Mr. Chairman and Members of the Subcommittee, I am Joseph A. Barbera, a residency trained, board certified emergency physician.  I am Co-Director of the Institute for Crisis, Disaster, and Risk Management at the George Washington University, where I teach masters and doctoral emergency management courses, and I provide emergency medicine services through the George Washington University Hospital.  One of my professional volunteer activities is chair of the Emergency Preparedness Committee of the District of Columbia Hospital Association (DCHA), a position I have held since the committee’s inception in 1995.  In this role, I have presided over the development and implementation of a comprehensive Hospital Mutual Aid System that provides effective coordination and communication between the District’s hospitals in emergency preparedness and response.  The four federal hospitals in the National Capital Region, Walter Reed, National Naval, Malcom Grow, and the Veterans Administration Medical Center are all very active and vital participants in this process.

During my medical career, I have also had the privilege of experiencing disaster response to major incidents.  I have participated in the FEMA and Office of Foreign Disaster Assistance Urban Search & Rescue programs for over a decade, including earthquake responses to Northridge California, Taiwan in 1999 and the Philippines in 1990.  I have responded to major terrorism incidents, providing medical expertise to the search and rescue effort after the Oklahoma City bombing and, after September 11, to both the Pentagon and the World Trade Center incidents.

I have additionally experienced the specter of biological terrorism.  I was the emergency physician on duty at George Washington University Hospital the day of the B’nai B’rith bioterrorism hoax in 1997.  I was a medical controller for the TOPOFF bioterrorism exercise in Denver in 2000.  Most recently, I was heavily involved in the recent anthrax dissemination incident here in the National Capitol Region.  In my role for DC Hospital Association, I established a daily conference call that became the basis for information exchange between hospitals, acute care providers, and the multiple public health authorities in the National Capitol Region.  We are currently developing a professional review of that incident response to capture the views of the hospital-based medical community.

I have been asked to speak to you today about the subject of hospital preparedness for mass casualty response.  I would like to note that I provide this testimony from the medical perspective of a hospital-based emergency physician with extensive experience in emergency public health and emergency response.  I have no remunerative relationship representing hospitals, or hospital associations, in this regard.

I would like to begin by congratulating and thanking you for focusing on this vitally important subject.  
As we face the specter of mass casualties from chemical, biological, incendiary or explosive attacks, the press and the public are continuously asking why the medical care community is not adequately prepared for these possibilities.  Many vague reasons have been put forth, but the cold hard reality is that adequate preparedness is impossible without basic changes in public policy attitudes towards funding medical preparedness.

First, one must understand that the non-governmental medical system must be viewed as a “first responder” in mass casualty care.

Next, one must understand what mass casualty care entails.  The medical infrastructure needed to care for one or ten injured or ill individuals is completely different from that required to care for hundreds or thousands of patients.  The infrastructure for mass casualty care also has very little to do with everyday hospital practice.  This is not a minor technicality to be recognized and understood only by medical planners.  This is a fundamental financial reality that must be addressed by the highest level of political leadership at all levels of government.  It is also critically important to understand the following key concepts:
· When you need firemen for fire suppression, you call 911 and the municipal fire department responds with the needed assets.  All non-governmental assets are bit players.  We stopped expecting private fire insurance companies to fund municipal fire services somewhere around two hundred years ago.
· When you need law enforcement to control a situation, you call 911.  Police respond and become the primary force that provides law enforcement.  Private security is only a bit player if involved at all.
· When you need acute medical care for hundreds or thousands of casualties, you call 911, but the response capabilities are completely different.  Municipal services have little significant acute medical care capacity beyond triage and transport of patients.  Definitive medical care in Washington DC, and most areas of the United States, is a function of primarily private sector assets.  As such, all hospitals should be viewed as critical emergency response assets within a community, and accorded security considerations similar to that provided to governmental emergency response entities.

