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Subcommittee on Oversight and Investigations
October 10, 2001
10:00 AM
2322 Rayburn House Office Building
Introduction
Chairman
Greenwood and members of the Subcommittee, good morning.
I am Dr. Joseph F. Waeckerle, Editor in Chief of the Annals of Emergency
Medicine, the Journal of the American College of Emergency Physicians.
I am a Board of Emergency Medicine certified physician, and the Chairman
of the American College of Emergency Physicians' Nuclear, Biological, and
Chemical Task Force. I am here
today testifying on behalf of the American College of Emergency Physicians (ACEP),
which represents more than 22,000 emergency physicians and their more than one
hundred million patients.
I
want to thank you for the opportunity to appear before you today to discuss the
readiness and capacity of the federal programs to provide needed health related
services in the event of a biological terrorist attack.
The
focus of the nation since September 11 has been on the tragic and senseless loss
of lives caused by terrorists willing to fly air planes into buildings.
I want to talk to you today about the new weapons of war that have
emerged in our modern world which perhaps represent the greatest long-term
threats to our national security. Preeminent
among them are biological warfare agents. To
date, our nation has had very little experience with threatened bioweapon use.
What experience we have had has involved small, isolated events not indicative
of the true potential devastation of bioagents.
The
use of biologic agents as weapons of war could approximate the lethality of a
nuclear explosion, can decimate a large population, and thereby destabilize a
nation. It can inflict
psychological and economic hardship and political unrest by attacking small
populations in multiple sites over a protracted period.
America's citizens, national security and international stature are at
risk should a bioweapon be used.
America's
State of Readiness
There
have been numerous analyses of the escalating risks to America and the
considerable deficiencies in our responses to the threat of any weapon of mass
destruction much less biologic warfare. Internal
reports from the Federal government (Defense Science Board, Defense Threat
Reduction Agency, General Accounting Office), external assessments by august
panels such as Hart-Rudman and the Gilmore commission, and private testimonies
including the Smithson report and individuals before Congress repeatedly warn of
the serious deficiencies in our planning and preparation. Authorities have acted
on these deficiencies, but we must decisively improve much more. Careful
consideration of the existing strategies and response protocols reveals major
deficits that are obvious points of interdiction.
National
Strategy Deficit
A
comprehensive national strategy must be predicated on an in-depth analysis of
threats and risks. By identifying credible threats, available assets, and
resultant vulnerabilities, a cogent national strategy can be generated. To date,
the approach has centered on an "all-hazards" approach. Most of our
nation's hospitals have policies to respond to hazardous materials (HAZMAT)
incident, which are inadequate for responding to some chemical agents and nearly
all biologic agents. Certainly,
conventional weapons are and should be our main focus. Current planning has also
focused on chemical weapons with many federal agencies and departments
specifically addressing these threats. This is appropriate to a degree because
there are currently about 850,000 facilities in the US using hazardous or
extremely hazardous materials. Better preparation for possible hazardous
materials incidents whether they are the result of industrial accidents or
perpetrated by terrorists is beneficial to our country.
Many
governments and civilian authorities rightly believe that biologic agents
suitable for warfare are readily available. The dissolution of the USSR has led to the cessation of
funding for their once formidable bioweapons facilities and financial hardship
for the employees. As such,
security is minimal and personal motivation to survive, much less profit, is
utmost, so bioagents may be "on the market." Compared with conventional
weapons, research and development of bioagents are economically feasible today
for many other nations as well. Research and development is now where once only
a few had the capability and resources to pursue these avenues. As a result,
many nations/states have aggressively and successfully pursued their own
biowarfare research and development.
There
is also legitimate scientific application of microbiology, which could be used
to develop biologic agents. The pharmaceutical industry, beverage industry, and
others pursue research in biology
to benefit mankind. Because of the overlapping assets used for producing
legitimate products and bioweapons, it is extremely difficult to estimate and
regulate research and development activities to prevent legitimate research from
falling into the wrong hands. Today, any bidder may easily procure samples of
bioagents from a variety of sources both legitimate and illicit.
