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Testimony of
Maureen E. Dempsey, M.D., F.A.A.P.
DIRECTOR
MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES
Jefferson City, Missouri
Before the
Subcommittee on International Security, Proliferation and Federal
Services
Committee on Governmental Affairs
United States Senate
October 17, 2001
Testimony presented by
Maureen E. Dempsey, M.D., F.A.A. P.
Director
Missouri Department of Health and Senior Services
“…and he that will not apply new remedies must expect new
evils; for time is the greatest innovator….”
The Essay of Sir Francis Bacon, 1601
Good morning, Mr. Chairman and members of the Subcommittee:
I am Maureen Dempsey, M.D., director of the Missouri State
Department of Health and Senior Services.
I would like to thank my Missouri Senator Jean Carnahan for
initiating discussions regarding my testimony before you today. It
is an honor to be here and I greatly appreciate the opportunity to
address the issue of terrorism preparedness.
Dr. Rex Archer, Director of the Kansas City Health Department in
Missouri appeared before the Senate Subcommittee on Labor, Health
and Human Services, Education and Related Agencies Committee on
Appropriations on October 3 and did an exemplary job explaining
the importance of the local public health system in the nation’s
bioterrorism preparedness. Today,
I would like to focus on the state public health system and the
role of state government in the nation’s preparedness and
response to bioterrorism.
First, I will briefly describe the foundation to address
bioterrorism preparedness that has been built by the Missouri
State Department of Health and Senior Services and to highlight
our ongoing planning efforts.
Second, I believe it is essential to discuss the important
relationship between the local, state and federal public health
agencies in our nation’s preparedness for bioterrorism and
emergency response.
Finally, I would like to bring focus on several critical needs and
present them for the consideration of your Subcommittee and others
partners at the federal level as we increase our national, state
and local ability to protect the citizens in our communities.
Missouri Department of
Health and Senior Services Actions for Bioterrorism Preparedness:
The practice of public health is defined by the alchemy
between the underpinnings of science, the mantle of unique
governmental roles and responsibilities and the art of community
engagement. The core functions of public health define the work that we
do on a daily basis and constitute our main areas of experience
and expertise. Chief
among our roles and responsibilities are risk assessment, trend
analysis, prevention, education and rapid response to threats
against the health and safety of our citizens.
The principles, protocols and practices for response are
remarkably similar for both man-made and naturally occurring
deadly threats: influenza
pandemic with worldwide implications, the innocent transportation
of disease by an ailing traveler or the covert release of an agent
against an unprotected and unsuspecting population.
All are known possibilities - perhaps even probabilities
– with unpredictable and unknown timelines.
The ultimate goals must be prevention and early
intervention. These
goals can only be achieved through the use of our only strategic
weapons: systematic advance preparation, rapid detection and early intervention,
all of which require knowledge, education, training and the
establishment of effective collaborative relationships with
clearly defined roles and responsibilities.
The question before us is the status of our collective preparation
for a terrorist event. It
is clear that while states have the knowledge and expertise to
intervene appropriately and rapidly, few states are prepared for
the scope or magnitude of a bioterrorism event.
The prevention of such an event is the province of
the law enforcement and intelligence communities, but the early
detection and the rapid, coordinated response are the province
of the states. Both
are key to mitigating the effects of the event by reducing
morbidity and mortality, preventing secondary transmission and
controlling public panic.
The tragic events of September 11 and the subsequent incidents of
release of mysterious white powders are a confirmation that
unpredictable and deadly threats - once the ingredients of
nightmares - are now the basis of our reality.
In Missouri we have been preparing for a number of years.
That preparation continues now, with a dramatic increase in
focused effort. As
you all know, Missouri is the Show-Me State.
In terms of public health preparedness for a bioterrorism
or emergency event, however, I am proud to report that Missouri is
not waiting to be shown how to become better prepared.
We have taken a proactive and aggressive approach to
preparation.
In May of 2000, we created a special Unit for Emergency Response
and Terrorism to respond to the potential threat of weapons of
mass destruction as well as chemical and biological agents in
Missouri. It is
staffed by a medical epidemiologist and an emergency coordinator
and supported by the expertise of the entire department, including
highly trained epidemiologists and communicable disease prevention
specialists. This Unit, located in the Director's Office and under
my direct oversight, advises the Department on the development,
planning, training and implementation of an emergency/ terrorism
management plan and coordinates with the state emergency
management system regularly.
