As part of the Public Health System, the Department of Health and Human Services (HHS) has developed specialized national medical response teams (located in Washington, D.C., Winston-Salem, Denver and Los Angeles) that can augment local resources in the event of a WMD threat or event. Instances where these teams have been used include: (1) in response to the bombing in Centennial Olympic Park; (2) pre-positioned to respond if needed during the Summit of the Eight last year in Denver; (3) during the Inauguration in 1997; and (4) in the Capitol during the State of the Union Address this year. It was also one of these teams, the one in Winston-Salem that responded under State auspices, to the event that occurred earlier this year in Charlotte, North Carolina. 

     Some of the key agencies with which Health and Human Services (HHS) has been working closely with to address counter-terrorism issues include the Centers for Disease Control and Prevention, the Agency for Toxic Substances and Disease Registry; the Food and Drug Administration, and the National Institutes of Health. External to HHS, other federal departments and agencies include the National Academy of Science's Institute of Medicine, and local and state governments, as well as with nationally recognized individual experts. 

     HHS has also supported 27 major metropolitan areas for the development of local Metropolitan Medical Strike Team Systems. These enhancements to existing local response systems are designed to provide initial on-site response and provide for safe patient transportation to hospital emergency rooms for treatment in the event of a WMD terrorist attack. These MMST Systems are characterized by specially trained responders for on-site triage and initial medical treatment; specialized pharmaceuticals and decontamination equipment; enhanced emergency medical transportation; definitive hospital care; and the provision of assistance from the National Disaster Medical System, if needed. Plans call for continued development of local MMST Systems in conjunction with the Domestic Preparedness Program's 120-city initiative. Further system development is necessary to assure adequate surveillance, laboratory support and pharmaceutical distribution systems in the event of a biological weapon release. 

     The program of enhanced preparedness that the President called for in his Naval Academy commencement speech on May 22nd, and his recent signing of Presidential Decision Directive 62, will strengthen the nation's defenses against the growing threat of unconventional attacks against the people of the United States. This directive designates HHS as the lead Federal agency in support of FEMA, to plan and prepare a national response to medical emergencies arising from the terrorist use of weapons of mass destruction. HHS will be supported by other Federal agencies in this effort. The plan is  to provide enhanced local response through the strengthening of local systems and the provision of Federal supporting teams, if necessary -- for the prevention, detection, identification and public health response to the release of a weapon of mass destruction. 

     Of significant concern is how best to protect our civilian population from biological weapons. In response to the President's directive, HHS is exploring a range of approaches for upgrading public health systems for detection and warning and for providing medical care for massive numbers of affected people. Broad spectrums of needs are being examined that include research and development, pharmaceutical stockpiles, public health surveillance, and response capabilities. 

     Secretary Thompson recently requested that the Assistant Secretary for Planning and Evaluation convene a working group to develop a HHS strategic plan for strengthening and expanding HHS’s role in the Government-wide bioterrorism effort. Implementation of the plan and oversight of the resulting activities will be the responsibility of the Assistant Secretary for Health and Surgeon General. 

     Presidential Decision Directive 62, "Protection Against Unconventional Threats to the Homeland and Americans Overseas," recognizes the Federal Emergency Management Agency as the lead for coordinating consequence management and designates HHS as the lead federal agency to plan and prepare for a national response to medical emergencies arising from the use of weapons of mass destruction by terrorists. Within HHS, this responsibility is coordinated by the Office of Emergency Preparedness within the Office of Public Health and Science. 

     The strategy is to develop complimentary medical response systems capabilities at local and national levels. A "bottoms up" approach has been taken and has been working in partnership with local governments in 27 geographic areas to enhance their existing local systems. 

     Although previous emphasis has been primarily focused on the initial medical management of a chemical incident, equal priority is being given to Bioterrorism medical response planning and preparedness. The Metropolitan Medical Response System (MMRS) program will be expanded to work with a total of 47 major metropolitan areas. 

     At the national level, federal partners will enhance the National Disaster Medical System (NDMS) to be prepared to respond to WMD incidents to assist the affected local jurisdictions as might be necessary. NDMS is a partnership between HHS, the Department of Defense (DOD), the Department of Veterans Affairs (VA), the Federal Emergency Management Agency (FEMA), and the private sector. Additionally, OEP has the responsibility for managing the Public Health Service’s Commissioned Corps Readiness Force. 

