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our judgment, to what the Department of Defense has been implying or has been developing. But we have asked the cities to plan what a comprehensive response would be a health response to one of these incidents.

We have been, as a second priority, providing pharmaceuticals. In fact, in some cases, in the case of New York City, all of their money was spent on pharmaceuticals, even though we have required that all the contract requirements be fulfilled, and if they have a plan for a response to one of these incidents in New York City.

Finally, should any funds be left over, we have provided that some of those funds can be used for equipment. But whatever equipment requests have been submitted by the cities, we have transmitted those to an interdepartmental group, made up of the Department of Defense, the FBI, FEMA, Department of Veterans' Affairs, and others within the Federal establishment, to review that equipment list to assure that it was not duplicative of what was being provided by other programs, and then to move ahead as rapidly as possible with the purchase of that equipment.

To date, we have received equipment lists from 13 of the cities; we have acted on 6 of them, and we're still in the process of reviewing the other 7; and, we expect the remaining cities to come in with their equipment lists after the fact. In other words, what we are trying to do is fill in the gaps that may exist after other programs have already been in effect.

Mr. Chairman, I could go on with some additional comments. I've submitted them for the record, in terms of response to some of the issues that GAO has raised in their report. However, I'll leave that for the record and your questions. Thank you, Mr. Chairman. [The prepared statement of Mr. Knouss follows:]

Mr. Chairman and Members of the Committee,

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

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

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

OEP coordinates the health and medical emergency preparedness activities within DHHS, and is the lead DHHS organization to coordinate disaster and emergency activities with other federal agencies, including the FBI and DOD. DHHS is the primary agency that provides the health and medical response under the Federal Emergency Management Agency (FEMA) Federal

Response Plan. We also manage the National Disaster Medical System (NDMS). NDMS is a partnership between DHHS, the Departments of Defense and Veterans Affairs, FEMA,

7,000 private citizens across the country who volunteer their time and expertise as members of

response teams to provide medical and support care to disaster victims, and more than

2,000 participating non-federal hospitals.

Disaster Response Teams

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

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

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

To make maximum use of our resources, we also allow state governments to activate our

teams as state resources, if necessary.

Special National Medical Response Teams for Weapons of Mass Destruction

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

Metropolitan Medical Response Systems

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

rooms, medical personnel injured while responding, and potential contamination of emergency rooms or entire hospitals.

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Consequently, in FY 1995, DHHS began developing the first prototype Metropolitan

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

Systems Approach to Preparedness

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

Our focus has been on the development of Metropolitan Medical Response Systems, which are components of local, city systems that would be called in to provide triage, medical treatment and patient decontamination. The city systems that we have been developing would then be able to transport "clean patients" to hospitals or other medical facilities for continued

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