Even
if only small samples of a bioagent are available, technologic advancements make
it possible for nations or organizations to culture and harvest adequate
quantities of an agent relatively inexpensively and virtually anywhere.
Bioagents can also can be easily stored and transported. Dissemination,
which may be most problematic in using these agents, is now more easily
accomplished as well.
For
those individuals seeking to gain competency in this area, knowledge is readily
available. Educational
opportunities are offered in the formal education process including high school,
college, and graduate level courses and informally through widespread
availability of knowledge via the Internet.
In addition, motivated researchers using advanced techniques can now
build engineered pathogens that are even more suitable for biowarfare.
The
list of agents that could be used in a biological attack is formidable and
growing. Legitimate and nefarious researchers have scrutinized the naturally
occurring agents as to what clinical and biologic effects are most requisite.
Also, newly engineered bioagents are now more than ever viable threats against
which the US is vulnerable because they are custom built as weapons.
The
capability is there, and today's world fosters malcontents, extremists and
malicious opportunists that view the United States with hostility. These groups
include nation/states, groups, and individuals - both domestic and
international - that are motivated by political, social, economic, religious,
or criminal intent. Nations who could not challenge the United States because of
the high cost of conventional warfare now have the capability through the use of
biologic weapons to challenge our dominance as the sole remaining superpower.
Individuals and groups of zealots, extremists and criminals also view the recent
availability of bioagents as an opportunity to wage asymmetric warfare in order
to exert influence and manipulate the system for their own gain.
Some
authorities have argued that moral constraints will limit the use of such
particularly lethal weapons (weapons of mass destruction) especially if
civilians are exposed. However, the
September 11 assaults on America have shown the contrary.
The
inevitable conclusion is that the availability of
biowarfare agents and supporting technologic infrastructure, coupled with
the fact that there are many who are motivated to do harm to the US means that
America must be prepared to defend her homeland against biological agents.
Denial of this threat or the excuse that this threat is too difficult to plan
for is no longer tenable.
Although
the probability of a bioattack is difficult to measure, the consequences are
high. Biowarfare is a multidimensional problem due to the diversity of bioagents
each with particular threat characteristics, plethora of vulnerable targets and
varied routes of dissemination. As such, there is no typical presentation, no
easily recognizable signature to allow easy detection or identification, limited
treatment options and a disturbing array of sequelae. A biological attack on America will impose unparalleled demands on all
aspects of our government and our societal infrastructure that must be met.
The
consequences of poor preparation are not tenable. Considerations for the use of
potential biological weapons are the sine
qua non of future defense readiness.
Biological weapons are such formidable weapons of uniqueness and
complexity that a specific defense strategy is essential. The triumvirate of
research, preparedness and response issues pertinent to biowarfare are central
to the formulation of a robust strategic blueprint. Congress must demand a specific, comprehensive and
sophisticated strategy of deterrence and defense.
Command,
Control and Communication Deficits
The
United States must designate and give adequate authority to a central office to
coordinate the various agencies involved in emergency response. A single line of
authority is traditional in the Defense Department and law enforcement for good
reason. Yet the United States has a multitude of federal agencies and
departments with vested interests in WMD preparation, and there is no authority
structure. The result is efforts in formulate and implement a national strategy
are fragmented, uncoordinated, redundant and inefficient. Unfortunately, the
absence of unity not only decays the Federal effort it undermines the critical
partnership between Federal authority and State and local authorities.
Communication
is also a major problem in domestic preparation today. Due to the lack of an
overreaching authority, there is little communication among active Federal
participants in domestic preparedness. Equally disturbing, the lack of
communication among the Federal families trickles down to the state and local
communities. As a result, preparation for the possible use of WMD especially
biological weapons without Federal assistance is not achievable for most
communities in America. Our communities desperately need guidance and support
but little communication results in little progress. This is an unacceptable
outcome given the risks.
Until
authority is mandated, centralized and implemented, turf battles, egos,
pettiness and power and money struggles will preclude effective use of our
dollars and prevent a collaborative and integrated preparedness process on a
national level or local level. Congress
should authorize and fund a centralized Federal management and oversight office.