     It is the view of HHS that the initial burden resulting from a major biological attack would primary be the responsibility of local government, with support from state and federal agencies. In such a scenario, key public health and medical response actions that would be taking place once people were aware that such an attack had occurred would include the following. 

     The Centers for Disease Control and Prevention would assist local and state government with making the determination of what has occurred, identifying what agent has been utilized, and identifying the population at risk 

     Office of Emergency Preparedness (OEP) would assist the local government with providing mass patient care including the establishment of auxiliary, temporary treatment facilities; providing mass immunization or prophylactic drug treatment for those known to have been exposed, those who may have been exposed, and those not already exposed but at risk of exposure from secondary transmission and/or the environment; and providing respectful and safe disposition of the deceased. 

     Probably one of the more daunting challenges of such a scenario is the possibility that HHS would have to vaccinate or prophylaxis hundreds of thousands of persons within a 24 to 48 hour time frame.

     Both CDC and OEP would be coordinating with local government, state environmental and health officials, and the Environmental Protection Agency in assessing the extent of contamination of the environment and identifying risk management steps to assure safe re-entry of the potentially contaminated areas.

     The question arises as to is the US prepared for such a scenario. Today, the medical bio-response capabilities are limited, but $160 million is appropriated for Bioterrorism in FY 99 to change that, and the President’s FY 2000 budget seeks a 44 percent increase in funding to further improve the capacity to protect citizens. Most cities do not have biological medical response plans in place yet. The public health infrastructure is beginning to be enhanced under the lead of CDC. Funding for the first national pharmaceutical stockpile has been appropriated, and CDC is working to make the stockpile. Local Metropolitan Medical Response System biological preparedness development has been underway for three (3) years, and is making good progress under the lead of OEP.

     Efforts to bolster state and local capabilities to respond to chemical or biological attack are being coordinated with other federal assistance programs, such as those established under the Defense Department’s Nunn-Lugar-Domenici program, through the Office of the National Coordinator for Security, Infrastructure Protection and Counter-Terrorism within the National Security Council. HHS is also working with the National Domestic Preparedness Office, which has recently been established within the FBI. 
OEP is working with the physician, nursing and hospital community to assure that appropriate professional education and standards of care are developed for the treatment of those who might be exposed to chemical or biological agents. 

     Research and development needed to improve civilian medical response to chemical and biological terrorism incidents has been expanded in FY 99, and the current budget contains additional resources for development of vaccines for smallpox and anthrax and for the review of candidate drugs and vaccines by the FDA. An R&D work plan has just been identified by the Institute of Medicine under a contract with OEP.

Presented below is information from the HHS website concerning the structure of the Department.

HHS: What We Do:

THE DEPARTMENT OF HEALTH AND HUMAN SERVICES is the United States government's principal agency for protecting the health of all Americans and providing essential human services, especially for those who are least able to help themselves. 

THE DEPARTMENT INCLUDES MORE THAN 300 PROGRAMS, covering a wide spectrum of activities. Some highlights include: 
· Medical and social science research 
· Preventing outbreak of infectious disease, including immunization services 
· Assuring food and drug safety 
· Medicare (health insurance for elderly and disabled Americans) and Medicaid (health insurance for low-income people) 
· Financial assistance and services for low-income families 
· Improving maternal and infant health 
· Head Start (pre-school education and services) 
· Preventing child abuse and domestic violence 
· Substance abuse treatment and prevention 
· Services for older Americans, including home-delivered meals 
· Comprehensive health services for Native Americans 

HHS IS THE LARGEST GRANT-MAKING AGENCY in the federal government, providing some 60,000 grants per year. HHS' Medicare program is the nation's largest health insurer, handling more than 900 million claims per year. 

HHS WORKS CLOSELY WITH STATE, LOCAL AND TRIBAL GOVERNMENTS, and many HHS-funded services are provided at the local level by state, county or tribal agencies, or through private sector grantees. The Department's programs are administered by 11 HHS operating divisions, including eight agencies in the U.S. Pubic Health Service and three human services agencies. In addition to the services they deliver, the HHS programs provide for equitable treatment of beneficiaries nationwide, and they enable the collection of national health and other data. 

