The National Disaster Medical Response System needs strategic
re-consideration. NDMS is in the Emergency Preparedness Directorate in
DHS. Its mission is to support Federal agencies in coordination and
management of the Federal medical response, to train voluntary disaster
medical assistance teams from various parts of the country to ``provide
care under any conditions at a disaster site'' and transport victims
into participating definitive care facilities. A report written by
senior advisor to the Secretary of DHS said that as of January 2005,
the staff had been reduced from 144 to 57; there were few qualified
medical personnel to develop doctrine or policies, and the agency
lacked defined, unified medical capabilities.
If NDMS is going to continue to exist, or if its work is
consolidated or moved to another HHS program, then its mission,
structure, and resources will need to be re-baselined:
It needs to be in HHS and integrated with other HHS
programs on hosp and public health preparedness.
It should have as a top mission the support of hospital
operations in communities in the midst of a crisis--this is not
currently the case. DMAT teams have utility in certain kinds of crises,
but would do little or nothing in the face of large scale crisis when
hospitals will have major roles to play. In setting whether there are
major medical surge needs, doctors and nurses will be necessary but
insufficient--patients will need a variety of common medications,
ventilators, oxygen, food, beds, IV fluids; doctors and nurses may need
personal protective equipment, security, etc. These cannot be provided
by teams. The only realistic or sustainable way to deliver this complex
set of needs is in hospitals.
NDMS plans should be integrated with the HRSA program that
now allocates hospital preparedness funds. They are now in 2 different
agencies, entirely distinct efforts.
NDMS should be coordinate with the ESAR-VHP and MRC
programs--which are all now completely distinct.
strengthening the public-private partnership with hospitals
Recommendations
(1) Congressional and Administration leaders should call America's
hospital leaders to action. Hospital leaders would be more convinced of
the long-term commitment of the Federal Government to hospital
preparedness and more clear on what was being asked of them if they
were gathered directly by national leaders and asked to commit to a
long-term partnership to prepare the country to deal with mass casualty
attacks. Hospital leaders now see very little Federal Government
engagement on this issue except for a grant program that grants money
that is far too little to accomplish what is called for.
(2) HHS needs to set more clear benchmarks for hospital
preparedness and pandemic funding. The 2004-2005 guidance for hospital
preparedness grant awardees is 49 pages long. HRSA is developing
guidance for this fiscal year, and it will be important to simplify the
guidance, eliminate some of the indicators, sets more clear priorities
in this next round. But the guidance is in the right ballpark--it's
just that the funding that accompanies it would realistically pay for a
tiny fraction of the work requested. The pandemic planning guidance
recently issued by HHS for hospitals is reasonable, for the most part,
but it needs more specificity, a clearer sense of top priorities, and a
funding plan to meet the costs.
(3) Increase funding for hospital preparedness.
The National Bioterrorism Hospital Preparedness Program
(under HRSA) has provided funding to hospitals of approximately $500
million per year nationally since 2002, and the fiscal year 2007
request is $487 million. This comes to about $100,000 per year per
hospital though in reality it is less because some of the money is used
by local health departments. In December 2005, Congress appropriated
$350 million for State and local public health departments for pandemic
preparedness; however, none of this appropriation is specifically
identified for hospitals.
The Center for Biosecurity rough calculation of the
minimum costs of realistic readiness for a severe (1918-like) pandemic
indicates a need for at least $1 million for the average size hospital
(164 beds). The component costs to achieve minimal preparedness
include:
Develop specific pandemic plan: $200,000
Staff education/training: $160,000
Stockpile minimal PPE: $400,000
Stockpile basic supplies: $240,000
Total: $1 million per hospital
With approximately 5,000 general hospitals in the United
States, the national cost for initial pandemic preparedness would be $5
billion. There would be recurring annual costs to maintain
preparedness, estimated to be approximately $200,000 per year per
hospital. These figures exclude stockpiling antivirals, since there is
a separate national plan to acquire these drugs. In addition, no moneys
are included for purchases of expensive equipment such as mechanical
ventilators, since it is not clear that extra ventilators would be
useful if there were no trained personnel to operate them. A rough
estimate of the cost to double the number of ventilators in the
country, using safe but inexpensive equipment, is $1 billion.
(4) Increase the priority of regional hospital coordination. Many
key health care system preparedness and response actions will require
regional coordination: regional resource allocation, patient
redistribution, and use of alternative care sites all require
collaboration among hospitals, and among hospitals and public health
and emergency management agencies, both in planning and in response. PH
Law of 2002 encouraged the development of regional coordination, but in
2006 there are only a few good examples of even nascent regional
organizations. The United States has a highly fragmented, private, and
competitive hospital sector with inherent disincentives for
collaboration.
To qualify for hospital preparedness moneys, hospitals should be
required to participate in Regional Hospital Coordinating groups. The
essential functions of such groups would include:
Standardizing planning and preparedness among the
participating hospitals;
Sharing of assets, staff, and patients among the hospitals
during declared crises;
Sharing situational awareness in disasters to elected
officials and health leaders;
Coordination of timing and means of surge processes (the
expansion of patient capacity within individual hospitals while
retaining near-normal practice standards) and supersurge processes (the
further expansion of patient capacity involving use of alternative
sites and/or significant alteration in practice standards);
Facilitation of a communitywide approach to ethical and
political challenges (e.g., altered standards of care);
(5) Modify the Stafford Act to allow for direct reimbursement of
hospitals for uncompensated costs and extraordinary hospital care in
the event of major catastrophes.
Hospitals' revenues will decrease dramatically during a
pandemic or in other catastrophes, even though they will be
experiencing record-high patient volumes. Hospitals will need to
provide care to many patients who are uninsured and/or unable to pay;
at the same time operating costs will be extraordinarily high.
According to the AHA, the average hospital has only 41 days of cash on
hand. Many hospitals would have insufficient cash reserves to survive a
severe pandemic or other crisis that significantly interrupts
operations for weeks.
Under current healthcare reimbursement schemes, hospitals
lose money on nearly every illness-related hospital admission--
especially those, like pneumonia, that are likely to result from flu.
Normally, hospitals offset these losses with profitable elective
procedures, but these elective cases will be among the first services
to be canceled or deferred in an attempt to respond to the demands of
flu patient care during an epidemic.
______
Summary of Written Comments
Ensuring the capacity to provide medical care to mass numbers of
sick Americans in the aftermath of a major regional or national
catastrophe should be a top national security priority. The Public
Health Security and Bioterrorism Preparedness Response Act of 2002
helped the country take a number of important initial steps toward that
goal. But planning for a medical response to mass casualties remains
the most neglected component of public health preparedness and homeland
security.
recommendations to the subcommittee
Increasing the Health Care Volunteer Work Force
(1) Create an Office of Citizen Engagement within HHS, presumably
within OPHEP.
(2) Increase funding and accelerate development of the state-based
Emergency System for Advanced Registration of Volunteer Health
Professionals (ESAR-VHP).
(3) Consolidate ESAR-VHP efforts and the Medical Reserve Corp (MRC)
(whether or not this occurs in new office of Citizen Engagement);
Clarify role of MRC teams.
(4) Make liability protection in emergencies clear and national in
scope.
Improving Organization of the Federal Medical Response
(1) HHS should be the Federal agency responsible for the Federal
Medical Response.
(2) HHS hosp prep programs would benefit from a stronger management
structure.
(3) The National Disaster Medical Response System needs strategic
re-consideration.
Strengthening the Public-Private Partnership With Hospitals
(1) Congressional and Administration leaders should call hospital
leaders to action.
(2) HHS needs to set more clear benchmarks for hospital
preparedness.
(3) Increase funding for hospital preparedness.
(4) Increase the priority on regional hospital coordination.
(5) Modify the Stafford Act to allow for direct reimbursement of
hospitals for uncompensated costs and extraordinary hospital care in
the event of major catastrophes.
Mr. Serino. First off, thank you for allowing me to be here
today, probably the one that is most out of his element. I am
used to being in the street, and recently in the last few days
with the crane collapses and being first on scene at multiple
shootings and bus crashes. This is a little bit out of my
element.
Senator Burr. May I ask you to pull that microphone just a
little bit closer? It is that Southern accent that I am having
trouble with.
Mr. Serino. Yes, I have a little bit of an accent, they
tell me. I don't know, I think everybody else here does, but
anyway, thank you for being here. I have a few remarks.
