Transcripts For CSPAN3 Hurricanes And Public Health Preparedness Hearing 20171024

Florida, puerto rico and the u. S. Virgin islands have been devastated by hurricanes. I first want to express our heart felt sorrow for the millions of americans impacted by these devastating storms and say all members of this committee on both sides of the aisle stand with those affected by the hurricanes. I would also like to thank dr. Burgess, both members of the subcommittee who each recently visited puerto rico to assess the impact the hurricanes have had and continue to have on our fellow 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 been effective 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 of infectious 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 dire condition 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 Recovery Efforts. 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 address the short and long term needs. Especially in the face of the Public Health risk that resulted and will continue to result from 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 Member from colorado. This 2017 Hurricane Season has been one of the most damaging on record. Hurricane harvey broke the record for the greatest amount of rain recorded from a single Tropical Storm or hurricane in the United States. Hurricane irma became strongest atlantic hurricane on record. Hurricane marias impact on puerto rico and the u. S. Virgin islands has been nothing less than 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 the Virgin 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 ricoen residents lack access to Potable Water. Contaminated water is spreading contagious diseases. While i certainly appreciate the effort by volunteers including physicians and nurses volunteering their time with the teams i am concerned that poor management 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 of 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 the ground 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 Business people down there in new orleans. You just cannot substitute for 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 President Trump said the administration deserves a ten for its response to the devastation of Hurricane Maria. Given the fat thakt most residents lack power, nearly a million americans lack access to safe and reliable Drinking Water i find that statement to be breath taking y. Hope that our Witnesses Today are better prepared than that to talk about what is really happening on the ground and what we can do to address this unfolding crisis. I hope it will be the beginning of an ongoing and concerted effort to understand what is going on and i would now like to yield the balance of my time to representative caster who wants to talk appropriately about the Health Challenges facing her state of florida. I thank you for yielding the time. This simply was a catastrophic Hurricane Season. We have so many challenges ahead. I want to thank our witnesses who are here today. I want tothank all of my colleagues for holding this hearing. Hopefully this is just the first of many because this is going to be a very long recovery period. After 75 lives lost in texas, 75 lives lost in florida including 14 related to a nursing home that were completely avoidable, we need to discuss that. We know that we have about 50 deaths in 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 their migration and what that means for the health needs of everyone. On the island the Drinking Water issue is simply critical. I look forward to your expert testimony today and the committees work in the days ahead. 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 to hear 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 subcommittees on these matters. As vice chairman stated this committee will be conducting oversight of the rebuilding of puerto rico and the u. S. Virgin islands for years to come. The Public Health risks typically associated with Natural Disasters are vary skpd include heightened incidences, diminished access to medical care and Long Term Mental Health trauma. These risks can be particularly dangerous especially for vulnerable populations such as infants, dialysis patients, individuals who may be immuneo suppressed and the elderly. We saw this in the after math of Hurricane Irma where 14 elderly residents lost their lives as a result of heat induced death issues after the facilitys air conditioning system failed during the storm. Last week this committee sent a bipartisan letter to the Nursing Homes owner requesting information on the facilitys Emergency Preparedness plan, inspection history and steps it took to protect residents after the air conditioning system stopped working. We will hear while three major hurricanes to impact United States in 2017 were distinct events that present and continue to present their own unique challenges, many protocols necessary to conduct effective Public Health response are federal agencies responding to disasters must be able to communicate effectively with each other and local, state and territorial officials to identify areas of need, insuring that individuals have adequate access to basic necessities such as food, water and medical supplies. As we head into recovery phase it is important we also carefully monitor patients as they transition from hospitals or under medical supervision back to their homes. News reports indicate more than 60 of puerto ricoens are now homeless as a result of the devastating hurricanes. We need to make sure when patients are discharged from hospitals that they have safe places to go and dont end up on the streets and back into the hospital. Following Hurricane Maria various media reports called into question whether the federal government is adequately meeting its obligation to protect health and welfare of american citizens. On this matter i look to gain perspective from witnesses who have been on the ground in the areas. Making sure the americans in need get the assistance they require cannot and should not be a partisan matter. Certain agencies arent