HHS Budget, FY 2001 -- $429 billion

HHS employees -- 63,100 

Leadership is provided by the Office of the Secretary, and administrative support is provided by the Program Support Center, a self-supporting operating division of HHS. 

The Department's Headquarters is in the Hubert H. Humphrey Building, 200 Independence Avenue SW, Washington, D.C., 20201. HHS has a long history. 

HHS Operating Divisions
Public Health Service Operating Divisions

National Institutes of Health -- NIH is the world's premier medical research organization, supporting some 35,000 research projects nationwide in diseases like cancer, Alzheimer's, diabetes, arthritis, heart ailments and AIDS. Includes 18 separate health institutes, the National Center for Complementary and Alternative Medicine and the National Library of Medicine. Established: 1887, as the Hygienic Laboratory, Staten Island, N.Y. Headquarters: Bethesda, Md. 
Employees -- 17,046
Director -- Ruth L. Kirschstein, M.D. (Acting)
FY'01 Budget -- $20.5 billion 

Food and Drug Administration -- FDA assures the safety of foods and cosmetics, and the safety and efficacy of pharmaceuticals, biological products and medical devices -- products that represent 25 cents out of every dollar in U.S. consumer spending. Established: 1906. Headquarters: Rockville, Md. 
Employees -- 9,333
Commissioner -- Bernard Schwetz (Acting)
FY'01 Budget -- $1.3 billion 

Centers for Disease Control and Prevention -- Working with states and other partners, CDC provides a system of health surveillance to monitor and prevent disease outbreaks (including bioterrorism), implement disease prevention strategies, and maintain national health statistics. Provides for immunization services, workplace safety, and environmental disease prevention. Guards against international disease transmission, with personnel stationed in more than 25 foreign countries. Established: 1946, as the Communicable Disease Center. Headquarters: Atlanta, Ga. 
Employees -- 7,511
Director -- Jeffrey P. Koplan, M.D., M.P.H.
FY'01 budget -- $4.2 billion 

(The CDC director is also administrator of the Agency for Toxic Substances and Disease Registry, which helps prevent exposure to hazardous substances from waste sites on the U.S. Environmental Protection Agency's National Priorities List, and develops toxicological profiles of chemicals found at these sites.) 

Indian Health Service -- Indian Health Service: The IHS has 37 hospitals, 60 health centers, 3 school health centers, and 46 health stations. It also assists 34 urban Indian health centers. In addition, through transfers of IHS services, programs, and facilities, tribes administer an additional 13 hospitals, 160 health centers, 3 school health centers, 76 health stations, and 160 Alaska village clinics. Services are provided to nearly 1.5 million American Indians and Alaska Natives of 557 Federally recognized tribes through a workforce of approximately 14,5000 federal employees and additional tribal and urban Indian health employees. Annually there are about 69,000 hospital admissions and 7 million outpatient visits, 4 million community health representative client contacts, and 2.4 million dental services. Established: 1924 (mission transferred from the Interior Department in 1955.) Headquarters: Rockville, MD. 
Employees: 14,826
Director: Michael H. Trujillo, M.D., M.P.H., M.S.
FY'01 Budget: $3.2 billion 

Health Resources and Services Administration -- HRSA provides access to essential health services for people who are poor, uninsured, or who live in rural and urban neighborhoods where health care is scarce. HRSA-funded health centers provide comprehensive primary and preventive medical care to more than 9 million patients each year at more than 3000 sites nationwide. Working in partnership with many state and community organizations, HRSA also supports programs that ensure healthy mothers and children, increase the number and diversity of health care professionals in underserved communities, and provide supportive services for people fighting HIV/AIDS through the Ryan White Care Act. Established: 1982, bringing together several already-existing programs. Headquarters: Rockville, MD. 
Employees -- 2,240
Administrator -- Elizabeth Duke (Acting)
FY'01 Budget -- $6.2 billion 