The Unit provides oversight and guidance to twelve work groups in
the areas of mass care, surveillance, public information,
operations, training, outbreak investigations,
radiological/chemical response, etc. These workgroups were designed to address weaknesses in
the state public health plans and infrastructure identified by
observation of the TOPOFF exercise in Denver, Colorado in 2000 and
our on state exercises for influenza pandemic preparedness.
The work groups are comprised of representatives from the
state health department, local public health agencies, as well as
state and federal agencies. The final product of these work groups
will be a broad emergency/terrorism response plan with updated
specific standard operating procedures for the Department.
This will prepare us to respond to the immediate emergency
needs of the area and to contain and minimize the impact on other
citizens and communities within our state.
The State already has in
existence an emergency response plan, but the Department will
include updates to assure a more coordinated and comprehensive
plan. This includes
the integration of Department specific new bioterrorism
initiatives into the overall state plan.
In addition, efforts are already underway to delineate
roles and responsibilities for other local, state and federal
agencies, as well as to increase the degree of focus and
collaboration to assure adequate medical and mental health care.
Missouri, like other states, has always had a disease surveillance
system. It has primarily been a passive system with physicians,
hospitals and laboratories reporting diseases to their local
health departments, which forward them to the state health
department. As a
result of the terrorist attacks on September 11, I have directed
the Missouri Department of Health and Senior Services to implement
a vigorous, active syndromic disease surveillance system.
Rather than waiting for reports to the state health
department, state employees are scheduled three times each week to
initiate calls to hospitals, physicians, federally qualified
health centers and a host of other sites to tabulate the
occurrence of syndromes designed to reflect the early onset of the
known bioterrorism agents on CDC's threat list.
The improved
surveillance program will serve a two-fold purpose:
early detection of agents for terrorism, as well as a
dramatic increase in reporting for any disease outbreak of natural
origin.
In addition to my role as the director of the Missouri Department
of Health and Senior Services, I am a practicing pediatrician. Many of the diseases present on the threat list are
clinically irrelevant to most physicians, because they do not
occur naturally or with sufficient frequency and volume to be
readily recognized. From
my weekly experience in a clinic serving low-income Missouri
children, I know that physicians see many patients with a
multitude of nonspecific symptoms – stomach upsets, fever,
muscle-aches, and rashes. In
the best of worlds, these symptoms would remain nonspecific and
for the most part be self-limiting or easily diagnosed and
treated. In the new
world, they could be the harbinger of something far more deadly.
It is imperative that we dramatically increase awareness of
these threats and their signs and symptoms, followed by
comprehensive ongoing training and education.
Through increased awareness, astute evaluations and timely
notification, we can assure early intervention, containment and
prevention of secondary transmission.
There is a new sense of urgency with regard to early
identification and notification – and it must come from the
front line of medical providers and facilities.
It then becomes the responsibility of the state pubic
health agency epidemiologists and research staff to recognize
abnormal patterns of symptoms and diseases that could indicate a
terrorism event in our state.
This will certainly increase both the volume and the complexity of
the work that public health performs.
Further, it will require additional, detailed reports from
those individuals and institutions on the front line of medical
care in Missouri communities.
Undoubtedly, it will be labor intensive on all fronts.
However, the benefits gained through the extra effort will
assure the interval between the identification of an event and an
appropriate response is markedly shortened.
We must make time work for us, not against us.
These benefits extend to the citizens throughout the state
by reducing exposure and potential harm.
In terms of Missouri’s early planning for possible bioterrorism
events, we also signed the first-ever Memorandum of Understanding
between a state health department and the Federal Bureau of
Investigation. That MOU was signed in 1999 with the FBI and details our
agreement to join forces in the investigation of crimes where the
use of chemical or biological agents that could affect the public
health and safety of Missouri citizens is suspected. Missouri’s
State Public Health Laboratory currently conducts testing for the
FBI in suspect bioterrorism events and is part of the national
bioterrorism response network. I can report that the Lab has
tested over two-dozen cases of suspected anthrax since signing the
MOU. Fortunately,
they have been hoaxes but have afforded us the opportunity to see
that our working relationship with the FBI is sound and provides a
valuable underpinning for the state’s bioterrorism preparedness.
