[House Hearing, 107 Congress]
[From the U.S. Government Publishing Office]
RISK COMMUNICATION: NATIONAL SECURITY AND PUBLIC HEALTH
=======================================================================
HEARING
before the
SUBCOMMITTEE ON NATIONAL SECURITY,
VETERANS AFFAIRS AND INTERNATIONAL
RELATIONS
of the
COMMITTEE ON
GOVERNMENT REFORM
HOUSE OF REPRESENTATIVES
ONE HUNDRED SEVENTH CONGRESS
FIRST SESSION
__________
NOVEMBER 29, 2001
__________
Serial No. 107-122
__________
Printed for the use of the Committee on Government Reform
Available via the World Wide Web: http://www.gpo.gov/congress/house
http://www.house.gov/reform
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COMMITTEE ON GOVERNMENT REFORM
DAN BURTON, Indiana, Chairman
BENJAMIN A. GILMAN, New York HENRY A. WAXMAN, California
CONSTANCE A. MORELLA, Maryland TOM LANTOS, California
CHRISTOPHER SHAYS, Connecticut MAJOR R. OWENS, New York
ILEANA ROS-LEHTINEN, Florida EDOLPHUS TOWNS, New York
JOHN M. McHUGH, New York PAUL E. KANJORSKI, Pennsylvania
STEPHEN HORN, California PATSY T. MINK, Hawaii
JOHN L. MICA, Florida CAROLYN B. MALONEY, New York
THOMAS M. DAVIS, Virginia ELEANOR HOLMES NORTON, Washington,
MARK E. SOUDER, Indiana DC
STEVEN C. LaTOURETTE, Ohio ELIJAH E. CUMMINGS, Maryland
BOB BARR, Georgia DENNIS J. KUCINICH, Ohio
DAN MILLER, Florida ROD R. BLAGOJEVICH, Illinois
DOUG OSE, California DANNY K. DAVIS, Illinois
RON LEWIS, Kentucky JOHN F. TIERNEY, Massachusetts
JO ANN DAVIS, Virginia JIM TURNER, Texas
TODD RUSSELL PLATTS, Pennsylvania THOMAS H. ALLEN, Maine
DAVE WELDON, Florida JANICE D. SCHAKOWSKY, Illinois
CHRIS CANNON, Utah WM. LACY CLAY, Missouri
ADAM H. PUTNAM, Florida DIANE E. WATSON, California
C.L. ``BUTCH'' OTTER, Idaho STEPHEN F. LYNCH, Massachusetts
EDWARD L. SCHROCK, Virginia ------
JOHN J. DUNCAN, Jr., Tennessee BERNARD SANDERS, Vermont
------ ------ (Independent)
Kevin Binger, Staff Director
Daniel R. Moll, Deputy Staff Director
James C. Wilson, Chief Counsel
Robert A. Briggs, Chief Clerk
Phil Schiliro, Minority Staff Director
Subcommittee on National Security, Veterans Affairs and International
Relations
CHRISTOPHER SHAYS, Connecticut, Chairman
ADAM H. PUTNAM, Florida DENNIS J. KUCINICH, Ohio
BENJAMIN A. GILMAN, New York BERNARD SANDERS, Vermont
ILEANA ROS-LEHTINEN, Florida THOMAS H. ALLEN, Maine
JOHN M. McHUGH, New York TOM LANTOS, California
STEVEN C. LaTOURETTE, Ohio JOHN F. TIERNEY, Massachusetts
RON LEWIS, Kentucky JANICE D. SCHAKOWSKY, Illinois
TODD RUSSELL PLATTS, Pennsylvania WM. LACY CLAY, Missouri
DAVE WELDON, Florida DIANE E. WATSON, California
C.L. ``BUTCH'' OTTER, Idaho STEPHEN F. LYNCH, Massachusetts
EDWARD L. SCHROCK, Virginia
Ex Officio
DAN BURTON, Indiana HENRY A. WAXMAN, California
Lawrence J. Halloran, Staff Director and Counsel
Kristine McElroy, Professional Staff Member
Jason Chung, Clerk
David Rapallo, Minority Counsel
C O N T E N T S
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Page
Hearing held on November 29, 2001................................ 1
Statement of:
Koop, Dr. C. Everett, former U.S. Surgeon General; Dr.
Kenneth I. Shine, president, Institute of Medicine,
representing the National Academy of Sciences; Dr. Mohammad
Akhter, executive director, American Public Health
Association; Dr. Joseph Waeckerle, editor and chief, Annals
of Emergency Medicine, representing the American College of
Emergency Physicians....................................... 34
Satcher, David, U.S. Surgeon General......................... 3
Letters, statements, etc., submitted for the record by:
Akhter, Dr. Mohammad, executive director, American Public
Health Association, prepared statement of.................. 57
Koop, Dr. C. Everett, former U.S. Surgeon General, prepared
statement of............................................... 38
Satcher, David, U.S. Surgeon General, prepared statement of.. 8
Shine, Dr. Kenneth I., president, Institute of Medicine,
representing the National Academy of Sciences, prepared
statement of............................................... 44
Waeckerle, Dr. Joseph, editor and chief, Annals of Emergency
Medicine, representing the American College of Emergency
Physicians, prepared statement of.......................... 64
RISK COMMUNICATION: NATIONAL SECURITY AND PUBLIC HEALTH
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THURSDAY, NOVEMBER 29, 2001
House of Representatives,
Subcommittee on National Security, Veterans Affairs
and International Relations,
Committee on Government Reform,
Washington, DC.
The subcommittee met, pursuant to notice, at 10:17 a.m., in
room 2154, Rayburn House Office Building, Hon. Christopher
Shays (chairman of the subcommittee) presiding.
Present: Representatives Shays, Putnam, Gilman, Schakowsky,
Tierney and Lynch.
Staff present: Lawrence J. Halloran, staff director and
counsel; Kristine McElroy and Thomas Costa, professional staff
members; Michael Bloomrose, intern; David Rapallo, minority
counsel; and Earley Green, minority assistant clerk.
Mr. Shays. We call this Subcommittee on National Security,
Veterans Affairs and International Relations of the Government
Reform Committee hearing to order.
The title of the hearing is ``Risk Communication: National
Security and Public Health.''
I welcome our witnesses. I welcome our guests to this
hearing.
Anthrax is not contagious. Fear is.
In the battle against bioterrorism, fear is one of the most
infectious diseases we face. For the terrorist, it is a potent
force multiplier, capable of amplifying a minor, manageable
outbreak into a major public health crisis. Driven by fear
alone, hordes of the ``worried well'' could overwhelm emergency
rooms and clinics, impeding diagnosis and treatment of the
genuinely ill. Many would needlessly expose themselves to the
risks of antibiotic treatments, incurring individual side
effects and increasing the general threat of antibiotic-
resistant criteria. Fear-based worst-case scenarios can draw
scarce medical supplies and vaccines to the wrong places at the
wrong times, diluting response capabilities to meet the real
threat.
The only antidote to terrorism's toxin of fear is the
truth.
When something as unthinkable as a biological attack
occurs, the public and the media need to hear one authoritative
voice conveying the unvarnished truth about the extent of risk
and the public health response. During a disease outbreak, the
right information at the right time can save lives. Rumor,
speculation, implausible optimism and mixed messages fuel panic
and endanger public health and safety.
In the Dark Winter exercise earlier this year, a lack of
information about the extent and pace of three simultaneous
smallpox outbreaks paralyzed national leadership
decisionmaking. Opportunities to contain the epidemic were
missed, irreplaceable vaccine stocks were wasted, public order
decayed, State borders were closed, and communications were
disrupted. National security was compromised, and for want of
the facts our very sovereignty as a Nation dissolved.
The recent anthrax attacks also taught some hard lessons
about effective communication of critical public health
information. In the hours and days after the first case was
discovered, Federal, State and local officials struggled to
rebut inaccurate, sometimes sensational, reports about the
risks of a rare, little-understood disease, inhalational
anthrax.
We heard inconsistent assessments of the virulence of the
pathogen and the sophistication of its manufacture. An
epidemiological tool, nasal swab culture, was widely
mischaracterized as a diagnostic test. It took some time for
the voices of public health and medical experts to be heard as
law enforcement and political officials gathered and
disseminated information on rapidly unfolding events.
To be prepared for the next biological attack, frank and
frequent communication of medical information, risk parameters,
treatment options and response plans should begin now, while
the information can be heard and deliberated calmly.
The draft response protocol for smallpox recently released
by the Centers for Disease control and Prevention [CDC],
recognizes the significance of public health education and pre-
emptive communication as integral parts of an effective
outbreak control effort. But in the event of a widespread
biological attack, one that threatens agriculture, food
supplies, water and human health, who will collect, synthesize
and reliably convey complex but critical information to a
nervous public?
One voice well suited to address public concerns about
bioterrorism is that of the Surgeon General, Dr. David Satcher.
As a former head of CDC, Dr. Satcher brings unique experience
and unquestioned credibility to our discussion of public health
information, public health infrastructure and medical data
technologies. In past oversight efforts on blood safety and
hepatitis-C, he was an indispensable partner to the Human
Resource Subcommittee. We appreciate his expertise and his
candor then, and we look forward to his testimony today.
All our witnesses this morning bring important information
and expertise to our discussion of better ways to fight
terrorism with the simple truth. We welcome them.
At this time we would recognize Dr. David Satcher, U.S.
Surgeon General, and invite him to stand. I'll administer the
oath, and then we'll take his testimony.
[Witness sworn.]
Mr. Shays. Thank you. Dr. Satcher, it is very nice to have
you here.
STATEMENT OF DAVID SATCHER, U.S. SURGEON GENERAL
Dr. Satcher. Thank you very much, Congressman Shays and
members of the Subcommittee on National Security, Veterans
Affairs and Intergovernmental Relations, the Committee on
Government Reform. I'm delighted to be able to join you and
certainly the outstanding members of panel two in discussing
this very important issue.
As you know, I'm David Satcher, the U.S. Surgeon General,
and I'm speaking to you about the public health response to
bioterrorism and the threats of bioterrorism, and specifically
the role which the Department of Health and Human Services
plays in information dissemination and risk communication.
The terrorist events on and since September 11th 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 sometimes was uncertain what we were
dealing with and to what extent. We had very little science of
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; and panic when it
occurs, as you said, supports the aim of the terrorists.
We have certainly encountered some bumps in the road, but
it is somewhat remarkable how well-coordinated our efforts have
been overall. 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. The Department of
Health and Human Services tried to deal with it by being
forthcoming. We tried to inform 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 tried to let them
know that. Through it all, vital public health information has
been disseminated promptly and we have delivered medicine and
expertise where needed.
I believe it is fair to say that, as a result, while we
have lost five people too many to this bioterrorist attack, we
have saved countless lives. Casualties were kept far below
expectations, in that the fatality rate for inhalation anthrax
has been thought to be around 80 to 100 percent.
Mr. Shays. Now, if you had been courteous, you would have
stumbled over inhalation to make me try to feel----
Dr. Satcher. Let me try it again. No, you did great.
The fatality rate to date in our experience has been only
40 percent. All of this demonstrates why effective
communication based on a strong and flexible public health
infrastructure is so critical.
I think under the leadership of Secretary Thompson, HHS has
been working to strengthen the overall public health
infrastructure so that we're prepared to respond to a range of
disasters and emergencies, including bioterrorism. Since
September 11th, we have intensified our efforts, resulting in a
heightened level of preparedness. We are committed to
increasing our preparedness based on lessons learned in recent
months.
Now, because I believe that the public health
infrastructure is a critical issue here and communication
before, during and after such an attack is so critical, I want
to discuss the public health infrastructure as it exists and
its role.
Our public health infrastructure consists of several
interrelated components at many different levels. Communication
within and among each level is critical, as is the need for
mutual support.
At the government level, the Public Health Service, the
Department of Health and Human Services, works closely with
State and local health departments. Our philosophy is to help
support local officials, rather than to try to replace them.
Throughout the recent crises, the CDC's Health Alert
Network and Laboratory Alert Network immediately notified State
and local health departments of the latest developments on
anthrax and the possibilities of other bioterrorism attacks. In
fact, the Health Alert Network was used September 11th to
immediately put State health departments on alert for anything
suspicious following the attack on the World Trade Center.
Now, the role of the Surgeon General in all of this, of
course is, No. 1, to command the Commissioned Corps, and the
Commissioned Corps consists of about 5,600 health
professionals--physicians, nurses, dentists, veterinarians,
environmental health specialists. That Commissioned Corps was
activated on September 11th and has been activated since. These
are people who are on call 24 hours a day, 7 days a week. We
have deployed hundreds of them to New York City and to other
places as needed.
