David Satcher, M.D., Ph.D.

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Testimony
Before the Committee on Government Reform, Subcommittee on National Security, Veterans Affairs and International Relations

Risk Communication: National Security and Public Health --The HHS Role

Statement of
David Satcher, M.D., Ph.D.
Surgeon General
U.S. Public Health Service
Department of Health and Human Services

For Release on Delivery
Expected at 10:00 am
on Thursday, November 29, 2001

Good morning, Mr. Chairman and Distinguished Members of the Subcommittee:

I am Dr. David Satcher, U.S. Surgeon General, and I appreciate this invitation to speak with you about the public health response to the threat of bioterrorism, specifically the Department of Health and Human Services' (HHS) role in information dissemination and risk communication. These have been issues of growing concern among those of us in public health and I am pleased to have this opportunity to discuss them with you today.

The terrorist events on and since September 11^th and the bioterrorist activities that began in the first week of October have been defining moments for all of us. Both as a nation and as public health officials, we have been taken to a place where we have not been before. It was uncertain what we were dealing with and to what extent; we had very little science or past experience to draw upon; and we literally learned more every day. The Nation's focus on issues related to public health has been greatly sharpened. There has been fear, shock, confusion, and - in some cases - even panic.

While we may have encountered some bumps in the road initially, it is actually quite remarkable how well-coordinated our efforts have been. The challenge was great. We were faced with the task of coordinating communications among local governments, state governments and the federal government. Each level came with its own set of elected officials and public health officials, all with their own concerns. HHS dealt with it by being forthcoming. We informed the public quickly. We let them know what we knew and when we knew it. When the information changed because we learned something new, we let them know it. Through it all, vital public health information has been disseminated promptly and we have delivered medicine to people who needed it.

As a result, while five people too many have lost their lives, we have saved countless other lives. Casualties were kept far below expectations, in that the fatality rate for inhalation anthrax was thought to be around 80 percent. The fatality rate in these attacks has been about 40 percent. All of this demonstrates why effective communication based on a strong and flexible public health infrastructure is critical.

Defining the Public Health Infrastructure
Components of a Plan for Bioterrorism

The Centers for Disease Control and Prevention (CDC), as HHS's lead agency for bioterrorism response, has developed a strategic plan for addressing bioterrorism. That plan has five basic components: preparedness and prevention, a surveillance and early detection, diagnosis and characterization of chemical agents, response and communication. Each component integrates training and research.

A strong and flexible public health infrastructure has within it the ability to carry out the components of that plan. Under the leadership of Secretary Tommy Thompson, HHS has been working to strengthen the overall public health infrastructure so that we are prepared to respond to a range of disasters and emergencies, including bioterrorism. Since September 11^th we have intensified our efforts, resulting in a heightened level of preparedness, and we are committed to further increasing our preparedness based on lessons learned in recent months.

HHS and the Public Health Service

This well-prepared and well-rehearsed public health infrastructure must consist of several interrelated components at various levels. Communication within and among each level is critical, as is the need for mutual support.

The federal component is within the Department of Health and Human Services. The Centers for Disease Control and Prevention is the lead agency for bioterrorism response and is closely allied with the Office of Emergency Preparedness. Recently, the Office of Public Health Preparedness was added by Secretary Thompson to respond to bioterrorist attacks.

Also within HHS is the National Institutes of Health (NIH), which focuses on research to facilitate development of new drugs and diagnostic agents and effective antitoxins and vaccines to fight bioterrorism. NIH works in tandem with the Food and Drug Administration (FDA), which has oversight of pharmaceutical and vaccine approval and must ensure their safety and efficacy. Also critical is the Health Resources and Services Administration (HRSA), which is responsible for ensuring access to that the poor and underserved have access to health care services. This is a critical component considering how much we depend on the public to respond early to unusual occurrences. Finally, the Agency for Healthcare, Research, and Quality is responsible for monitoring the quality of care provided.