One of the things I heard people say that I want to echo is
there was a Congressman that had some influence up here a few
years ago by the name of Tip O'Neill, and Tip said quite often
that all politics is local. My expertise and experience has
told me that, in fact, all disasters are local, as well, and I
think that that is important to remember.
Today, as you mentioned, I would like to focus on the 2004
Democratic National Convention, where we had over 70 different
local, State, and Federal agencies that took part in planning
for an event and some of the lessons that we learned from that
event. In 2003, it was designated a National Special Security
Event, an NSSE, and that is an important fact because when we
led to the creation of the executive steering committee and 17
planning subcommittees, medical planning was not initially in
the NSSE structure. There was nothing to look at, no medical
component at all. As a result of local efforts, we established
a medical subgroup as part of the consequence management
committee and Boston EMS was designated as a lead for all
medical consequence management planning.
The medical subgroup was composed of 39 different partner
organizations, Federal agencies, private sector, local
hospitals. As a result of this highly successful partnership of
local expertise with Federal assets and agencies--the formation
of the medical subgroup--it established a role for the medical
community on the executive committee and represents one of the
major successes. The event is actually having a medical voice
with the law enforcement agencies, which doesn't exist even now
as we move forward.
The primary task for the medical subgroup leading up to the
DNC was to plan and prepare for major medical response issues.
Our planning process addressed issues of surge capacity,
hospital readiness, public health surveillance, requests for
Federal assets, traffic impact--we don't have any traffic
issues in Boston--and medical treatment of prisoners and
protesters.
As a result of the subgroup's work, over 200 ambulances
were available. Using DHS grant funding, we provided actually
mini-grants to mutual aid providers that had not been able to
get any sort of assets at all for the purchase of medical and
basic personal protective equipment. We completed additional
training exercises with the hospitals. Surgeries were canceled
within the city for the week. Also, throughout the week, we
were able to maintain 500 free beds in the city of Boston,
where in a normal week, we are lucky--almost every hospital in
the city is on diversion with no beds.
We also prepared for a specific threat of a bioterrorism
attack using caches of chem packs, emergency response packs,
stocking hospitals with nerve agent medications and radiation
treatments. Finally, the city of Boston prepared to activate
the local Metropolitan Medical Response System Agreement, which
is a mutual aid system. We have a memorandum of understanding
guaranteeing the availability of hospital staff and resources
to assist in response to an emergency. We have an MOU with all
the different hospitals so we can bring staff and move them
around as necessary from the hospitals.
The DNC proved to be a huge success in terms of emergency
preparedness with few exceptions. The planning allowed for a
successful blending of security and medical responding to
threats during the DNC. Our success in medical planning came
from bridging the gap between a well-integrated medical
community and the public safety and Federal agency responsible
for managing the event.
Well before the DNC, we had a lot of experience working
with the Conference of Boston Teaching Hospitals to manage
disaster plans in the city. It came time to plan for a major
event. There was already a local group, local officials and
private organizations that we have been working hand-in-hand
with for years. Bringing them into the NSSE structure, the
medical community, law enforcement, and Federal agencies were
able to meet each other personally and understand each other's
personal and specific needs.
As a result, planning for ambulances to access road
closures, which turned out to be one of the major issues, as
well as treatment of patients, deployment of resources were
worked out in advance, and perhaps most importantly, the
relationships developed and nurtured have carried forward
today. Relationships are the key to developing them and
fostering them is the greatest asset in a response. By
establishing and carrying forward committees and organizations
that addressed planning and response issues, the people who
have to work together in a disaster already have to know each
other.
Many of the same groups that were brought together for the
DNC continue to meet, coordinate on medical issues.
Furthermore, by including the medical community in the planning
process, other agencies have learned how important that
planning is, law enforcement and the public safety agencies,
and that was a seat for the medical community on the U.S.
Attorney's Anti-Terrorism Advisory Council. The medical
community is now an integral part of Boston's homeland security
planning. Every day, the impact is felt in Boston. As we
prepared to receive victims from Hurricane Katrina, the same
planning and staffing agreements that were refined during the
DNC allowed us to plan for an unknown number of medical cases.
In less than 2 weeks, we will have the Boston Marathon
coming to Marathon, the 125th, I believe--no, 110th running of
the marathon, and we look at those incidents. We treat it as a
mass casualty event and practice medical planning and volunteer
integration, as we were talking about earlier. We look at these
events as a special event as a planned disaster in order to try
all these different assets out. As a result of this
integration, in Boston, we are trading business cards at the
scene of a disaster, and not something that should be
happening.
There is, however, much to be done. The lessons learned
here must be brought to a national level. While medical issues
are addressed in Boston, nothing in the guidance from the
Department of Homeland Security addresses that the medical
community needs to be included in everyday planning and
coordination. While integration of the medical community in the
NSSE structure in the DNC was a resounding success, the
structure has not been formalized. These lessons must be
learned nationally to address local planning and integration.
Again, thank you for giving me the opportunity to speak and
I look forward to answering questions.
Senator Burr. Thank you very much.
Doctor.
Dr. Bresnitz. Senator, thank you and thank you for inviting
me to come to participate in this roundtable today. There is
some written comments. Just a couple of highlights.
I want to say that we think that the guiding principles for
reauthorization are some that have been already talked about
earlier this morning. Certainly, an all-hazards approach is the
way to go, but with the understanding that every--just like we
talk about every event is local, every event is different. So,
for example, dealing with influenza pandemic is different than
dealing with an anthrax attack or plague or anything else or
flooding.
We must have predictable and sustained funding. I think
that those of us in the States have experienced sort of the ups
and downs of funding and they have impacted on how we went
about our preparedness efforts and we are facing additional
reductions in the coming year because of shifting of
priorities.
Workforce development, we have talked about the volunteers,
but on the professional side, we need to really pay attention
to that because the professionals, who are full-time, are the
ones that are going to be assisting and guiding the volunteers.
And finally, there is the issue of accountability with the
use of performance measures, which I know the CDC and HRSA have
done a lot of in the last few years and I think that has helped
us in terms of our preparedness efforts.
I have to emphasize, I know the focus today is sort of how
the Federal Government can get better in preparing for an all-
hazards approach, but really, a Federal response for health
care is really built on a solid foundation of State and local
preparedness and I think people have highlighted that this
morning.
Secretary Leavitt has actually stressed in reference to a
pandemic that the first response has to be local, and I can
tell you that at the State level, we are not going to be
waiting for the Federal Government to ride in on a white horse
to save us because we don't think that is going to happen. I
mean, every single community will be impacted. They may not be
impacted exactly the same amount on any given day, but they
certainly would be impacted over a few months' period and then
perhaps in successive ways.
New Jersey has had the--in terms of preparedness, it has
had the good fortune, I don't know necessarily in terms of
outcome, but we have had a real bioterrorism attack back in
2001. We were the epicenter for the anthrax attack, although in
DC., they may have thought they were the epicenter. The letters
went through the Hamilton Post Office, and we did have a very
significant local response. At that time, we had very little
funds in the State for surveillance issues and for other
response issues and we very much depended on the CDC and the
epidemiologic SWAT team to come, if you will, to assist us, and
they did assist us and it was mostly local response and I think
overall, given that we had never experienced that before, we
came through it very well despite not having lots of local
resources.
Last year, we had a staged event. We had the TOPOFF III
exercise. I don't think it went as well, as we did during the
anthrax attack in 2001, as a staged event. We had some
decisions--the bottom line is the decision was made to
basically prophylax the entire State within 24 hours. Well,
there are not enough people within the State or even at the
Federal level to do that, so the solution was basically to
deploy Federal workers as well as postal workers to come in and
hand out antibiotics in post offices. Unfortunately, that
really wasn't a workable decision, and nevertheless, that was a
decision that was made, and so we had--for a virtual reality
problem, we had sort of a virtual unreality solution that
didn't really work.
One of the questions to us today is who should be the lead
Federal agency. You asked that this morning. I don't think
there is one lead Federal agency for all situations. I think
for medical and public health events, it needs to be the
Department of Health and Human Services. Similarly, at the
local level or at the State level, it depends on the event. For
something like influenza or a plague attack, it does have to be
health. It is mainly a health issue, although clearly there are
infrastructure implications, as well.
For an explosion, for an example, it may not be a health--I
mean, clearly, health is involved, but there are other issues
related. Health can usually handle that, but shouldn't
necessarily be in the lead at that time except certainly to
care for the individuals.