The second role of the Surgeon General is to communicate
directly with the American people based on the best available
public health science. Usually this results in a report from
the Surgeon General after months and years of study of a
particular topic, such as smoking and health, mental health,
suicide prevention. But in the case of a bioterrorist attack,
the role of the Surgeon General in this communication has never
been clearly defined, and that is one of the things that we
have been struggling with.
The anthrax cases in Florida provided a good example of how
CDC works with State and local health 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 7th. The Centers for Disease Control and Prevention and
other components of HHS, the Federal Bureau of Investigation,
the Department of Justice, the Florida Governor's Office, the
Florida Public Health Department and local public health
departments quickly formulated a plan that got word out
overnight to the AMI employees that they needed to come to the
clinic for medicine and testing the very next morning. The CDC
shipped medicine to Florida overnight and immediately deployed
epidemiologists to Florida; and CDC and Florida officials
issued a joint release at 11 p.m. on October 7th notifying the
media and the public of the second case. So it was a good
example of local, State and Federal officials working together
to get the message out to send medicine and to mobilize people
to come to 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 on their perception of the needs of the community, and we
respect those decisions. At the same time, when you try to
communicate that tests are merely preliminary, you hope that
the public and the media will hear that and appreciate what
that means.
That is the first layer of the public health
infrastructure.
The second layer of the public health infrastructure is the
health care delivery system, and it consists of not just the
private sector but also there are public components like
community health centers, community mental health centers and
others. It is a very critical front-line part of the public
health infrastructure.
The Department of Health and Human Services and especially
the 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. Together with the
CDC, a conference call with the State and territorial health
departments took place immediately.
We also realize 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, and we should not wait until there is a
bioterrorist attack. CDC and HHS have done two major satellite
conferences with physicians and hospitals on anthrax, smallpox
and bioterrorism. We must continue to look for new ways to
reach out aggressively.
The third layer of the public health infrastructure is
really the general public. The third level is by no means any
less important than the other two, especially since it actually
serves as the real front line: the public. Bioterrorism attacks
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 the
efforts to detect disease early.
The public must also be informed and educated about good
public health habits, such as handwashing after handling
foreign objects, safe handling and washing of foods, thoroughly
cooking meats, for example, and the careful handling of
suspicious mail and other packages. Good public health habits
are individual and community in nature.
After October 4, we immediately made available to the media
an array of medical/scientific spokespersons, in addition to
myself and Secretary Thompson, and that included CDC Director
Jeffrey Koplan, Tony Fauci at NIH, the Secretary's recently
named special adviser D.A. Henderson, and other officials at
CDC, NIH and the FDA. The CDC also made officials available to
the local media during the news conferences conducted by local
officials, whether that was in Florida, New York or in
Washington.
One challenge that we faced in these situations was the
volume of demand--and I want to really make that point. There
were so many news shows and networks who wanted to interview,
there was no way that one person could have met the media
demands. By making several people available with expertise, we
could more readily service this demand and at the same time
draw upon the diversity of expertise that we had available, and
there were times when the media requested specific people based
on what they saw as a specific area of interest or expertise.
Now, the second week in October, the Secretary and senior
members of the HHS team began holding daily teleconferences
with the media. The CDC began doing daily press calls with the
media about a week later.
Now, the interesting thing about bioterrorism, of course,
and the way it differs from the public health response to other
problems and infectious diseases, is that it requires a
partnership with the criminal justice system. In instances of
naturally occurring disease outbreak, those three levels would
be sufficient. But because the disease outbreak is
bioterrorism, it is intentionally triggered, a public health
emergency response must include the criminal justice system as
part of this infrastructure, while striving to maintain the
appropriate independence of the public health system. That has
been an ongoing challenge, but I think, for the most part,
communication with the Department of Justice has been good.
I would make four types of recommendations for
strengthening risk communication before, during and after a
bioterrorist attack.
First, it is critical that we continue to strengthen the
public health infrastructure, and we must ensure that all
components of that infrastructure are strengthened. And this is
not just about treating diseases or emergency. This is about
promoting health and preventing diseases. That is right now, in
my opinion, the Achilles heel of the American health system. We
have not adequately invested in the public health
infrastructure, especially as it relates to health promotion
and disease prevention, and that is why we have trouble with
antibiotics and antibiotic resistance and people understanding
why it is not appropriate to take antibiotics when not
prescribed--or not as prescribed.
We must continue to improve educational opportunities and
information sharing between the Public Health Service and
front-line health providers. This is critical. Many doctors at
the local level still fail to report disease diagnosis to
Federal officials, and this has been a long struggle to get any
reportable diseases, unusual cases reported to the Public
Health Service. By the same token, Federal officials sometime
fail to provide local providers with a national picture on a
timely basis that they can use in terms of their index of
suspicion. This can be strengthened, and it must. The mechanism
must be put in place to ensure that we have an ongoing dialog
that will make it easier for providers to access information.
In the minds of some people, and it is an old saying, that
all public health is ultimately local, and there is a lot of
truth to that saying, so there must be local efforts as well as
Federal and State efforts to educate the community as well as
health care providers.
We have a tremendous opportunity to improve our system of
risk communication and to be much better prepared for the next
major bioterrorist attack, which hopefully will not come, but,
in order to do that, we must work together, and we must begin
by making a commitment to strengthen the public health
infrastructure.
Thank you, Mr. Chairman. I will be happy to respond to any
questions. As you know, I have submitted a more extensive
written statement for the record, but the Department would also
be happy to respond to any questions that you would like to
submit.
Mr. Shays. Thank you very much.
[The prepared statement of Dr. Satcher follows:]
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Mr. Shays. I want to just first get some housekeeping out
of the way. I appreciate your statement. It was thorough and
very helpful.
I ask unanimous consent that all members of the
subcommittee be permitted to place an opening statement in the
record and that the record remain open for 3 days for that
purpose. Without objection, so ordered.
I ask further unanimous consent that all witnesses be
permitted to include their written statement in the record.
Without objection, so ordered.
And I would note the presence of Ms. Schakowsky from
Chicago and Mr. Tierney from Massachusetts.
I'd be happy to start with questions, but I'd be happy--if
you're all set, we could start with you. I recognize Ms.
Schakowsky.
Ms. Schakowsky. Thank you, Mr. Chairman; and thank you very
much, Dr. Satcher, for being here.
I have to tell you that I was somewhat surprised by your
description of the administration's handling of the anthrax
crisis, that it was so glowing, frankly, especially considering
some of the major missteps that we have all seen. You call
these mere bumps in the road, and you said that actually you
thought coordination was remarkable in your statement. But I
was surprised because the administration has, in fact, been
highly criticized by many highly qualified experts, especially
in the arena of risk communication, which we're mainly focusing
on today, and especially in light of several deaths, which at
least some people say might have been averted.
I'd like to direct your attention to some of the statements
that were made--and some of the individuals are going to be on
our second panel with--well, there are four--remarks were made
on the record, so you'll excuse me if you're being quoted here.
But Dr. C. Everett Koop, former U.S. Surgeon General, said
that, ``I'm communicating information to the public on
bioterrorism. I would not give the administration a high
mark.''
Dr. Mohammad Akhter, executive director of the American
Public Health Association, said, ``health departments have
obtained information from CNN more rapidly than they have from
each other or from the CDC.'' It went on to say that law
enforcement, intelligence agency and public health officials,
``stumbled over each other in responding to the anthrax
outbreak.''
Dr. Kenneth Shine, President of the Institute of Medicine,
believes, ``the effectiveness of communications to the public
and to health professionals about the anthrax terrorism were
found wanting.''
And, finally, Dr. Joseph Waeckerle, editor of the Annals of
Emergency Medicine, found that, ``crisis communication was
often inaccurate and misleading or too scanty. No centralized
leadership, no voice of authority and inconsistent information
resulted in the American public remaining in an informational
vacuum.''
My concern, therefore, in terms of your remarks is that I
think it's important that we take a very cool eye as we look
back and take a studied look at what exactly happened in order
to put in place what needs to be done, and so I'm wondering
really, in light of those comments, how your interpretation of
the events could be so different from those that I just quoted
to you.
Dr. Satcher. Well, let me first say, as you know, I have
tremendous respect for the four people you've quoted. I've
worked very closely with them over the years, and even since
this outbreak. And clearly, as I said in my statement, there
were problems in our response to this outbreak, and it is true
that, since I knew that they were going to emphasize the
negatives, I thought it was important to also point out that
there were many positives. And we don't point that out. We do a
great injustice to the people at the local, State and Federal
level who have been working so well together. There have been
problems, but they have saved a lot of lives.
I could go into that in more detail, about what could have
happened and what the terrorists intended to do and what
anybody would have projected would have happened if we had
discussed this 6 months ago, what would have happened when you
had the first anthrax attack. Most people would have projected
that we would have lost many more lives, especially dealing
with aerosolized anthrax.
So the rapid response of getting medication to anyplace in
the country within a few hours, the rapid response of getting
epidemiologists on the scene within a few hours and acting in
such a way as to determine who was exposed and therefore who
needs to be--receive prophylactic antibiotics--over 30,000
people, perhaps 35,000 to 40,000, have been started on
antibiotics, and at least 5,000 continued it for 60 days. Many
of those people could have gotten inhalation anthrax.
We deeply regret the five deaths that have occurred, and
obviously we keep retracing what could have been done
differently to save those lives. But I think the point of the
matter is we have to also build on our strengths. We have to
know what they are.
And we have to also know what our weaknesses are. I've
tried to point out what I think those weaknesses are.
It is going to be very difficult to satisfy the media with
one person being the spokesperson, for, No. 1, there are--I
have done 40 interviews on television and radio within the last
few weeks, and that doesn't begin to tell you how many requests
there have been. What about all the other people--Tony Fauci,
Dr. Fauci from NIH, who has done many interviews, Dr.
Henderson, the Secretary? There have been many people.
The problem--and I think you're right, and I would agree--
we have to figure out a way to better coordinate the message
that we send out. But the difficulty is, this is a dynamic
situation. I mean, it's changing every minute, and we don't
actually know what the terrorist is going to do next, and we
don't necessarily know how he or she is going to do it. And in
that environment to try to communicate a message----
The public wants to hear from you on a very timely basis,
but they also want your statements to be definitive. They don't
want you to say, our preliminary information is the following.
The CDC is continuing to do tests. And then tomorrow you come
back and say, well, on further testing, that sample was not
negative. It was positive. Well, that, in fact, is accurate,
that is true, but the fact of the matter is it's a dynamic
situation, so if you're going to keep the public informed----
And there is a lot to be said for that in terms of dealing
with the kind of panic that Congressman Shays described. You
try to give up-to-date information.
But the question is, do people really appreciate that a
test may be preliminary, that using nasal swabs to screen
people at the outset was not necessarily a bad idea in terms of
determining who might have been exposed in a given situation?
The problem was that the public misunderstood that nasal
swabs were not definitive tests. And so when people came back
and said, even though your test was positive, when we did
further tests at CDC it was negative, so you don't have to
continue Cipro--or, in other cases, even though you had a
negative nasal swab, because we have determined that you could
have been exposed, we're going to put you on Ciprofloxacin or
Doxycycline for the next 60 days.
Those are not easy messages to communicate to the general
public, and I think anyone could be justified at selecting the
negative things that have happened and weaknesses and focusing
on those. And I think there is something to be said for that,
and I think it makes a contribution to the whole distribution,
but I also think somebody needs to stop and say, some things
went right here, and we've got to build on those things that
went right and to make sure that in the future more things go
right.
That is the perspective that I'm taking. Because it is very
clear to me that you have the experts here to criticize what
happened.
Mr. Shays. What I'll do is I'll ask questions. Then we'll
go to Mr. Tierney, and then we'll go to Mr. Putnam.
I think it's very clear that it's been a pretty dramatic
few months, and I think it's pretty clear that we had some
people who were not only having to deal with this issue but
they were new to the job as well. But you have been around for
a while, and I consider you a pretty steady hand. I'd like to
have you give me an assessment of whether you felt you were
playing the role you should have played as the Surgeon General.
I view you as, you know, the chief health care spokesperson for
the government.
Dr. Satcher. Well, let me say a couple of things.
I think I could have played a more impactful role. The
Surgeon General functions best--and there is a lot of history,
Dr. Cooper and others--when the Surgeon General has the ability
to base his or her statements on the best available science.
Throughout history, Surgeon General's reports have been based
on extensive examination of the research that has been done in
an area. The American people have come to trust those reports
because they are so solidly based in public health science, not
politics, not personal opinion.
We have not been here before where you have to respond to
an ongoing bioterrorist attack. You really don't have time to
assemble all of the science, and the science is also changing,
and therefore there are a lot of questions that people want to
ask. Some of them relate directly to the science. Some of them
relate to organization and management. And so there have been
interviews done in all of those areas.
I think Secretary Thompson saw himself as responsible for a
department that included the Centers for Disease Control and
Prevention, the National Institutes of Health that is
responsible for the research to produce better drugs and
vaccines and supplies----
Mr. Shays. You can move the mic a little away because----
Dr. Satcher. I'm sorry.
