Transcripts For CSPAN Hurricanes And Public Health Preparedness Hearing 20171029

Recently visited puerto rico to assess the impact these hurricanes have had and continue to have on americans. This committee has been conducting oversight of the federal response to the recent hurricanes since shortly after harvey made landfall in texas. Unfortunately, i expect that our work here will continue for years to come. The committees jurisdiction involves not just Public Health issues but rebuilding the electrical grid, addressing environmental cleanup and restoring telecommunications to name only a few. The people of puerto rico and the u. S. Virgin islands continue to face a long road to recovery and many are living without power and Running Water. I believe we are going to be joined today by representative Jennifer Gonzalez from puerto rico, someone who knows all too well about the difficult challenges her home is facing. Thank you for being here at this important hearing. From coordinating overall response to insuring that individuals have the medical treatment they need to protecting the blood and pharmaceutical supply, to granting medical waivers hhs has been working tirelessly to provide medical care and services to individuals affected by the storms. The overwhelming majority of Health Care Facilities in the impacted areas went above and beyond to protect and cheat those in harms way yet media reports indicate that some Health Care Providers failed in their duty to protect their patients. There was a tragic situation at a nursing home in florida where 14 residents died after the facility lost its air conditioning and this despite a hospital across the street that never lost power or cooling. The response in puerto rico and the u. S. Virgin islands has involved numerous federal agencies working together with each other and state and local officials. For example, before Hurricane Maria made landfall in puerto rico and every day since hhs, the department of defense,the department of Veterans Affairs and federal Emergency Management agency have been coordinating with local Emergency Response officials to provide medical care and help reestablish the health care infrastructure. Hhs has worked with puerto ricos department of health to prioritize resources needed for dialysis facilities and have coordinate would fema to help ensure critical supplies are delivered where they are needed. Similar efforts are ongoing in the u. S. Virgin islands, as well. Many questions remain. Has the interagency response beeneffective from the hhs . Are we utilizing our resources in the most efficient and effective ways to help our fellow americans in puerto rico and u. S. Virgin islands in particular . It is critical that we understand the Public Health challenges ahead. Mold formation is likely in nearly all the effected regions. As we have seen after Hurricane Harvey there is increased risk of spread ofinfectious disease. Over one million americans are still without clean, safe Drinking Water. Rebuilding puerto rico and u. S. Virgin islands will take years. The Health Care Systems are in direcondition and most of the operational facilities need some degree of assistance. To make matters worse the electrical grid has been devastated which has significantly hampered recoveryefforts. We dont know the full extent of the damage let alone when we will have electricity and Running Water restored. We are trying to make sure we do Everything Possible to addressthe short and long term needs. Especially in the face of thePublic Health risk that resulted and will continue to resultfrom these storms. I would like to thank the witnesses for testifying today and i look forward to hearing your testimony. I yield five minutes for Opening Statement to the Ranking Memberfrom colorado. This 2017 Hurricane Season has been one of the most damagingon record. Hurricane harvey broke the record for the greatestamount of rain recorded from a single Tropical Storm or hurricane in the United States. Hurricane irma became strongestatlantic hurricane on record. Hurricane marias impact on puerto rico and the u. S. Virgin islands has been nothing lessthan catastrophic. Mr. Chairman, as you said, the scope of potential health risks caused by this ongoing crisis is still coming into focus. The infrastructure on puerto rico and theVirgin Islands remains decimated. Nearly 80 of puerto rico still doesnt have power. Hhs reported that a substantial number of puerto ricos hospitals are either nonoperational or require diesel to run generators. Over a third of puerto ricoenresidents lack access to Potable Water. Contaminated water isspreading contagious diseases. While i certainly appreciate the effort by volunteers including physicians and nurses volunteering their time with the teams i am concerned that poormanagement of the hurricane response at a federal level may be hindering response efforts. The federal government i believe probably does not have a complete picture of what Health Care Challenges exist because frankly most of the island of puerto rico lacks adequate communication. I think that this committee needs to hold further hearings to address the status of all these Vital Services that you talked about. I think as time goes on we should have field hearings on puerto rico in particular but also the vergeant islands as much of the recovery effort as you accurately describe involves jurisdiction of this committee. I cant stress enough how important it is for us to send our staff down there to investigate this and how important it is for members to go and investigate this. I was part of a group of members that went after Hurricane Katrina to new orleans to observe the Recovery Efforts. What we found through years of oversight on this subcommittee was that washingtons understanding regarding the situation on theground was very different than we were able to observe firsthand when we went into the basement of Charity Hospital and we saw what happened to those records. When we had field hearings and we saw what had happened to small businesspeople down there in new orleans. You just cannot substitutefor that. As we begin to think about our public responses, members of congress, we need to see what we are doing on the ground. Mr. Chairman, last week deserves trump says it , i find that statement to be i will now yield my time to representative castor. This simply was a ca catastrophic Hurricane Season. I want to thank our witnesses here today and all my colleagues holding this hearing. The first of many because this is going to be a very long recovery. Lost in texas and 75 lives lost in florida, including those that were completely avoidable. We know that we have 50 deaths and puerto rico so far with the threat of bacterial infections growing. Im very concerned about puerto rico and the whole interplay between the folks that live there and the u. S. Virgin islands and a migration and what that means for the health needs of everyone. On the island, the Drinking Water issued a similar critical. Is simply critical. I look forward to your testimony. Now recognizes the chairman of the full committee, mr. Waldman. Thank you. Now recognize the chairman of the full committee. I thank the vice chairman for the support. I want to express my deepest sympathy for those impacted by the horrible storms particularly fellow citizens in puerto rico and the u. S. Virgin islands. This committee stands ready to assist in whatever way we can. We will continue to be diligent in the oversight in the work that the agencies are doing and the needs of the people. I am pleased that dr. Burgess has already been to puerto rico, visited some of the hospitals and looked at the health care issues. We know we have much more work to do and we hope tohear from all of you today about what is out there ahead, we need to uncover and get better solutions. Today we are examining continuing efforts to protect the Public Health in texas, florida, puerto rico and u. S. Virgin islands in the aftermath of hurricanes harvey, irma and maria. This is the first of series of meetings and in the coming weeks we will hold hearings before the energy and environment associated with Natural Disasters are varied, and include heightened instances of infectious diseases, longterm Mental Health trauma, to name a few concerns. These risks can be particularly dangerous for vulnerable populations such as infants, dialysis patients, individuals who are immunosuppressed, and the elderly. We saw this in the aftermath of Hurricane Irma, where 14 elderly residents, as weve heard before, lost their lives as a result of heat induced health when the commissioners failed. This committee sent a bipartisan letter to the Nursing Homes owner, requesting information on their Emergency Preparedness plan, inspection history, and steps it took to protect residents. That whiler today the three major hurricanes to impact the United States in 2017 were distinct events but present their own unique challenges, many of the protocols necessary to conduct an effective Public Health response are mutable. For example, federal agencies must be able to communicate effectively with each other and local state and territorial officials to identify areas of need, ensuring individuals have adequate access to basic necessities such as food, water, headal supplies, and as we into our recovery phase, it is asortant we monitor patients they transition from hospitals or under medical supervision back to their homes for longterm living arrangements. Than 60 of Puerto Ricans are now homeless as a result of hurricanes. Patientso make sure are discharged from hospitals and have safe places to go and dont and up on the streets and back in the hospital. Following Hurricane Maria, various media reports have called into question why the federal government whether it is adequately meeting its obligation to protect the health and welfare of residents of puerto rico and the Virgin Islands. Our witnesses who have been on the ground in the area, making sure that americans in need get the assistance that they are aquired, it should not be partisan matter. Certain agencies are not pulling their weight. We need to know if there are federal laws or policies that are impeding their efforts. In addition, we want to hear about best practices that can be gleaned from the Recovery Efforts to be utilized in the future. Thanks to you and your teams for being on the ground trying to do the best you can in these horrible circumstances. We need to know the facts, what is working and what isnt, whether there have been shortfalls, what are the Lessons Learned and whether you need additional help. With that, i yield back the balance of my time and look forward to the testimony of our witnesses. Before that, i would like to welcome our newest member, mr. Duncan, who was just approved by the house conference this. Orning, replacing dr. Murphy we are delighted to have you on the committee. I yield back. I recognize the Ranking Member of the full committee. Thisank you for Holding Hearing on this critical issue. I hope it is the first of many hurricane related hearings. This Congress Needs to hear ther from hhs and other and all of the affected areas. I would like to take a moment to recognize the federal, state, and local responders working hard to address the Public Health issues that exist as recovery continues in all areas impacted by these hurricanes. Of the tragicnd devastation caused by a immense Natural Disasters. In 2012, my district was hit by hurricane sandy. Ive never seen worse storm damage in our area in my lifetime. For many, it was a worstcase scenario. ,ost lives, home flooded businesses lost. We still have a lot of people not back in their homes or businesses. Is experiencing historic levels of destruction and loss in puerto rico and the Virgin Islands, and in florida, texas, and along the gulf coast. While no to Natural Disasters are alike, the areas affected by these hurricanes have unique needs. Work to ensure that puerto rico and the u. S. Virgin islands received the full and immediate support of the federal government. I recognize a number of ongoing challenges facing the residents of south florida and the gulf coast. Need tothe hearing will address the situation in puerto rico and the u. S. Virgin islands. That hundredste of thousands of americans continue to struggle to meet daytoday needs, and there are still reports that residents dont have access to food and sources ofd reliable clean water. Accounts from those areas paint the dire situation that contradict the often rosy stories that come from the president and white house. Hurricanes irma and maria caused widespread destruction in puerto rico and u. S. Virgin islands, including Critical Damage to electrical grids, teleCommunication Systems, transportation infrastructure. Virtually all residents have been impacted, and these infrastructure failures create acute Public Health issues. Dehydration,ath, and desperation as residents of puerto rico and the u. S. Virgin islands continue in a postapocalyptic landscape even after Hurricane Maria and two months after irma. Andlist of serious needs challenges as long. Hospitals still do not have reliable power, communities lack safe Drinking Water. People are drinking from questionable water sources. Residents are still unsure if the water is safe, and in a recent briefing to the committee, cruise going into communities to test Water Quality work finding that people still lacked adequate food and drink and water. Our that will help us understand what needs to be improved so congress can more in the months and years to come. I wanted to Say Something about the fact that many Puerto Ricans are coming from the island to our states, particularly new jersey and my district. Mayors and elected officials locally are saying is there any kind of help for us echo a lot of these people come here, they dont have money, need support. Like to yield the remainder of my time to mr. Green. Thank you, mr. Chairman. I think my colleague for yielding to me. My district in houston and harris county, texas was heavily impacted by Hurricane Harvey. We had at least eight yes in our district alone. First responders, Public Health professionals, Community Members for helping houstonians and texans in this time of need. I thank my colleagues for supporting our two supplementals so far. There will be much more for a number of other disasters. Of texas needate to Work Together to make sure we are taking advantage of every opportunity, especially when it comes to medicaid. I hope to get necessary to help uninsured uninsured disaster victims. Responding