Local, State and Federal
Public Health Agency Relationship in Our Nation’s Preparedness
for Bioterrorism and Emergency Response:
The second issue I would like to discuss with the Subcommittee is
the important relationship between local, state and federal public
health agencies in our nation’s preparedness for bioterrorism
and emergency response. First,
let me say that I believe this system is not only important for
bioterrorism and emergency events, but it is integral in the
everyday health of our communities and citizens throughout the
United States.
In 1988 – thirteen years ago—The Institute of Medicine
published “The Future of Public Health”.
It was a study undertaken “to address a growing
perception among the Institute of Medicine membership and others
concerned with the health of the public that this nation has lost
sight of its public health goals and has allowed the system of
public health activities to fall into disarray.” This national
report concluded “Public health is distinguished from health
care by its focus on communitywide concerns-- the public
interest--rather than the health interest of particular
individuals or groups.” The
report pointed out that at the local, state and federal levels,
public health focus had shifted dangerously to health care –
primary, urgent, and emergency health care to individual citizens
– rather than the fundamental public health focus of protecting
the community. There
is an incipient danger in the trend to medicalize public health
that has occurred in the last several decades.
Instead of a comprehensive approach to prevention,
education and appropriate disease control measures, we have
focused on the delivery of palliative cocktails and disease
support measures. The
implications of their impending failure are enormous in terms of
the cost in human life and to the meaning of public health in the
future.
It is interesting to note that between 1900 and 2000, the life
expectancy of United States citizens increased by approximately 30
years. The value of
public health is indisputably clear when we acknowledge the
advances not only in life expectancy, but also in the quality of
those years gained. The
practice of public health with its focus on disease prevention and
health promotion and its ability to establish both causation and
the benefits of early intervention, has provided 25 of those years
of additional longevity - years that cannot be purchased at any
price - through advances in medicine or technology.
Improved health care (i.e. successful treatment of disease
that have already occurred) accounts for 5 years of the increased
life expectancy for our citizens.
There exists an interesting paradox between these relative
contributions and where we as a nation and as a state allocate our
resources. Most
funding is directed toward health care services, treatment of
existing disease, and research into better treatments.
Much, much less is invested in the public health systems
and interventions that have proved far more effective in the last
century.
We recognized the weaknesses in our Missouri public health system
in the early 90’s and have been working at both the state and
local level to increase the public health infrastructure.
We continually ask: “What is the core business of state
and local public health agencies – what is it that we must do as
governmental agencies that will be left undone if we do not
fulfill our public health responsibilities?”
The core functions of public health translate into every daily
activity, permeate all levels of the system and provide guidance
for all that we set out to achieve.
Those functions must be performed as a matter of routine,
with the knowledge that we must be prepared to perform them in an
extraordinary manner given a bioterrorism or emergency event.
Missouri has invested state general revenue funds directly
in our local public health partners to assure an adequate
infrastructure for concerted response. Despite these efforts, Missouri will only be as safe as our
neighbors both here and abroad.
According to Laurie Garrett, author of Betrayal of Trust: “The
idea that the health of every nation depends upon the health of
all others is not an empty piety, but an epidemiological fact.”
The Missouri Department of Health and Senior Services has been
diligently working to train and educate key staff and partners on
emergency response. We
have dramatically improved our state health department
preparedness. We have
consistently built strong relationships with our federal partners.
More must be done.
Federal-level Issues to Increase our National, State and Local
Ability to Protect the Citizens in Our Communities:
And that brings me to the third and last point of discussion:
We request that this Subcommittee and all of our federal
partners provide support to states in the form of both resources
and leadership on public health’s preparation for bioterrorism.
The public health infrastructure must be prepared to prevent
illness and injury that would result from biological, chemical or
radiological terrorism. Early detection and control depends on a
strong and flexible public health system at the local, state and
federal levels. Building on the existing infrastructure is
critical. We have a long road ahead of us to achieve the
capacities – workforce, equipment, supplies, training,
information systems - we require in order to detect and respond to
an act of terrorism quickly and to prevent the spread of disease.
Current resources are wholly inadequate to address the needs
associated with this issue. Time
is the greatest innovator and in this respect, it is also our
greatest enemy.
Our federal partners must be assured adequate manpower with
appropriate levels of expertise, coupled with the ability to
mobilize rapidly. They
represent a critical support to the states, serving as a source of
knowledge, information, epidemiologic and technical assistance, as
well as providing guidance and leadership on field investigations.
Even now, the proposed budget include hundreds of billions
for research and direct care, yet only a few scant millions for
the primary public health response arm related to bioterroism and
communicable disease control.