Mr. Shays. No, you don't need to apologize that you have
such a nice voice. It carries well.
Dr. Satcher. Thank you--the Food and Drug Administration.
So he is responsible for all of these agencies, and I think he
felt there was a responsibility to communicate about the
overall picture within a department.
Now, has the Secretary--has the Surgeon General in the past
been in a position to speak for the entire Public Health
Service? Yeah, many years ago before the structure was changed.
But the structure is completely different today than it was
when the Surgeon General was the head of the Public Health
Service, and so the situation in terms of day-to-day
communication about what is happening in a department is not a
role that the Surgeon General has played in recent years.
The Surgeon General has reported on specific issues based
on the best available science. Surgeon General Koop reported on
HIV/AIDS in 1986. The AIDS epidemic started in 1981. We learned
a lot about AIDS in those years before the report went out. I
could say the same thing about my report on mental health.
So I think one of the problems we have here is we have not
done the job that we need to do at redefining the role of the
Surgeon General, communication about a dynamic bioterrorist
attack, that are ongoing, where the science is evolving on a
day-to-day basis. We think we need to do that because I think
there is a critical role.
Mr. Shays. I'm going to have you turn the mic a little
closer but not too much closer. That's perfect.
You basically said that we've learned a lot. Just about
say, anthrax, just walk me through some of the things. One of
the things we learned was that inhalation anthrax was something
we thought could kill somebody. I mean, when we had hearings on
the anthrax vaccine in the military, it was, you know, if you
inhaled it, you were dead, and we learned that is not so, where
also it's conceivable that--we're learning that--some of the
people that died were people who were dealing with some--who
were either older or were dealing with some physical
challenges, that they become more susceptible to the inhalation
anthrax, killing them, as opposed to being healed through
antibiotics.
Just walk me through some of the things we've learned.
Dr. Satcher. Well, let me just say I think one of the most
painful lessons that we have learned involved the deaths of the
two postal workers at the Brentwood facility, because I think,
up until that occurrence, the assumption and the public health
line was that people exposed to an envelope in an office that
had been opened were susceptible to anthrax and needed to be
treated prophylactically. But many statements of the CDC up
until that time had said we have no reason to believe that a
closed envelope passing through a post office could expose
people. We know better than that now, and it would have been
greater if we had known that before.
We know more about, for example, how mail can be handled
and how envelopes can be ripped apart, but there was no
evidence in this case that had happened. So let me just say we
still don't have the full answer to what happened in the
Brentwood post office, but we do know that somehow at least two
postal workers were exposed.
You would have to assume, Congressman Shays, that many more
workers were exposed; and the question is, why haven't they
come down? Because, obviously, we got to them early enough. If
we had known beforehand of the potential of the spores to
escape in a post office setting and infect people in that
environment, we could have perhaps saved those two people.
By the same token, getting back to the second level, if
people on the front lines who take care of patients had been
more acutely aware and had the appropriate level of suspicion,
it might well be that we could have saved those two postal
workers. But all of that is in retrospect. I think that is the
most painful lesson we've learned, is how critical it is to
really have the kind of working relationship with the front
line that leads people on the front line to have the
appropriate level of suspicion at a time like this and to make
sure that everybody is asked about their work environment. If
they show up with an upper respiratory infection--but,
remember, there were hundreds of thousands of people who showed
up with upper respiratory infections during those 2 days.
I think we've also learned that the American public needs
much more information about the use of antibiotics and
vaccines, the appropriate use. I know CDC has had a strategy
going to try to reduce drug resistance in recent years, and
part of that has been to make sure that people understood that
if you take antibiotics inappropriately you do great damage not
only to yourself potentially but other people. I can tell you
that the American people are going to a doctor's office today
asking for antibiotics for the common cold, as we speak. There
are people going saying, I want a penicillin shot or I want
this antibiotic, because I believe that will help me get over
this cold that I have. So we have a lot of education to do so
that the American people really understand and appreciate the
dangers, and we take that responsibility----
Mr. Shays. Just a second--and I appreciate Mr. Tierney's
patience here, but it is absolutely imperative in that
circumstance that the physician tell the patient it would be a
terrible mistake to have an antibiotic. Correct? I mean, it's--
--
Dr. Satcher. That brings you to the second level. You know,
I've trained primary care physicians in my career; and I
remember in an area like Watts training them and counseling
them about when you go out there to take care of patients make
sure that you do this and that. And they come back and say,
well, if we don't do it, the patient goes to find another
physician who will.
So we're caught up in a situation here where many
physicians on the front line--and we've talked about this
with--the American Academy of Pediatrics and the American
Academy of Family Physicians feel an unusual pressure to
prescribe antibiotics for patients, and they've done it within
recent weeks, patients who have requested antibiotics and even
other things that they wanted.
So it is a team, it is a partnership, and I think everybody
in that partnership has to be empowered and better informed.
Mr. Shays. I look forward to asking some more questions of
you, but let me recognize Mr. Tierney for a good 7 minutes.
Mr. Tierney. I don't need all that time. Thank you.
I have a question to followup on----
Mr. Shays. Could I just interrupt? I apologize. I didn't
acknowledge the presence of Mr. Putnam or Mr. Lynch and
appreciate both of them being here. I'm sorry. Thank you. Thank
you.
Mr. Tierney. Thank you.
I want to followup on what you have just spoken about in a
minute, but first let me ask you, there was a Dark Winter--it
was the name of a program or the exercise I guess that was gone
through by a number of people. During the course of that,
former Senator Nunn made a comment that there is an inherent
conflict between health and law enforcement when you have a
situation like we have with anthrax, and then there were
reports in the newspaper in Florida that the FBI had actually
told public health officials that they couldn't speak publicly
about what was going on. Would you talk about what happened in
Florida and what happened and a little about that conflict and
how you would remedy that?
Dr. Satcher. Well, let me just say that I'm not going to
give details about what happened that you might want, but let
me just say there is a difficult situation when you have a
bioterrorist attack. Everybody wants to find out who is doing
this. And I think whether you're in public health or law
enforcement your first priority is how do we stop this from
happening. So if the Department of Justice or the FBI say to
us, we really want to treat this information carefully so that
we don't tip off the terrorists as to what we have, we have to
cooperate with that.
I mean, when there's a natural occurrence of influenza or
something, we can control the prevention. We can't when it's a
bioterrorist attack until we find the person or persons who is
doing it. Our hands are tied, and we don't know what they're
going to do next.
So I would say those of us in the Public Health Service
appreciate the role of the criminal justice system in dealing
with a bioterrorist attack, and when they need cooperation that
is critical to carrying out their responsibilities we believe
that it's our responsibility to cooperate.
Mr. Tierney. Do you see that conflicting sometimes with the
need to get information to the public?
Dr. Satcher. Most definitely.
Mr. Tierney. And how do you reconcile that?
Dr. Satcher. Well, we've tried to do that, and you've seen
several interviews done even with the White House and Governor
Ridge where people have asked questions and we've just said we
can't respond to that right now. That's in the hands of the FBI
and Department of Justice, if they were not there to respond
themselves. So we have tried to explain that in some cases we
were not able to give information because we felt that it might
endanger the investigation. That is what we've tried to do.
It's not easy, and it is a very difficult conflict to deal
with, as Senator Nunn pointed out in that exercise.
Mr. Tierney. Do you think that we're properly using
technology that is available to us to get the public health
message in a crisis situation down to doctors at the local
level and hospitals at the local level community centers?
Dr. Satcher. I think we are now, but I think we should have
done it before there was an attack. I think we educated and
communicated with hundreds of thousands of physicians since the
attack. But what it says to me is that, whereas in the past we
have relied on physicians to go to meetings and conferences to
become educated about bioterrorism, we could have used the
satellite system for ongoing communication with providers, and
hopefully in the future that is what we will do. I think it's
an area where we can make a lot of improvement, and I made that
as a recommendation.
Mr. Tierney. You have.
Dr. Satcher. Yes, and included it in the testimony.
Mr. Tierney. Last, let me just ask you this. The end of
your answer responding to the Chairman Shay's question, you
talked about doctors going out and saying that they've got a
great deal of pressure from patients to give antibiotics to
others. How much of that do you attribute to this phenomenon of
advertising by the manufacturers and placing their seed in the
mind of patients?
Dr. Satcher. Yeah. I think in recent years, with the
Internet especially but with advertising in general, I think
many patients come to physicians asking for drugs that they've
heard about through the newspaper or through the Internet. So
it is a major part of the problem. I don't think it's a problem
that we can't solve, because I think there are a lot of
positive things about a better-informed patient and patient
community, but somehow we've got to get to the point where we
have everybody on the same wave length as to how we protect the
health of the public.
Again, my opinion is--and I had this opinion for many years
and I've stated it for many years--there's no place in the
world better than this country when it comes to treating
diseases and crises. The problem is, how do we protect the
health of the public? How do we promote health and prevent
disease? I think that's the Achilles heal of our health system,
and it's reflected in that interaction.
Mr. Tierney. Thank you.
Dr. Satcher. Uh-huh.
Mr. Tierney. Yield back.
Mr. Shays. I recognize--thank the gentleman and recognize
Mr. Putnam.
Mr. Putnam. Thank you, Mr. Chairman.
Dr. Satcher, to followup somewhat on the previous line of
questioning, there have been a number of complaints from local
law enforcement officials about the FBI's refusal to share
information with them that were critical to their mission. Have
you found the FBI unwilling to share information, even if it
may be of--information you don't share publicly, but have you
found them to be willing to share with you the information you
need to accomplish your mission as a public health officer?
Dr. Satcher. Well, because that's handled at a departmental
level, I can only say to you that Secretary Thompson's position
has been that he's had good communication with the Department
of Justice and the FBI, and that communication would take place
at his level. And that is--you know, his official position is
that he's had good communication with the Department of Justice
and the FBI.
Mr. Putnam. I've just been handed something that indicated
that the Secretary has admitted to being frustrated at times in
attempting to acquire and pass on information to the public on
anthrax due to the classifications or other FBI restrictions.
Dr. Satcher. Well, I think that is a different issue. I
think clearly, as I said in answer to Mr. Tierney's question,
it's frustrating when the public wants you to pass on
information that you can't pass on because it's a part of the
investigation. But I thought your question was, are we getting
information that we need from the FBI, as opposed to can we
pass on information that we'd like to pass on to the public? In
the latter case, it has been very frustrating, as Senator Nunn
defined it. But I thought you were asking me, is the
communication between the Secretary and Attorney General and
the FBI satisfactory? I have not heard him complain about that.
I've heard him complain about being limited in his ability to
then pass on this information to a public that expects him to
pass it on.
Mr. Putnam. You're correct. The first question you did
answer adequately.
With regard to sharing of the information with your local
health officials, State and local health departments, how many
of them have access to your Health Alert Network and Lab Alert
Network?
Dr. Satcher. The Health Alert Network is actually now
available to all State health departments. As you know, the
State and local health departments vary tremendously in their
capability. That is one of the weaknesses of the public health
infrastructure, the tremendous vulnerabilities among State and
local health departments. There has been a program in place now
for over 5 years and Congress has provided funds through the
CDC to strengthen State public health laboratories. We still
have a long ways to go, as you know.
There are States in this country that don't have a trained
epidemiologist. There are local health department--there are
local communities that don't have a local board of health. And
so the problem in the country today as I see it is a great
heterogeneity among the various States and local communities.
I think the Health Alert Network needs a lot of support. It
needs more funding. We also need the Laboratory Alert Network
to be continually developed and strengthened.
So the official statement I think from the CDC is that 50
States are receiving funding under the Health Alert Network
grant program, in addition to Guam, the District of Columbia,
New York City, Los Angeles and Chicago. You know, we fund some
localities as if they were States because they are so big.
Thirteen States are connected to all of the local health--
all of their local health jurisdiction, only 13. Thirty-seven
States have begun connecting to local providers.
So it is true that 50 States are receiving funds, but
there's a lot of difference--there is a lot of heterogeneity in
terms of what happened within those States and their ability to
use the information.
Mr. Putnam. It's essentially--in terms of disseminating
information quickly, it's little more than an e-mail or a fax,
isn't it? I mean, please----
Dr. Satcher. Well, the Health Alert Network is based on the
best technology.
Mr. Putnam. So, I mean, surely the technology and the price
pressures for cheap technology would be such that there
shouldn't be any States or any health department or any
hospital or any doctor's office out there that not have access
to----
Dr. Satcher. Well, I would like to refer you to Senator
Frist's statement when he and Senator Kennedy introduced
legislation to provide $3.5 billion for strengthening health--
the public health infrastructure. He pointed out how many
health departments did not have a computer in this country. So,
as strange and shocking as it may seem, there is tremendous
heterogeneity among--especially among health departments but
also State health departments. But I would refer you to his
testimony about the major problem that we have in terms of the
technology that is available in many different situations.