The next reality is that private medicine has been shaped by medical economic forces beyond the control of the medical and hospital community.  Hospitals now survive by adopting “modern business practices” such as just-in-time inventory, bare minimum staffing patterns, closure of empty hospital beds.  All these make smart business sense, but they have severely impacted health care surge capacity for both mass care and for specialty care of unusual victims such as critical care patients, ventilator patients, burn patients, patients requiring isolation, and so on.  In an era of barely survivable medical economics, the government and the public have expected private medicine to pay on its own to cover the exorbitant costs of the community’s mass casualty preparedness.  It hasn’t happened, which is why we are here today.

Mass casualty medical care must be recognized as a public safety function, and therefore as a governmental responsibility equal in importance to fire suppression, emergency medical services, public works, and law enforcement.  Until public policy changes to address this financial reality, we have little chance of adequate preparedness for mass casualties.  Hospitals, in their current financial circumstances, can at best make a good-faith effort at reasonable preparedness, and indeed they are doing so.  The difference between adequate and reasonable is wide, and I believe it is unacceptable to the American public.  

How can we address this gap?  

Begin with a fundamental change in governmental attitudes towards hospitals, and I commend you for taking this important step.  Government must actively solicit the hospitals’ planning input through hospital group efforts such as the DC Hospital Association’s Emergency Preparedness Committee.  Government agencies must understand that they have an obligation to support hospitals in planning for mass casualties – Hospital’s are in fact in the driver’s seat of providing medical care.  Government, including government public health entities, must allow hospitals to have significant input in developing the most effective ways for them to organize and to be assisted by governmental assets in preparing for and responding to mass casualty events. 

A major fact of emergency management is that the planning process is far more important than any actual plan.  The process must promote the development of effective planning and response relationships between key players, and this is even more important in areas such as healthcare, where many of the key resources are non-governmental.  It again is a governmental obligation to assure that this objective is accomplished, and I believe this should be a goal of your legislative efforts.

Finally, government at all levels must accept that mass and specialty casualty care is a public safety function and must have adequate funding provided to hospitals who are willing to accept the responsibility for this community need.  Hospitals do not need, nor should they accept, “seed money” that begins expensive emergency preparedness programs that result in additional unfunded federal mandates.  Hospitals need to become funded partners in community emergency preparedness, fully integrated into emergency response.  Hospital mutual aid systems, effective collaboration between public health and the hospital community, mass decontamination capabilities, critical care surge capacity, improved information systems for communicating between hospitals and with key health officials are only a few of the requirements that would provide immense public benefit.  Publicly owned and military hospitals, including our federal hospital partners here in the Washington DC area, must receive the same financial attention. 

Many hospitals, I believe, would be very willing to agree to a contractual relationship with the local community that adequately funds development, training, and maintenance of defined surge capacity and other specialized resources.  Medical realities, such as the twenty- percent annual turnover in emergency department staff found in many hospitals, must be addressed in the training aspect of system maintenance.
Many models exist for this type of public-private emergency response partnership, and have been described more fully in an article I co-authored for the Kennedy School of Government at Harvard University, titled “Ambulances to Nowhere: America’s Critical Shortfall in Medical Preparedness for Catastrophic Terrorism.”  

In closing, I would like to emphatically state that this is not a time for political maneuvering, and it is not a time for shaping public perceptions of medical response competence through any route other than actually becoming competent in a planning process that could mean life or death for future terrorism victims in the United States.  The coming together and voluntary commitment to community well-being that I witnessed by hospitals in the National Capital Region since September 11 have been both encouraging and inspiring.  We have a very strong medical foundation upon which to expand our mass casualty preparedness.  I urge you to thoughtfully develop a program that promotes creation of operational medical response systems that are effective, sustainable, and multi-use.  

Mr. Chairman, that concludes my prepared remarks.  I apologize that they are not more detailed, but I was invited to furnish this testimony only two days ago, and my schedule did not provide the amount of time I would have liked to further shape my comments.  I would be pleased to answer any questions you or members of the Subcommittee may have at this time.