States have to take the lead on surge capacity issues. It
is hospitals that provide the health care, but even in the
pandemic, it depends on the pandemic because we don't know
really how it is going to play out, but many people may be only
mildly ill or moderately ill and not require a hospital.
Hospitals will be overwhelmed. But we have to have other
solutions to care for all those people.
Clearly, any health response has to be a State and local-
based response. The Federal Government can only assist to a
certain extent, but when you have a disaster all over the
country, it can't just be a dependence on the Federal
Government. It has got to be State and local.
And finally, I just have to comment, there was a question--
I know today we are not talking about surveillance, but since
the last panelist brought it up, I want to say that the States
believe that surveillance is best done at the State and local
level and not at the Federal level in terms of public health
surveillance and epidemiologic surveillance for reportable
diseases, whether they are intentional or natural in nature.
With that, I thank you and will be happy to participate and
answer any questions.
Senator Burr. I appreciate your insight and will assure you
we got an earful last week as it related to the surveillance
issue, and I think that is an area that we have now flagged to
sort of take a second, third, and fourth look at as we go
through.
[The prepared statement of Dr. Bresnitz follows:]
Prepared Statement of Eddy A. Bresnitz, M.D., M.S.
Mr. Chairman and members of the subcommittee, my name is Dr. Eddy
Bresnitz, Deputy Commissioner for Public Health Services and State
Epidemiologist in the New Jersey Department of Health and Senior
Services, and Secretary-Treasurer of the Council of State and
Territorial Epidemiologists (CSTE). Thank you for your invitation today
to participate in a roundtable on All-Hazards Medical Preparedness and
Response.
The questions before us today are: How do we, (Federal, State and
local agencies) appropriately prepare for and respond to events that
require Federal healthcare resources, using effective financial and
logistical support, based on evidence-based best practices? At the
outset, we would like to echo the statements of Dr. Leah Devlin and
others, representing the Association of State and Territorial Health
Officials, made recently before the Senate HELP Committee. The key
guiding principles for State and Federal preparedness outlined in their
testimony included an all hazards integrated approach, predictable and
sustainable funding, workforce development, implementation of
performance measures, and accountability.
It should be clear that an effective Federal response must be built
on a solid foundation of State and local infrastructure consisting of
well-trained public health (PH) personnel, state-of-the-art equipment,
flexible healthcare surge capacity, comprehensive preparedness
policies, plans and procedures, and sufficient operating funds to
sustain capacities and capabilities. As Secretary Leavitt has stressed,
a nationwide PH emergency, such as an influenza pandemic, could only be
effectively addressed by comprehensive and sustained preparedness at
the State and local levels as the Federal Government could not possibly
provide direct healthcare support at the local level when the outbreak
is occurring in every community. Predictable Federal funding is the
key.
Two events last year, one real and one staged, highlight the
disorganization in the Federal response to provide healthcare personnel
for healthcare and prophylaxis. In Louisiana, where the infrastructure
had virtually disappeared, there were many impediments to effectively
mobilize and support needed healthcare personnel from other States. In
New Jersey during TOPOFF 3, the Federal solution to mobilize personnel
to distribute antibiotic prophylaxis was developed through an ad hoc
approach and was unrealistic but imposed on the State despite expressed
reservations on its likely effectiveness. The MRC and ESAR-VHP systems
for recruiting trained healthcare providers are relatively early in
their development and require better coordination and sustained efforts
on the part of all parties to enhance recruitment and address the
cross-state credentialing and liability issues. And States must be
equal partners in personnel deployment decisionmaking.
Federal logistical support for local needs in a PH emergency must
work through existing State and local command and control and emergency
response infrastructure. The appropriate lead Federal agency should be
determined by the event. For example, for biological PH emergencies
such as an influenza pandemic or a plague attack, DHHS is the most
appropriate agency to coordinate the medical and public health
response. Similarly, State health departments have strong relationships
with State Hospital Associations, in addition to their statutory
regulatory oversight. The lead Federal agency must work through the
State DOH, in conjunction with the State Hospital Association, to
coordinate preparation and response to mass casualty events where
Federal resources are required. In summary, the appropriate Federal
healthcare response is one coordinated and led by existing State
emergency response systems. Thank you.
Senator Burr. Doctor.
Dr. Gougelet. Good morning, Mr. Chairman, and thank you for
the opportunity to testify before your committee today. I have
presented written comments that are included in your packet of
information. I will be very brief so we can get on to some
questions, I believe, considering the time.
I would like to discuss, just for a minute or two, that we
are actually very concerned about surge capacity and widespread
events overwhelming public health emergencies, surge capacity
events. We have identified what I believe to be a significant
gap in terms of the personnel needed for staffing for
alternative care facilities and community-based health
response, including immunization, prophylaxis, hospital bed
surge capacity, isolation and quarantine.
We believe and have worked through some of the details
related to sub-state regionalization and interstate
regionalization, which I believe are very useful tools to
enhance the response and to coordinate and efficiently bring
resources together. We have an example of that through the
Interstate Regionalization Program. The Northern New England
Metropolitan Medical Response System brings the resources of
Maine, New Hampshire, and Vermont together in a planning
mechanism and response capacity which we feel is very
successful and brings three primarily rural States together to
have capabilities that they might not have otherwise.
In terms of the Federal Government's role in this, of
course, they have multiple roles, but one of the most important
roles I see the Federal Government to have is to provide
concise planning and technical information to communities so
that we can form within sub-state regions and within States'
uniform capabilities, the framework that we need--the framework
that we desperately need across the Nation that has
similarities. There are differences between States and local
communities, but there are common structures that I believe
that we can incorporate into local communities so that there is
a standardization, and maybe standardization isn't the right
word, similarities between these structures from State to State
so that staffing can move across borders, we can have common
equipment and supplies, but more importantly, that we have a
foundation for establishing performance standards that can
reliably make up the Nation's response by adding all of these
State and sub-state capabilities together.
The question came up of logistical support for a massive
Federal response, and I believe there is a role for the
Department of Homeland Security to control large-scale
logistical support in cooperation with the Department of
Defense. I would emphasize--having been a DMAT member since the
late 1980s--that if any changes occur through the Federal
response system and NDMS, that particular care be taken to
maintain the services that are currently available and to let
the many thousands of volunteers that currently do this work
know that they are not only valued in their services, but those
services are going to continue and that the work that they do
has significant merit. I feel that is a very important
notification that we should give to that group.
In addition to that, I think that at this point in time,
with all of the potential shuffling around going on, that I
would encourage both the Department of Homeland Security and
the Department of Health and Human Services to look at each of
their agencies' strengths and weaknesses and to bring those to
bear to create a rapidly mobile and efficient response
capability that can really be preserved in the coming months
for the hurricane season and other threats coming up.
And the last issue relates to the private health care
delivery system. I think that there should be resources
available for private sector facilities to participate in
emergency response and planning as well as we should be aware
that if penalties exist or loss of income exists, when private
institutions help, that those should be discouraged at the
Federal level and that in terms of involvement of private
health care facilities, I think that the sub-state regions that
we talk about in our documentation is a good way to get the
private health care system into the planning table and to
participate in the response capability of both the State and,
therefore, the Nation.
Thank you.
Senator Burr. Thank you very much.
[The prepared statement of Dr. Gougelet follows:]
Prepared Statement of Rob Gougelet, M.D.
The Nation's ability to respond to a mass casualty national
emergency is the inherent capability of the Federal Government to
respond and the composite of each State's ability to respond. They each
present with their own limitations.
The Federal Government has limited resources to respond to
overwhelming and widespread natural events such as Hurricane Katrina or
a Pandemic influenza event. Overwhelming and widespread terrorist
events will further challenge the Nation's ability to respond, as there
would be no advance warning, and there would be intentional attempts to
injure as many civilians as possible including direct attacks on first
responders, health care workers and medical facilities. Federal
response to locally catastrophic events is limited by the time it takes
for resources to arrive in a community. Many times death and injury
occur during the event or within the first few hours of the incident,
emphasizing the need for an appropriate local response. In these two
cases, the Federal response should be to anticipate, plan for, provide
guidance and technical support, communicate with, and efficiently
respond to communities where these incidents occur.