to Public Health concerns related to harvey, including mold and the spread of disease carrying mosquitoes. We must be fully responsive to of Environmental Impact harvey, including possible exposure to toxic chemicals and wastewater. I look forward to hearing from our witnesses and working with Public Health agencies to address these concerns. In our office in houston, we do a lot of casework, typically on social security, medicare, veterans. Because because it goes through the process, and we are working through it with our federal agencies helping us to make sure we can get people back to where they are before the storm. I thank my colleague again for yielding. I yield back my time. Thank you, gentlemen. I ask that the Opening Statements be made part of the opening record without objection, they will be added to the record. I ask unanimous consent that energy and commerce members be participate be permitted to participate. Further, so everyone knows what we are doing, mr. Duncan has joined the committee and subcommittee, and we are glad to have him on our subcommittee. Until a formal motion is made on the floor at approximately 12 30, the parliamentarians tell us we have to treat him as a member, but not yet on the subcommittee of oversight and investigations. He will be treated like all other members in that circumstance, which means he will go last. As the newest member, he would go last anyway. [laughter] we are just rubbing it in. I want to let everybody else know what the status was so when they hear a motion later today, they will understand that that is what the parliamentarians have told us we need to do. Mr. Chairman. I assume he knows his other coffeeibilities, to get we will make sure he is aware of those duties. We welcome nonenergy and Commerce Committee members who are with us who may show up later. Members not on the committee are able to attend our hearings and we are glad to have them, but are not permitted to ask questions. I would like now to introduce our panel of witnesses. Honorable robert kadlec, assistant secretary of preparedness and response of the department of health and human services. Welcome. Next is the honorable scott gottlieb, commissioner of the u. S. Fda. Then we have miss kimberly , the deputy administrator for the centers for medicaid and Medicaid Services medicare and Medicaid Services. Rear admiral stephen redd, director of the office of Public Health preparedness. Thank you all for being here and providing testimony. Responses to the recent hurricanes. As a part of what we do in this committee, we are holding an investigative hearing. It has been the practice of the subcommittee to take testimony under oath. Do any of you have objection to testifying under oath . None. The chair advises you that under the rules of the house and committee, you are entitled to be accompanied by counsel. Do any of you desire to be accompanied by counsel echo by counsel . In that case, if you may rise and raise your right hand, i will swear you in. Do you swear that the testimony you are about to give is the truth, the whole truth, and nothing but the truth . I am hearing affirmative answers from all. Thank you very much, you are under oath and subject to the penalties set forth in the United States code. You may give a five minute summary of your written statements, and we will begin with the honorable mr. Catholic. Kadlec. Olic it is a privilege to appear before you to discuss our response to a series of unprecedented and nearly simultaneous category 4 and category five hurricanes to hit the u. S. Mainland and territories so far this season. As well as our interagency partners at fema, the boundariesd in unprecedented ways to stabilize and support the communities of people affected by these hurricanes. I recognize that some regions in puerto rico and the Virgin Islands, people are facing dire conditions. The devastation myself firsthand and can assure you that hhs continues our response of 110 , and we will continue to work as hard as we can until conditions improve. This is my first time testifying before this committee, so i will begin with a brief description of my view of the role of this position. After it was created almost 11 years ago in response to , its objectivena was to create unity of command by consolidating all hhs and Public Health under one person. I had the privilege of serving as a staff director of the subcommittee that drafted this legislation. Its mission is to save lives and protect america from Public Health security threats. On behalf of hhs, we lead and Public Health emergencies, in accordance with the National Response framework, emergency number eight. Our countryfacing are increasingly diverse and lethal. Capabilities to 21stcentury threats i aim to do that through four key areas. Providing strong leadership, National Disaster Health Care System, sustaining robust and Public Health security capabilities, and advancing medical countermeasure development. Irmacanes harvey, maria, created unique challenges, especially in puerto rico. No place, no person, no life was untouched. During my trip there, i was overwhelmed by the resilience of do in anens, making extraordinarily difficult situation. The three major hurricanes today , our strategy has been threefold. Save lives, stabilize health care, restore healthcare services. In puerto rico, we are still responding. In other areas, recovery underway. Here some of the many actions taken. In order to save lives deployed more than 2500 personnel from 21 states and hundreds of other federal employees, including u. S. Public Health Commission corps personnel to communities impacted by the storms. In fact, each of these storms, we deployed teams before the hurricanes made landfall, and they were ready to respond immediately. We care for more than 15,000 patients, and more than 10700 and puerto rico alone. Tons ofalso sent medical equipment and supplies. It declared Public Health emergencies before landfall of each storm. To identify medicare and medicaid beneficiaries that each impact the area. As well as people who rely on dialysis. We evacuated more than 200 dialysis patients from the u. S. Virgin islands. Joined urban search and rescue teams to locate and evacuate dialysis patients. Hhs activated the Emergency Prescription Assistance Program in puerto rico which provides free medication to disaster victims who cannot afford to pay. Hhs deployed Mental Health teams to aid people, hoping helping with the psychological effects of these storms. I would like to show you a map that illustrates the comprehensive approach of providing health care and dod services. Together with our interagency partners, as well as the Puerto Rico Health department. Of activities we took on behalf of americans and distress is just a fraction of what we actually do. Theuld not speak to all work that hhss disaster medical assistance teams, Public Health services did. They are true american histories. They left their families and practices to render aid and arduous circumstances. We are committed to the long year. Of recovery ahead, and reflect to improveence our capacity to respond to future Public Health emergencies. Naturally occurring or manmade. I thank you again for the opportunity to address these issues. Happy to question answers to answer questions you may have. Five minutes for an Opening Statement. Members of the subcommittee, i appreciate the invitation to theuss the response to hurricanes. My remarks are going to be focused on the impacts of maria on puerto rico because of the unique role they have on the islands recovery and the devastation caused to our fellow citizens. Our commitment is to the people of puerto rico as they begin the long recovery from the overwhelming devastation. , a fda has a Broader Mission substantial portion of the islands economic base is comprised of the szilagyis that manufacture comprised of facilities that manufacture medical products. Collectively, they produce more than 1000 different kinds of devices. To date, we are especially focused on 50 types manufactured by 10 firms in puerto rico. These devices are critically important to patient care because they may be lifesustaining or supporting, or the island may be the only manufacturing site for these devices. Time, we are focused on medically important drugs and 10 biological devices that are solely or primarily manufactured on the island. 14 of these art solesource, manufactured only in puerto rico. Have been working closely with our partners in fema, dhs, and hhs to troubleshoot challenges related to getting fuel for generators, as well as of moving finished products off the island. Our conventions have involved the nature of the risk of change. We help individual firms secure cases, rights in some at risk of being destroyed by flooding warehouses. We started to get more involved in helping securities secure diesel fuel for generators. In the last week weve been engaged in helping the szilagyis manufacture products critical to the blood supply, medical grade gases. As Recovery Efforts proceed, a lot of these challenges are being per being solved by better logistics and no longer require active intervention. We have processes in place are helping guaranteed supply of easel fuel for our manufacturing ingredients. The one that concerns us the most is longterm power. Many generators were not meant to function for months on end. Moreover, some facilities cant return to full production on generator power alone. Theyre producing percent of their normal capacity, based on our informal survey. If they do not return to the power grid by the end of this year, we are concerned we could face multiple potential shortages unless we come up with facilities to temporarily shift manufacturing off the island. I would like to give you a perspective on the human factor we see every day, where we see the islands residents taking off on heroic steps to keep supplies and critical products flowing. Taking their own extraordinary steps as good corporate citizens to support these efforts. Be inis going to consequence of these efforts, i would like to take note of these and support them. First and foremost, i want to take note of the americans and puerto rico. The medical industry directly employs 90,000 Puerto Ricans. And support them. Will be primarily because of our fellow citizens who returned to their post at these critical times even as their own families are displaced. We owe them a debt of gratitude. Take measure of the good Corporate Citizenship that we have been witness to. Even as we watched some Companies Take extraordinary efforts to maintain production, they took equivalent steps to deliver direct assistance to those harmed by maria. Disaster relief stations across the island, helping distribute fema aid to outlying towns. Companies distributing gasoline for employees and general items like water, food, and batteries. Facilities have been using their cafeterias to feed employees and families. One company said they shipped thousands of generators to the island as part of hundreds of tons of release aid. We know of companies that have created programs to help employees rebuild their homes and resume their lives. Programs include cash grants and matched donations they except from employers across the globe to help puerto rican employees rebuild their homes. I want to take a moment to recognize these efforts. These kind of commitments will be a full part of helping puerto rico recover. I want to recognize the resilience of the people of puerto rico and their fidelity to our Public Health mission. Fda has a history of operating on the island. We owe them our steadfast and longterm commitment. Thanks a lot. Thank you for your testimony. I recognize miss brandt. , rankingan griffith member to get, and other members, thank you for the opportunity to respond to the recent hurricanes. Plays an integral role in the Emergency Response during these National Disasters. I have almost 20 years of experience, and even with that perspective, i was surprised by the depth and breadth of their involvement this is a role that the agency takes seriously. In ministrator is obtaining valuable insights. Many people think of cms as a pair, reimbursing chip beneficiaries. Secondly, as a regulator, overseeing and enforcing standards. While cms does not directly provide care to beneficiaries, we have a direct impact on the care they receive. The last several weeks have allowed cms to demonstrate the Important Role we can play in Emergency Preparedness and response efforts. Our ability to waive or modify Certain Program requirements, which cms can do after the president declared a major disaster and Public Health emergency. Cms is using the full breadth of this authority to make sure providing flexibility to medicare and medicaid providers so they can provide quality care to those who need it. Use waivers to allow medicare providers to move patients between facilities and administrative care and alternate locations. Nearly, we have approved 100 waivers and total across the impacted disaster areas. Last month, on a visit to houston texas, we were able to speak to several who were impacted. They demonstrated how important how how important these flexibilities are to them. Providing urgent care without worrying about reimbursement policies. We heard firsthand during our visit what a difference this flexibility has made. That is why cms is taking an active approach and listening to on an ongoing basis to make sure we understand their needs and are able to meet them. One of the administrators Top Priorities has been to provide access to dialysis patients during these challenging circumstances. One of the ways we have done this is to temporarily the facilities located that are not yet certified. That they can provide care for medicare beneficiaries. We were able to designate one of these facilities in florida before the storm hits to make sure patients were dialyzed in anticipation of the storm. In puerto rico and the u. S. Virgin islands Virgin Islands, cms has been working closely with and the End Stage Renal Disease Network to monitor conditions before, during, and after the storms. Here are two examples of our combined efforts. Working withre these partners to track the status of dialysis facilities in puerto rico and their status with respect to fuel, water, and other supplies, as well as developing for the nearly 6000 dialysis patients on the island. Cms also partnered with evacuated from the u. S. Virgin islands to atlanta when conditions were no longer safe in the Virgin Islands. This included working with staff on the