Even without the threat of bioterrorism, adequate resources
are needed to assure that we can respond to naturally occurring
infections or threats. Once
an event has occurred, it is far to late to prepare, hire staff,
train them and deploy them – and far to costly in terms of human
suffering and threat to life – to delay.
Funding for research should be directed at the development of
rapid techniques for identification of a variety of pathogens to
assure early detection, new biomedical tools to assure rapid
diagnosis and new therapeutics such as drugs and vaccine to assure
prevention and early treatment.
The public health system must work rapidly to educate and enhance
awareness of chemical and biological terrorism among emergency
medical service personnel, police officers, firefighters,
physicians, nurses, hospitals and other community groups. We must
develop and implement joint training exercises to assure adequate
and timely coordination of multi-agency, local, state and federal
partner responses during actual events. Demands are high and the
needs are great, yet state resources are inadequate to address the
multitude of needs. It
is essential that all partners have clearly defined roles and
responsibilities, recognize those of their partners, develop plans
jointly and actively train together far in advance of an actual
emergency. If the federal system were to become overwhelmed with
requests or rapid transportation is interrupted as it was on
September 11, such knowledge and training will allow states to
assure that critical response roles are considered in all
contingency plans and assumed by the state, if necessary.
Only by doing this, will these agencies foster trust and
collaboration between each other and within their communities?
States must have adequate equipment and personnel to respond to an
actual emergency. We must have a front-line response team prepared
to respond, whether the emergency is a result of a terrorist or
natural disaster. There must be multiple teams ready to respond on
a 24 hour a day basis, 7 days a week. These teams must have
expertise in outbreak investigation, epidemiology, emergency
response, risk communication, information technology, and
laboratory protocols and procedures. Emergency equipment must be
available at a moment’s notice, at multiple geographic
locations.
Resources for response to mass casualties must be made available
to hospitals on a regional basis.
The state of the health care industry and its current
reimbursement system assure that their inventory is ordered on a
“just in time” basis. Equipment and supplies are lean with respect to daily
needs and will never support a large influx of ill or injured
citizens. Interruptions
in transportation will prevent the delivery of emergency supplies
to areas of need, contributing to much poorer outcomes.
The current state of mental health capacity and funding must be
rapidly addressed to assure both the immediate and long-term
treatment of the behavioral and psychosocial sequelae of
catastrophic or terrorist events.
Public health needs the support of federal agencies to enhance
existing disease surveillance systems, build sufficient
epidemiologic expertise and enhance capacity to monitor these
systems. It is essential that we explore new technology and
communications systems that improve efficiency, effectiveness and
timeliness of data collection and analysis. State and local public
health agencies must have active disease surveillance systems or
ongoing computerized collection of data with pre-set thresholds,
coupled with human oversight capable of detecting unusual patterns
of disease or injury, including those caused by unusual or unknown
threat agents. It is important that epidemiologists at state and
local health agencies have the necessary experience, expertise and
resources for data collection and analysis to recognize and
respond to reports of clusters of rare, unusual or unexplained
illnesses. They must have effective, cutting-edge communication
systems to ensure delivery of accurate and timely information
between local, state and federal agencies.
State public health laboratories across the nation play a crucial
role in protecting the health of the population. These facilities
must be state-of-the-art and keep up with new technology and
testing protocols. They must establish and maintain statewide
laboratory networks with private medical laboratories and assure
that that laboratory personnel in the private sector are trained
to detect possible bioterrorist agents. State laboratories must
have the capacity and technology to communicate with the FBI and
CDC in matters involving transport and laboratory testing of
samples. Missouri is fortunate to have a state legislature that
understands the importance of a strong public health laboratory.
Money has been appropriated to construct a new state-of-the-art
facility to effectively detect and identify biological threats to
the citizens of Missouri. Unfortunately, we lack state resources
to update our testing equipment, recruit highly trained personnel
and assure adequate resources to provide testing 24 hours a day/7
days a week.
I believe one of the most important things we, as state and
national leaders, can do is provide quality public educational
campaigns. Rapid intervention will require communication and
credibility. Should a
situation arise that requires quarantine or evacuation, the public
will need to hear and to heed those messages and comply
immediately. This
will require implicit trust and mandates that we must establish
effective relationships with the both the media and the public
now. We must inform
and reassure the public before, during and after a biological
attack. We must be proactive in providing information to the
public not only about the inadequacies of gas masks or the risks
of stockpiling antibiotics, but credible information on ways they
can assume responsibility for their protection and that of their
families. Currently,
there is a dizzying array of “experts” competing for airtime,
often with conflicting and inaccurate information, which leaves
the public dazed and confused.