Individual States also have limited capacity to respond to
overwhelming events. Each State should be broken down into sub-state
regions that can provide critical response capabilities. Each State's
capacity to respond to an overwhelming mass casualty event is then a
composite of capabilities of sub-state regions. A Regional Response
System (RRS) is sub-state region described as a metropolitan area, a
sizable town and its surroundings, or multiple towns in a rural
setting. An RRS is determined on its ability to plan for and provide
critical services during the time of an overwhelming mass casualty
public health emergency. Although all towns currently plan for and
respond to a wide variety of emergencies, critical response
capabilities necessary to respond to mass casualty events can only be
provided by smaller towns or regions working together. Some examples
include setting up community-based mass prophylaxis and immunization
sites, community-based hospital surge capacity beds, or isolation and
quarantine facilities. The Nation's capability to respond at this sub-
state level is where a critical gap exists between resources needed and
resources available.
Hurricane Katrina in particular demonstrated how a catastrophic
emergency can overwhelm local response and leave a critical gap in
response efforts until massive Federal help arrived days to weeks
later. During this gap in effective response, death, and suffering
continued in an environment of hopelessness and chaos. Analyses of
potential biological terrorist attacks involving tens of thousands of
casualties predict a similar gap in response capabilities.
The timely and effective use of the vast, distributed regional
response resources requires careful and practical planning among
communities and States before the actual need arises. Once an incident
occurs, it is too late to develop the relationships, policies, and
procedures to figure out how to integrate and apply such diverse
resources in a timely and effective manner.
The concept of using regional response resources is predicated on
comprehensive planning for use of local, State, and Federal resources
from within a region. This planning along with appropriate and
realistic exercises is needed before a catastrophic emergency. During
such an emergency, the local medical and emergency first response
resources would be the first line of defense. Any serious flaw in this
first response would seriously jeopardize all of the following
responses. The first responders must be able to quickly build the
foundation by which outside resources are efficiently integrated and
effectively utilized within the community. The use of regional
resources is necessary because of their close proximity and they may
possibly have sufficient numbers to effectively fill the gap between
the local and State response and the subsequent Federal response.
Regional planning both interstate and intrastate can be useful
tools for closing the gap between local State and Federal response.
The intrastate Regional Response System (RRS) can facilitate
planning and response to catastrophic emergencies for all types of
hazards. Man-made and natural disasters include a vast array of threats
from fires, floods, hazardous materials releases, transportation
accidents, earthquakes, hurricanes, tornadoes, pandemics as well as the
terrorist arsenal of chemical, biological, radiological, nuclear, and
high-yield explosive weapons. The development of Regional Response
Systems (RRS), along with implementing actions in order to ready
communities, States and, indeed, the entire Nation to respond
effectively to all-hazards catastrophic emergencies will provide a long
needed framework to incorporate local, State and Federal resources
during the time of an emergency.
If each State's sub-state region or regional response system (RRS)
is tasked with critical capabilities such as setting up an alternative
care center, then we begin to form the building blocks for a true and
reproducible national response.
Estimates or predications of casualties anticipated during
different types of outbreaks, natural disasters or terrorist attacks
are a necessary first step to determining the types, numbers, location
and timing of responders necessary to deal with varying mass casualty
events. The next step would be to determine the medical care necessary,
and the resources needed to give that care.
For example, if hospital bed surge capacity is the response
required, the first step is to define the role and limitations of
hospitals during the event. Hospitals are the only resource other than
field treatment that have immediate or near immediate health care
capabilities. During a Pandemic event, it is anticipated that hospitals
will be filled to capacity with seriously ill patients and also
severely limited in their response capability by staff (and their
families) illness and death. Hospitals will also be compromised by the
loss of critical medical supplies and pharmaceuticals, and possibly
even power and communications failures.
Community-based facilities extend the State's surge capacity beyond
acute care hospitals. These facilities allow definitive health care for
patients during mass casualty incidents that exceed hospital surge
capacity. They also provide an alternative site for treatment should a
hospital be evacuated or incapacitated. There are two different types
of community-based facilities: alternative care facilities (ACF) and
acute care centers (ACC).
Alternative care facilities are community-based medical facilities
usually used for outpatient treatment that during the time of a mass
casualty event, can be readily converted to care for patients needing
hospitalization. An example of an ACF would be a nursing home or
ambulatory surgery center.
Acute care centers are located buildings of opportunity. These are
community facilities that simply provide space. Examples include
armories, auditoriums, conference centers, and gymnasiums. The ability
to provide treatment is dependent on all medical supplies and staffing
being brought to the site. This type of facility would also be the
receiving facility for outside Federal resources such as the Federal
Medical Contingency Station.
Using this scenario, local Medical Corps personnel can plan for and
staff an alternative care facility. NDMS, and commissioned corps
personnel can later provide backfill upon arrival.
A large gap exists in trained health care workers to staff
community-based health care facilities including alternative care
centers, immunization and prophylaxis clinics and isolation and
quarantine facilities.
To successfully recruit, train, exercise and sustain health care
providers is a difficult task. Critical concerns by staff are very
common sense and understandable:
Am I safe, is my family safe?
Where am I going to work and for how long?
Am I protected from liability and workman's compensation
issues?
Am I trained to recognize and treat the disease or injury?
If I take off work, will I be compensated?
What is my specific job action, where do I fit within the
chain of command?
Am I qualified and trained to do the job?
Do I have any physical limitations or restrictions that
prevent me from responding?
Federal, State or private medical staffs that provide medical care
as their full or part-time employment should be provided opportunities
to train, exercise and drill for a wide variety of all hazards
catastrophic events during the course of their employment.
One major objective for staffing would be to recruit volunteers
before an incident occurs. This allows the opportunity to verify
credentials, issue IDs, educate and train, and to participate in
exercises and drills. The completion of the ESAR-VHP program would be
valuable.
Interstate regionalization is also a tool for filling in the
critical gap between local, State and Federal response.
To fill this gap in Northern New England, the Northern New England
Metropolitan Medical Response System (NNE MMRS) functions as a
coordinating resource for Maine, New Hampshire, and Vermont in
preparing for and responding to the health and medical consequences of
a mass casualty event affecting the tri-state region. When the national
MMRS program was founded in 1996, the intention was to mitigate
casualties from terrorist events using weapons of mass destruction by
improving and coordinating planning efforts within metropolitan areas.
Recent events, such as Hurricane Katrina and fears of an Avian Flu
Pandemic, have underscored the need to improve planning and response
efforts for natural disasters and disease epidemics nationally.
The population of the three States exceeds 3 million with 52.6
percent of residents residing in rural areas. Major population centers
and seasonal tourist attractions within the region represent
vulnerabilities for terrorist attacks. Furthermore, all three States
share borders with Canada, necessitating close cooperation across an
international boundary. Maine and New Hampshire both have active
seacoasts, busy with commercial and leisure vessels.
In addition to the threats to northern New England, the region must
be concerned with terrorism and disease epidemics occurring in southern
New England. Due to geography, in the event of a mass casualty incident
in the urban areas of southern New England, it is likely that the tri-
state region will provide surge capacity for victims of the event.
While some patients may be legitimately transported to northern
hospitals, there is a distinct possibility that tens of thousands of
individuals might flee the urban areas, overwhelming resources in the
northern States and potentially spreading disease. There is also a need
to be prepared to act on alerts from the Boston BioWatch program.
(1) A large gap exists in trained health care workers to staff
community-based health care facilities including alternative care
centers, immunization and prophylaxis clinics and isolation and
quarantine facilities. Basic issues such as liability, workman's
compensation, personal and family protection, education and training,
motivation and sustainability are high priorities for this group of
health care personnel.
Sub-state regionalization and inter-state regionalization are two
useful tools that can fill the critical gap between local and State
response, and the Federal response. Critical health care staff, medical
equipment and supplies and pharmaceuticals may be available within
neighboring communities or adjoining States. An example of interstate
regionalization is the Northern New England Metropolitan Medical System
which provides a planning mechanism and response capability for Maine,
New Hampshire and Vermont.
The Federal Government should provide concise planning guidance and
technical information to communities that outline critical response
capabilities. Common structures within States and across State lines
allows for familiarity and cost effectiveness. A common structure would
allow for seamless integration of staff, equipment and supplies
(2) Significant logistical support for a massive Federal response
should be through the Department of Homeland Security. This would
enable close support of multiple agencies within DHS, as well as with
DOD. DHHS and DHS should identify strengths and weaknesses within their
agencies, and combine efforts to insure a rapidly mobile and competent
medical response system. To optimally support the Federal response, a
solid foundation in affected States and communities is needed to
maintain an effective response capability. Strong medical direction at
the senior level should direct the field deployment, response and
logistical support.