Mr. Putnam. And very quickly, as my time has expired,
because of the crossover of anthrax, for example, being
essentially an animal disease and some of the--how much
coordination is there between the HHS and USDA and between the
medical professionals and veterinarians to coordinate
information as the entry points for some of these may actually
be through animal or agricultural products?
Dr. Satcher. Yeah. I think there's room for improvement in
this area, but I do want to say that the Commissioned Corps,
which I oversee, which has 5,600 health professionals, has over
100 veterinarians; and we have sent people from our department
to areas where there were outbreaks that involved animals,
including outbreaks recently in England and in places in Europe
in terms of mad cow disease. So we do have veterinarians in the
Public Health Service, and we do have a working relationship
with the USDA. I think everyone would agree that we can do much
to strengthen that working relationship.
Mr. Putnam. Thank you, Dr. Satcher.
Mr. Shays. I thank the gentleman.
At this time, I would recognize our newest member. It's
wonderful to have you here, Mr. Lynch. Do you have questions?
OK. Thank you.
Mr. Gilman, do you have any questions you would like to
ask? Or I have some that I could quickly ask and give you some
time.
Mr. Gilman. Well, thank you, Mr. Chairman. I want to thank
you for holding today's hearing to examine the overall level of
communications between the Federal Government and the public
health system regarding bioterrorism risks, and I want to thank
our panelists who are here today.
For many years discussions about the possibility of a
biological terrorist attack occurring in our Nation was
relegated to the academic and policy discussions. Regrettably,
the terrible events of September 11th and the subsequent
anthrax incidents in New York and Washington sharply focused on
our national attention on terrorism and underscored our
vulnerability.
You and I attended a hearing earlier today with our arms
Secretary in the State Department, and he noted how many
nations there were who have been developing biological weapons.
It's certainly an important element for us to take a good, hard
look at, both in terms of where the threat originates and what
specific agents pose the greatest danger. So far, the media has
focused its attention only on anthrax and smallpox, yet those
represent only two out of the many agents which could
conceivably be utilized. Still, those two agents are the ones
that have garnered the most attention.
In the case of anthrax, the events following the
contaminated mail incidents in October have shown that there is
much room for improvement on the part of our own government and
the communication process, and while officials at CDC and HHS
have demonstrated improvement in their communication strategy
over time, their early missteps, particularly in downplaying
the initial risk of exposure, has led to additional
complications as the situation--it's vital, therefore, that
these Federal health officials have learned from those past
mistakes and are able to ensure the public that they will not
be repeated in the future.
So I want to just ask one question. Have the various
Federal and public health services considered adopting a daily
briefing program similar to those conducted by the White House,
the Department of Defense with regard to the bioterrorism
situation?
Dr. Satcher. Yes. Congressman, I mention in my testimony
that both the Secretary of Health and Human Services and the
CDC have initiated daily briefings for the press since the
second week in October. So there have been ongoing
interactions. I think that is the part of the strength of the
communication, but it is also a part of the things that people
are going to be able to criticize. Because by having daily
briefings, you're also going to give information that is
evolving, which means that some of it is preliminary, and
therefore how do you deal with preliminary information where
the results are going to change.
But I think the daily briefings are important and think
they have been very helpful to members of the media and,
therefore, to the general public.
Mr. Gilman. Dr. Satcher, who has the overall responsibility
of conducting our Nation's defense against bioterrorism? Is
there any one person or any one agency?
Dr. Satcher. Well, it's really the Justice Department that
has the overall responsibility for defense against
bioterrorism----
Mr. Gilman. And is----
Dr. Satcher. And all of the bioterrorists, including the
exercise that was discussed earlier with Senator Nunn. It is
understood that the first responsibility in terms of protecting
the American people and guarding against criminal behavior,
which we're talking about here--we're talking about criminal
behavior, where there is a criminal somewhere attacking----
Mr. Gilman. But, Dr. Satcher, what I'm trying to pinpoint
is where is the overall responsibility for coordination and to
make certain all of the agencies are working together on this.
Dr. Satcher. Oh, right now, of course, it's the new Office
of Homeland Security in the White House, but that's a new
office.
Mr. Gilman. And does that Homeland Security Director have
the responsibility then of coordinating----
Dr. Satcher. Coordinating, yes.
Mr. Gilman [continuing]. All of our efforts on
bioterrorism?
Dr. Satcher. Governor Ridge, the head of homeland security
today, has the overall responsibility for coordinating all of
the efforts.
Mr. Gilman. And do you report to him with regard--or do you
work with him with regard to----
Dr. Satcher. I report to Secretary Thompson in the
Department of Health and Human Services, and he deals directly
with Governor Ridge.
Now, Governor Ridge has often asked me as Surgeon General
to join him at the White House for conferences with the media.
But, in our department, that relationship is with the
Secretary, as it is with--you know, with other departments,
Department of Justice, Attorney General.
Mr. Gilman. Dr. Satcher, do you sit in with other agencies
to explore what has to be done on bioterrorism?
Dr. Satcher. Agencies within the Department of Health and
Human Services?
Mr. Gilman. All of the agencies.
Dr. Satcher. No. Again, that interaction would be at the
level of Secretary Thompson.
Mr. Gilman. And do you sit in with Secretary Thompson on
that kind of direction?
Dr. Satcher. There are times, but that is really not the
major role of the Surgeon General. If the Surgeon General did
that----
Mr. Gilman. I realize that.
Dr. Satcher. If the Surgeon General did that, it would be
very difficult then to be responsible for the Commissioned
Corps and deploying people under an emergency basis and
continuing to speak with the American people all over the
country. So it is not a day-to-day responsibility of the
Surgeon General.
Mr. Gilman. So the Surgeon General then doesn't have any
responsibility on planning with regard to bioterrorism or----
Dr. Satcher. Well, the Surgeon General has input to
planning, yes, definitely, but not to be involved in meetings
with departments. Because when you say--you're talking about
meetings with the Department of Justice and----
Mr. Gilman. Well, I want to ask you, if you had some
thoughts, constructive thoughts on what should be done on
bioterrorism, who would you pass that on to?
Dr. Satcher. Secretary Thompson of the Department of Health
and Human Services.
Mr. Gilman. Thank you.
Thank you, Mr. Chairman.
Mr. Shays. I thank the gentleman.
Dr. Satcher, we could ask you a lot more questions. We have
another panel we want to get to. I want to ask you just a few,
though.
I want to ask you how you would define the role of the
Surgeon General in terms of you and anyone who follows you as
it relates to bioterrorism.
Dr. Satcher. The Surgeon General has two major areas of
responsibility as I see them today. The first area is the
responsibility for the Commissioned Corps, the 5,600 health
professionals who are on call 24 hours a day, 7 days a week to
respond to any threat to the health of the American people,
whether it's a bioterrorist attack or whether it's a natural
outbreak. And we often deploy people when there are floods,
tornados, an epidemic in this country or even in another
country if it's a threat to the health of the American people.
So September 11th, while on the way to the airport, I
stopped and activated the Commissioned Corps readiness force,
and we have sent many of those people to New York City and
other places to respond. That's a very important day-to-day
responsibility of the Surgeon General; and, as you know, we
deployed the Deputy Surgeon General to Capitol Hill, Dr. Ken
Moritsugu, who has been intimately involved with briefings on
Capitol Hill since the letter to Senator Daschle.
The second and perhaps in some ways most important
responsibility of the Surgeon General when you really think
about it is the direct communication with the American people
based on the best available public health science. The context
of that communication historically for the most part has been
to look at an area of concern to the American people, does
smoking cause lung cancer? So Dr. Luther Terry's report was the
first ever Surgeon General's report on smoking and health.
There have been many reports on that topic since, and
during my tenure, of course, I have released reports in areas
of mental health, suicide prevention, youth violence
prevention, oral health. I released three reports on smoking
and health, including women and smoking. Those reports were all
based on thorough public health science examination of those
areas.
So when we speak to the American people, we speak with the
kind of authority based on a lot of the investigation.
But I believe that we have to define a clearer role for the
Surgeon General in terms of bioterrorist attack. I think that's
one of the things that we've learned that the American people
do, in fact, want to be able to rely on the voice of authority
and credibility in public health science. And so I think that
as we look at how to improve the system of communication, I
think the role of the Surgeon General is critical in this. But
it's got to be very clear that there are political issues
involved in responding to an outbreak, there are organizational
issues. And the question is, which of those issues are we going
to look to the Surgeon General to speak on? And I think the
Surgeon General has to speak on the public health science.
Mr. Shays. It strikes me that the Surgeon General has
consistently over the years, you and those who preceded you, as
basically being the voice where the science takes you and not
an office that can be manipulated by political considerations.
Obviously, political considerations can come in terms of typing
of a report and so on, but in the end, what you issue is viewed
to be the truth untainted by political considerations, and I
mean, you and those who preceded you.
In other words, I consider you, kind of your position, an
honest broker, an honest voice, and is that a view that I
should consider or should I consider you basically under a
secretary, and if the secretary says change your report, you
have to change your report?
Dr. Satcher. Well, I think the first description is the one
that is accurate for a Surgeon General. But I also want to add
something to that.
Mr. Shays. Sure.
Dr. Satcher. As you know, there are times when there are
disagreements. I've issued a report on promoting sexual health
and responsibility for sexual behavior, which was not supported
by the Secretary or the White House, but they did allow the
report for the public health science, but it was not
necessarily politically a report that was supported.
I do want to make it very clear, Congressman Shays, that
the Surgeon General's office is, in fact, impacted by politics.
The budget of the Surgeon General's office has been virtually
depleted since 1994. So there is virtually no budget. The
Surgeon General relies upon NIH, CDC, other agencies when we do
a report even. Because there is no--the funding is not there. A
lot of the changes that have taken place have resulted from
disagreements with things that came out of the office of
Surgeon General.
I have been very fortunate, I think it has something to do
with the fact that I was director of CDC before, and I've had
an ongoing working relationship with people in these various
agencies now for several years, so I have not had difficulty
getting support to do a report on mental health, for example. I
didn't have the money in the Surgeon General's office to do
that. I didn't have the money to do the youth violence
prevention report. I had some.
So in every one of these areas, I've had to rely upon other
agencies within our department. So while on the one hand I say
to you that it is the responsibility of the Surgeon General to
issue reports that are based on the best available public
health science and not politics and not personal opinion, I
would not be honest if I said those things don't impact upon
the strength of the Office of the Surgeon General. As you
imply, clearly, organizationally, the Surgeon General reports
through the Secretary.
That's the way the organization is. That affects budget,
that affects everything. And that's the reality. I would like
to see it--to be honest with you, I would like to see it
different. I would like to see the Surgeon General able to have
a strong office and able to report on based on the best
available public health science, even when there is
disagreement about that. I'm talking about the future, not
talking about myself.
Mr. Shays. I appreciate your candor. I know you're talking
about the future. I apologize that I haven't been as aware that
since 1994, this office has gotten less and less resources.
Dr. Satcher. You might want to look at the budget of the
Office of Surgeon General.
Mr. Shays. There's a lot we should look at. I would ask
this one last question. You have to respond to the FBI. But do
they ever have to respond to you? Can you ever trump the FBI?
They trump you, they trump the health care side. Can the health
care side trump the FBI? You go from detection and prevention
of a terrorist attack, you have crisis management,
investigating the crime, you got the consequence of the act.
But isn't there times when the consequence of the act should
trump the crisis management?
Dr. Satcher. Yeah. I don't know if I would use that term
because it implies expedition when I think it ought to be
looked at as a partnership. The FBI is very dependent upon the
public health service for information. Whether it's the CDC
and, of course, there is the U.S. Army Medical Research
Institute for Infectious Diseases [USAMRIID], that does a lot
of the analysis. But the FBI is often dependent upon the public
health service for information that they will use in their
work. And that's certainly been true with the anthrax outbreak.
They have looked to the CDC for information about the nature of
the strain, for example.
It is very important that in all of the four letters that
have been sent with anthrax, they have all been of the same
strain. It's upon, it seems as if to date, the letter sent to
Chile may well be a different strain. All of this is
information that comes out in a laboratory. It is all
information that the FBI uses in its investigation.
Mr. Shays. But would it be wrong for me to make the
assumption that if someone's life is in danger, that trumps
their trying to protect evidence? In other words, if an
envelope is there that could be dangerous, and if we could have
that envelope and we could begin to see what's in it, should I
believe that because they may want to protect the evidence
that----
Dr. Satcher. Oh, I see your point, yeah. I don't think that
the decision would ever be made. You know, at least I don't
think so. I can't think of an instance where someone's lives
have been put at danger because the information was protected
for the investigation. I think the overall goal here is to save
lives. And we believe that in the case of a bioterrorist
outbreak, finding the person who is behind it is very critical
to saving lives. But I can't think of an instance where we have
endangered lives of people because, you know, we don't get
information where it was suppose to. We didn't take action. We
may not have explained to the public why we took a particular
action.