ground in atlanta to greet and medically assessed each patient as they arrived. Not beecent events will the last Public Health emergency our nation faces. Making sure providers and suppliers are prepared for future disasters, whether hurricane, wildfire, or disease basic health and safety requirements, including Emergency Preparedness standards, which we updated last fall. Updates include a more comprehensive approach to Emergency Planning and location specific hazards. We require facilities to meet additional Emergency Training standards for staff and implement a Communication System to contact patients, physicians, and other necessary persons. Done, thereas been is much to be done, particularly in puerto rico, where over 50 of the population is covered through femas program. We must continue to think creatively about the ways to make sure beneficiaries have access to needed care. We appreciate the subcommittees interest in these efforts and look forward to working with you through the process. Now we recognize we read more red for five minutes rear admiral redd. Good morning this thing which members of the subcommittee. I am rear admiral stephen redd, director of the center for. Isease control and response i appreciate the opportunity to be here to discuss the cdcs efforts in response to the hurricanes. To address the impact of these hurricanes, cdc has provided to thehealth support coordinated and responses. Efforts havecdcs been in epidemiology and health surveillance, laboratory support, environmental and occupational health, and health communications. On august 30, 2017, cdc activated its Emergency Operating Centers to coordinate our response to Hurricane Harvey and subsequently, weve expanded that activation to include hurricanes, and maria. August 500of Staff Members supporting the response. We have deployed over 70 staff to the affected areas to provide on the ground support, including 34 to puerto rico and 12 to the u. S. Virgin islands. To address immediate Health Concerns, the cdc deployed medical stations to serve as temporary not acute medicare facilities medical facilities. To 200n accommodate up 50 patients and includes a cache of medical supplies and equipment. We employ medical teams to staff these facilities, and deployed six of these to puerto rico, four to texas, and two to florida. Monitoring healthrelated data that may signal disease outbreak , National Syndrome x toveillance program on patienta encounters and works closely with the American Red Cross to monitor data on shelter populations so that Health Officials can respond quickly when it is called for. Surveillance during this response has indicated elevations and Carbon Monoxide poisoning, increased messaging to prevent this condition and guidance on the safe operation of generators. Identifying and controlling Public Health diseases of Public Health importance in puerto rico and u. S. Virgin islands are priority. Puerto rico department of health sustained significant damage during Hurricane Maria, including damage to their laboratories. These laboratories are not able to conduct any health Public Health tests, able to confirm diagnoses of infectious or environmental diseases. Cdc is working with the department of health and fema to get these laboratories back in operation, and in the meantime, we have arranged for packaging and shipment of clinical assessments of suspected priority infectious diseases, such as tuberculosis, rabies, influenza, salmonella to the u. S. Mainland for testing. A shipment of diagnostic specimens recently arrived in atlanta. Let me touch briefly on a few other components of our response. We have provided Technical Assistance to the affected areas to address Health Issues such as food safety, water issues, including sewage. We provided guidance on injury prevention from debris and drowning. Weve helped with shelter estimates, guidance regarding the safety of responders, and we have developed and disseminated key Public Health messages to individuals in these affected areas. The cdc recognizes that the full recovery from the recent hurricanes will take time, particularly in puerto rico and Virgin Islands where the damage has been extensive. Toare going to continue provide that support. Thank you, again, for the opportunity to appear before you to discuss our response efforts. Testimony. U for your i will now begin questioning by recognizing the chairman of the committee, chairman walden, for five minutes. I thank all of you for your testimony and the work that the work you are doing in these terrible tragedies. We know there is more to be done and it is hard to get it right in the aftermath. We appreciate what youre doing. On behalf of the at large resident from puerto rico, thank you for joining us. I know you are not able to ask questions as part of our committee rules, but i can on your behalf. I appreciate your submitting some of these, because i think they are important to get on the record. Puerto rico remains in response mode of saving lives and stabilizing healthcare services. What major milestones must be completed to progress from the . Esponse phase two recovery you can be fairly brief on that, because i have a couple others. I think it has been highlighted by members of your committee, the power situation on the island represents a significant limitation. We have 60 of the 67 hospitals that are on the power grid have reliable power. 36 , a total of 24, that still do not. That is an important benchmark in terms of our ability. What do you think the timeline is . Positiond not be in a to answer that. I think the u. S. Army corps of engineers is trying to move as aggressively as possible. Have prioritized hospitals, health clinics, Dialysis Centers , to reelect a fry with the grid. Two reelect or five reeli ctrify with the grid. Some of them have physical that theyto ensure can resume full functionality, it is working closely with fema and the army corps of engineers. We performed assessments to identify which hospitals need and there arer, issues federally to supplychain restoration, things like oxygen, which i think is a matter of topical interest. Rear admiral, thank you for being here and for the work youre doing. How is the cdc being utilized during this recovery effort . And one more for you. Branch was affected just like every other location in puerto rico. As of october 10, the laboratory operation. It is functioning at a low level under generator power, so i think it is more in the affected than the responses on of the effort the response zone. I think some of the issues that dr. Kadlec raised would be germane to the full activation and operation of the branch lab. Particularly concerning is the damage to the Puerto Rico Department of health and Public Health labs. The labs are not able to conduct any Public Health testing, confirmg the ability to diagnoses of infectious environmental diseases. What will it take to get them up and running, and in their absence, what is happening . Restoring power is the first step. There is work with the army identify the generator capacity needed to bring the laboratories back to power. There will be a second level of effort to determine what equipment can be salvaged and what equipment cant be. We dont know the results of that assessment until the power is back. It is going to be some time. You dont have a timeline on power . For generators, weeks at the most. They will be running on generators . Yes, may be less than that. I dont know about back on the grid, but there should be power to the labs in a short here. Of time. We are working with the department of health in puerto too to ship specimens atlanta for testing, and that is where the first shipment of cases. Are you comfortable perhaps you and others on the panel with that kind of arrangement, to do the lab testing . Is that quick enough, adequate and off . It is not optimal. Need is to bee where this test can be done in puerto rico, having the lab back up to full speed. If its going to be weeks, is there a temporary lab they can be flown in . A bit ofhad quite discussion on that. I think in general, the feeling getting specimens to atlanta for testing is going to prolonged amount of time, a temporary measure. Its not that its not optimal, but it works. Thank you for this hearing. Take you for your testimony. You, mr. Chairman. Now recognize the Ranking Member of the subcommittee. Thank you. To remind the panel, you all know very well, its been over a month since maria hit both the u. S. Virgin islands and puerto rico. Even now, there is an article in the New York Times today, which is titled, like going back in time. Puerto ricans put survival skill to use. It is a very powerful article that talks about how people still dont have power, people are still eating canned food, elderly people are afraid to go gangs. Because of what it talks about is the way everybody is helping themselves, the neighbors are bonding together. There is a fellow, the director of a local nonprofit, said most of the aid to neighborhoods appears to be in san juan, not in the remote mountains that had received from private citizens and celebrities. The government has not arrived. Having been, as i mentioned, having been on this subcommittee when we investigated katrina, it is wonderful to reflect back on what we have done, but it is more important to think about how quickly we can do more and what we can do to improve our efforts in the future. Everybody,emind listening to a lot of this testimony, you would think that everything is swell. I hope not of you intended to intimate that. Mr. Gottlieb, i wanted to hone in with you about your testimony. As you said, there are a lot of drugs and devices produced in puerto rico. 13 of them that are drugs that are only produced in puerto rico. 13that correct . More than. Probably in the nature of 40 Single Source drugs, but only 14 that we think are critical in so far as they are medically important and we could not find a therapeutic alternative. Plants were those drugs are being manufactured are relying on generators, right . I believe almost all, if not all. And now, i think you testified that this is not a longterm solution. Is that right . Thats right. There are some facilities that have substantial generators and could probably operate for a sustained amount of time. What you mean sustained . Some of them are hardened. I dont want to say there are some that couldnt operate indefinitely on generators, but that is the exception. Most facilities will not be able to operate for a sustained amount of time. If we get into the First Quarter of next year and these facilities are not back on the grid, we will have concerns. We are trying to think of how we can work to prioritize a handful of the facilities that are critical. The reason you have concerns is twofold. One, the generators dont produce the kind of energy they need for these products. Even if you can use it, it is going to be a reduced supply. Thats right. Firm that is producing at 100 output right now, that they have dialed back certain portions of the facility. In most cases, these facilities cant operate at 100 production on their generators, and other pointt the is that the generators themselves are going to start to break down. Without men to operate these plants. Quickly. K you friday, you released a statement saying the fda is monitoring 50 types of medical devices manufactured in puerto rico that are important to patient care, including insulin pumps and pacemakers. Is this the same kind of problem we are seeing with this drug manufacturers . Same challenge 50 devices we are monitoring manufactured by 10 different firms. In some cases, device manufacturing is more energy dependent, and the facilities themselves need a more reliable flow from the grid. If the grid itself is unreliable, they might prefer to stay in their generator power for a longer amount of time. Before somea while of these facilities can get the kind of connections to the grid that they need. That if anybody has concern that this is impacting all american families, my daughter, a type one diabetic, just got a letter from medtronic saying her new insulin pump was not going to arrive because of the problems in puerto rico. Everys impacting american, not just the americans in the u. S. Virgin islands and puerto rico. I would like to ask unanimous consent to put that New York Times article into the record. Without objection, so ordered. I recognize the vicechairman of the full committee. Thank you. I want to extend my personal welcome to our newest member, mr. Duncan. He is an outstanding member of the risk of the Republican Baseball Team im in. Im sure you will do just as good if not a better job on the committee. We are glad to have you, jeff. Mr. Chairman, i appreciate this hearing. Another primary focus is puerto rico and the Virgin Islands, but we had a hurricane in texas, too. We are a little more developed and sustained, so our ability to endure it was possibly somewhat stronger. Having said that, there is still issues in texas. Be torst question will mr. Redd. Year, theres a lot of mosquitoes in houston. Given the amount of water that was sustained, and we still havent had a freeze. We have that issue still. What cooperation, if any, has your agency had on helping to themize that problem in houston area, specifically, and with the gulf coast generally . We operate as part of the combined federal response here. We have worked with dod through the fema managed response system to provide advice on what kind of Mosquito Control efforts would be most appropriate. Weve looked through that system. We dont do the spraying ourselves, but we provide expertise. There is not an issue of not enough i dont know what you call it, disinfectant. This is a problem that happens after virtually every hurricane which has a rain element. The types of mosquitoes that follow a hurricane typically arent the ones that transmit pretty, and there is much a Standard Approach to that with cdc providing technical advice, dod providing the equipment, and doing the spraying, in consultation with the local Mosquito Control districts. Similar question, this would kadlec, is that correct . Lots of medicare patients in the texas gulf coast area and many of them have had to go to the hospital for treatments. , doescurrent regulations cms have the opportunity to reimburse these hospitals for the emergency treatment of medicare patients . Since we have a representative from cms, i will ask miss brandt to respond. Thank you. We are currently working with on thefficials uncompensated care issues and to develop a plan to