(3) Private health care delivery systems should be utilized as
resources during the time of emergency and incentives should be in
place for preparing for and responding to these emergencies. There
should not be penalties or loss of income for private healthcare
systems participating in emergency response. Participation of private
health care can be easily added at the sub-state and community level.
Senator Burr. Your written statements are invaluable to us
and we have looked at those. I probably will stay away from
some of that because there are some loose ends that I would
like to wrap up in the 15 minutes that I have got with you.
I think that your membership on NDMS response entity is a
unique opportunity that we have to better understand, not
necessarily today, but as we go through this process, I hope
you will make yourself available to us as we talk about this
relocation and, more importantly, how it is then structured. I
think that this is not simply another Washington attempt to
redesign the deck chairs. It is to create a robust and
responsive entity with its focus on health response, and the
threat, and not to hope that on any given day with any given
situation, that these different pieces sort of come together.
It should be a planned response, because they are all part of
one unit and it is merely a question of how much of that unit
you turn on.
I am curious with the exercise you went through in New
Jersey, given that you ended up with a distribution at the post
offices, was the mail delivered that day?
Dr. Gougelet. Well, as I said, it was a virtual reality
event. Nothing was delivered that day----
Senator Burr. But had you not decided on post offices as
the distribution point, the mail would have been delivered that
day, wouldn't it?
Dr. Gougelet. It may have been. I mean, certainly in some
jurisdictions in the State.
Senator Burr. In all likelihood, you could have done the
distribution given the choices you made, in 1 day, utilizing
the same entity that you chose but utilizing it in a different
capacity. Versus the post offices, you could have used the home
delivery. I only point that out to you because I want to share
that we have looked at every potential option that exists in
this country for distribution. I think at the end of the day,
we can come up with a consensus on a lot of the structural
changes that are necessary and we will pass the test of
workability.
The one question that I have yet to figure out the answer
to is, under numerous situations, how do we distribute what it
is that we have got, and have we explored the use of the U.S.
Postal Service as it relates to national distribution? We have
looked at Wal-Mart and Home Depot and Lowe's that do this with
great proficiency. I think it is safe to say, we do not have
the answer yet that gives us the assurance there is one thing
that we can turn to that gives us the capacity to do that. I
think we are convinced that we have to answer that question
before we complete this reauthorization, if not in total, in
part, and that there be a quest to fill in the rest of that
gap, which I think probably will exist.
But I think many in the Federal Government have overlooked
that capability that exists every day in this country, and that
is that across the country, the mail is delivered every day,
and in all likelihood, that person that delivers it, Richard,
is the only one that knows actually how many people live in
that house. It is not the Census Bureau, it is the postman.
Dr. Bresnitz. If I could just make a comment on that, I got
to know the local postal officials quite well during 2001 and I
got an education about the U.S. Postal Service and labor-
management relationships in the U.S. Postal Service. It is
sticky in many cases and I would only urge those at the top to
understand that those who are the postal carriers and postal
workers are not necessarily ones that have bought into such a
system. I think that it is true that upper management has done
that, but I am not so sure that at the local level, given the
scenario that might play out in an attack, given that many of
these carriers would require security and just that alone might
give them hesitancy to participate in something like that. And
so at the end of the day, even though postal leadership might
think that this could work, I would want to know from the local
people whether they would consent to doing something like that.
Senator Burr. Feel certain that we have drilled down to the
point that we understand the challenges that even that as a
distribution choice present to us. I think it is safe to say
that for a pandemic model, where HHS would model in 35 or 40
percent of the individuals as no shows, all of a sudden, that
choice is eliminated because you are looking for total coverage
and that is conditional on a given person who shows up on a
given day. You can fill in to a certain degree, but you can't
fill in the 35 or 40 percent scenario that we have been
presented. So I think we are truly trying to deal within the
variances of the likelihood of what we are going to experience
so a sufficient answer actually does meet the needs of whatever
the threat is.
Let me--yes, sir?
Dr. Inglesby. On that point, I think, just if I could
endorse your potential enthusiasm for using the Nation's great
distributors that already give these kinds of medicines and
vaccines out on a regular basis, I think there is a lot of
evidence that the leaders of the major retail chains in the
country would be interested in doing this if it became more
clear how they could get involved. They have the physical
plants. They have the parking lots. They can provide some
modicum of security and they give out medicines and vaccines
all the time, every day, but they have not, for the most part,
been included in any kind of strategic thinking on that. But if
I had to put my nickel down on some new huge operation that
already exists that we could tap, I think that would certainly
be worth doing, to put my nickel on.
Senator Burr. I can safely assure you that we have looked--
--
Dr. Inglesby. You have done it.
Senator Burr. We have left no stone unturned as it relates
to at least exploring what our options are.
Let me ask you, if I can, what would be the greatest needs
of a hospital in the event of a mass casualty incident?
Dr. Inglesby. Well, the thing that would change the game
entirely obviously would be vaccine. If we can't get vaccine,
we jump down three or four levels to having to deal with a
pretty terrible situation. So absent vaccine, hospitals are
going to be in desperate need of the personal protective
equipment that keeps health care workers--that gives health
care workers the best chance to keep from being infected. They
are going to need to have caches of anti-virals, if they are
available, and a communications system which tells them what is
going on elsewhere in the State, what is going on in the
Governor's office, what is going on at CDC, because right now,
most hospitals are pretty much autonomous entities which are
competing across the street, which don't necessarily have a lot
of connections. It depends on the State. New Jersey may be
different. In some places, it may be stronger, but in many
places, hospitals are entirely separate from the public health
apparatus and have only kind of moderate personal connections.
So they need to know what is going on. They need to have
situational awareness about what is happening, where the
medicines are, is there more coming, where are the patients
that are sick, what is the overall sense of the State
leadership. You need to have personal protective equipment.
Senator Burr. Tom, the average hospital could last how long
without being resupplied on the essentials?
Dr. Inglesby. It depends on the kind of crisis, but I think
some hospitals have already purchased Tamiflu and have
purchased as many masks as they can get from Kimberly Clark or
other suppliers. But there are sharp limits even now for
hospitals who want to spend their own money on this.
Senator Burr. I guess I am drilling down to just the
basics, the basic supplies that a hospital has. How long can
they maintain the treatment of patients if there are not new
supplies coming in the door?
Dr. Inglesby. The basics? So if you had complete or
interruption of the supply chain for the typical needs of a
hospital, probably a couple of days at the most. Most of them
operate in just-in-time in most different areas of
infrastructure. And if they lose one of them, if they lose
electricity like they did in Louisiana, or if they lose water,
or if they lose medical gases, then parts of their operation go
down completely.
Senator Burr. Rick, you talked about the surge capabilities
designed for Boston, of 500 beds by a number of different
methods, that the partnership was able to come up with. Did you
ever model how long you could maintain that surge capacity to
500 beds?
Mr. Serino. We have had numerous tabletop drills, ERT
summits. The most recent was a couple of months ago when we had
over 350 people all in the room. To answer that, I am actually
going to go back to what you were just asking about--hospitals
and an individual hospital. One thing that we have found is
that the hospitals initially were individual, and what we have
done is bring them together. We have looked at the medical
community as the medical community, including EMS, hospitals,
public health and community health centers, which prove to be a
very great asset in the city and also in rural areas, having
the local community health centers or whatever they are called
in their area in order to be part of a system. Having that as
part of a system, having a seat, as they do, on the city's
Emergency Operations Center, one for each one of those sit
together so that 2 days out, when supplies start to dwindle
down and there aren't enough medications or medical supplies in
the hospital, that it is not a hospital requesting that, that
they go through a centralized, organized at the city level, and
then bumping that up so it can then be distributed in an
organized manner rather than one hospital asking for one thing,
another hospital asking for the same thing, somebody else
asking for something else.
We have tested that. That has worked, and it is important
in order to do that, and I think that probably the most
critical asset in the hospitals is not necessarily the
equipment that is going to run out in 2 days. I think it is the
people----
Senator Burr. You have highlighted a couple of times this
partnership that was created, not just within the family of
medical. I would imagine that for the purposes of the DNC
convention that that probably included law enforcement, it
included----
Mr. Serino. It included law enforcement at all levels and--
--
Senator Burr. Let me ask you, what were the most difficult
problems that you encountered as you tried to set up the
agreements between all these entities.