Planning
Deficits
Any
response to a weapon of mass destruction on American soil will first be local
and community-based perhaps for an extended period of time. This means that
communities must have plans that are well conceived and effectively coordinated.
Although a general plan in most communities today, the local response is
currently not well informed, not well financed, not well trained or drilled, and
not properly integrated into the overriding federal response. Federal
authorities must ensure coordinated ventures with the local communities but they
must first cooperate among themselves to do so.
Furthermore,
current disaster preparedness programs in US communities are often insufficient
in their design in that they are generally inappropriate for specific
preparation and response against biowarfare. A biological agent incident
requires a vastly different response with regard to management and personnel and
resources needed. The multi-agency, multi-jurisdictional character of the many
uncoordinated strategies being delivered by the Federal family to the local
community makes success against biowarfare a remote possibility.
Congress must direct the centralized the federal management and oversight
office to provide preparedness and response, education, guidance, and financial
support directly to State and local communities.
Response
Deficits
The
cornerstone of the Nation's response will lie in the medical and public health
communities. It is critical they be
actively involved in the threat-assets-risk analysis and subsequent national and
local preparation efforts. They are essential to controlling disease outbreaks
through appropriate and timely detection and identification, investigation and
management.
Detection
and Identification Deficits
The
United States must establish, strengthen, and expand sophisticated surveillance
systems that are integrated with the public health systems and the nation's
emergency departments. Efforts
to detect bioagents in the environment before people become infected currently
face significant technical obstacles. This is unfortunate because the best
defense is to detect the agent prior to its infecting individuals. Likewise,
the current technology has not matured to the point that rapid and reliable
diagnostic testing of individuals is available. The absence of such capabilities
will significantly impede timely response and appropriate management.
At
present, the detection of a disease outbreak depends on alert clinicians - or
human surveillance. However, most health care professionals are not trained to
recognize the symptoms of most of diseases from bioweapons agents nor do they
have any experience with these agents. Patients may only exhibit non-specific
flu-like symptoms during the early stages of their infection, and clinicians
probably would recognize an outbreak only after a number of patients presented
with highly unusual symptoms or died of unusual circumstances.
The
United States must improve the partnership between health care system and public
health agencies. Physicians are not
prone to reporting puzzling cases of illness to health officials. Moreover, few
public health departments have the personnel or resources to conduct real-time
disease reporting or provide expert advice.
The
absence of real-time surveillance and simple, quick and reliable diagnostic
testing further complicates matters. It will be difficult for clinicians to
determine the location and scope of the attack. Infected individuals could move
about without overt manifestations during the incubation period of infection.
Depending on the agent, contagion could be spread unknowingly, further
amplifying the peril. The ability
to determine who is actually infected so needs treatment and who is not infected
so needs only reassurance is paramount. Potentially, the "worried well" may
overwhelm the health care system just as it needs to be entirely focused on the
truly infected. The inability to distinguish the infected victims also does not
allow appropriate disease containment.
Complicating
this, most hospital and commercial labs cannot definitively identify the
bioweapons pathogens of greatest concern, such anthrax or smallpox.
There are also serious concerns about the capacity of laboratories to
cope with increased demands, and the capacity of hospital emergency departments
that are already operating at critical capacity to respond. The CDC has been
working with state public health laboratories to augment their abilities and
capacities and foster a national laboratory system.
Congress
must support public and private research for the development of real-time
alerting and tracking surveillance systems with analytical capabilities as well
as rapid and reliable diagnostic tests for bioagents.
Investigation
Deficits
Suspicion
that a bioterrorist attack has occurred will provoke public health officials to
begin an immediate investigation. Epidemiologic investigations are essential to
managing outbreaks of contagious disease. However, the U.S. public health
infrastructure is fragile and in much need of rebuilding as has been previously
reported. State and local health departments often lack sufficient professional
staff, office support and equipment, and the laboratory capacity to perform the
basic public health functions much less respond to a large-scale incident.
As
noted above, the absence of real-time electronic surveillance systems is a
serious problem. These systems could provide information and analysis of data
from key testing and monitoring sources thereby allowing up-to-date
understanding of an incident. Better understanding will result in more focused
and presumably more successful interventions.