My role as Surgeon General has included oversight of the Commissioned Corps of the Public Health Service. The Commissioned Corps is one of the federal government's seven uniformed services and comprises 5,600 health professionals, including physicians, pharmacists, nurses, dentists, dietitians, therapists, veterinarians, and others involved in health services. Commissioned Corps members are highly-trained and mobile health professionals who carry out programs to promote the health of the Nation, understand and prevent disease and injury, assure safe and effective drugs and medical devices, deliver health services to Federal beneficiaries, and furnish health expertise in time of war or other national or international emergencies. They are on call 24 hours a day, 7 days a week.

The Surgeon General is also responsible for communicating directly with the American people based on the best available science. To date, most communications with the Surgeon General have been based on topics for which there has been extensive research and investigation. While the role of the Surgeon General in communicating in response to bioterrorism has never been clearly defined, I can assure you that the Office of the Surgeon General has been directly and substantially involved in public communications related to the anthrax outbreaks.

Between October 4 and November 14, 2001, I participated in roughly 40 TV programs, interviews, HHS and White House media briefings, and other press outreach events on the subject of the anthrax mailings. At the direct request of Secretary Thompson, I also made Deputy Surgeon General Kenneth Moritsugu available to act as a full-time liaison between HHS and Capitol Hill on the anthrax situation. Dr. Moritsugu took part in numerous briefings of Congress as well as Congressional and White House press briefings. He also represented HHS at a Town Hall Meeting with D.C. Del. Eleanor Holmes Norton, and appeared alongside Rep. Shays at a similar meeting that was televised live on WJLA-TV in Washington.

Internally, HHS faced challenges with fluidity of information and the geographic divide. We had staff in the field in the affected states, as well as in offices in Atlanta, Bethesda, and Washington. The Secretary instituted daily conference calls with all involved offices to make sure everyone had the latest information.

The Department of Health and Human Services works closely with state and local health departments. The challenge maintaining communications increases, considering that local health departments vary widely in their size and scope. Some do not even have local boards of health.

Throughout the recent crises, the CDC's Health Alert Network and Lab Alert Network immediately notified state and local health departments of the latest on anthrax and the possibilities of other bioterrorism attacks. In fact, the Health Alert Network was used September11 to immediately put state health departments on alert for anything suspicious following the attack on the World Trade Center.

The cases in Florida provided a good example of how CDC worked with state and local officials. After the first case there resulted in death, the CDC moved quickly to confirm the case of the second victim early on the evening of October 7. The CDC, HHS, FBI, DOJ, Florida Governor's Office, Florida Public Health Department and local public health department quickly formulated a plan that got the word out overnight to AMI employees that they needed to come to the clinic for medicine and testing that very next morning. The CDC shipped medicine to Florida overnight so it was there when people arrived in the morning. And CDC/Florida officials issued a joint release at 11 p.m. on October 7 notifying the media and public of the second case. So it was a good example of local, state and federal officials working together to get out a message, send medicine and mobilize people to come get treatment - literally overnight on a Sunday evening.

In a federalist system, there are going to be communication challenges between federal, state and local government. In all of the anthrax situations, for example, once the CDC receives initial test results, it promptly begins doing more accurate confirmatory tests. But a mayor or governor may decide to go out and talk to the media before the confirmatory tests are concluded. Those officials make the decision whether to do that based upon their perception of the needs of the community. We respect those decisions. At the same time, when you try to communicate that tests are merely "preliminary," you hope the public and the media hear that and appreciate what that means.

The Health Care Delivery System

The second level consists of the health care delivery system, including the private sector, which, although we refer to it as "private," is very much a part of the public health infrastructure. Health care providers have a major role to play in limiting the prevalence of disease and in reporting unusual occurrences on a regular basis, not only in times of high alert. They serve on the front lines and play a valuable role in our ability to ensure rapid detection of outbreaks through regularly reporting unusual diseases to the Public Health Service. Likewise, the Public Health Service must provide feedback to providers.