Not only must we have leaders at the highest level providing
messages which allay public concern, these messages must be
coordinated at all levels of the system – federal, state and
local. We need to be
united in our voice and consistent in our message.
Information must be up-to-date, accurate and specific.
Our credibility depends upon it – and it is critical to
remember that the public’s safety, security and perhaps their
life may depend on their trust in us and the timeliness and
accuracy of our messages.
We have no special forces, no reserve forces and no public health
guard troops to rely upon. I
cannot emphasize more strongly that absent prevention, we have
only a limited number of weapons in our armamentarium:
advance preparation, rapid detection and early intervention.
States must have credible and timely information from the FBI, the
CDC&P and other federal partners in order to plan, prepare and
mobilize. For
example, when investigations become criminal the information flow
halts, thus preventing state and local public health agencies from
intervening appropriately. While we may not need to know all of the details, certain
information is critical in protecting the public’s health.
We can participate in delivering consistent messages to the
public that do not conflict with those of our federal partners and
do not so clearly make us seem to be out of the loop – creating
discomfort at the professional and the public level.
Knowledge of outbreaks or unusual events in other areas of
the country and the world allows states to develop contingency
plans for specific agents or scenarios, enhancing the quality and
scope of our preparation and response.
It has not escaped our attention that unless public health
does an exemplary job at early detection and intervention, first
responders, medical personnel and public health outbreak workers
will rush headlong into disaster – or flee in panic.
The final request I would make of you is to consider the
development of a rational, national vaccine manufacture and
distribution system. We
must have the support of the federal government and elected
officials to assure the availability of critical vaccines in order
to adequately protect our public health workforce, our medical
community, and our most vulnerable populations against
vaccine-preventable diseases.
It is a national tragedy that we are unable to protect our
populations in peacetime with preventatives such as vaccines.
Last fall, the United State did not have an adequate supply
of vaccine, distributed in a timely manner to meet the needs of
the influenza season. There
are hints of shortages and delays this year as well, further
compounded by steep price increases.
We cannot assure that those most in need receive the
vaccine or receive it in a timely fashion.
An already vulnerable population is at greater risk of
disease and death.
We are entering our second year of tetanus vaccine shortage –
with most of our current stockpile having been sent to New York
– and we are no longer routinely vaccinating adolescents.
We have just spent four weeks of confusion regarding
availability of childhood vaccines such as DTaP, which prevent
potentially deadly diseases such as diphtheria, tetanus and
pertussis. The media
reported the initial notice of potential vaccine shortage.
In the subsequent weeks, we have had great difficulty
obtaining guidance and direction.
It remains unclear as to the vaccine’s availability and
recommendations for its use have not been clarified.
We must educate our private health care providers to assure
adequate protection, but have no clear direction to proceed.
We need credible, timely information.
Many of our relationships with health care providers have been
damaged by lack of coordination, leadership, guidance, consistency
and support. Providers
will need to implicitly trust our messages regarding vaccine
protocols, as well as signs, symptoms, treatment and reporting for
bioterrorism. Many of
these providers feel that public health has not done enough in the
arena of vaccine supply and distribution, health communication and
education – and are therefore, disinclined to participate
actively.
I believe that now is the time for the federal government to
examine our system of vaccine production and distribution.
I do not know the answer, but I know the question for all
of us must be “Is a supply and demand, profit-driven market
place system the right system in the United States for producing
and distributing vaccines that are essential to the health and
protection of our citizens?”
We need a rational, national vaccine policy.
I would call on Congress to begin the discussion and help
us answer this question to ensure that not only are emergency
vaccines available to fight bioterrorism, but that our day-to-day
vaccines are available and distributed to keep our citizens
healthy and protected.
Thank you for this opportunity to meet with you today.
Thank you for your leadership on this important issue.
I am confident that the federal, state and local public health
systems and the citizens and communities in this great county will
be better prepared as a result of your work and the work of other
public servants. As
we often say in Missouri, we have a known problem and the best
people are working on it. In
Missouri and throughout the country, that includes thousands of
dedicated public health personnel.
Thank you.
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