Mr. Shays. As always, I appreciate you coming before our
committee. Appreciate your candor. I appreciate your good work.
I would just invite you to make any closing comment if there is
anything you wanted to say or question you wish we had asked, I
invite you to make a comment before we go to our next panel.
Dr. Satcher. One of the things that we've talked about is
the dynamic nature of this situation. And when the exercise
that Congressman Tierney mentioned with Senator Nunn took
place, we were actually in a different place in this country
than we are now. The FBI had the lead for crisis management
with bioterrorism. FEMA had the lead for consequence management
and the department reported through them. There was no homeland
security office. So even since the bioterrorist operation took
place, we have seen changes even in how we're organized and how
people report. This is a dynamic situation and hopefully moving
in the right direction. I think this hearing is so important in
that regard.
Mr. Shays. Thank you very much. Appreciate you being here.
We'll call our final panel and obviously thank them for their
patience. All of them are busy people and I know have other
places to be. I invite Dr. C. Everett Koop, former U.S. Surgeon
General; Dr. Kenneth I. Shine, president, Institute of Medicine
representing the National Academy of Sciences; Dr. Mohammad
Akhter, executive director, American Public Health Association;
Dr. Joseph Waeckerle, editor and chief, Annals of Emergency
Medicine, representing the American College of Emergency
Physicians. I will invite you gentlemen to stand. I will catch
you before you all sit down and administer the oath.
[Witnesses sworn.]
Mr. Shays. Note for the record that our witnesses have
responded in the affirmative. I would invite you to give your
testimony as I called you. We'll start with you, Dr. Koop, and
go to Dr. Shine, Dr. Akhter and Dr. Waeckerle. What I'll do is
I'll--we'll have a 5-minute clock. We'll roll it over, but hope
that you could stay within the 5 minutes, but if you roll over,
you have another 5 minutes if it's necessary.
Dr. Koop, it's always wonderful to have you here. Thank
you. We'll start with you. Let's make sure that mic is on.
STATEMENTS OF DR. C. EVERETT KOOP, FORMER U.S. SURGEON GENERAL;
DR. KENNETH I. SHINE, PRESIDENT, INSTITUTE OF MEDICINE,
REPRESENTING THE NATIONAL ACADEMY OF SCIENCES; DR. MOHAMMAD
AKHTER, EXECUTIVE DIRECTOR, AMERICAN PUBLIC HEALTH ASSOCIATION;
DR. JOSEPH WAECKERLE, EDITOR AND CHIEF, ANNALS OF EMERGENCY
MEDICINE, REPRESENTING THE AMERICAN COLLEGE OF EMERGENCY
PHYSICIANS
Dr. Koop. Good morning, Mr. Chairman and members of the
committee.
Mr. Shays. It's not on yet, Dr. Koop.
Dr. Koop. Now?
Mr. Shays. Yeah.
Dr. Koop. Sorry. I am C. Everett Koop, a pediatric surgeon
by training and the Surgeon General of the United States for
two 4-year terms, from 1981 to 1989. I appreciate much your
invitation to testify before you.
Our public health care system has been weakened in the past
8 years and the recent bioattacks have stressed its ability to
protect the American public. We were not prepared for the
anthrax bioattack, regardless of its source, and the fear
generated by it far outweighed the health threat.
Morally, I think we really never thought anyone would do
it, but they did and the public is still uncertain, that they
would deliver a catastrophic attack by some other bioterror.
Think of the distraction and chaos involved with fewer than 50
anthrax victims, real or uncertain, in the anthrax scare, how
would our resources handle not 50 but 5,000? How about 50,000?
How about 5 million?
The public health service has a long and distinguished
history of protecting America in the past from many threats
that have reached our border or have originated domestically.
However today's threats are unique in a world without borders,
and therefore require new strategies and policies coupled with
operational plans to combat the threats to our Nation's health
care and to our people.
Our domestic defense system has not been able to protect
the American people or their economy from the present small
bioterrorism attacks. What will we do with weapons of mass
destruction or weapons designed to maximize panic and mistrust
in our health care system?
Mr. Chairman, your staff asked me to answer a few questions
on communicating information to the public on terrorism. And I
would not give the government high marks in this recent
episode. The spokesperson in such situations is usually the
Surgeon General, and usually in the setting of a press
conference and not a talk show. And yet I have heard almost
nothing from him and those who were his surrogates, except Drs.
Fauci and Koplan, who have not been accurate.
I don't mean Fauci and Koplan, I mean the others. That is
particularly egregious because as you know, the current Surgeon
General was, for some time, director of the Centers for Disease
Control and is eminently qualified in this area.
Communicating threats to the public are based, I think, on
common sense. And I have a few rules that I don't really think
about when I talk, but I made them up in response to the
question. First of all don't make statements especially
predictions that are not based on fact. Deliver warnings with
enough information to prepare and protect without causing
panic. Choose words understandable to a 10th or 12th grader,
and go over the draft again and again so there is no ambiguity.
Make certain that the public understands the difference between
an immediate threat versus a long-term outcome, and between
fatal and a nonfatal threat. Inform the public frequently and
in increasing depth. Squelch rumors that are untrue, such as
AIDS can be transmitted by contact with door knobs and toilet
seats. Translate science for the non scientific public and
never speculate or indulge in opinions. And finally, and
perhaps most important, keep the press on your side through
honesty and forthrightness.
There will likely be a series of biothreats, chemical
threats, agro threats and cyberthreats, nuclear threats and
threats to our food supply and our water supply over the next
months and years until we win our international war against
terrorism. While recent actions were designed to cause maximum
panic and economic harm, future threats may indeed be aimed at
causing catastrophic numbers of casualties.
This likelihood needs a new strategy where all of America
is linked together using our strengths of command communication
and control technologies to defeat future attacks. We need to
be able to rapidly mobilize all of our health care resources to
be concentrated on wherever the threat appears, even if it
appears in multiple sites simultaneously. The defense against
bioterrorism is not to be found in the military, their
responsibility is primarily strategic offense. Anticipated
threats against civilians cannot be prevented unless we destroy
the source or have extraordinary and credible intelligence for
a specific site at a specific time. But we can mount multiple
plans tailored to the threat aimed at managing the assault,
containing its spread, treating victims and controlling the
ensuing panic.
A new biodefense system needs to address the possibility of
weapons of mass destruction such as contagious weapon that will
overwhelm the limited surge capacity of our health care system,
our pharmaceutical industry, and the public health service.
These weapons can be unleashed from abroad and move silently
within individuals traveling throughout our country,
undetected, until the first sentinel case is found.
At a similar time in history, Winston Churchill, deeply
troubled by England's lack of preparation for World War II said
this, ``the responsibility of ministers (that is, government
officials) for the public safety is absolute and requires no
mandate. It is, in fact, the prime object for which governments
come into existence.''
A new biodefense system must be created based on a net
centric command information and control technology, based on
advances in biotechnology, telemedicine and robotics that can
reduce the effect of bioattacks on us with weapons of mass
destruction. A terrorist attack designed to cause catastrophic
levels of casualties by spreading a contagious disease or a
chemical or radiation illness across America needs to be met
with a health care system that increases dramatically that
surge capacity to respond within hours and not days. This will
protect the health of America and provide security to our
people, our economy, and ultimately to our freedom-based way of
life.
Fortunately, most of the bioterrorist agents are treatable
with antibiotics, with the exception of smallpox, a deadly
disease without treatment with a latency of incubation period
of 12 days. Again, fortunately, the victim of smallpox is
usually rendered sedentary by the severity of the illness by
the 14th to 16th day after exposure. Smallpox, as you know, has
been eliminated from the globe since 1977. And few people have
been vaccinated since that time.
The doses of vaccine on hand are minuscule compared to the
number needed to immunize the public. We have no experience at
all that says our vaccine is efficient against modern smallpox,
which may have mutated or have been bioengineered. There is,
indeed, frightening evidence published this year suggesting it
is possible to make people more susceptible to a pox virus,
while at the same time, turning off the victim's own natural
immune protection.
After a dirty nuclear bomb or radioactive material in
conventional explosives goes off in some major city, or we have
a smallpox epidemic, the country will settle down in disarray
to establish a widespread protection plan. And if we will do it
then, why not now. I don't know if CDC's plans announced in the
Washington Post 2 days ago are inclusive of this knowledge.
The creation of this new system should be done as a large-
scale project. It will be expensive, but not nearly as
expensive as doing nothing. It would take advantage of the
strengths of America and can be accomplished rapidly if we
start now to build it. If we commit to this plan, this
administration can assure the American public that we can
protect them from any biothreat. We cannot not stop all
threats, but we can help to reduce the harm to both our people
and our economy.
Without such a plan in place, I don't think we can reduce
the present panic which many of our people feel. We need to
uphold the trust in our health care system and the ability of
our government to provide security to the American people. To
win the war, we need both a successful offensive strategy that
will work in time, and a defensive strategy that will protect
America while we wait for this win in the war against
terrorism.
Mr. Chairman, I would be pleased to, as you and your
members of the committee choose, to elaborate further.
Mr. Shays. Thank you very much, Dr. Koop.
[The prepared statement of Dr. Koop follows:]
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Mr. Shays. Dr. Shine.
Dr. Shine. It's a privilege to meet with you. I'm Ken
Shine. I'm president of the Institute of Medicine. For the last
3 years, I've also served on the Commission of--congressionally
mandated Commission on Weapons of Mass Destruction, chaired by
Governor Gilmore of Virginia.
I should preface my comments based on the discussion with
Dr. Satcher that 2 years ago, we recommended the creation in
the Executive Office of the President of an entity which
provided overview of threats of weapons of mass destruction
including bioterrorism. That office as a consequence of
September 11th has been created with Governor Ridge in charge.
One of the recommendations we made was that there ought to
be an associate director of that office for health. And that's
not happened. We believe that it's extremely important that
there be such an individual because that's the site at which
the interface between HHS, the criminal justice system, the
Department of Agriculture, a lot of other places would come
together and that's the place where relationships between the
medical professions, the public health community also could
come together in an overall approach to bioterrorism.
As the chairman pointed out, terrorism is about creating
fear, rumors, anxiety, misinformation and chaos. I would argue,
sir, that credible information is critically important as
medicine for that terrorism. We did not do well in the anthrax
outbreak. There were multiple talking heads on television,
including a number of pseudo experts, one identified himself as
an expert on the anthrax virus, anthrax is not a virus, it's a
bacteria. We had situations in which the Web was covered with
all kinds of information about anthrax which was incorrect. We
had all kinds of promoters promoting all kinds of variety of
materials that you should purchase or promoting antibiotics and
so forth.
We were so concerned about this that the Presidents of the
National Academy of Science Engineering and myself issued a
statement early in October identifying what we thought were
reliable Web sites, those at the National Library of Medicine,
the CDC and, at that time, Johns Hopkins. But we believe that
we did not do a good job with regard to communication with the
American people.
There are four issues that I would like to just briefly
touch upon. First, within the government, within the Department
of Health and Human Services there needs to be a single
credible medical public health expert who is the spokesperson
for the Department. That doesn't mean that other people can't
speak on the subject, but it means that that individual should
be responsible for communicating with the public about these
issues, that individual is credible because he or she has
professional knowledge, has current information, and in
coordination with law enforcement, is articulate, knows, like
Dr. Koop has shown over and over again, how to translate
information to the public, and doesn't talk down to the public.
That individual ought to be able to stand next to political
leaders and administrators and be available so that when a
question is asked by the media, that the political leader to
turn to that individual and get an immediate answer. That
individual has to be so credible that when he or she doesn't
know, she can say he or she doesn't know. And in a report we
did in 1996 on understanding risk, our evidence is that if the
person is credible, if the person provides information, saying
I don't know in fact increases the credibility. Does not
diminish it.
Tony Fauci performed that function extremely well when he
was put into use in this area. But that didn't happen until
well into the outbreak. And the fact that there was no
individual doing that was a clear deficit. The Associate
Director of the Office of Homeland Security, if that individual
were a health person, could serve a similar function. But if
that's the case, they ought to coordinate their activities so
the same information is provided that does not confuse the
public.
Second, we need much more attention to the Internet, the
Web sites within government, in this case, the CDC. The CDC
does have a Web site. We identified it as one of the more
reliable ones. But, in fact, there were times when you couldn't
get into it. It was not always easy if you were a health
professional to get the information you needed. And I should
emphasize that we heard at our commission hearings from people
in local public health departments about the number of calls
they got from health professionals about what to do. And they
were not informed during the early stages of the outbreak.