make sure we appropriately reimburse those providers. Is there anything the state of texas needs to supply cms to get that put together quickly . Workingntly, we are with the state officials to do what is called a multistate 1115 , and that would be for those people who have been received or need to care within the disaster area. We are working with the state and hope to complete that in the foreseeable future. Of the the cochairman texas congressional delegation harvey task force. Ifocrat cochairman there is anything the delegation needs to do, let his office or my office no. Let his office or my office know. With that, mr. Chairman, i yield back. I recognize the chairman of the full committee. Thank you, mr. Chairman. A recent press event with the governor of puerto rico, President Trump said he would give his administration at 10 for his response. What i hear from my mayors and counsel people and people coming to my district from puerto rico, i would give, at best, a two on a scale of one 10. As i expressed in my Opening Statement, this is not only an issue of what is happening on the island. The people coming to the United States have needs, and i dont think they would be coming here if they were able to stay in puerto rico. As an example, i am looking at the home news, my daily in new brunswick, a town in my district. It says when the puerto rican governor visited with President Donald Trump thursday to ask for aid, he said that without immediate help from the United States to rebuild the island, there would be a mass exit this to the mainland. To the unitedus states mainland. The number of Puerto Ricans who would move to the garden state would likely spike when people determine they cannot stay on the island longer. Hereld like people to come if they cant get basic necessities on the island, but this is the fact that the president would call this a 10 is absurd in my opinion. Let me start with dr. Kadlec. Research reports still indicate that nearly 80s percent 80 of americans on the island are without electricity. Ambulances responded to at least four calls where a patient have lost power for oxygen tanks or ventilators had died. Reports of patients taken from medical centers where ventilators have failed. When we had sandy, i think our power was out for two weeks and it was impossible. I cant imagine going months without power. Reliable electricity has created a serious risk for the health of american citizens in puerto rico. Would you agree . There is a detriment to the whole society, yes, it is dangerous to people. I appreciate your honest response. Cnn was that cnn reported that 35 about residents still lack access to Running Water. Populationsat run the risk of serious gastrointestinal and related diseases. Again, with sandy, i think i only went for couple days without a shower and i couldnt deal with it. , dr. Redd. Read does this pose a Major Health Concern . Yes, sir. An article in the New York Times described the situation in puerto rico by going back in time. The breakdown in electricity and teleCommunication Systems had pushed puerto rico back a century or so. Just yesterday, the fcc reported that nearly 70 of the islands cell phone towers are still out of service. Lack of cumin indication, cell towers, you cant even address emergencies. Kadlec, would you agree that communication is also an effective to ensure that Health Care Needs are met . Done our and we have best to ensure we have positive communications, either by radio, cell phone, or landline. Weve worked hard to maintain weve maintained weve guard tonational ensure we could keep positive contact. Your point about the generators, i think that is fair, but frankly, we created a whole system to basically address that. I was there the first week after the storm, one of the hospitals loss our teams was located generator power. Several patients in the intensive care unit, a couple having surgery at the time, we were able to transfer those patients without loss of life to our shelters where our teams ambulances. Grand weve gone to extraordinary steps to basically help. As my me do one thing time runs out. The president said it was a 10, i give it a two. Would you give me a number between one and 10 . Im not in the business to give you marks, but we are working 110 to help those people, our fellow americans, on the island. We recognize the gentlelady from indiana, miss brooks. Thank you mr. Chairman, and to our Panel Members for being here. I want to talk about the National Disaster medical system that youve described. I know youve only been on the job for a few months now, how many months . 60 days. Tough first 60 days. Obviously, you were very familiar with the Organization Prior to becoming in charge. The their reforms to disaster medical system that you are already considering, or are there challenges you have already faced, whether from the number of resources you have, or the authorities you have . All of the above. I think one of the things that this event demonstrated is the extraordinary nature this is ipresentative begets point never saw anything like what i saw in puerto rico. Number two, that would simulate aat we would expect if we had Nuclear Detonation without fire radiation. The physical destruction to the island affected everyone, and the psychological and physiological effects are extraordinary. To that point, we were stretched in terms of our demand capabilities. I give credit to those physicians, nurses, paramedics, pharmacists, who deployed down there on numerous occasions. We had people from colorado who were at harvey, irma, and maria. Answer is we probably have to do some creative thinking. We worked very well with the da in puerto rico. We need to work better with the dod. There are a lot of things we need to do to remove dependencies, that require us to do mother may i for transportation. We need to move things faster and better. That said, we deployed before in sanl, had 150 people wen riding out the storm, so have Extraordinary People doing extraordinary things. , and we probably dont give them enough credit or resources. With respect to the authorities of has it been to who iso what as actually in charge of the response efforts, or do there need to be additional operational capabilities provided . I think that is something we are going to do after action. We were able to do pretty well, and we could do better. I would like to hold an answer on that to work with your staff to identify these things, remove ,ependencies for ambulances transportation, things we need to resolve. Questionsandt, i have provided by representative gonzales. Apparently, prior to the hurricane, retention of medical personnel has been a challenge to puerto rico. Prior to Hurricane Maria, according to my colleagues, almost a physician a day would leave the island, would not be practicing their. A number of specialists left the territory. How was that impacting the short and longterm Recovery Efforts . I receive communication from a constituent of mine whose cousin was a specialist oversees at the time it hit, and she had difficulties getting back onto the island to help her people. What is cms doing relative to the Physician Retention issue . Thank you for the question. That is something that cms is concerned about and aware of. In terms of the retention issue, weve been working with the department of health on the island and seeing what flexibilities we can do administratively to lift requirements to make it easier for people to stay on the island , to see what other types of programs we have that would provide incentives for physicians and other medical personnel on the island. Ultimately, that is a decision by the government of the island, in terms of allowing people to come in, especially in the wake of what has happened. We have waived many different regulations and other authorities that we have that would have limited out of state thist of territory, in particular instance, providers to come in and provide care, working with the department of health on the island to ensure they have as much access to personnel as we need them. My time is up, i yield back. I recognize the gentlelady from florida, ms. Castor. Over one month later, folks in florida and across the country are still reeling from the avoidable deaths in nursing facilities in florida. There are now criminal cases, civil cases, trying to figure out why floridas governor has deleted voicemails that came directly from the center to his cell phone. There is an important back story here. In 2005 after Hurricane Katrina and the 215 deaths in Nursing Homes there, cms and everyone determined while many Skilled Nursing centers are not prepared. They went into Rural Development to try to ensure there would be an alternative power source available. Benderstand that it will november when cms rule relating to alternative Power Centers will come into being, will become effective. Why has it taken so long and are you confident that it will do what we need to do . I want to recognize my colleague congressman Wasserman Schulz from florida and think think the florida delegation that has been pressing this issue as well. The florida delegation thas been pressing this issue as well. First of all, let me just state from cmss perspective, we share everyones concern about the tragedy that happened at Hollywood Hills. Thats an event that should not have occurred. From the cms perspective our first and ultimate priority is ensuring we have Patient Safety and Patient Protection at every one of the facilities that accepts medicare and medicaid beneficiaries. With respect to the rule itself, to clarify the rule went into , effect last year. Well begin serving against it in the rule actually went into november. Effect last year. Its just the actual surveys against it will go into effect starting next month. However, it month. However, it is something that we think does go a long way towards addressing a lot of theconcerns that have been raised by Hollywood Hills. In light of the event we want to continue to look at it to see if we can domore. Do more. Some of the things it does that were pointed out as part of the problem at Hollywood Hills are ensuring that there is an Emergency Preparedness plan at every facility. Ensuring every facility has quality backup supplies, generators, others to be able to provide a temperature of 71 to 81 degrees within thefacility the facility and it does not go beyond that. Suree also working to make that the appropriate staff are trained so they know what to do in the case of the emergency. Based on the reports i read of the incident in Hollywood Hills, several of the failings that led to the unfortunate circumstances were that those personnel did not respond to the Emergency Preparedness plan. The personnel were not adequately trained on the plan, and they werent able to take steps accordingly. Those are things were going to be working with to ensure, as i said, we survey people Going Forward starting in november. I encourage you to do that on expeditious basis because that timeframe is not acceptable. Miss brandt healthservices provided under medicaid provide Critical Role in how quickly families are able to recover from Natural Disasters. Following katrina Bush Administration took a number of action to ease barriers to Health Insurance coverage through medicaid. For example, cms allowed for temporary expansion of Medicaid Eligibility infected areas, moratorium on determination, selfattestation of Medicaid Eligibility factors and various waivers. In congress and deficit reduction act acted to ensure states were fully reimbursed at 100 fmat. Does cms plan to take similar actions in response to harvey, Hurricane Irma and maria . What if any difference will be there between puerto rico and u. S. Virgin islands and state on the mainland. Multiple parts to mainland . Multiple parts to the question. With respect to the selfattestation and eligibility requirements, we have already put in place same flexibilities in place for katrina to allow it so that people have the flexibility to self attest. If they dont have appropriate documentation, if it was lost in the floods or the winds or any of the other Natural Disasters. That is already taking place. With respect to the uncompensated care pools you mentioned, that is something were working with office of management and budget to work with congress on, because that is something only congress can address from a funding perspective. Then with respect to how the states are treated differently than the territories with respect to that, we basically have been holding them all having the same amount of waivers and same amount of flexibilities across the board. One of the things we are watching as has been mentioned, the number of people leaving puerto rico and going to the states and making sure were working with the states that they are going to, make sure those states are compensated for the care they are providing to those evacuees. Ill look forward to working with you more on that and thank you to the panel. Thank you very much. Now recognize the gentleman from michigan, mr. Wahlberg. Five minutes. Thank you, mr. Chairman. Thanks to the panel for being here. I have a few questions as well that congresswoman Jennifer Gonzalez asked to address and the importance i think addressed some concerns now, but even for future consideration. The first would it be beneficial to postpone medicare Enrollment Period to january 2018 . I asked this of miss brandt. Given that 80 of the population electricity and telecommunications remains largely down throughout the island. What would be your answer to that . We have been working to establish a special Enrollment Period for the citizens of puerto rico so they have flexibility becausewe recognize many of them may have trouble meeting the current Enrollment Period. So that is viable . Yes. Ok. How are you ensuring that puerto rico has the medicine it needs . On that one i would refer to dr. Kadlec because thats more of a supply chain issue. We simply pay for the prescriptions. Mr. Kadlec. There have been several approaches to basically address medicines on the island. Probably the most important thing wedid with the principle medical supplier on the island was provide them fuel to maintain their generators so they could keep refrigerated products for the supply chain and make sure they had gas to deliver it. Weve been monitoring functionality of pharmacies. Theres over 700 pharmacies on the island. Them are open at the present time. We have worked with mainland distributors of temperature sensitive items to ensure they can basically push