Substance Abuse and Mental Health Services Administration -- SAMHSA works to improve the quality and availability of substance abuse prevention, addiction treatment and mental health services. Provides funding to the States to support and maintain substance abuse and mental health services through federal block grants. Targeted Capacity Expansion grants provide Mayors, town and county officials, resources to address emerging drug abuse trends and mental health service needs and related public health problems, including HIV/AIDS, at the earliest possible stages. Funds hundreds of programs nationwide to increase the use and improve prevention and treatment methods shown by research to be effective through "Knowledge Development and Application" grants. Established: 1992. (predecessor agency, the Alcohol, Drug Abuse and Mental Health Administration, was established in 1974.) Headquarters: Rockville, Md. 
Employees -- 624
Administrator --Charles G. Curie, M.A., ACSW
FY'01 Budget -- $3 billion 

Agency for Healthcare Research and Quality -- AHRQ is the lead agency charged with supporting research designed to improve the quality of health care, reduce its cost, improve patient safety, address medical errors, and broaden access to essential services. AHRQ sponsors and conducts research that provides evidence-based information on health care outcomes; quality; and cost, use, and access. The information helps health care decision makers, patients and clinicians, health system leaders, and policymakers -- make more informed decisions and improve the quality of health care services. Established: 1989. Headquarters: Rockville, Md. 
Employees -- 294
Director -- John M. Eisenberg, M.D.
FY'01 Budget -- $270 million 
Human Services Operating Divisions

Centers for Medicare & Medicaid Services (formerly the Health Care Financing Administration) -- CMS administers the Medicare and Medicaid programs, which provide health care to about one in every four Americans. Medicare provides health insurance for more than 39 million elderly and disabled Americans. Medicaid, a joint federal-state program, provides health coverage for more than 34 million low-income persons, including nearly 18 million children and nursing home coverage for low-income elderly. CMS also administers the new Children's Health Insurance Program through approved state plans that cover more than 2.2 million children. Established: 1977. Headquarters: Baltimore, Md. 
Employees -- 4,435
Administrator -- Tom Scully
FY'01 Budget -- $339.4 billion 

Administration for Children and Families -- ACF is responsible for some 60 programs that promote the economic and social well-being of families, children, individuals and communities. Administers the state-federal welfare program, Temporary Assistance to Needy Families, providing assistance to an estimated 7.3 million persons, including 6.3 million children in September 1998. Administers national child support enforcement system, collecting some $15.5 billion in FY 1999 in payments from non-custodial parents. Administers the Head Start program, serving more than 877,000 pre-school children. Provides funds to assist low-income families in paying for childcare, and supports state programs to provide for foster care and adoption assistance. Funds programs to prevent child abuse and domestic violence. Established: 1991, bringing together several already-existing programs. Headquarters: Washington, D.C. 
Employees -- 1,532
Assistant Secretary for Children and Families -- Wade F. Horn, Ph.D.
FY'01 Budget -- $43.4 billion 

Administration on Aging -- The Administration on Aging (AoA) is the federal focal point and advocate agency for older persons and their concerns. The AoA administers key Federal programs mandated under various titles of the Older Americans Act. These programs help vulnerable older persons remain in their own homes by providing supportive services, including nutrition programs like home delivered (meals on wheels) meals. Other programs offer opportunities for older Americans to enhance their health and to be active contributors to their families, communities, and the Nation. The AoA works closely with its nationwide network of regional offices and State and Area Agencies on Aging to plan, coordinate, and develop community-level systems of services that meet the unique needs of individual older persons and their caregivers. The AoA collaborates with Federal agencies, national organizations, and representatives of business to ensure that, whenever possible, their programs and resources are targeted to older persons and coordinated with those of the network on aging. 
Employees -- 121
Assistant Secretary for Aging -- Josefina G. Carbonell
FY'01 Budget -- $1.1 billion 

The U.S. Public Health Service Commissioned Corps is a uniformed service of more than 6,000 health professionals who serve in many HHS and other federal agencies. The Surgeon General is head of the Commissioned Corps. David Satcher, M.D., is Surgeon General of the U.S. Public Health Service. In addition, the Program Support Center, a service-for-fee organization, utilizes a pioneering business enterprise approach to provide government support services throughout HHS as well as other Departments and Federal agencies. Administrative operations, financial management and human resources are solution- and customer-oriented, state-of-the-art and highly responsive to customer needs. Departmental leadership is provided by the Office of the Secretary, including five staff divisions.