The role of the Internet in this regard needs to be
enhanced. And Mr. Chairman, that would require resources
because it is necessary that all public health departments have
computers, that you can have the use of the Internet as a way
of getting them information. I would emphasize that the people
working in this area work 24 hours a day, 7 days a week during
this outbreak. In fact, that was the testimony to how poorly
staffed they were and how poorly prepared we were. But we need
to invest in the Internet the Web site communications.
Mr. Chairman, I would emphasize we need to learn from the
lesson in anthrax so that if there's a problem with
agriculture, the Department of Agriculture is prepared with a
spokesperson and a Web site. If there's a problem with the
radiologic episode, that the Department of Energy is. We don't
know who the spokesperson would be if there was a chem
outbreak. It seems to me that we need to think about that.
Third, we need to do a better job in both understanding and
doing risk communication with the public. What is the risk,
what is the benefit, how do you measure those. Dr. Satcher has
made reference to some of the problems with antibiotic use. I
would use the smallpox debate as an excellent example. Here we
have an agent where once we have stores of vaccines, we got to
decide how to use them. The public needs to understand, if we
vaccinate the entire population, we will kill several hundred
people by the act of vaccinating. In fact, we're going to
probably kill and make sick a lot more than that because of the
large number of immuno-compromised people that were not around
at the time that smallpox was being protected against.
And I would remind you that choosing not to vaccinate such
individuals may not protect them from the virus of vaccinia if
we did mass vaccination. On the other hand, we know how to use
the vaccine to surround cases of smallpox. That was how it was
eradicated from the globe. So if you have adequate stores, you
can follow the cases, you have several days after exposure in
which you can vaccinate. There is probably some residual
immunity in our population. And so if you look at the risk
benefit, you can come up with some logical ways to develop a
policy that the public can understand. I'm very worried about
the potential in agricultural terrorism of hoof and mouth
disease. But in contrast to the situation in Europe in which
cattle were slaughtered by the tens of thousands, you can
immunize animals against hoof and mouth. Do we have the vaccine
and did the public understand that meat would be safe if, in
fact, you stopped an epidemic using it?
Finally you already heard the concerns about public health.
I would emphasize in 1988, the Institute of Medicine issued a
report called the ``Future of Public Health.'' In that report,
we said that the public health system was in disarray. And
everything has been downhill since. The reality is that we
missed hantavirus for a significant period of time because
reporting systems for hantavirus were inadequate. We know that
West Nile virus got going because we laid down on the mosquito
abatement programs and allowed mosquitos to proliferate, so
when a bird got infected we now had an outbreak.
You've heard about the problems with regard to resources.
We need people, facilities, research and particularly
communications. And may I emphasize that we need that for the
entire system all the time. We had an outbreak of two cases of
meningococcus meningitis in a town in the middle of the country
earlier this year. Thousands of people took antibiotics and
vaccines because of one uninformed statement by a doc on a
television station. It was entirely inappropriate. The point is
that the communications become absolutely critical.
Finally, there are communications about risk which are
based on science and are based on the need for the truth, as
you put it. But remember, there are many irrational kinds of
fear and anxiety. And we need to understand what those are. And
it is entirely possible that we ought to have a mechanism by
which the CDC either through focus groups or through networks
similar to what Nielsen uses or others can test what the public
is, in fact, frightened of and communicate information which
will be addressed to their fears as well as addressed to the
scientific truths. Thank you, Mr. Chairman.
Mr. Shays. Thank you very much Dr. Shine.
[The prepared statement of Dr. Shine follows:]
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Mr. Shays. Dr. Akhter.
Dr. Akhter. Thank you, Mr. Chairman, members of the
committee. I really appreciate the opportunity to be here this
morning. My name is Mohammad Akhter. I am the executive
director of the American Public Health Association. We
represent the public health workers in this country, both
Federal, State, local level of protecting the health of the
American people every single day. So what I'm going to say is
not----
Mr. Shays. You don't represent, say, the directors of the
public health?
Dr. Akhter. Many of them are our members, yes, sir. It's a
professional organization. We are a professional organization,
scientific organization, and as such, many of the members are
professional directors. Like Dr. Satcher is, for example, one
of the members of the American Public Health Association. So we
speak on the basis of science and actual on the ground
experience.
So, Mr. Chairman, despite what my senior colleagues and
some of the other folks in the government may have said before,
I want to say one thing about the previous anthrax attack and
that is, that a lot of people worked very hard, but the fact is
we got lucky. We were very fortunate that there were handful of
cases and that took place in an area where we have very good
resources.
And we were able to deal with it. If the same situation
would have taken place in another part of our Nation, we
wouldn't be so lucky. And so my comments are based upon what
can we do for the future. And there are four areas of risk
communication that I very quickly want to run by you for your
consideration: The first is the communication between the front
line workers in bioterrorist attack. It's not the fire chief
who pulls the alarm. It's not the disaster preparedness
director who pulls the alarm. It is the physician, a paramedic,
a nurse, an EMT on the front line. If those people were not
connected with the health department, there is no
communication. Then we have difficulty.
Handful of health departments right now have that
capability. Where the cases are reported, as long as somebody
sees a suspicion case, the case gets reported to the health
department. So that this system could be activated, we could do
the followup, do the tracking. So the capacity needs to be
built at the local level, the local health department,
particularly those health departments that are 50,000 or less
population. They are the ones who really do not have that
capacity.
My second area of communication, risk communication deals
with the communication between the Federal Government, State
government and local government. Despite the grants that were
given, despite the health alert network that's been in place,
the reality on the ground as we speak, Mr. Chairman, today, is
that 10 percent of the local health departments do not have e-
mail capability. 50 percent of the local health departments do
not have high speed Internet connection. So you can give them
the information. Even if they receive it, they cannot forward
that information to their physicians in their area, to the
hospitals in their area, to the ambulance providers in the
area. So there is a bottleneck there. And we really don't have
the full communication in place that could be very effective in
saving lives and protecting against disease.
The third area, Mr. Chairman, is the area of communication
between the public health community, the Department of Defense,
and the Intelligence Community. I had the great honor of
serving for 30 years of public health positions, including
being the director of health for the State of Missouri.
Not until I became Health Commissioner in Washington, DC,
did I ever have the opportunity to work with the Defense
Department or the Intelligence Community. These communities
have not worked very well together. We don't have the history,
we don't have the tradition of working together. So when they
come together, as is the case is imperative now that we all
work together to deal with this new situation, we don't have
any structure. We don't have any authority, any way to really
do this thing together. And collaboration between different
agencies at the State level, even within the agency, is a very
difficult task. And it will not take place, Mr. Chairman, until
and unless there is a directive from the very highest level of
our government, perhaps from the President, to make sure that
the Defense Department that has a wealth of information on
these areas, Intelligence Community, law enforcement, and
public health community, work together to share information.
And if necessary, give several key health officials the FBI
clearance so they can get the information on a need-to-know
basis they can prepare and protect the health of the American
people.
And finally, Mr. Chairman, I come to the major issue of
communication with the public. When it comes to bioterrorist
attack, we aren't dealing with anthrax or smallpox virus, we
are dealing with people who may have been exposed to anthrax,
who may have been affected by the anthrax and who are afraid of
anthrax. And what these people need is clear, concise, usable
information from an authoritative source. And I'm sorry to say
and I agree with my colleagues here that we were unable to
provide that in the past. And I see no change as we speak
today, Mr. Chairman, to be able to do that. All the things that
I've learned in the communication is that you need to have a
single, centralized person responsible who could provide that
information to the American people.
Dealing with bioterrorism is a public private partnership.
All the doctors, the hospitals, the ambulance providers are
private people. They work with the Health Department very
closely to be able to protect the health of the American
people. One of such entity out there is the American news
media. Frankly, many of our people learned--got the information
from the news media faster than they got through our own
channels of communication in public health. And we should bring
the news media in on the table so that we could have the news
media sit down with the key folks.
So here is what I recommend in my closing. That at each
level of our government, Federal Government, State government,
and the local government, a single source be identified for
communication with the public and that the news media be
brought in in communication, and we need to work out the
protocols and the way how we're going to provide the
information to the people so people get the right and accurate
information so we can get the support and the confidence of the
American people to deal with this new and emerging situation.
Mr. Chairman, I thank you very much for this opportunity.
Be glad to answer any questions you might have.
Mr. Shays. Thank you, Dr. Akhter.
[The prepared statement of Dr. Akhter follows:]
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Mr. Shays. Dr. Waeckerle.
Dr. Waeckerle. Chairman Shays, members of the subcommittee
and fellow panelists, good morning. It's a privilege to be
here.
Mr. Shays. Privilege to have you.
Dr. Waeckerle. I'm Joe Waeckerle. I'm a practicing
emergency physician, board certified and residency trained. I
live in Kansas City, MO. I currently serve as editor-in-chief
of the Annals of Emergency Medicine of the American College of
Emergency Physicians and have chaired the Task Force on Health
Care and Emergency Services Professionals on Preparation for
Nuclear Biologic and Chemical Attacks. I also have worked as a
consultant to the Federal Bureau of Investigation. I have
served on the task force of the Defense Science Board for the
Department of Defense looking at biologic threats to the
American people and the American continent and have worked
closely with the CDC and the Office of Emergency Preparedness.
I'm here today to testify on behalf of the American College
of Emergency Physicians who currently has 23,000 members. We
take of over 100 million patients per year, and hopefully I
will represent them well.
Emergency physicians as earlier stated are in the front
line of biologic preparedness in this country. We are the new
first responders along with our colleagues, the nurses and the
EMT paramedics. And the new scene of terrorism in this country
will be the emergency departments of America where the patients
present for care.
To that end, we must be clinically able to recognize and
initiate a response because early detection will save lives and
mitigate any biologic terrorism in this country. We have
attempted to foster that in our membership and across the
country by the task force educational programs and the
development of curricula for the public and our patients as
well as for our members.
Today we're going to focus on a discussion of the
challenges of crisis communication. This is appropriate since
the September 11th incident has centered on a tragic and
senseless loss of innocent lives. More importantly, however, we
have witnessed what many of us have feared most for a long time
and have discussed with you previously, including my visit here
in September 1999 before you. And that's the use of biologic
agents by terrorists. America has unfortunately learned that
the consequences of a biologic attack are incredibly severe,
even of the small isolated incidents that we have faced
recently, much less a large scale attack. Biologic weapons are
formidable weapons of uniqueness and complexity that a specific
defense strategy is fundamental to our protection.
As many of you know in the room, good communication is
absolutely essential to any national strategy. That's what
we're here for today. In times of crisis, the citizens of
America look to you, other elected leaders and government
officials, for information and direction. At no time in
contemporary history was this more evident than after the
recent tragic events that we've experienced. In the early
stages of this event, it was apparent that crisis communication
strategy was evolving. There was no obvious centralized
leadership, no voice of authority, and inconsistent information
that was soon outdated or required correction on a daily basis.
This resulted in the American public remaining in an
informational vacuum as stated earlier. The public did not have
a steady flow of updated information, so seized any information
from anyone, no matter how unproven, to reassure themselves.
For example, many patients presented to our emergency
departments across the country asking for diagnostic nasal
swabs to determine if they had anthrax. Because they thought
this was the right thing to do. They did not know and were not
told by anybody that nasal swabs were not diagnostic entities
but were, in fact--they did determinations of exposure and use
for epidemiologic investigation. Therefore, they were
erroneously informed. The appropriate treatment of anthrax
caused an unnecessary public controversy as well. Initially,
the public was appropriately told that cipro was the treatment
of choice. Later the public was told that doxycycline was the
preferred treatment.
Many of those who were potentially exposed and therefore
prophylactically treated, including many in this area in the
United States, in the Washington, DC, area, became concerned
that they did not receive the best treatment. This issue, in
fact, became contentious at some point, but it could have been
prevented with proper communication. Appropriate authorities,
all they had to do was explain to the American people that
ciprofloxacin was initially chosen because we didn't know if
the bacteria had been genetically enhanced to be weaponized.
Once tested, determined that it had not and was sensitive to
standard therapy, standard therapy was appropriate and
preferred.
During difficult times, it is also natural for the general
public, who is uneducated in these areas, to respond with
unreasonable solutions. The preoccupation of the media with the
question of gas mask use was likely provoked by the public's
unanswered concerns for personal protection. Although the use
of gas masks was repeatedly dismissed by many experts, the
public look for a credible Federal authority to convince them
that the use of gas masks and other protection devices was
unnecessary.
Finally, there was the dilemma of how to balance the
release of sensitive information to inform and protect our
American public versus when to keep it confidential to maintain
national security or prevent public panic. This decision should
have been carefully analyzed on a case-by-case basis. And
despite the fact that it may have been, mistakes occurred. The
controversy surrounding the release of potential threats to the
Golden Gate Bridge in California was an example. The FBI and
the governmental authorities were in a no-win situation, as was
the Governor of California. If they released it and it did not
occur, they were wrong. If they didn't release it and it did
occur, we suffered a tragic event unnecessarily.