in there insulin is one weve worked with people as well as with the major transporters of materials in to make sure those materials are prioritized. Also turn to dr. Gottlieb because his agency has been very influential as well as working with mainland suppliers to bring in products. A varietyen working of different ways. Our dmat teams havecaches they take, pharmaceutical supply. Hospitals to patients they see anywhere. We have done tailgate medicine. Weve actually gone into areas that are rural, remoteand have been cut off. Done so by helicopter and altering vehicles to ensure we can deliver medicines to people who need them. Weve gone to a variety of different lengths. Some straightforward and some pretty exotic to do so. We try to meet whatever need is out there. Ok. Commissioner gottlieb, could you respond to that as well . Especially in context with the power problems and how were keeping up with the pharmaceuticals . The point id add to the comments, there is a number of facilities that manufacture largely and predominantly for the island of puerto rico on puerto rico. Weve prioritized those facilities. In terms of how weve thought about our mission, we have prioritized manufacturers who supply critical products to the people of puerto rico. There are some local manufacturers that provide sterilization for hospitals, follow regulatory scope. Early on we worked to prioritize getting those back online. One more question. Medicalported that oxygen and access continues to be a challenge in puerto rico. Could you please update the both the actions the fda is taking to ensure that all patients and facilities that require oxygen are able to receive it as well as the agencies actions to guard against potential shortage of medical oxygen. Weve worked with partners at hhs. Im going to defer to them because they have played a more active role with these facilities. Sir, there are two principle suppliers of oxygen on the island. Both of them are back operational on the grid right now. There was a smaller supplier and Large Supplier of oxygen. They both suffered loss of electricity in the immediate aftermath of the storm. Again, barging in oxygen cylinders, not something you can fly in necessarily. But oxygen is not the only gas that is needed. Co2, night again, argon are all medical gases needed by manufacturers as well as the clinics out there. So we basically have been trying to move what we could uss comfort, which is floating around the island on the western side can produce oxygen. So were actually filling cylinders of oxygen usingcomforts capabilities to provide that, liquid oxygen generators so we could provide temporary filling. So right now i think were on the right side of the oxygen problem. Both facilities are operational. I think the supply should be sufficient as we go over time as the capacity, particularly larger manufacturer comes full steam. Just to build on that, steam. Just to build on that, ill tell you there is a number of medical product manufacturers who use oxygen, night again in theirManufacturing Processes. They have been able to secure the supply they need in a few instances historically we had to prioritize getting some of those supplies onto the island or from the island. But in most cases theres source outside the island that seems to be stable right now. Weve moved past what i think is critical phase of trying to work through this. Most of the facilities that need access to medical gases for the Manufacturing Processes are getting them now. Thank you. I yield back. Thank the gentleman. Now recognize the gentleman from california dr. Ruiz for five minutes. Thank you, mr. Chairman, for holding this hearing. By way of background im a Board Certified emergency physician. I was trained by the Harvard Humanitarian Initiative on humanitarian disaster aid including International Committee of red cross and one of the First Responders after the earthquake in haiti and the medical director for the largest internally displaced camp in all of portauprince after that earthquake and worked hand in hand with the 82nd airborne. I have seen firsthand the challenges that arise in the middle of humanitarian crisis and the importance of having clarity and plan and clarity coordinating among agencies, government officials and ngos in the field. While im grateful were having a hearing on this issue with hhs, we need a fuller, more accurate view of what is happening in puerto rico from all stakeholders, all levels of government and all different agencies including clinical workers and ngos and people on the field. Two weeks ago i flew down to puerto rico to see the conditions for myself and do a Needs Assessment based on my training and my experience. Im here to report to you what i saw and give you some helpful recommendations. One, the people of puerto rico are very hardworking, humble people with respect for themselves and their dignity and they are doing Everything Possible to help one another, to get the job and take care of one another. Number two, the people who work in your agencies are giving 110 . I have to give kudos to the dmat teams i spoke with firsthand. Firsthand. California one, california 11 from orangecounty and sacramento did fabulous jobs. Hhs liaison was there doing an amazing job. I went further Spot Community and did not stay in san juan and listen just to leaders. I listened to pediatricians on the ground, shelter coordinators, patients that were on the ground. What i can tell you, these are the problems. One, theres a lack of clarity of leadership. Im talking to highlevel officials from all the different agencies and im not going to mention names but the folks in the puerto rican government are saying fema is running the show. People at fema are saying were taking orders from the puerto rican government. I talk to people from hhs and they are saying we do not communicate very much with the needs with the dod. So theres a lack of clarity with who is actually running the show in puerto rico. Two, theres a lack of coordination. Youre not going coordination. Youre not going to get the full picture, folks, if you stay in san juan. Youre not going to get the full picture if your leadership and people making decisions are based in san juan in a Convention Center with air conditioning and food and drinks and everything. Youve got to get your butts out of san juan, intothe remotest areas in puerto rico to talk to people and see firsthand. So these three the other thing is the problem is theres a lack of priorities and clarity in the metrics that youre using and what youre telling the American People what yourefforts your efforts are. What does it mean when you say bottles and food delivered to all municipalities for pr purposes so people get a sense that youre doing your job when in fact what you should be talking about is capacity. Capacity for food supply chains. Capacity for electrical grid repairs. Capacity to deal with theneed. All of you have mentioned numbers and enumerators and number of clinics and people on the ground. What you havent mentioned is the denominator. The actual need. So of your hospital capacity, what is the capacity to the overall need that the people on the ground actually need. This is my one recommendation, and i strongly agree you will be able to better handle the situation on the ground with a mayor sense of urgency and realtime flexibility. Yes, keep your command center in san juan but create command posts on the ground with representatives from the hhs, the army corps of engineers, the dod, department of housing, department of Homeland Security with fema, the representatives from the local grid, federal and state counterpart including ngos and local mayors so they can have Daily Briefing and problem solving as they arise on the ground. Let me give you an example. I went to one clinic, they had a generator fixed by fema. The local clinic didnt know when that generator that fema installed went down. They were without power two days turning patients away. They didnt have a number to call army corps of engineer to determine whether they were on the qe. I went to a local school in one of the communities. They were going to close their doors on october 23 when school starts. Mothers telling me their children needed bottled water. Theres a department of defense army guy saying we have a case load of bottles. Can we get bottles. Can we get authorities to move them down . Hell, yes. Having command posts on the ground in every municipalities, ngos, local mayors and everybody can hold each other accountable to address needs and realtime actions and cut a mother may eyes, like you suggest, and get a food, get the transportation, get the medicine that people need in realtime, addressing problems in realtime is what the people of puerto rico need. Theres a lack of sense of urgency when we talk about these issues. Your folks on the ground are doing an incredible job but the urgency to meet the needs of 3. 4 million people. Water, food supply chain,. Lectrical grids those are your top three priorities to prevent unnecessary loss of life of americans on the island. I feel very passionate about this because i took care of a woman who in front of me in a shelter had a seizure. I caesar. Had a seizure. I protected her airway. I tried to get her to emergency care. There was no oxygen, no medicine at this temporary seizure. We need to do a better job on the ground coordinating with different agencies so we can save more lives and do what all your mandates are about to do. So i think the people on the ground, they are incredible workers and i look forward to working with you more to make sure that we have command posts out in the field. We appreciate your passion and agree we probably ought to get down there and get out and see things and appreciate you and dr. Burgess having both visited down there and look forward to your ip put as a Committee Works further on these issues. Now turn to mr. Costello from pennsylvania for five minutes of questions. Thank you, mr. Chairman. Dr. Kadlec in your written testimony you mentioned puerto rico faced Public Health and Public Health infrastructure challenges prior to Hurricane Marias arrival which , exacerbated the hurricanes affects. Could you describe what some of these challenges were and how they adversely impacted the Public Health response efforts . Sir, im going to make a quick comment. Remember puerto rico sustained two hurricanes not one. The first Hurricane Irma tooka wallop. Then on the northern side of the island where a lot of their Public Health infrastructure is, laboratories will have to refer to admiral redd to talk more about the particulars there. But remember there were two events on puerto rico not one. That was the challenge right there from the getgo. Thanks. I think that the nature of the event really is what stressed the system so much. It was so destructive. I think also some of the things that have been talked about migration of physicians and the overall waning of the number of providers is really a risk factor for damage to the Public Health system. So are you saying that the infrastructure was sufficient and that even if the infrastructure is more improved than the condition it was in, it wouldnt have mattered because the storm was so devastating . I think whatever amount of destruction you sustain, it is changed from what you had before. A stronger system for an event would mean youd have a stronger system afterward. It wasnt 100 destruction. I guess what i think im trying to drive at, didnt mean to cut youoff, what kind of Infrastructure Improvements are necessary to make moving forward so that maybe a storm of lesser destructive magnitude but still nevertheless damaging, there be a better response there would be the ability to have a better response because better infrastructure was in place. Sure. I think that some of the instances of damage, for example, if the laboratory had been constructed in such a way that it wouldnt have sustained that Severe Damage if there had been a generator keep ability that could have been set up more quickly than what is going on now. Those of the kind of things that would have been able to bring the system back on my more quickly. Could i ask you to supplement your answer in writing with any additional type of infrastructure elements . Happy to do so. Thank you. Dr. Kadlec, can you elaborate on Lessons Learned from previous natural disasers from Hurricane Katrina improved hhs is response to storms. I said storms, more than one. Thank you, sir. I think one of the things from katrina was basically unity of effort to capitalize on dr. Ruiz comments earlier. One created the idea of a medical response. Well i cannot dispute the issues of field command post, i can say certainly, and with great authority, that throughout our efforts we were trying to work very closely, not only with department of health in puerto rico which sets the requirements for what they need that we try to service and satisfy, were working across not only department of health and human here,es as we show solidarity with cdc, fda and cms and other but dod. The uniqueness of that is displayed in puerto rico that was not displayed in katrina where you had clinics providing for not only veterans and their families, which is typical of the general population and doing that with combined dmat assistance with our National Disaster medical service teams. So that just gives you a flavor of that. I think the other part is Lessons Learned. We saw it in texas and we saw it in florida that there are hospital preparedness grants. These grants basically help hospitals prepare. First it was initially for hospitals, then coalitions of hospitals that basically were able to demonstrate communication and capability within those coalition that is made them more sufficient and resilient to these effects. Give you an example, one in particular which is pretty extraordinary, which is in houston with ben taub hospital which if you recall back several years ago there were very bad floods. In 2008 inhouston flooded out hospital infrastructure in downtown houston. They took hospital preparedness grants you authorized and appropriated against and basically ensured they could not only withstand flooding, developed a watertight doors to basically prevent that, set of procedures they could continue operations despite hurricanes, despite floods. That was not only the case in houston but beaumont, texas, same dprants made sure had waitedrsonnel errors so that the hospitals could go out there and recover patients. A lot of great Lessons Learned in this. One about capacity of