HHS and CDC worked extensively to reach out to various groups within the delivery system to inform them of what we knew. The Secretary met early on with the medical associations, the biotech industry, the pharmaceutical industry, the food industry to address bioterrorism concerns. He and CDC did a conference call with the State and Territorial Health Departments Association. He gave a speech, along with the SG, at the annual meeting of the American Public Health Association.

We also realized that there are tremendous opportunities to strengthen our lines of communication at this level through the use of conference calls and through satellite and video technologies. CDC and HHS has done two major conferences with physicians and hospitals on anthrax, smallpox and bioterrorism. We must continue to look for new ways to reach out aggressively.

The General Public

The third level is by no means any less important than the other two, especially since they also serve on the front lines: the public. Bioterrorism attacks will first impact the public, either individually or in groups. We rely on the public to seek treatment or advice regarding unusual occurrences and to assist health care providers in their efforts to detect diseases early. In order for this to happen, they must have access to quality health care. Moreover, the public must cooperate with health care providers by taking prophylactics as prescribed and avoiding panic.

The public must also be informed and educated about good public health habits, such as handwashing, safe handling and washing of foods, thoroughly cooking meats, and careful handling of suspicious mail and packages.

After October 4, we immediately made available to the media an array of medical/scientific spokespeople in addition to myself and Secretary Thompson, including CDC Director Jeffrey Koplan, Tony Fauci at NIH, the Secretary's recently named special advisor D.A. Henderson, and other officials at CDC, NIH and FDA. The Secretary remained readily available, and other specialists were made available when needed. The CDC also made officials available to the local media during the news conferences conducted by local officials, whether in Florida, New York, or Washington.

One challenge we faced in these situations was the volume of demand. There were so many news shows and networks who wanted people to interview, there was no way one person could have met the media demand. By making several people available, we could more readily service this demand and at the same time draw upon the diversity of expertise that we had available.

On the second week in October, the Secretary and senior members of the HHS team began doing daily teleconferences with the media. These teleconferences allowed us to overcome geographic divides and bring in people from various offices with different areas of expertise. About a week or so after the Secretary began doing his conference calls, the CDC began doing daily press calls as well.

In the face of this unprecedented threat, our communication got stronger as each day passed.

When bumps were hit, they were quickly addressed.

The Criminal Justice System

Let me also add that in instances of naturally occurring disease outbreaks, those three levels would be sufficient. But because the disease outbreak in bioterror is intentionally triggered, public health emergency response must also include the criminal justice system as part of its infrastructure, while striving to maintain appropriate independence.

Recommendations

Let me outline several recommendations in terms of where we believe we should go from here.

We must continue to strengthen the public health infrastructure. We believe that the best and most successful response to bioterrorism is to have a well-prepared, well-rehearsed, strong and flexible public health infrastructure. We must ensure that all components of that infrastructure are strengthened.
We must continue to improve educational opportunities and information sharing between the Public Health Service and front-line health providers. Many doctors at the local level still fail to report disease diagnoses to federal officials, and federal officials sometimes fail to provide local officials with a national picture on a timely basis. The mechanisms must be put in place to ensure that we have an ongoing dialogue that will make it easier for providers to access information. One of the ways to do that is through regularly scheduled satellite broadcasts that they can tune into in their offices or at a local site within their community.
The old saying is still true that all public health is local, so there must be local efforts as well to educate the community, as well as health care providers.
We believe the nation will benefit from a clear and coordinated communications strategy for responding to acts of bioterrorism.

Mr. Chairman, the optimal response to bioterrorism requires a well coordinated response before, during and after an attack. Communication is the glue. We realize that there are many opportunities for us to strengthen our communications role, and we will continue to strengthen our ability to respond to such situations in the most timely and accurate manner possible. The people of this country deserve nothing less.

This concludes my testimony. I would be happy to answer questions from you or Members of the Subcommittee.