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Testimony on Anti-Terrorism Measures by Robert F. Knouss, M.D.
Director, Office of Emergency Preparedness
U.S. Department of Health and Human Services

Before the House Committee on Government Reform and Oversight, Subcommittee on National Security, International Affairs, and Criminal Justice
October 2, 1998

Mr. Chairman and Members of the Committee,

Thank you for inviting me to appear before you today to discuss activities of the U.S. Department of Health and Human Services (DHHS) in responding to the health and medical effects of terrorism. I am Dr. Robert Knouss, Director of the DHHS Office of Emergency Preparedness (OEP).

The first link in the response chain to any terrorist incident in the United States will be local in nature and will be supplemented by state and federal assistance. This is why local capability and capacity building is absolutely crucial to reducing preventable mortality and morbidity caused by terrorist attacks. The critical issues are the level of preparedness, rapidity of response, and the integration of all levels of government that will result in either the success or failure of our nation's ability to respond to a major terrorist attack.

My remarks today are organized in the following manner: First, OEP's role and the role of the National Disaster Medical System; second, the Department's role in implementing the Domestic Preparedness Program with emphasis on our "bottom up" strategy and the development of local Metropolitan Medical Response Systems; third, the unique challenge of biological attacks; and fourth, some comments on two recent GAO reports, one of which is still in draft.

OEP coordinates the health and medical emergency preparedness activities within DHHS, and is the lead DHHS organization to coordinate disaster and emergency activities with other federal agencies, including the FBI and DOD. DHHS is the primary agency that provides the health and medical response under the Federal Emergency Management Agency (FEMA) Federal Response Plan. We also manage the National Disaster Medical System (NDMS). NDMS is a partnership between DHHS, the Departments of Defense and Veterans Affairs, FEMA, 7,000 private citizens across the country who volunteer their time and expertise as members of response teams to provide medical and support care to disaster victims, and more than 2,000 participating non-federal hospitals.

Disaster Response Teams

Our primary response capability is organized in teams such as Disaster Medical Assistance Teams (DMATs), specialty medical teams (such as burn and pediatric) and Disaster Mortuary Teams (DMORTs). Our 24 level-1 DMATs can be federalized and ready to deploy within hours and can be self sufficient on-the-scene for 72 hours. This means that they carry their own water, portable generators, pharmaceuticals and medical supplies, cots, tents, communications and other mission essential equipment. These teams have been sent to many areas in the aftermath of disasters in support of FEMA-coordinated relief activities.

In addition, staff from OEP and our regional emergency coordinators also go to the disaster sites to manage the team activities and ensure that they can operate effectively. Within the last week alone, we have deployed to the Virgin Islands, Puerto Rico, Florida, Mississippi and Alabama to assist with relief efforts after Hurricane Georges.

Our mortuary teams can assist local medical examiner offices during disasters, or in the aftermath of airline and other transportation accidents, when called in by the National Transportation Safety Board.

To make maximum use of our resources, we also allow state governments to activate our teams as state resources, if necessary.

Special National Medical Response Teams for Weapons of Mass Destruction

Last year, we provided additional training and specialized equipment to three of our DMATs, to develop a specialized capability known as National Medical Response Teams (NMRTs). These teams, in North Carolina, Colorado, and California, are capable of providing medical treatment after a chemical or biological terrorist event. They are fully deployable to incident sites anywhere in the country with a cache of specialized pharmaceuticals to treat up to 1,000 patients. They also have specialized personal protective equipment, detection devices and patient decontamination capability. A fourth NMRT is located in the National Capital Area and remains locally to respond in our nation's capital.

Metropolitan Medical Strike Team Systems

Several years prior to initiation of the Domestic Preparedness Program, DHHS realized that the nation was not prepared to deal with the health effects of terrorism, and that should a chemical, nuclear or bombing terrorist event occur, our cities and local metropolitan areas would bear the brunt of coping with its effects. In addition, we realized that the local medical communities would be faced with severe problems, including overload of hospital emergency rooms, medical personnel injured while responding, and potential contamination of emergency rooms or entire hospitals.

Consequently, in FY 1995, HHS began developing the first prototype Metropolitan Medical Strike Team in partnership with the Metropolitan Washington Council of Governments and their 18 local member jurisdictions in and around Washington, D.C. This system became the prototype for the team that we developed in Atlanta in 1996 to prepare for the Centennial Olympic Games, and for the 25 systems that we began in 1997 as part of the Domestic Preparedness Program. The FY 1999 budget currently before Congress includes a total of $14 million to begin additional local Metropolitan Medical Response Systems and to supplement systems already begun with a bioterrorism component. We hope to begin development of 24 additional local systems in the coming fiscal year.

Systems Approach to Preparedness

To put this system in perspective, this chart (Chart 1) depicts the systems approach to preparedness during a chemical incident. As you can see, once the incident occurs, the local first responders - police, fire, emergency medical services - would respond. HAZMAT teams would be called in to provide agent identification and hot zone management. These first two actions have been the focus of DOD, FEMA, and the Department of Justice (DOJ) under the Domestic Preparedness Program.