americans to not only help but volunteer as were witnessing in puerto rico right now. The idea is were going to do a little more formal one totake to take advantage of these terrible events to see what we could do better. Such a thorough response that you actually answered the question i didnt get to ask as part of the answer to that question. Could i just ask you to supplement in writing any additional Lessons Learned, not an admission you didnt do anything right but sort of consistent with congressman ruizs comments relative to what moving forward can be done in order to improve the next time a tragedy like this might occur so were better prepared. Thats what we all want to do. Thank the gentleman. Now recognize you for five minutes for questions. Thank you very much. Fourteen people died at the Rehabilitation Center in Hollywood Hills, florida, when it lost power and overheated from september 11th to september 13th. Miss brandt, as seniors went into distress workers struggled to provide 911 with basic information including the address. It was also reported that the same facility with previously laid off hundreds of workers, including nurses. The nursing home stated that it employs fulltime and parttime employees but did not state if a nurse was present when the paint patients went into cardiac arrest. Did cms find can you give me yes or no in simple questions. Did cms find there was a nurse on site at this nursing facility from the 11th of september to 13th . We have a full report on that, madam congresswoman. I dont know the specifics of it. There was specifically a nurse. Is a nurse required to be present in nursing home . We have conditions of participation which require clinical staff to be present. And are the requirements for nursing home Disaster Preparedness plans, that is a requirement . That is a requirement, yes. Were they followed . According to the report that we got from our state facilities, they were not followed in this instance and thats why the facility has been terminated from accepting medicare and medicaid patients. That is the consequence. That is the consequence. I wanted to talk to dr. Kadlec about the hospitals. A week after Hurricane Maria hhs told Committee Staff that most hospitals would face major challenges getting food and water. We have talked about that. Of course more than a month after Hurricane Maria reported surgery is being done by cell phone flashlight. There is pictures that show that. So i guess its pretty well documented. And so what i wanted to know is do hospitals connected to the electric grid have access to full regular power, or is it only being provided intermittently . Depends where those hospitals are. There have been issues of reliability. Ill have to turn you over to u. S. Army corps of engineers to talk about when you say all hospitals are connected to the grid no, maam. Theres only 60 of the hospitals connected to the grid currently, as of today. And the others, are they operating they are operating on generators and basically working with fema to actually have n plus one, where they actually have two backup generators. They have a principle generator and backup so if they need to switch, if the generator fails, they can go immediately to the next one. Again, the plan is to basically have 911 fema generator repair team to come out and fix primary generator. As a consequence of all this, you would say theres now 24 7 jen power at what percent of the hospitals . 0 on the grid would have regular power. Theres reliability as relates to transition wires and distribution that i have very little understanding of because i did very badly in Electrical Engineering but i think the point is that there are hospitals outthere that are on the grid. Even those hospitals have generator backups. Ok. I want to turn for a minute to the Virgin Islands, dr. Kadlec. I i understand Hurricane Maria tore the roofs off of thetwo largest hospitals in st. Croix and saint thomas. So what is hhs doing to ensure americans in the Virgin Islands are receiving the health care they need . Maam, immediately after the storms passed, both irma and maria had effects on both saint thomas and st. John, st. Croix where the hospitals are. With the passing of those storms, the initial storm irma, we basically set up dmat team with temporary shelter there and that was replaced with a more capable army support clearing medical station which is 40 bed mini hospital thatsthere. Now were in the midst of basically deploying a westernshelter assembly, so that would allow physicians and nurses and Health Care Practitioners on Virgin Islands to go back to work and take care of their patients while the hospitals are being assessed i the army corps of engineers. Replaced. To be we have provided Immediate Care and providing intermediate support and basically transitioning to a capability that would allow Health Care Workers on Virgin Islands to go back to work. Then with that give time to basically repair andreplace those hospitals. Thank you. Hospitals. Thank you. I yield back. Thank you, gentlelady. Now recognize mr. Collins for five minutes for questions. Thank you, mr. Chairman. Thank you all the witnesses for coming. Dr. Kadlec, while were operating hospitals under generator power and the like, as people are being transitioned out of the hospitals, in many cases, in fact probably in most cases, the residents dont have power at home and dont have Running Water. Could you perhaps explain whats going on relative to these patients leaving and how are you and othersnow dealing with the fact that they are moving into an environment without power. In power, and in many cases, without Running Water. Just to highlight a comment made earlier by admiral redd, thereare six federal medical stations that have been deployed to puerto rico at the present time, two are operational, two 250bed facilities that are being staffed by v. A. Workers as well as volunteers in one case by Greater New York hospital association. A great example of combined effort between our federal and volunteer partners that are basically providing those kind of transition places for people who need additional medical support or care, dont need to be in the hospital, cannot go home for what ever reason. Weve set up those and had more in position as were required to do so. Thats reassuring that youre basically assessing patients one by to make sure that when they one are released they are getting the care they need. Yes, sir. Another question, again, back to the individual situations is the report that the pharmacies are asking for Cash Payments because of a lack of ability to connect into insurance companies. Yet in many cases the folks needing prescriptions filled dont have that cash. What are the questions should go to you or dr. Gottlieb, what are we handling thats beenreported in that case . In puerto rico theres a Prime Minister called emergency pharmacy Assistance Program which provides free medication for individuals who cant pay for it. Thats been invoked. People who dont have cash but need medicines can get it. That is one way. The other way is if they would go to one of our dmatfacilities colocated in seven of the regions in puerto rico, theycan get medicines from there as well. We provide prescriptions or medications is required. That is reassuring as well. Now, in some cases, someone thats been on prescriptions, im assuming theres some difficulty even in the pharmacy contacting the physicians office. I know if i go to one and they say its expiredt they say well contact the physician and get back to you. Again, because of the lack of infrastructure how is that being handled . Not only medicines but prescriptions filled out for people whoseek them out. They have to basically present themselves to either one of our dmat teams or military facilities or v. A. Facilities and they will get a prescription, if not the medication itself. Again, i appreciate youre basically taking what i would call a one by one by one approach. Every situation is somewhat different. Im getting different. Im getting comfortable that youre taking care of people as best we can given limited infrastructure. In some cases doing things in an unusual way. Yes, sir. Way. Yes, sir. So dr. Gottlieb, representative gonzalez that asked me to askyou, on the fda issue related to food and agriculture, what would be your overall assessment and are there cases where the fda is granting waivers and things of that sort, understanding it is not business as usual at all. Thanks for the question, congresswoman congressman. We would typicallygrant waivers, for example, if crops damaged in it hurricane, the producer was looking to divert crops intended for human consumption into animal feed. Weve already conducted i believe 20 not inspections but site visits to various agricultural facilities and Food Production facilities to help them back online. Weve done this in the last week or so even as our own employees down there have been devastated by the hurricane. We have abo 100 employees on the island. Weve conducted i believe a total of 36 inspections of various medical product facilities and Food Production facilities to help them get back into production. I want to thank you. Mr. Chairman, ill yield back. I guess i need tosay im happy to hear of the response in puerto rico given the fact the island was devastated. It is an island nation. While its always easy to criticizes response, what im hearing is a lot of actions have been taken one by one to make sure people are getting the services they need. We cant snap our fingers and rebuild an electric grid overnight. Everything im hearing is, and i would disagree with the member that was going to give them a to on a scale of one to 10. I also dont like to give grades, but i think thats a bit harsh, considering the devastation that the island withstood and the fact we have never seen anything like this before. Again, i want to thank all four witnesses for coming here today. I certainly am leaving today feeling much more comfortable about whats being done to take care of the tragedy that didoccur on puerto rico. I yield back. The chair now recognizes the gentleman from california, mr. Peters for five minutes for questioning. Questioning. Thank you, mr. Chairman. When you get down at the end like this, a lot of questions have been asked already. I am going to ask you an openended set of questions from of prevention. I think a lot about what we might do with respect to preparing communities to deal with earthquakes or fires orfloods. But from a health perspective, i havent really given itmuch thought. Do you have thoughts on what you would have liked to have seen the federal government or puerto rico do before this that would have mitigated kind of the need to respond to the extent that we had . Anybody . Ill just comment that in all the three hurricanes, the major ones, harvey, irma, and maria, that we were very aggressive in deploying our assets, people, capabilities, logistics. As far forward as we could safely in the case of puerto rico, actually putting people in harms way to be there when things happen. You can never anticipate how things will unfold. In particular, florida, if you recall, the turn of irma that went from the eastcoast to the west coast, thankfully, and then that kind of deceleration of the storm just before it hit tampa. Thats a little bit of good luck. You cant always count on that. But i think one of the things that comes out of this is importance for community resilience, individual resilience, those are things that somehow, again, are not necessarily the domain of hhs, but i think fema and department of Homeland Security often use october as preparedness month and ask people to see if they have a plan, if they have supplies, if they have the necessary things at home. I think these events highlight that element that individual preparedness, no matter how good we may be, it will always be a circumstance that we may not be able toget to you immediately and youre going to have to provide for yourself and your family in the immediate term. From your perspective, the health agency, including the cdc, do you feel like you have input into the content of the outreach happening in october, to tell people how to be ready from your perspective . I would like to defer to admiral red, but we do interact in these interagency conversations, but if you wonder what kind of messaging you need, i think as we look to the 21st century and my role in preparedness and response, the circumstances that we found ourselves after 9 11 are clearly different today. The circumstances that we find ourselves when this position, my position was created in 2006, are different today than they were then. And so i think the thing is, part of it is keeping up with the rapidly changing threat environment. Thats the premise of my question. The question is, are we keeping up with it . Is there something we need to be doing, is there something reflecting back on . Im going to take advantage of an opportunity to point out that the pandemic preparedness will be reauthorized hopefully in the spring of 2018. I believe there should be things that reflect that change threat environment. I think ms. Brooks mentioned the issue about the structure of the Natural Disaster medical system. I called for the idea of a National Disaster Health Care System that would be basically built potentially on what hasbeen proposed with the National Trauma system. Basically insure that we have the capabilities the country needs to face whatever the threats may be in the future, whether they are natural or manmade. Thank you. Let me turn to the admiral quickly. Yes, i think the answer to your question, i think, is different depending on the horizon. I think certainly since 9 11, there have been remarkable improvements in our ability to respond in a coordinated, cohesive way. One comment that i would make is that these three different hurricanes were actually very different events. In texas, it was really a flooding event with not very much wind damage in the most populated areas. In puerto rico, it was primarily a destructive wind event. So i think what we the lesson from that is really being adaptable is a critical capability. And i think that we are continuing to get better at being adaptable to the circumstances that we are confronting. Great. I want to thank the witnesses and yield my remaining time to dr. Ruiz. Great, because i just have a few seconds, but the idea of peripheral field command posts, would that be helpful tobetter coordinate on the ground realtime with all the stakeholders . Sir, it is. We have