Congress
must ensure that the public health system be retooled with the appropriate
capabilities and capacities needed for biowarfare, and be linked to emergency
healthcare systems.
Management
Deficits
Personnel
Deficits
The
United States must train emergency healthcare personnel to recognize and treat
victims of a biologic attack, as well as to report incidents. This is vital to
our nation's preparedness for a successful response to a bioagent, medical
personnel and medical resources are paramount.
Local civilian medical systems - both out-of-hospital and hospital -
are the critical human infrastructure. These
professionals will be integral in recognizing a bioagent and minimizing the
devastation. As in any emergency,
concerned or infected patients may come to the "ER" seeking medical help.
Emergency physicians and nurses and emergency medical technicians will
therefore be the "first responders." Thee
first and most critical line of defense for detection, notification, diagnosis,
and treatment of a bioincident. However, this may be delayed if the treating
emergency physicians and nurses do not have the clinical knowledge and high
index of suspicion to recognize the features of a biologic attack and activate a
response.
Emergency
physicians and nurses along with other health care professionals in current
preparedness programs. Emergency
health care professionals need to be integrated and educated. These
professionals, in turn must understand the need to become active participants in
the preparedness arena. This
specifically includes understanding of local disaster plans, including incident
command systems and hospital disaster plans.
An
overall plan must be implemented for providing, sustaining, and monitoring
appropriate educational experiences for these emergency health care
professionals in the field of biologic warfare.
Unless this training is forthcoming, a critical link in the management of
a bioincident will be missing.
To
that end ACEP's Task Force of Health Care and Emergency Services Professionals
on Preparedness for Nuclear, Biological, and Chemical Incidents assessed the
needs, demands, feasibility, and content of training for emergency physicians,
nurses, and paramedics for nuclear/biological/chemical (NBC) terrorism.
The task force recommended that training programs and materials need to
be developed and incorporated into these professionals' formative education
and into their continuing education. The
task force developed the core content essentials for incorporation into
Educational
programs and recommended that each of the three groups be trained relative to
their particular job responsibilities and anticipated levels of involvement.
It
was suggested that a multidisciplinary oversight panel of content experts,
educational specialists, and representatives of major professional organizations
representing each of the three audience groups implement these educational
strategies. The oversight panel
would be tasked with the responsibility for the consistency, quality, and
updating of the products developed. Additionally,
the oversight group would work to establish partnerships with organizations and
institutions to assist with the implementation of the recommendations discussed
in this report. The multi disciplinary oversight group is an integral part in
the development of each recommendation for each of the target audiences.
They also formulate and manage formal plan for evaluating each
educational product. To support the work of the oversight group, a national
clearinghouse or repository should be established to collect relevant
information, including articles, books, reports, research, instructional
materials, and other media.
An
important overarching strategy to support the proposed recommendations is to
work with national professional organizations and associations to increase all
health care professionals' understanding of the necessity of this type of
education.
Working
through national professional organizations and associations, Congress must
authorize an implement an overall plan for providing, sustaining, and monitoring
appropriate educational experiences for emergency healthcare professionals in
the field of biologic warfare.
Hospital
Deficits
Unfortunately,
civilian health care facilities are not, in general, integrated into a community
or regional disaster response system. Hospitals tend to be autonomous,
competitive institutions so most are not committed to cooperative efforts that
would be needed during a community-wide disaster. Furthermore, hospitals do not
possess or regularly exercise requisite communications networks.
Hospital
capacity and capability are very real dilemmas today. Many American hospitals
are financially frail. They have responded to financial pressures by cutting
staff, reducing inventory and eliminating money-losing operations.
"Just-in-time" staffing and supplies flow models now govern the number of
personnel working and the resources available on a given day. These cost-cutting
measures have reduced hospitals' flexibility; they have no surge capacity in
the face of sudden or sustained stress. As a result, it would not take many
casualties presenting for evaluation and specialized treatment to overwhelm the
hospital system of a large American city. Nowhere
is this more evident than in the emergency departments where overcrowding, and
lack of critical resources are the norm.