Fortunately, many of these communication deficiencies can
be corrected. Consistency is an absolute must. The American
public expects leaders who are knowledgeable authorities, and
more importantly, who can effectively communicate the knowledge
to the public. A consistent message is usually best conveyed by
a recognizable voice, regularly scheduled press conferences
located at the same site and time to be considered. The media
deadlines also conveys a message of reliable and responsible
leadership. The message delivered should be clear, for all to
understand, concise and to the point without much elaboration
or any speculation and above all, credible and correct.
The public can appreciate, in my opinion, that the
situation may change if they are told it may change so that the
message may vary from moment to moment. The partnership with
the media established prior to any incident will promote the
goals of crisis communication. I have not seen evidence of the
partnership in our national strategy. Disseminating correct and
helpful information will control rumors, limit the use of
pseudo experts, foster cooperation and thereby enhance our
ability to respond. The partnership with the media is
critically important because they are the public's primary
source of information. Go to any emergency department in
America and we had on CNN so we could learn what was going on.
We only have to remember the most trusted man in America during
his tenure was Walter Cronkite, not a Federal, State or local
official, and that's because he demonstrated those areas of
crisis communication that we just discussed.
These communication deficiencies are not limited to just
the public. My colleagues have talked about it, we have
discussed in the past, they include the Federal agencies'
ability to deal among themselves to deal with the State and
local officials, and to deal with the private sector as well as
State and local officials have failed, in my opinion, to deal
effectively with the Federal Government, with, or, and other
State and local officials including, of course, the important
private public health and medical sector.
In conclusion, crisis communication using a partnership
with the media to provide clear concise credible information
consistently delivered by a recognizable authority, is, in my
opinion, an absolute requirement. We must also develop
principles for communication to the public that address the
dilemma between the public's right to know and the Nation's
national security.
Congress must provide the leadership, financial investment
and organizational and logistical support to develop not only a
comprehensive national strategy with solid domestic
preparedness and response plans, but also a comprehensive
communications strategy. Good communication provides knowledge
that results in an informed and cooperative America. Without
information, fear prevails. And as President Roosevelt once
said, the only thing we have to fear is fear itself. Thank you
for the opportunity to be here. I look forward to answering any
questions.
[The prepared statement of Dr. Waeckerle follows:]
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Mr. Shays. I thank you all very much. I'm going to start
with the questions, and just it seems to me, make an
observation, it seems to me that you pretty much all agree. I
mean, your message is pretty consistent, but I'd like you to
tell me where you would disagree with anyone else who have
spoken on the panel, and you point that you might disagree. Or
Dr. Satcher. Any comments that were made today that you would
just take exception to or not as strongly but just disagree?
Start with you, Dr. Koop.
Dr. Koop. In general, we seem to be of one mind. We might
have little different ways of dotting I's and crossing T's, but
I think the thrust has been the same from all of us.
Dr. Shine. Dr. Satcher talked about the notion that one
person can't be everywhere and that you should have multiple--
there may need to be multiple spokespersons, that the media
demand is very high and so forth. While he is quite correct
about the media demand, the fact is that if there is a single
source of information holding a daily press conference and
coordinating his information or her information with other
players, you can still have multiple exposures to the media. I
don't see that the two are in conflict with each other. But I
do believe that the notion that you can have multiple people
talking is not credible.
Mr. Shays. I'm going to come back, because I think I
disagree with you. I would love to follow through.
Dr. Akhter. I also generally agree with what my colleagues
have said, but I do believe in a single credible spokesperson
and that person be the Surgeon General of the United States. We
were very distressed to see the General absent in the war
against terrorism at home. What kind of army you want to see--
the public health community, we consider him to be our leader.
The leader is not visible, then the people just got confused,
looking to every direction, every which way. It was not the
public who were confused but the public health people who were
confused. I think, to clarify that, it ought to be the Surgeon
General of the United States who should stand up and speak and
be the leader.
Mr. Shays. Which will lead me to a question, Dr. Koop, I
will ask you about, because you had the AIDS epidemic to deal
with and you were pretty much the spokesperson, it seemed to
me. I'll come back to you on that one.
Dr. Waeckerle.
Dr. Waeckerle. Probably don't have a lot more intelligent
remarks, but I do think that----
Mr. Shays. You should have----
Dr. Waeckerle [continuing]. I could give you one example of
what I think was a very effective leader who did a very good
job, and that was Mayor Giuliani. In fact, throughout the
crisis in New York, he demonstrated all of the characteristics
and all of the behaviors that we've all discussed before you
today and reassured, informed and calmed New York City.
I would also point out to you that maybe the most effective
press conference I saw during this whole incident is when
Governor Ridge took command and had Surgeon General Satcher and
had Secretary Thompson and the Post Office Director and others
involved. And while he was the main spokesperson he allowed
each of those individuals to give us an update on information
so that there was one credible person leading the news
conference at that time or the President briefing but that we
had a cadre of informed, intelligent, responsible authorities
behind him.
Mr. Shays. That's a good lead-in to tell you, Dr. Shine,
where I get a little uneasy. I would begin to think if there
was only one spokesperson for the government that the
government was trying to hide something, that they weren't
allowing so and so to speak or they won't allow so and so to
speak. I would become very suspect and begin to question
whether I was being told the full story.
Dr. Shine. Congressman Shays, I am not suggesting that
other people don't speak at all. What I'm saying is that when
Secretary Thompson has a press conference, for example, the
individual who is charged as the spokesperson is, just as Dr.
Waeckerle described, a certain person standing next to him, and
who is able to provide that information. Similarly, at a daily
briefing that individual could provide those briefings.
That doesn't mean that a lot of other people will not be
communicating but does mean that some--one of the things that
was striking, if you looked at the media during these episodes,
was that there are all kinds of experts who, when on
television, if you watched them carefully there were two kinds
of experts. Most of them knew the history of anthrax
previously. None of them had ever had any experience with
inhalation anthrax because it hadn't existed to any significant
extent except in Russia. And what would happen is the media
would then say, after they gave this articulate description of
anthrax, but what does it mean, though they just had a case in
a postal worker or whatever, and there were two responses.
The credible people said, well, I don't really know the
details of that. I don't know what the organism is. The other
response was--of the expert was to speculate based on what he
or she----
Mr. Shays. I know that, but you can have experts on TV all
the time, including some of you will be on TV and you'll be
debating somebody else who calls himself an expert. So that
will happen on TV. But I mean truly it will.
Dr. Shine. That's why there needs to be someone who has
knowledge of the actual event who is in the department, who as
a consequence was being briefed by what's going on in the CDC,
was briefed by the FDA, whatever the problem is, who has access
to all that information for purposes of being the spokesperson.
Mr. Shays. Let me get to Dr. Koop.
I'm struck by trying to process what you're saying, that
you want someone to help coordinate, bring people forward. But,
for instance, if I want to hear from the head of CDC, I may
want to hear from the NIH, I may want to hear particularly from
the Surgeon General.
But just refresh me, Dr. Koop. There was and still is an
AIDS epidemic, but I would guess the AIDS epidemic is more
prevalent in places in Asia and Africa but still an epidemic
everywhere, or am I being sensational?
Dr. Koop. It's still an epidemic everywhere. And the
African countries are being very hit very hard, and some of
those are actually facing genocide. Our own problems here are
specifically concentrated on Afro American women. So the
country has its own problems.
Mr. Shays. I just didn't want to not call it an epidemic if
it wasn't to be correct.
Dr. Koop. An epidemic means----
Mr. Shays. I called anthrax a virus at one time before
someone corrected me, like this person.
Dr. Koop. Anthrax affected very few people, but it was more
people that you would ever expect to have it, so that's an
epidemic.
Mr. Shays. I recall you became the spokesperson pretty
early on when we were dealing with HIV/AIDS.
Dr. Koop. No, I wasn't. I was given specific orders that
AIDS did not come under my purview.
Mr. Shays. No kidding.
Dr. Koop. It wasn't until the end of Mr. Reagan's first
term when the first-termers began to go back to their homes the
Public Health Service was filled with innumerable vacuums.
Filled as many of those as I could. That's how I became the
spokesperson. I was really self-appointed.
Mr. Shays. But good thing. Because there began to be some
real knowledge about this disease. But walk me through it. So
did we have the same kind of thing we have now, a lot of
different people speaking or nobody speaking?
Dr. Koop. In those days, nobody wanted to speak; and the
people surrounding President Reagan thought those who had AIDS
deserved it. It was a very tough time.
Dr. Shine. But having that spokesperson did not mean that
Tony Fauci couldn't speak about HIV, that people at CDC
couldn't speak about it. In other words, I don't think having a
spokesperson doesn't mean you don't have--but what it does
mean, as Dave Satcher described, you have a telephone
conference call of key players, you review where you are, you
agree on what, in fact, you know and what you're able to say so
that the message is consistent and not contradictory.
Mr. Shays. Right. It begs another question, though. If the
truth is sometimes contradictory, how----
Dr. Shine. Then you have to acknowledge that. That's what
the truth is about.
Mr. Shays. Mr. Tierney, have as much time as you want.
Mr. Tierney. Thank you. Thank all of you for your
testimony.
I guess, going back to an underlying theme that the
chairman was talking about also, is there any way that we can
get the media to be more responsible, or are we always going to
be subject to the talking heads? I noticed this in legal
matters. Everybody is all of a sudden a legal constitutional
expert. It takes the whole gamut. Now it seems to be medical
issues. Are we going to be subjected to whoever they decide to
throw on the air and people are going to get innuendo and
surmise and speculation and bad information? Or is there some
way through what we do that we heighten the responsibility that
there will be a responsible message and voice out there?
Anybody that wants to respond.
Dr. Koop. I hinted at this in my remarks, and that is that
the thing that made it possible for me to do the job that I did
during AIDS I think was largely because, in the beginning, I
appeared in the press conference atmosphere and there those
days the Surgeon General could get time on any network within 2
hours if he had an emergency. I don't know whether that still
exists or not.
Mr. Tierney. Probably need to put it on a soap opera.
Dr. Koop. But when you have all of the stations really
turning health issues into entertainment on the talk shows,
then you do get controversy because they don't always know how
to pick the right people. And the second thing is they have
very strict time constraints, and many times you can't on the
Today Show or Good Morning America get out the whole message
you have to get out because you only have a 90-second sound
bite.
Dr. Shine. In a free society it's going to be very
difficult to manage that. On the other hand, I lived for 20-odd
years in Los Angeles. Shirley Fannan was the spokesperson for
the Department of Health in Los Angeles County. When a problem
emerged, she was the first person who got interviewed. She gave
information to health providers. She gave information to the
public. She was a recognizable spokesperson. And it out
balanced all of the other experts.
I would argue if you look at what happened with the
American Flight 587, the crash, the woman who was the Chair of
the National Transportation Board--I don't remember her name--
but every day for the next 5 days she was giving very good
information and she trumped--using the chairman's term, she
trumped all the talking heads because she knew what was going
on. She was prepared to say how long it was going to take to
get the information, what they knew and so forth.
And that's I think the way you deal with the media, is make
sure that you've got some way of getting information across
that--where they know where to go and get it. They knew to go
and get Koop.
Dr. Akhter. Two quick things. As the health commissioner in
Washington, I had to order 2 million people to boil the water
for about a week or so when I was health commissioner. And the
first thing you do is to make the highest level possible in
your government available to the news media according to their
needs, their morning news and afternoon news. So that I was
available to be available for them to talk to them and provide
them the information.
Once you provide that information every single day, day in
and day out, then the need for the other side experts goes
down.
The second thing, you need to really sit down with the
media, as I said earlier, in a partnership, sit down and
develop a strategy. In case of a true national emergency, how
are we going to assess the information and provide the
information? And that plan has not been worked out as we speak.
Mr. Tierney. I think we're talking about something that
this current situation didn't have done, the administration
didn't do, was single out somebody and put them in an
authoritative position. Given what the Surgeon General said
about not having any budget, his position almost being
downgraded somewhat, amongst the four of you, who would that
individual be in your estimation? Who should that individual be
that takes the stand on health issues, public health issues in
the Federal Government? Should it be the Surgeon General or
should it be the Secretary or what's your opinion?
Dr. Shine. Well, I've made it clear in my testimony I think
that the Secretary, for example, may be communicating with the
public, but I think a credible medical public health expert has
to be the individual to play that role. Because only under
those circumstances will the public believe that it's getting
effective medical public health information.
My colleagues have made reference to the Surgeon General.
The Surgeon General would be an excellent choice, but I would
argue that for certain kinds of problems it might be the
Assistant Secretary of Health, who is a physician, if that
position is filled. It could be the head of the CDC. It could
be Anthony Fauci, whatever.
Mr. Tierney. Professional as opposed to political.