Mr. Serino. Lawyers. I say that in a room full of lawyers,
but----
[Laughter.]
I think that probably one of the problems, aside from the
lawyers, was trying to actually get people to understand the
concept of what we wanted to do, and once we got people, and
especially the CEOs, because we had the disaster coordinators,
the ER staff all brought into it and it was how we were going
to get everybody into it and it was the mayor, Mayor Menino,
who was actually able to bring, you know, the CEOs together and
to say, this is a priority.
Senator Burr. I open this to anybody who would like to take
a shot at it. I think everybody mentioned that there was a
need, a necessity to tailor the needs of a response team to an
area in which they are deployed and better integrate the
Strategic National Stockpile with local responders. From the
local perspective, how can we at the Federal level facilitate
this increased integration? I think this is vital as we begin
to create this framework that we know, what is the trigger?
Dr. Gougelet. Well, you know, I believe the direction from
the Federal Government in terms of what this framework should
look like, should give a clearer understanding at the local
level of what is expected in terms of response. For example, I
think that when we did the smallpox planning several years ago,
when we were given some specific criteria, you know, your total
population immunized in 10 days, that was really the first time
we got specific numbers and guidance and timeframe from the
Feds in terms of what the local community should be doing,
because obviously, with the smallpox epidemic or incident, the
Federal Government wouldn't be involved in that. So this was
the first time I think that the local responsibilities were
thrust--or responsibilities were thrust upon the local
communities.
So the guidance from the Federal Government would be
important, and then performance criteria and funding follows
that. So we are talking about basic structures only in local
communities or regions of local communities to stand up a
capability, and then by testing those and reinforcing that
financially and everything, I think is a reasonable thing to
do.
Senator Burr. Am I wrong to believe that we should create a
public health floor that is the same in every community, not a
ceiling, but a floor, that you need the confidence of knowing
whether you are in the town you are in or whether it is 30
miles down the road that the capabilities to some minimal level
exist within the public health infrastructure in that
community?
Dr. Gougelet. Actually, I think you are correct in assuming
that that is what we need. I mean, having this common framework
doesn't necessarily--we tell them who is in charge in each
community, what building to use, what is going to be the lead
group, how many organizations should be at the table. I mean,
those things are characteristics that the communities can
determine on their own. But I really do believe we need that
ground framework to get things going.
Dr. Bresnitz. I would agree, as well, and I think most
State and local health officials would, also. There are
national public health practice standards, and we are not
talking just about emergency preparedness but standards for
public health in general. Those standards have been around for
a few years. A number of States have taken those standards and
adapted them to their own specific requirements at the State
level.
In New Jersey, for example, we actually have regulations in
place, adopted a couple of years ago, that require local health
departments to do an assessment of their capabilities and the
gaps and then basically develop plans to move forward with
basically improving their public health capabilities. The issue
always comes down to, okay, so we have identified the gaps. Now
where are the bucks to actually fill the gaps?
Senator Burr. You see the difficulty that we have got in
trying to create a national framework to operate within. If, in
fact, community by community that public health piece changes
from a standpoint of its capabilities, you can't plug it in in
an overall template where it works the same or has some
expanded capacity based upon local input, but there has got to
be a minimal, as I see it, force to integrate them into any
type of national model.
Dr. Bresnitz. Agreed, and I would say that all public
health agencies at the local level would like to be at that
level, whatever that floor is, as you put it. The issue is, how
do they get to that floor and beyond?
Dr. Inglesby. Can I make a comment on that?
Senator Burr. Yes.
Dr. Inglesby. You asked before, how can the Federal
Government respond? I think, to local triggers in a crisis. At
UPMC during Katrina--Pennsylvania was entirely unaffected by
Katrina--the CEO and the leadership of UPMC attempted to put
its entire fleet of helicopters, 500 medical personnel, and
beds--like countless institutions across the country, a similar
experience. Over a week, it could not figure out a way to get
into the Federal Government or into local or State governments
in Louisiana to give any of it. They tried to knock on every
door they could get.
Now, maybe it was UPMC's own lack of familarity with the
government, but volunteering was too hard on an institutional
basis and on an individual basis. There were volunteers around
the country who wanted to--health care volunteers who wanted to
get involved, but they saw multiple new systems being set up on
the fly, multiple credentialing systems, complete uncertainty
about whether they would be covered from being sued.
I think simple consolidation and clarity and simplicity in
terms of what HHS could do. If you could find a way to say,
this is where the volunteers should call. This is where
interested institutions should call. There are a lot of things
going on, but if we could kind of bring them together--ESAR-
VHP, MRC, the Public Health Civilian Corps, the Commissioned
Corps, I think there are just too many small pieces and they
are too far out across government. They are in DHS. They are in
CDC. They are in HHS. They are in HRSA. I think we could bring
them together, make it more simple and say, one-stop shopping.
Senator Burr. Unfortunately, the clock has gotten me and I
can assure you I could sit here for another hour and read
through some questions. I hope you will allow me to do some, as
well as other members, in writing.
I think that is the opportunity we have, to take all of
those different pieces and, No. 1, figure out which ones could
be moved, which ones are absolutely crucial to our capabilities
to respond and should be moved, and then the last test will be
is there a willingness to fight the battle of the impact of
that on Federal agencies. When you move responsibilities, as
you know, there is a budget that goes along with them and
budgets are very protected in Washington within certain
agencies.
Truly, this is an attempt on the part of the bipartisan
subcommittee to look at how it should be designed and what the
makeup should look like for us to respond in the best possible
scenario. We will struggle between our inability to supply
enough money--I think all of you know that--but I would refer
to it a little bit differently. I would tell you that there is
a short-term piece and there is a long-term piece.
Short-term will always be driven by the urgency of the
threat, and I think it is evident as to the investment we have
made in a very short period of time in pandemic anti-viral
vaccine research, preparation, versus the known threats that we
have got out there today where there is not that sense of
urgency. Therefore, there is not that quick injection of cash.
My belief is, short-term as these threats or other threats
emerge, we will respond to those short-term, and it is
important that those dollars be used in a very effective way in
the overall design of what it is we have put together. Long-
term, we have to be a partner just like you are partners with
local entities that make up that successful response
capability. And in long-term successful partnerships, there has
to be, No. 1, a clearly-defined goal, and there has to be
accountability for how one uses the money to, in fact,
accomplish it.
I sort of put you and everybody else on notice that I think
one of the absolute essential requirements of this legislation
and this subcommittee is to come up with the appropriate
accountability piece that assures us that the right things are
being invested in, and No. 2, ensures you and all the partners
of the local entities that, over time, those resources that are
needed for this function to take place will, in fact, be in
place.
I alluded to the first panel that one of the striking
differences that existed in the Gulf Coast was a State that
chose to put the majority of their Federal dollars in their
surge capacity and a State that chose to put a majority of
their dollars in their preparation and actual practice of their
preparedness plan. As a result, you have two distinctly
different outcomes between Mississippi and Louisiana.
That is not to fault one and to highlight another. It is to
say that in that case, we provided the choice. In the case of
one, they chose wrong. Surge did them no good when the
facilities that they built up were no longer available. I think
that there is a lesson there that the subcommittee will go down
and look at first-hand so that we can try to figure out a way
not to design choices that might not be appropriate long-term
into the structure of what it is we think we need in place.
I will have on my wall, if you want to come by my office
any time after today, ``Volunteering was hard.'' You have
termed what I have been trying to tell Federal agencies since
Katrina and before Katrina. We almost make volunteerism for
anything where the Federal Government is involved impossible,
and I think Senator Hatch alluded to it. I think Senator Harkin
was on the fringes of it. We have to figure out a way to make
volunteerism easy. We have to figure out a way to recruit
individuals to commit to volunteer. If not, we can handle some
of the threats that our communities are going to be faced with,
but I will assure you there is a handful of threats, many of
which we don't know what they are today, that will come at us
as a country and a world in the future that we will not be able
to handle if, in fact, we have not answered that one specific
challenge.
So on behalf of the subcommittee and the chairman and the
ranking member, let me thank you for your willingness to be
here. Hopefully, as this year goes on, we will consult with you
on the product that we are trying to produce even more. Thanks.
Senator Burr. This hearing is adjourned.
[Additional material follows.]