Our focus has been on the development of Metropolitan Medical Response Systems, which are components of local, city systems that would be called in to provide triage, medical treatment and patient decontamination. The city systems that we have been developing would then be able to transport "clean patients" to hospitals or other medical facilities for continued care. The hospitals are developing procedures to ensure that patients coming in would be decontaminated before entering the facility where they would be treated for their exposures. They are also developing procedures to determine which patients should remain in the hospital, and which patients can and should be moved to facilities elsewhere in the city or in other cities for care, if necessary. Through NDMS, DOD can evacuate these patients to VA and DOD-managed NDMS Federal Coordinating Center areas across the country where participating non-federal hospitals have NDMS beds available should patients need to be relocated out of an affected area. In addition, our response team doctors, nurses and support staff can help relieve or augment overburdened hospital staff.

Domestic Preparedness Program

As legislated, DHHS'role in the Domestic Preparedness Program was the development of Metropolitan Medical Strike Team systems. The purpose of these systems is to ensure that a city's health system is able to cope with the injuries and chaos that results from a terrorist act. DHHS has contracted with 27 cities to date. Because each city has a public safety and public health system with unique characteristics, the contracts specify that each city will develop an enhanced health and medical response system, within their current emergency response structure. These Systems provide an integrated pre-hospital, hospital and public health response capability to local metropolitan areas. Each system must ensure that health workers be able to recognize a chemical injury, know the proper treatments (or know where to get the information), be able to ensure that medical facilities do not become contaminated, and that the local system is integrated with state plans. Our goal is to develop 120 of these medical response systems across the country.

The DHHS program is a health systems development program, not an equipment or training program. If a city identifies equipment as one of its cost elements under the contract, DHHS requests that DOD, FEMA, VA, FBI, DOE and EPA review the list and comment on it, to eliminate any duplicate equipment purchases by the federal government. Training is not usually one of the cost elements under our contracts. In fact, training requirements which are identified are referred to our interagency partners.

Biological Incident

However, these activities to date have primarily dealt with the consequences of a chemical or nuclear attack, or a bombing. A different response is needed should biological attack occur. We may not know for days that a biological event has occurred, until local health departments have reported clusters of unexplained symptoms or deaths. This second chart (Chart 2) shows the necessary actions to effectively respond to an attack with a biological weapon.

Local and state health departments must have effective surveillance programs in place to be able to detect that a biological event has occurred, and then must be able to identify the bacteria, virus, toxin or other organism being used. Appropriate treatment (such as antibiotics, antivirals and vaccines) must rapidly be made available to prevent those exposed from becoming ill and to treat those who are already symptomatic. Today, in many cases, the specific drugs needed are not available in sufficient quantity to treat large number of unexpected patients at multiple sites across the U.S. This is why DHHS has proposed a national pharmaceutical stockpile of antibiotics and other medications to treat victims of biological agents such as anthrax, plague, tularemia and botulism.

Mass patient care, mass fatality management, and environmental clean up may also be required. The NDMS would mobilize to help assure that patients can access needed services. It may be used to agument local medical resources, including pharmaceuticals, or it may assist in assuring safe transportation of patients to other regions where the hospital systems have unused capacity.

General Accounting Office Reports

After this brief description, I would like to offer a few comments about GAO's recent draft report on "Combating Terrorism: Opportunities Exist to Gain Focus and Efficiencies in the Nunn-Lugar-Domenici Domestic Preparedness Program" (September 1998).

The report made reference to the lack of a "sound assessment process, such as a threat and risk assessment" for the 120 cities included in the program. I am concerned that threats are evanescent -- what may be valid today may not be valid in the future. We believe that population density continues to be a valid basis for measuring risk. Within the funds available for preparedness activities, this interagency approach has focused on population centers of our nation in their descending order of size.

The report mentions that the training subcommittee formed by the interagency group made little progress in compiling a list of terrorism related courses. DHHS' Public Health Service (PHS) was represented on this DOD lead training subcommittee and through substantial effort, the subcommittee did, in fact, generate a rather comprehensive compendium of existing courses.

The report also recommended consolidating training and equipment delivery locations on a regional basis. In a chemical response, it is important to note that capabilities/assets are almost immediately required. A regional approach could prolong response time for local jurisdictions. The time factor in a chemical response is crucial.


The U.S. Department of Health and Human Services through the Public Health Service is committed to assuring the health and medical care of our citizens. We are prepared to quickly mobilize the professionals required to respond to a disaster anywhere in the U.S. and its territories and to assist local medical response systems in dealing with extraordinary situations, including meeting the challenge of responding to the health and medical effects of terrorism.

Mr. Chairman, that concludes my remarks. I would be pleased to answer any questions you may have.

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