that Communications Capability with our dmat teams. It can happen . It can happen. As it is, you define so dr. Reed, would that be a solution that yes, it would. Just in a narrower way, from a surveillance standpoint having , hubs that can report in would be something that would be helpful to understand what the facts on the ground are. Im going to highly suggest that we start doing that as well. And another metric to count is unnecessary deaths. Epidemiology, it is one thing to be killed by a Falling Branch or drowning from the river. The other is to die from not having medications that they could have had if it wasnt for the hurricane. So theres a lot ofunidentified bodies and a lot of deaths occurring. We need a better way to count how many are due primarily and secondarily from the hurricane. Thank you. Thank you for yielding back. I recognize the gentleman from texas for five minutes for questioning. I thank the chair, and welcome the chair as our new chairman of the subcommittee. I thank you for allowing me to participate even though im not a member of the subcommittee, im here to talk about Hurricane Harvey. The three aspects of Hurricane Harvey, ill call them the three ms, Mental Health, mold, and mosquitoes. I moved to the texas coast in the summer of 1972. Time, were there at that you hear the legend of hurricane galveston in 1900. Worst Natural Disaster in our countrys history. Over 6,000 lives lost, probably 8,000 to 10,000 if you count them all. I was there for hurricane alicia in 2001, ike in 2008, harvey did more damage than those hurricanes combined. It hit us twice. Hit us once, stopped and hit us again. We faced many health challenges. The centers were breached, there were chemical spills, raw sewage spills, walls of fire ants, toxic smoke fires that got out of control, flesheating bacteria to two lives. One in galveston, one in kingwood. A First Responder in my district was infectedbut beat it with heavy, heavy antibiotics. Mental health became a big issue. I saw this firsthand. I was at a school, an Elementary School hit by the tornado that hit a plantation called scanlan oaks. Talked to the parents, school kids come the class. Young man came very proud, the one tornado hit my home. Knocked out my window as i was sleeping. Mom came back, and i said, man, he is doing great. She said, no, hes not. Hes great atschool. A great story. I be the hurricane. The tornado. But says that since it hit his house, he cant sleep in his own bed. He crawls in with mom and dad for security and safety because he fears for his life after what happened with Hurricane Harvey. And thats just one example of how kids are traumatized bythese events. Also, the adults. We went through days and daysof tornado warning, flood warning, three nights, probably slept for hours over three days. Four days after harvey cleared, there was a little flash flood. Those alarms went off. People all around said i kind of freaked out hearing the alarms again. My question is, what resources, and maybe you, mr. Gottlieb,what resources are you providing our communities to address the mental Health Issues they face because of Hurricane Harvey . What can be done for these people . Well, ill defer to my colleagues in the panel. In my role as fda commissioner with respect to what we have been focused on coming out of Hurricane Harvey in addition to there being some medical product facilities in the region, the predominant issue has been related to crop destruction. And issues related to requests for waivers for diversion of crops into animal feed and Going Forward, we will probably have to take some steps to help with remediation of certain fields that might have been exposed to heavy metals from the flooding, but were primarily focused on issues related to the crops that were damaged in the aftermath of the hurricane. Thank you. Admiral red, any comments on that, sir . On the Mental Health question in particular, i think that there are maybe three points. One is understanding four points. One is that these events are devastating. And they have effects oneveryone. Most of those effects are relatively short term for most people, and i think for people, when those effects are notshort term, we need to be able to make sure that there is availability of services. Second point is really understanding the magnitude of that group of people that need longterm help. If i can remember my third point. I think thats it for me, two points. Ill add to his point, really quick, which is simply that we have used the Public Health commission corps, Behavioral Health teams that have basically been going out. They have been most recently deployed in Virgin Islands. But also samhsa has provided a hotline to call for people who have had it, and they have had 11,000 calls and basically can speak to a counselor on the phone to ask about their emotional issues and find some assistance and solace in that way. So there are some capabilities out there and we , have been working with again, its dependent on the local authorities to initiate these things, but we certainly stand ready to assist when it is appropriate. Thank you. Admiral redd, youre ready for your third point. There may be a couple more. Let me talk about mold. Were working closely with the department of health, when theres a flooding event, structures that are flooded will become moldy. Were actually doing three Different Things in mold. One is training of responders, the other is working on communication materials, and the third thing is working with the department of health to investigate the potential for an increase in infections due to invasive mold. I want to remind everybody about the region. S one thing i yield back. There are also Three Islands with respect to the u. S. Virgin islands. St. John, st. Thomas, and st. Croix. I dont want us to see this as a monolith. Each of these islands have their own identity and inhabitants. Deep enoughing a dive into what is happening with the inhabitants of all of these territories. It is not one singular event. It is an event that hit three separate geographic territories. Im putting that out there because im going to want to hear more about what has happened in terms of response to those territories. We are not hearing at all about how the people of st. John are receiving health care, deceit the people of the act is were not hearing that information and that is important. I would like to start my question about the evacuation process. Assistance was there for an efficient evacuation plan for those whose health is compromised . To thet was provided local Health Department in the wake of the hurricane to track evacuees who are sent to other islands where the mainland . I would highlight our map that we provided which identifies where hhs gave support. On also we had a presence ques as well. Irma struck st. Thomas first, and we were doing on president things. We were able to identify dialysis patients on the island. We recovered a hundred and 20 of them and evacuated them. Point in time and we evacuated them the day before the day of landfall of maria. We evacuated them to miami to a shelter so we could ensure they were being cared for. In the cases of other patients evacuated from the Virgin Islands, they were evacuated to atlanta and were receiving care through their, through local resources. We not only evacuated they had atients, Family Member to assist them along the way. Has only been a handful of evacuations off the island to the mainland. There were two pediatric patients who were evacuated from san juan to miami soon after landfall. And helpto maintain with the destruction of puerto rico. Those people need to be closer to family and support units. The way we address the problem in puerto rico, we created seven regional hubs, hospitals we opened with disaster medical assistant teams. We made the eastern have a receiving hospital, and use the uss comfort as a mobile hub we to collect patients. Use dodbeen able to medevac helicopters to provide response on the island. And use Naval Medical assets to fly if there is a document that outlines this, that would be great. I want to talk about the Public Health challenges of these island territories. The islands only the assistance of the federal government in the weeks, months, and years to come. What is the agencys position on the medicaid cap as it relates , and doirgin islands you support a full federal contribution as the federal government did for katrina . Thank you for that question. That is something we are looking at, and exploring whether we have the flexibility to do that. The federal map is set by congress, it is a statutory about yourng recommendation. You have these island theirories, in one case major employment is through tourism. No one is working. Are we requiring that government to come up with the match, or are we going to suspended and do a full federal contribution as we did for katrina . On the mainland. We are pursuing that. We are working with the office of management and budget for congressional approval. I reckon the gentleman from georgia. Mr. Carter for five minutes. Chairman, andr. Thank you all for being here today. Can you help me here . Withw a situation exists the Nursing Homes in florida. Are you going to require Nursing Homes to have generators . Is that going to be a requirement and can you briefly tell me how that will work . We have an Emergency Preparedness role which is finalized last year that is going to be starting next month. It requires generators. Requires Emergency Preparedness plans. It requires training on a continual basis. I spent much of my career as a nursing home consultant. They are pushed for trying to stay solvent as it is. Is there going to be any help for them, or is this just another government mandate . That is something we are looking at, but i cannot speak specifically to that at this time. Thank you. Ere was an article in the wall street journal about the was offip and how it the coast of puerto rico but it was not being utilized. I want to get your input on how we can do a better job in the future of making sure, from what hospitaland, a 250 bed , and only 150 beds were being utilized. What can we do to make that uster . It is costing 180,000 a day to have it there. The people in puerto rico desperately need help. Again, the comfort was used as a capability to deal with high acuity patients, particularly in circumstances were hospitals on generators would fail. We would need to urges the chance for ill patients somewhere. We were using the 50 bed icu on the boat we understand and appreciate that. It seems like we couldnt make better use of that. Is there anything we can do differently to make it more accessible . We are in the midst of looking how we can utilize it more. And make it more accessible. That is a ongoing conversation with the department of health in puerto rico, how we can use that more to their needs. Thank you. Its my understanding the fda can declare on a shortage list medications that are not available, and they can be compounded. Is that true . Look atnt typically the opportunity to compound as an alternative. Our staff would work to get the approved product. It might look to help source the same product from overseas. Itht be inspected by is the case in certain situations you might see practitioners go to approved compounding facilities within the confines of the statute for certain products. You are actually increasing access to medication, is that what you are tried to do . Thanks to some of the new Authority Congress gave us an respect to our staff, and ability to identify shortages further out, we have been taking steps to mitigate the shortages that have occurred, but also situations where we see the potential. We are looking out one to two months of what we think could potentially happen if production does not resume, and taking steps to move temporarily certain manufacturing out of facilities that might be damaged or not up to full production. I would ask you as you forinue on your process dealing with compounded medications, and he would take into consideration Natural Disasters, and there would be exceptions put in there were pharmacies could be utilized so they could get those medications to those patients in the case of Natural Disasters such as this. We would be happy to work with congress. I look forward to working with you. I would be glad to work on that with you. One final question, dr. Gottlieb what about treatment . It works better with diseases identified is that being supplied to puerto rico right now . It is. They are not anything special. Tetracycline is not as available as it ought to be. Unless you getting it for fish tanks. Im serious. Thank you very much. I yield back. Never denies the gentleman from new york. Five minutes for questions. Recognize the gentleman from new york. With clean Drinking Water, theres a major focus. I am pleased the committee is responding to it. Address that concern, clean Drinking Water. There are many reports about a lack of jigging water in puerto rico. Unfortunately, neither fema nor the apa is before us today. Im hoping you might share insights into the water situation in puerto rico and the Virgin Islands. News has reported one third of order rico has no reliable asess to Potable Water hoped. Because of this we have heard reports of people tricking and baiting in rivers and streams in puerto rico. Last tuesday puerto ricos thereiologist announced reported on cases the island this month. Sees 60 casesly of this disease and a given year. Thisreports have connected outbreak to use of contaminated water sources. Thisou tell us about concern with this disease . Bacterial infection. , tricking ord being exposed to contaminated water water water. The vehicle for. He transmission of the disease we are working closely with the department of health to confirm or determine if those are actually cases. We have specimens in the laboratory at the cdc right now, doing those tests. We are aware of one confirmed case that was diagnosed in a patient. How large this outbreak is, if it isnt outbreak that remains to be determined, the best way to control the outbreak is to prevent exposure to contaminated water, and that is an issue you started with wider availability of Potable Water. And early treatment for people of fever,symptoms weakness, exposure to those things. Are more stages characteristic, jaundice, yellowing of the skin because of liver damage. For the question about the extent of the water supply system, i might referred to dr. Kadlec. We have been following 25 of the 100 and 15 public water facilities are out of