ADDITIONAL MATERIAL
Response to Questions of Senator Burr by Richard Serino
Question 1. Effective medical response to a national catastrophe
requires a sufficient number of medical personnel. Establishing
alternative care sites will only be effective if they are staffed with
trained health care providers. Currently, the Federal Government
possesses several mechanisms to support this activity--NDMS, ESAR-VHP,
Medical Response Corps, and the Commissioned Corps. How should the
recruiting, credentialing, training, and managing of permanent and
temporary Federal health care providers best be accomplished? How can
the Federal Government best organize and deploy health care providers
to assist in the response to a national emergency?
Answer 1. The staffing issues that will arise during a medical
crisis are some of the most challenging surge planning issues that
local, State and Federal officials face. The programs in place to
address these challenges represent a good start in the effort to
provide adequate trained staff, however these programs must be expanded
and coordinated. Specifically, the National Disaster Medical System
must be expanded and better supplied; the Emergency System for Advanced
Registration of Volunteer Health Professionals must be fully
implemented and expanded; and the Medical Reserve Corps must be fully
funded and supported. Additionally, it is essential to promote and
assist local efforts to address surge capacity needs.
The National Disaster Medical System must be expanded and
adequately supported. The Disaster Medical Assistance Teams (DMAT) are
primarily local and regional organizations that can be federalized
during a crisis. For the most part, the DMATs are managed in States
that face a regular need for medical surge capacity. While this often
means that the teams are very well trained, it also means that during
the time of a crisis teams are being pulled from locations where the
personnel are still needed. For example, many of the Florida teams that
responded to the Gulf Coast had just recently been involved in
hurricane response in their own jurisdictions. Furthermore, the current
structure of the DMATs, mandating a ``three-deep'' format, still does
not provide adequate depth to insure full mobilization. The depth is
not uniform across all specializations and thus leads to teams with
significant gaps. The DMAT teams need to be expanded in numbers and in
distribution. Through funding and other incentives, all States should
be encouraged to help establish teams, and those teams should have
sufficient depth to field well-rounded medical organizations during a
crisis.
While federalized assets such as the DMATs provide one critical
surge resource, volunteers will provide the bulk of any medical
response during a sustained crisis. The credentialing and organization
of these volunteers provides an ongoing and unique challenge. While
programs such as the Emergency System for Advanced Registration of
Volunteer Health Professionals (ESAR-VHP) are steps in the right
direction, they have yet to make a significant impact on the local
level. The program is only in its very initial stages of rollout and it
does not address many of the broader credentialing issues likely to
come up during a crisis. ESAR-VHP must be fully implemented and
expanded in conjunction with the Medical Reserve Corps, but it must
also be supplemented with a broader national initiative. The Federal
Government must push for a way to achieve universal credentialing for
medical professionals involved in disaster response. If there is even
the slightest chance of responding to a crisis, the individual must
have pre-existing credentials and these must be recognizable across
local and State boundaries. A credentialing program could include a
universal symbol added to a driver's license or an additional national
card issued during the time of initial credentialing.
Additionally, volunteer organization remains a distinct challenge.
The Medical Reserve Corps must be completely funded. While surge
capacity is a universally recognized issue, the funding for the Medical
Reserve Corps is constantly threatened. The program must be expanded
through more effective recruitment, advertising, and improved training.
The program should also be organized in conjunction with further
efforts.
Finally, in Boston, one of our great successes has been the
Metropolitan Medical Response System staff sharing agreement. The MMRS
agreement applies to staff and equipment and establishes that
participating institutions cover liability and compensation for their
staff, whether it is to help the city or another health care facility.
Furthermore, the sending institution guarantees the staffs'
credentials. The agreement has been implemented three times, twice for
immunization clinics for Hepatitis A outbreaks and once during
Hurricane Katrina. Efforts like the MMRS agreement provide the basis
for expanded surge capacity and can serve as a model for State and
Federal efforts.
Once our volunteer programs are guaranteed long-term support, they
need to be integrated into a comprehensive response plan. Those with
experience, specifically the DMATs and the military will always best
perform local response at the site of a disaster. Shelters and overflow
hospitals are perfect places to Incorporate ESAR-VHP and medical
reserve corps volunteers. If leadership and organization can be
incorporated from the various hospitals, as our MMRS staff sharing
agreement has done in Boston, these groups will be up and running
faster. Additionally, if we are to guarantee these volunteers will show
and be able to perform to their maximum capacity then we must guarantee
that their workers compensation and liability protection is covered.
Finally, these groups can provide added service at vaccination clinics
and during the reception of displaced persons.
Question 2. The medical preparation for, and response to disasters
requires significant logistical support--medical supplies,
pharmaceuticals, transportation, medical evacuation, etc. What is the
most effective way to optimally support a Federal medical response?
Which Federal agency should take the lead?
Answer 2. During a large-scale medical response to a crisis, the
primary logistical challenge is not the initial one, but the immediate
follow-on response. Specifically, in addressing the needs of the
National Disaster Medical System and the Disaster Medical Assistance
Teams, the medium term logistical support requirements must be re-
examined.
DMATs are specifically designed to deploy with a 72-hr supply of
materials. One of the great successes of the DMATs was the initiative
to provide all teams with dedicated trailers for pre-packaged
deployment. This, however, has not solved the issue of supply, both in
terms of immediate needs and longer-term requirements. Many DMATs are
unable to sustain sufficient supplies for many types of deployments. In
particular, there remain outstanding equipment requirements that must
be addressed. While these needs are specific to each team, for example
some Massachusetts teams lack environmental control units for their
medical tents, it creates a larger problem during a deployment,
critical time is spent trying to acquire or borrow needed equipment.
Furthermore, while the teams do deploy with a 72-hour supply, the
follow-on for this supply is inadequate. One suggestion is to develop
additional DMAT caches such that a replacement 72-hour cache is
immediately deployed behind a DMAT team. This way, as a team runs out
of supplies, they need not spend critical time tracking down specific
items, but will always have a complete additional stock of supplies
waiting to fill in needs.
Since the DMATs were incorporated into FEMA, logistics have
improved: they now have emergency pharmaceutical caches, trucks,
warehouse space, and a radio cache ready for deployment. However, there
is still much to be done. For example, in the Katrina response,
providers found that only certain antibiotics could be used for soft
tissue wounds because of regional variation in the bacteria. FEMA
logistics was unable to process this change from the usual antibiotic
cache even after several weeks. Clearly, we need strong logistics, with
a medical background.
Logistical needs are not confined to the DMATs. The Federal
Government must find a way to better address equipment needs during a
surge incident. The National Pharmaceutical Stockpile and the Strategic
National Stockpile are critical assets, however, they are not well
integrated into local response capabilities. While the need for
confidentiality and security in these caches is understandable, they
are only useful if the people who use the equipment know what they will
find and are familiar with its use. Federal and local agencies must
find a way to coordinate the security needs of these stockpiles with
the practical needs of efficient deployment.
Question 3. National medical preparation and response to mass
casualties is dependent upon integrating multiple components, including
a largely private health care delivery system. What steps must be taken
to foster a more coordinated response that includes a strong public-
private partnership?
Answer 3. Federal, State, and local governments must pursue every
opportunity to incorporate the medical community into planning and
training. The worst possible outcome is for people to be exchanging
business cards on the day of a crisis. It is only through ongoing
coordination, exercises, and trainings that full integration is
maintained. In Boston, we have had real success by insuring the medical
community has a seat in homeland security planning and discussions, by
including the medical community in regular exercises and drills, and by
providing effective training that spans disciplines.
Locally, we have learned the value of existing relationships. Our
successes in medical planning come from bridging the gap between a
well-integrated medical community and the public safety and Federal
agencies that play central roles in homeland security and emergency
preparedness. As the result of extensive experience working with the
Conference of Boston Teaching Hospitals to manage disaster planning in
the city as well as more mundane day-to-day emergency planning, there
is an existing group of local officials and private organizations that
have worked hand in hand for years. By establishing and carrying
forward committees and organizations that address planning and response
issues, the people who will have to work together in a disaster already
know each other. Furthermore, by including the medical community in the
planning process, many people have learned how important such planning
is. There is now a seat for the medical community on the U.S.
Attorney's Joint Terrorism Task Force and the Anti-Terrorism Advisory
Council. The medical community is an integral part of Boston's Homeland
Security planning, and while some formal structures are still missing,
they now have a seat at the table.
One of our lessons learned is that the medical community needs to
be considered part of the critical infrastructure. Communications,
infrastructure protection, and integration into existing emergency
management structures are all tasks that flow from this acceptance of
the private medical infrastructure into the public response community.