Staffing
issues are also challenging. Although many if not most, physicians and nurses
hold hospital privileges at several facilities so this will be available to only
one institution. Hospital staff privileges requirements and state licensing
restrictions are barriers to doctors and nurses from outside the community
assisting. Further complicating the
local shortage, many health care professionals are committed to military duty as
reservists or have volunteered to serve on medical assistance teams or at
emergency operations centers.
In
addition to professional staff, hospital operations depend on a wide array of
skills - the absence of lab technicians, security guards, food service, or
housekeeping personnel would significantly affect the efficiency and
effectiveness of the whole institution. Furthermore, a significant proportion of
a hospital's staff may fail to report to work in the midst of an epidemic due
to fear of a deadly, contagious bioagent.
Medical
Treatment Deficits
For
almost all of the bioagents thought to represent a serious threat, the speed
with which appropriate medical treatment is administered is critical, i.e. early
detection. Different bioweapons agents will require different medical treatment
and in some cases there are scant scientific and clinical data available to
support treatment decisions. The
effectiveness of existing antibiotics and vaccines to prevent or limit the
severity of diseases caused by bioweapons pathogens is quite limited as well.
For some bioagents, antibiotic treatment is effective but in some cases only if
given before symptoms begin or become severe. In other instances, the mainstay
of care is supportive which can be very labor intensive.
Currently,
there are no effective vaccines for many important bioweapons agents. When
available, some vaccines have undesirable features and in other cases, existing
vaccine supplies are limited. Special populations, such as children, pregnant
women, and immune-compromised persons may be a particular risk or have
contraindications for specific therapies. The possibility of bioengineered
weapons resistant to traditional therapies must also be considered.
It
is clear that there is major shortfall in the readily available capacity of
drugs and vaccines. It is also clear that there are many vaccines yet to be
developed. This is due to the lack of existing commercial partners interested in
undertaking the production, minimal excess capacity within the drug and vaccine
industry even if there were interested parties, and the regulatory and
technology transfer issues that need to be overcome in order to rapidly
manufacture critical supplies.
In
addition, there is a lack of a coherent acquisition strategy for national
pharmaceutical and vaccine stockpiles. The
federal government has recognized that the availability of necessary vaccines
and antibiotics is a critical component of an effective bioterrorism response
and has taken steps to create a National Pharmaceutical Stockpile (NPS) of
medicines and supplies. However, significant logistical problems were
encountered in the handling and distribution of the supplies during Operation
Topoff that must be remedied.
Congress
should direct the centralized federal management and oversight office to partner
with private industry interested in undertaking the research, development, and
production of necessary pharmaceuticals; maintaining some surge capacity.
Congress should also address the regulatory and technology transfer
barriers that impede rapid development and availability of critical supplies.
Conclusions
The
United States homeland is vulnerable.
We are a free society; our greatest right is our greatest liability.
We are an inherently trusting and tolerant people so we are not overly
suspicious. We are peace loving; we
do not act offensively but only respond when provoked. Finally and fortunately, we have had essentially no first
hand experience with any form of modern warfare waged in our country until
recently
An
attack against the homeland using a biological weapon would severely test us.
Foremost, the ability to mitigate the consequences of a bioterrorist attack is
directly tied to the deficits of the civilian medical and public health systems.
The importance of limiting casualties and minimizing interference with daily
life is obvious. In addition, failure to deliver adequate medical care or to
execute appropriate public health measures could lead to loss of public
confidence in the government's ability to protect our citizens, raise the
possibility of profound, even violent, civil disorder, and possibly diminish
America's position internationally.
Americans
must now commit to not allow such heinous acts to occur in our country. We must
all vow to become involved. Our goal is to deter or mitigate any terrorist
action against our people or our country. Federal authorities must provide the
leadership, the financial investment and the organizational and logistical
support requisite to develop a comprehensive national strategy, solid domestic
preparedness and appropriate response plans. Health care professionals and state
and community leaders must pledge dedication and involvement.
Such preparation is very costly, financially, and personally.
There is never enough time. But
American must remain resolute, for what is the price of our freedom, of our
country's well-being, of our lives.
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