service. Significant me, 10 out of the 51 wastewater facilities are out of service. Estimate of a rough what the situation for water is. That is being followed by the u. S. Army corps of engineers. With the disease itself, is it normally treatable . It is treatable. It has significant mortality cases, five toe 15 fatality. It is a serious disease we need to take steps to try to prevent, and when recognized treat probably. How critical is it for patients to be treated in a matter of days or hours . Like many bacterial infections, the sooner treatment can be started the more effective it is. Early recognition is very important. Some of that has to do with access to medical care. Diseasesere other associated with tricking in rivers and streams after these heavy rains and flooding that we saw in puerto rico . Other other Health Concerns . There are. The conditions that can cause gastrointestinal illness is going to be more common in flood water, wastewater that has sewage and it. There are also Skin Infections that can be more common when people become exposed to that. Diseases, asty of well as something that has been alluded to earlier, washer hands, things that will have other beneficial effects. Thank you. I yield back. I think the gentleman and appreciate everybody bearing with me. I reckon eyes the gentleman from florida for five minutes. I recognize the john nunn from florida for five minutes. Preparednessal program uses grant funds to help defray costs associated with procurement and maintenance of generators for assisted living. Acilities the way to grants are structured are principally for Health Care Facilities and for coalitions thereof. As part of a plan of the coalition, that could be considered as part of it, but we dont take that. We look to identify how these hospitals and Hospital Systems can become more resilient. If i make it back to you, i can give you more of a followup. Please. That is very important. There are nursing facilities that do not have generators. That is a priority. I will get back to you. Maybe they have 10 patients or less. We have to make sure they have generators. , at the Hollywood Hills in florida, raising concerns about the nursing home residents where 14 died after the facility lost airconditioning in the wake of Hurricane Irma. It was a fully functioning hospital across the street. Unbelievable. According to the health care administration, the facility administrator and medical professionals did not know to call 911 in an emergency. I cannot understand this. What is wrong with these people . How could a nursing home be so unprepared for a medical , and 14 residents lost their life . Especially when theres a hospital across the street. Can you answer that question. The question. Or as you are aware Hollywood Hills has been terminated from participation in the medicare and medicaid program. We make patients our number one priority. This was a complete management failure at Hollywood Hills, which is why they were terminated. They did not meet our conditions for participation for keeping the temperature at a proper level. He did not provide medical care. They had several levels of immediate jeopardy for patients, which is why they were terminated. Who is ultimately responsible for their safety . Terms of the Patient Safety, the facility has the responsibility, and the management has the responsibility to make sure they are meeting preparedness requirements, that they are providing adequate care, and we hold the facility accountable to those requirements. Thats very important, the accountability. Do to ensure this tragedy never happens again . One of the things we have done, we have an Emergency Preparedness role requires a plan that they train on that plan and are all aware of it. Generators and other things to ensure they have adequate Power Supplies soap patient care can be provided. And they have a plan where the patients can go if it cannot be provided. What about puerto rico now . I understand there are Nursing Homes operating without air conditioning. Is responsible for this . Who is supervising this . Is it cms . Hhs . In situations like in puerto rico where you have an unheard of situation with no water, no power, you have no ability. We work with all of our partners as well as the fema teams and everyone on the ground. They work with federal and state, and the territory officials in puerto rico to pull together, to get patients to a safe place. If they dont have that ability to provide care, we were together to get the transported to a safer place. Thank you. I appreciate it. I yield back. Recognize the gentleman from texas for five minutes. Thank you mr. Chairman. Area, anom the houston urban area, i heard today we had our second death from flesh eating bacteria in galveston county. We had one to the south of us, but also to the north we had a 77yearold lady that passed away. We have great medical facilities. Is that brennan hasnt that been prevalent in puerto rico. Im not aware of cases that have occurred in other hurricane affected areas. The condition you are describing is pretty infrequent and the u. S. , about six to 700 cases per year over the last five years. It is not common. Xposure to floodwaters Hurricane Harvey greeted so many Health Issues with chemical fires and air pollution. Epa confirmed that in the aftermath of Hurricane Harvey, we have a location called the , it was in my district. We changed those, but our constituents still contact us. The analysis found there were concentrations 2000 times higher than the level which the epa required cleanup. The epa administrator was there two weeks ago. The decision has been made to permanently clean up the facility. I was glad of that. Are associated with this . Parties inponsible theythe state of texas, put signs up in english,s banished, and vietnamese to not eat the crabs of the fish. I go out there you can find anybody who does not have a hing pole stop a lot of people still do. I dont want to say anything that is incorrect. Especially with the levels that we are seeing in that setting. Decision has been made to clean it up. My concern is a lot of my constituents who go out there and fish and crab. I keep explaining to them you need to Pay Attention to the signs. According to the Health Department there were contaminants in floodwaters covering most of the city. Following Hurricane Harvey, what role did the cdc play and warning communities of possible waterborne risk and other Public Health risk . In general, and that part of the response we were working in support of the epa. The kinds of things we would do is to make the kinds of warnings you described, make sure people know those things. The Public Health communications. Additionally, not just from industry, at about 50 Drinking Water systems were shut down following Hurricane Harvey and more than 160 systems. An issue we are seeing in puerto rico. Given the lack of power, some people are not able to boil water. Without boiling water being an option, what are some of the options to drink water without boiling it, and how does the cdc communicate these hazards . We may be over it, i hope in southeast texas, but in the Virgin Islands and puerto rico. To hazards one would be exposed to Drinking Water that could be contaminated with sewage would be the things we talked about before, gastrointestinal illnesses, the to have hygiene that prevents other diseases. Exposureis superfund to some of the material in those waters, just to bring back one other point, that is one of the reasons having the Public Health laboratory in puerto rico is so important so that testing can be done. And when water is safe to drink that will be easier to confirm when the test is available. Every year the upper texas coast, we get a hurricane or Tropical Storm. Longully it will be that of a time. Are we learning any lessons from harking harvey from Hurricane Harvey . I hope were learning to be better prepared. When our water system shutdown, that is a human need that we have to have. Thank you mr. Chairman for letting me run overtime. I appreciate that. Thank you. I recognize myself for five minutes. Will be the end, so you are almost done. Dr. Gottlieb, black mold. Everybody knows there will be some black mold issues. Heres one of the issues i dont think Many Americans know. One of the symptoms, if you see it you will do something about it. Oftentimes it is a hidden concern. What should people be on the lookout for . I defer to cdc. Correct. E absolutely flooding leads to mold contamination. The two different hazards from exposure to mold, one is the worsening of allergic conditions. That can be serious in the case of somebody that has asthma is sensitive to mold. The other is, particularly for people with weakened immune systems, infection from mold can be serious. How are they to know . What will they be seeing . When Building Materials have been damaged, if mold can grow on it, it will. Of remediation, in other words, report services, report services, and removing them. Guidance in those areas is what i am concerned. ,f you dont know it is there you could start have rasping. Particularly if you have asthma. When you have congestion wouldnt you have congestion . When you have those floodwaters you can do it immediately. All right. Octor, it has been a month. We of hospitals in puerto rico that are not accepting the of hospitals in part to rico not accepting patients do we have hospitals in puerto rico not accepting patients . Three. Are open ones not accepting patients . I would have to refer to the census. Dialysis is available. That may be some services are not available. Even though dialysis was available, they were cutting short the treatment for time. We were looking to work that problem out in terms of lowering the stress on some of those clinics. For places that had more functionality. Brings us to the uss comfort. Sitting out there. This is a question my colleague gave earlier. What is the approval, or admission process, to be approved for the comfort . Island based on the swath of the hurricane, there we patientactue centromedico was the level one trauma center. We would transport them there. Would be byation centromedico that would talk to doctors to say, what is this patient suffering from and what kind of cure do they need. Then they would be transferred to the centromedico or comfort. We have an asset we are not using with the comfort. Based on the longterm concern you have, what is your biggest organization the may be having . May have product shortages heading into the critical First Quarter. My biggest longterm concern is that we dont do our jobs getting facilities backup in a timely fashion, production could move out of the island. That could put a strain on the economy of puerto rico. We have to make sure we retain that production. My time is up. I yield back. Following up. It would take away good jobs from the island if those facilities closed. 90,000 people are directly employed by the industry. Manufacturing jobs. Estimates, 20he percent30 of the gdp of puerto rico. I want to thank all of the witnesses and the members for participating today. We can submit questions for the record. Witnessesat the respond properly to the question they receive after the hearing. Was a good hearing. Thank you for participating. I have a better understanding. Maybe you can suggest where we should go, but i look forward to the subcommittee perhaps visiting the islands to see what we have. Other areas that have been affected by the recent hurricanes. With that, the committee is adjourned. [captions Copyright National cable satellite corp. 2017] [captioning performed by the national captioning institute, which is responsible for its caption content and accuracy. Visit ncicap. Org] on the sunday shows this weekend, there was talked about the Russian Investigation being led by Robert Mueller. After recent report that an indictment is coming as early as monday. An opinion sunday, was offered on the investigation. We also heard from Chris Christie on cnn. All, we all know whos big we argue the whos in charge. We dont know what they are in charge for, we dont know the time period. The only conversation ive had with Robert Mueller was stressing to him the importance of cutting out the leaks, with respect to serious investigation. It is kind of ironic that the people in charge with investigating the law and executing the law would violate the law. Disclosing grand jury material is a violation of the law. As a former prosecutor, im disappointed we are having the conversation, because of many have violated their oath of secrecy. I think bob mueller has a distinguished Careers Service to our country. I think your viewers can think of a single thing he did that call for them to have a lack of confidence in him. Most of your viewers have to be reminded that he was the fbi director, that he was a u. S. Attorney, because hes an apolitical guide. I seen the reporting, he an call me our friends, im not sure what the definition of that is. I have a lot of coworkers that wouldnt thought me from investigating them. They are not Family Members, they were not business partners. I would encourage my republican friends to give the guy is just to do his job. The result will be known by the fact, by what he uncovers. The personalities involved are much less important to me than the underlying facts. I say give the guy a chance to do is job. Calling on bob mueller to step down as special counsel, im not sure where you stand on this issue. Recently come great and its why he should have you seen any concrete evidence on why he should step down . I think he should be careful about making sure the public believes that he has no conflicts and his integrity is unquestioned. Mueller has tor continue to review that with his own death his own staff. Its absolutely indisputable conference. Hes been around lawenforcement for a long time. He has a lot of knowledge and it involves a lot of folks over the point of time. So that people in this country can have absolute confidence that whatever conclusions he comes to in this investigation. This weekend, President Trump took to twitter to offer his assessment of the mueller investigation. In once we, the president said all of this russia talk right when the republicans are making the big push for historic tax cuts and reform. Is this coincidental not. A thisek on q and week on t. R. Knight. This week on q and a. I was behind him and it looked like he was going to fall to the ground. Man, i didyearold what any decent human being would do, i grabbed him by the arm to make sure he didnt fall, it was a large