Response to Questions of Senator Burr by Ellen Embrey
Question 1a. Effective medical response to a national catastrophe
requires a sufficient number of medical personnel. Establishing
alternative care sites will only be effective if they are staffed with
trained health care providers. Currently, the Federal Government
possesses several mechanisms to support this activity--National
Disaster Medical System (NDMS), ESAR-VHP, Medical Response Corps, and
the Commissioned Corps. How should the recruiting, credentialing,
training, and managing of permanent and temporary Federal health care
providers best be accomplished?
Answer 1a. The medical response to a national catastrophe begins
first and foremost with State and local first responders. The Federal
Government must anticipate and be prepared to rapidly respond if State
and local governments are not able to mount an effective response, even
before a formal request for Federal assistance is received. The
mechanisms to provide Federal health care provider resources are
through the National Disaster Medical System (NDMS), the Emergency
System for Advance Registration of Volunteer Health Professionals
(ESAR-VHP), the Medical Reserve Corps, and the Public Health Service
Commissioned Corps. However, the Defense Department, to the extent
health care resources and providers are not deployed on other global
missions, can provide additional health providers to supplement the
workforce. DOD needs to synchronize these assets and capabilities with
the overarching coordinating body. Specific recommendations include:
i. Recruiting
1. Recruiting from retired or currently unemployed but qualified
volunteer providers within the community and State.
2. Making use of reserve military medical and nursing providers and
other responders, as well as an expanded group of allied health
professionals, such as veterinarians, dentists and dental auxiliary
providers, pharmacists, and students in training.
ii. Credentialing
1. HHS, working with State government and specialty/professional
associations, needs to continue to build a robust and comprehensive
Federal health care providers database.
2. HHS needs to continue to research regulations to cross-
credential Federal providers, including DOD providers during times of
crisis/national emergency.
3. HHS needs to continue to develop ESAR-VHP and other databases to
allow for online validation of credentialing requirements to facilitate
rapid certification of medical professional volunteers.
4. HHS attorneys need to work with the States' Attorneys General to
ensure federally credentialed providers do not require additional
credentialing when deployed within any given individual State.
iii. Training
1. HHS needs to determine what types of providers are required in
catastrophic events and provide guidance to the remainder of the ESF#8
partners and recommended training standards.
2. Train an expanded group of providers, such as veterinarians,
dentists and other allied health professionals to provide ``triage''
and basic care requirements.
3. Create a system to train a pool of non-medical responders to
support health and medical care operations (e.g., military personnel at
sea are all trained in BLS and basic responder care to act as first
responders). Note: Although the ``best possible care'' will be
delivered during a mass casualty event, the ``standards of care'' may
be different than what can be provided during daily routine scenarios.
4. Determine processes to reallocate providers from non-emergency
care and non-emergency sites to emergency response assignments and from
unaffected regions to affected regions (this will involve identifying
skill sets of each practitioner group [such as paramedics and nurse
midwives], so as to optimize reassignment potential).
Question 1b. How can the Federal Government best organize and
deploy health care providers to assist in the response to a national
emergency?
Answer 1b. Collectively, Federal agencies, including DOD, have many
trained medical personnel who can be called upon to respond to a mass
casualty event. The problem is a need for improved coordination,
consistency in policies and procedures, and regular simulations/
exercises. The National Incident Management System should be used to
affect clear command and control and provide improved situational
awareness to the healthcare situation at the site of the disaster.
Specific recommendations include:
i. HHS should work with the ESF#8 partners, including DOD, to
develop capabilities-based concepts vice pre-established units (e.g.
Federal Medical Stations).
ii. DOD should include HHS, VA and DHS/FEMA and other ESF#8
partners in its determination of capabilities, including interagency
deployable capabilities
iii. DOD should work the Services and the interagency partners to
develop and more broadly apply Unit Type Codes (UTC's) which identify
capabilities, team readiness, and deployment status.
Question 2a. The medical preparation for, and response to disasters
requires significant logistical support--medical supplies,
pharmaceuticals, transportation, medical evacuation, etc. What is the
most effective way to optimally support a Federal medical response?
Answer 2a. i. DHS/FEMA needs to provide the overall construct of
logistical support to include the infrastructure available for public
health and medical requirements.
ii. Establish an ESF#8 logistics coordinator (like the Strategic
National Stockpile) that will:
1. Establish medical supply chains and support capabilities to
prioritize, acquire, distribute, and redirect assets based on HHS
guidance.
2. Monitor and report the status of critical medical materiel and
items during emergency response operations.
3. Coordinate logistics support from commercial suppliers.
4. Assess emergency response capability.
5. Plan and build deployable sets.
a. Plan and coordinate return, re-use, or disposal of assets
after the contingency is over.
iii. The idea of establishing a Federal Medical Materiel
Coordination Group (FMMCG) was originally proposed as a result of Sept.
11, 2005 and the anthrax scare when one Federal agency negotiated their
own contract price for antibiotics, but failed to include other Federal
agencies. The FMMCG is designed to establish procedures for
coordinating and allocating critical medical materiel items among the
different Federal agencies seeking the same products in the event of an
all-hazards catastrophe. Once established, this coordination group
would represent the Federal agencies engaged in acquisition and
management of medical materiel to support emergency operations. It
would focus on defining criteria that elevates allocation decisions for
medical materiel items across Federal agencies. This group would work
to develop the above requirements to feed into the existing FEMA
logistics management and distribution processes. The lessons learned
from Hurricane Katrina for medical logistics could be resolved with
this FMMCG.
iv. Patient movement and evacuation of displaced persons should be
removed from this function and ``managed'' through ESF#1/Department of
Transportation (DOT). All requests should come through the NRCC to
determine the most efficient use of transportation assets, to include
the use of pre-existing transportation contracts to move patients that
do not require medical care during movement. A national (Federal,
State, local) system for evacuee and patient transport, regulation, and
tracking should be developed that begins at the incident site, follows
the evacuee/patient to intermediary locations (e.g., hospitals, nursing
homes, rehabilitation centers, etc.), to final disposition (e.g. home).
Transportation assets at Federal, State and local levels need to be
coordinated and visible, and related communication needs to occur
throughout all levels.
Question 2b. Which Federal agency should take the lead?
Answer 2b. i. DHS/FEMA Logistics should develop standard processes
to accomplish the above for all ESF's.
ii. DHHS should be the lead Federal agency, as detailed in ESF#8.
DHHS should plan, exercise and coordinate a medical response. If the
catastrophe is beyond their capability, DOD could be considered to
assume the lead. However, this should be a Presidential decision based
on:
1. the extent to which State and local first responders are
effectively managing the situation,
2. the extent to which Federal civilian responders are able to
effectively manage the problem,
3. the nature of existing relationships in the jurisdictions
affected, and
4. the nature of existing relationships between the military and
the States affected.
Question 3. National medical preparation and response to mass
casualties is dependent upon integrating multiple components, including
a private health care delivery system. What steps must be taken to
foster a more coordinated response that includes a strong public-
private partnership?
Answer 3. Steps begin with aggressive regional, State, and private
sector coordination between the ESF#8 functional lead and appropriate
parties. Lack of pre-event planning can result in an ineffective,
inefficient and dysfunctional response. Local healthcare providers and
agencies should be knowledgeable of local requirements and assets
available on scene. The Federal response should be geared to supporting
those requirements and filling gaps at the State or regional levels,
when requested.
Under the NORTHCOM model, Joint Regional Medical Planning Offices
(JRMPOs) exist in peacetime to coordinate medical support to local and
State civilian authorities. This effort is being expanded by FEMA and
DHHS and should continue to be expanded to include all Federal agencies
and the private sector.
i. Messages should be developed that clearly include the private
health care industry as our partner.
ii. Incentives should be developed to recruit private industry and
academia to provide assistance.
iii. Reimbursement strategies for loss of elective surgery (the
main source of hospital income) need to be developed to ensure
solvency.
iv. Legal considerations should be evaluated to ensure the ability
to view all types of patient data, location, status, etc. during a
catastrophic event.
v. HHS, in coordination with the other NDMS partners, should re-
evaluate NDMS to potentially expand its functions to include the
private sector and make recommendations on the adequacy and feasibility
of utilizing the current NDMS structure to support catastrophic events.
Inclusion of other ESF#8 supporting Departments/agencies within NDMS
should be considered (e.g. DOT).
[Whereupon, at 12:07 p.m., the subcommittee was adjourned.]