Dr. Shine. The critical issue is, what are the attributes
of that individual? What does that individual know? Can that
person communicate? Can that person be credible?
As I indicated to Congressman Shays, we've got lots of data
from our studies that individual can say we don't know all the
answers and people will feel better that there is such an
individual. But the problem is, if you don't have someone who
has medical public health credentials, then there is always a
doubt on the part of the public as to whether somebody who is
an administrator or political appointee is the right person.
Dr. Koop. It depends on who the person is and how careful
he wants to be. I can assure you that many of the things that I
said as so-called spokesperson for the government on AIDS went
through Tony Fauci's mind and Jim Mason's mind at CDC before I
ever said them in public. We talked about those and frequently
met with the Vice President on the same issues.
Mr. Tierney. I just want to mention something aside on
that. I first met you some years ago when you spoke at Salem
State College up in Salem, MA, and you spoke on the subject of
tobacco and the propensity of----
Dr. Shine. That is unusual.
Mr. Tierney [continuing]. And the propensity of this
government to support the export of tobacco. Even though we
might be doing a better job in trying to diminish smoking in
this country, we have started to export it and allow the export
of it or whatever, and I just want to thank you for speaking
out on that issue and continuing to do the good work that you
do there.
Let me just conclude by asking one last question. You, Dr.
Koop, said that we had no assurance that today's smallpox
vaccine would be effective against the modern smallpox threat.
Could you expand on that a little bit and tell us what we might
do to counteract that problem?
Dr. Koop. Well, the smallpox vaccine that we have was
prepared against a smallpox virus that now has been frozen in
Atlanta and supposedly Russia, but maybe many other places, for
about 30 years, and there are two things that can happen. One
is the virus can mutate, but the thing that is more likely to
happen is that it can be tampered with biotechnology, so that
maybe the vaccines we have would not be effective against the
virus that we're going to meet.
Mr. Tierney. Is there anything we can do about that?
Dr. Koop. I don't think there's a thing you can do about it
until you know that is the situation, but then you've got to
make new vaccine to cover that thing.
Mr. Tierney. So all of the vaccine that's being ordered up
right now in today's papers indicate that there's enough
vaccine to take care of the entire country, all of that may be
ineffective?
Dr. Koop. I don't know the details of that, but I don't
know how they would get a terrorist version of a smallpox
vaccine to work with.
Mr. Tierney. So are we wasting money?
Dr. Koop. No. I think in the protection against terrorism
of any kind, when it is all over, you're going to say we wasted
a lot of money, but I think you have to waste the money,
because it is the only kind of precaution and prevention that
you can undertake. And when you think about the money, it is a
pretty small amount of----
Mr. Tierney. Well, I guess I was thinking in terms of money
and false sense of security for people, too.
Dr. Koop. Yeah, well, the false sense of security might be
secretly good for the panic that ensues, but I think you'd know
pretty soon whether or not the vaccine worked, because if--as
was explained to you today, you get one case, and you surround
the patient and vaccinate the people that were in touch with
them, and if they come down with it in 12 days, you know you
haven't got an adequate vaccine.
Mr. Shays. Would the gentleman yield?
Mr. Tierney. Sure I'll yield.
Mr. Shays. Because it ties into a point. That was the old
method, you kind of circle your suspects.
Dr. Koop. It worked.
Mr. Shays. It worked, but it worked kind of in a rural--I
don't know if it can work in Chicago.
Dr. Shine. No. It was used in New York City in 1979 when
there was a case of smallpox, and several million people were
vaccinated.
Mr. Shays. How do you do it in an airport, that they
contracted it in the Atlanta airport, and they went to 100
towns?
Dr. Shine. Well, again, you have a--first of all, you don't
become infectious until you've got the virus, that is until
you've got pox, until you have the actual disease. So, I mean,
somebody has to enter the country through Atlanta with a
disease, and it has to be spread in some way.
Mr. Shays. I don't want to take the gentleman's time, but
you--on record, you believe that still the best method is
identify the potential candidate and encircle it----
Dr. Shine. Because this is a key issue for the Gilmore
Commission. We consulted with D.A. Henderson and Bill Fagey,
both of whom were responsible for eradicating smallpox in the
world. We consulted with people in public health and so forth.
So it is not just my own opinion. This is opinion based on
people who have very active experience with smallpox that is a
feasible way to approach it.
The issue is--there are always ifs and ands about it, but
the issue is balancing that against trying to immunize everyone
where you know you're going to produce a certain amount of
encephalitis, and you're going to produce a certain amount of
death. So you're trying to balance what is the risk/benefit.
Mr. Shays. Let me give the time back to----
Dr. Shine. Could I just respond to you, Mr. Chairman? Two
quick points I would make. One is in terms of the investment we
make in the public health enterprise, we need a much better
investment in vaccines and vaccine development that include--
the anthrax vaccine is a lousy vaccine. It takes you 18 months,
6 shots at the present time to immunize somebody. You know, we
can--there are reasons to believe that with a modest
investment, we can genetically engineer P antigen, which is the
effective antigen, and create vaccines, and then if we have the
technology, if somebody comes up with an anthrax bacteria that
has a different genetic makeup, which is what Dr. Koop was
talking about, you've got a rapid ability to respond because
you have the technology to make a new vaccine to a new antigen.
And the same thing is true with smallpox.
But the other point I would emphasize, and this is again
part of the Gilmore deliberations through the years, if you
want--if you're a terrorist and you want to produce terrorist
effects, you don't have to go to the highest technology to do
it. I mean, it was box cutters on September 11th. It was
envelopes with anthrax. With regard to smallpox, if you can get
ahold of any of the existing stores of smallpox someplace, that
is a terrible threat in and of itself. While engineering--
bioengineering is important, and we need to prepare for it, we
need to prepare for the greater probability, which is what if
somebody gets it, it's the currently available pox, and
therefore you want to be able to deal with it.
Mr. Tierney. I actually don't have any more questions, and
that is actually intensive, because the information you all
gave was thorough and helpful, and I want to thank everybody.
Dr. Shine. Could I emphasize again, because my colleagues
have brought up the law enforcement issue, the agriculture
issue and so forth, when the Gilmore Commission assessed our
country's preparedness, it said there had to be a place where
all these came together, and you heard from Dave Satcher that
he doesn't meet with people in Agriculture or the Justice
Department. There has to be a place to bring those together,
and that is why we think the role of health in the Office of
Homeland Security is so critical to bring those various
interfaces together, including communication.
Mr. Tierney. Well, I wish I could be more helpful with you
there. I'll tell you, Chairman Shays has done a great job of
bringing this to everybody's attention. We were having hearings
on the need for a homeland security director and office long
before others would pay any attention to this committee. The
problem is that now that the President has appointed obviously
a guy without a portfolio--and the real shame of this is that
if you really look at what's going on, he has no direction, no
legislative guidance, no portfolio at all, and a great
reluctance that I still sense in this Congress to give that
kind of authority and specificity and budget authority to cut
across all those different agencies and be the one to draw them
together with any authoritative basis. And I think we've got
some work as this Congress to do and move in that direction.
We've got several bills that are filed. We need to encourage
this administration to stop saying that, oh, it can wait until
next year or sometime down the line and move forward, and I
know that Chairman Shays will keep moving on that issue.
Mr. Shays. Do all of you agree that office would make
sense? I mean, would you recommend--I know you do, Dr. Shine,
but would you, Dr. Akhter, Dr. Koop or Dr. Waeckerle?
Mr. Waeckerle. If you remember in September 1999, we
discussed this for a long period of time, and it was the
consensus of all the State and local authorities who Attorney
General Reno convened that was the single foremost problem in
America. There was no central oversight management, and as a
result----
Mr. Shays. As it relates to health care?
Mr. Waeckerle. As it relates to all of the defense, to the
strategy and specifically with public health and medical, as
well as hospitals, because we were never able to have a
coherent, collaborative plan that integrated those three
important areas.
Mr. Shays. Dr. Koop.
Dr. Akhter. Mr. Chairman, it is absolutely necessary that
it be Homeland Security Office. Not for today, tomorrow, but
for years to come this threat is going to be with us. But it
does need its own budget and its own authority, and without its
own budget and its own authority, we just have window dressing.
Mr. Shays. I'm talking more specifically about within that
office, someone direct--we're trying to get the--the way they
broke out the task, because I thought there was someone on--
within the office----
Dr. Shine. But it's second level, Congressman Shays.
There's an associate director for prevention and so forth, and
then a health person reporting to that individual, and that is
never going to get the health issue to the level that I think
it needs to be--deserves.
Mr. Shays. Dr. Koop, would you respond to this?
Dr. Koop. I would agree with that entirely, and I think you
have to--I don't like to run things by committee, but I named
the most likely threats. I think there's got to be somebody
representing agriculture, medicine, chemistry. We need probably
eight people on a panel that--making this their own job.
Mr. Shays. Right. OK.
Dr. Koop. Could I raise one other quick question?
Mr. Shays. Sure.
Dr. Koop. A lot of people have said that the Surgeon
General should be the person that we think about for the
responsibility at hand. I would remind you that David Satcher
will not be with us much longer, and the person who replaces
him will be a very key person in the next administration.
Having been through it myself, I can tell you that you don't
walk into that job 1 day and know how to do it the next, and I
would hope that somebody could influence the appointment of a
person who knows something about what we've been talking about
rather than be a political appointment.
Mr. Shays. OK. That's very important. I think the same
thing applies even to the Homeland Security Office themselves.
I was not eager to see Governor Ridge be a spokesperson early
on, because there's such a steep learning curve, which we all
knew he had to have, anyone in that position, and so I was very
concerned the press wanted to hear from him right away, forcing
him to speak on health care issues, on defense issues and so
on.
Lots we could talk about. We have a vote, and I'm not going
to keep you. Is there anything----
Mr. Tierney. No. Thank you.
Mr. Shays. You--this has been an excellent panel, and
it's--we've learned a lot, a tremendous amount. Is there
anything that any of you want to say in closing before we go?
Dr. Shine. Just to reinforce the notion that when we
recommended an office in the executive branch for home
security--we didn't use that term--we said that individual
should be confirmed by the Senate and should have budgetary
authority, because we just don't see--and I think Mohammad has
emphasized this. Getting the agencies to work together, you've
got to have some kind of leverage, and I don't think you can
give them the budget--the budget can't be that big that it
covers all of the areas. Therefore, it has got to have
authority to work with the OMB and say if you're not
cooperating, if you're not collaborating, if you're not--
there's a stick; there's some penalty if you don't do that.
Mr. Shays. I think Mr. Tierney and I disagree a bit on
this, and so I'd be happy to have him respond, but my view
right now is the President has combined the Gilmore and the
Hart-Rudman Commissions. In one sense, he has given it a
Cabinet level, but he hasn't made it a department. You don't
have a homeland security. But he's given Ridge the opportunity
to write his job eventually, and he's already said, you know,
he's going to probably suggest there be a homeland area.
And in terms of the budget, I just have to say, if anybody
crosses Ridge, they're crossing the President of the United
States. And so I know eventually the budget is going to matter,
but right now, I mean, if you cross Ridge, it's going to get to
the President right away. Their offices are next door, and
you're mincemeat.
Dr. Shine. That is absolutely true right now. The question
is--Mohammad said it well--this is a long-term problem, and
what is going to happen a year from now, 2 years from now.
Mr. Shays. And I think he's going to get his way, which is
also what I'd like to see happen. I think it's going to happen.
Any other comment?
Mr. Waeckerle. Yeah. I'd like to thank you for the
opportunity to be here, and I'd like to close with the
following remarks for you to consider. Biologic terrorism, in
my opinion, has the potential to be the doom of mankind. Now
and into the future, especially as we get into bioengineering
genetically designer--designed bugs, because the State-
sponsored--the State-supported, the States and the local nuts
and zealots of the world, because of the technology today and
the information available today, will be able to carry out
terrorism against us. And I think that it requires an
appropriate strategy and response, as you all know and we've
discussed today.
And there's one major fault that I believe we need to focus
on, and that is the critical human infrastructure and the
response to biologic terrorism in this country will occur in
the local community, and it's the triumvirate of health care
professionals, public health and hospitals, and to date,
despite numerous committee hearings and much writing and
rhetoric, the local community and those key players have not
been integrated or coordinated with any national programs, and
they have no input. And I hope that when we talk about
communication with the public and crisis communication, we
remember that many of us believe that the communication between
the Federal family and the local and State partners that we
have in this war has been neglectful, and it needs to be
greatly improved.
Mr. Shays. I thank you for that. There's a minicrisis, a
tiny crisis that we're going to have a vote in 4--5 minutes.
So, I mean, it's in the process. We have 5 minutes left. Thank
you all very much. Wonderful job. This hearing is closed.
[Whereupon, at 12:29 p.m., the subcommittee was adjourned.]
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