pulling their weight we want to know. If there are federal laws or policies that are impeding the Recovery Efforts we want to know. We want to hear about any best practices that can be gleaned from ongoing Recovery Efforts to utilize in response to future Natural Disasters. Thanks to you and your teams for being on the ground trying to do the best you can in these orable circumstance horrible circumstances. We need to know the facts. What are the Lessons Learned and where do you need additional help. With that i yield back the balance of my time and look forward to the testimony of our witnesses. Before i do that, i would also like to welcome our newest member to the committee. I was just approved by the house conference this morning. And we are delighted to have you on board the committee. Thanks for being here today. I yield back. Thank you, mr. Chairman. Recognize Ranking Member of the full committee. Thank you, mr. Chairman and thank you for holding this hearing on this critical issue. I hope this hearing is the first of many hurricanerelated hearings as Congress Needs to hear further from hhs and other agencies regarding ongoing response and Recovery Efforts in all of the effected areas. I would like to take a moment to recognize the federal, state and local responders who are working hard to address the many Public Health issues which exist as response and recovery continues in all areas that were impacted by the three major hurricanes. I know firsthand of the tragic devastation caused by such immense Natural Disasters. In 2012 my district was hit hard by hurricane sandy. For many the storm was a worst case scenario, lost lives, homes flooded and businesses lost. The fifth anniversary is coming up this weekend and we still have a lot of people not back in homes or businesses. Our nation is experiencing historic levels of destruction and loss in puerto rico and Virgin Islands as well as florida, texas and the gulf coast. While no two Natural Disasters are alike the areas have unique needs and challenges. While Congress Continues to address the response in florida and texas must work to ensure that puerto rico and u. S. Virgin islands receive full and immediate support. I recognize a number of ongoing challenges facing the residents of south florida and the gulf coast but much of the hearing will likely teed laly need to situation in puerto rico and Virgin Islands. Hundreds of thousands of americans continue to meet day to day needs. Im particularly concerned of reports that residents do not have access to food or medicine. In the areas effected paint a dire situation that completely contradict often rosy stories from the president and the white house. Hurricanes irma and maria caused widespread flooding and destruction including Critical Damage to electrical grids, Drinking Water systems and transportation infrastructure. Virtually all residents of puerto rico and the u. S. Virgin islands have been impacted and these infrastructure failures create acute Public Health issues. We have seen and heard reports of death, dehydration and desperation as residents continue to struggle where fundaMental Health needs remain unaddressed even a month after Hurricane Maria and almost two months after Hurricane Irma. The list of serious needs and challenges is long. Many hospitals do not have reliable power. Many communities lack safe Drinking Water and people have resorted to drinking to questionable water services. Residents are still unsure if the water is safe and recent epa briefing we learned crews going into communities to test for Water Quality were arriving to find that people still lacked adequate food and Drinking Water. Congress must provide ongoing support in the aftermath of these hurricanes to restore and rebuild. I hope our witnesses will help us understand what needs to be improved so that congress can more effectively provide assistance and understand the impacts on Public Health not just today but in the months and years to come. I wanted to Say Something about the fact that many are coming from the island to our states in particular new jersey in my district. You know, my mayors and my elected officials locally are saying is there any kind of help for us because a lot of these people come here and dont have a lot of money and need support, as well. That is also something we need to look into. I would like to yield the remainder of my time to mr. Green. Thank you. Our district in houston and Harris County, texas was heavily impacted by Hurricane Harvey. We had at least eight deaths in our district alone. I thank the tireless work of First Responders, Public Health professionals, Community Members for helping fellow texans during the time of need. I would like to thank my colleagues. There will be much more for not just texas but louisiana, florida, puerto rico the Virgin Islands and a number of other disasters. The state of texas and cms need to Work Together to make sure we are taking advantage of every opportunity to help people in need especially when it comes to medicaid. Get necessary resources to our local hospital in texas to help uninsured disaster victims. We shifted to recovery in houston and texas gulf coast and are responding to Public Health concerns related to harvey including spread of mold and spread of disease carrying mosquitos. We must be responsive to the Environmental Impact of harvey including Community Members, possibility of exposure to toxic chemicals and wastewater. I look forward to hearing from witnesses and working with federal Public Health agencies to address these pressing concerns. In our office in houston we do a lot of case work on social security, health care, veterans. Now every staff member is case work with fema. We are working through it with our federal agencies helping us to make sure we can get people back to where they are. I yield back, as well. I ask unanimous consent that Opening Statements be made part of the record. Without objection they will be entered into the record. I ask consent that energy and commerce members be permitted to participate in todays hearing. Without objection so ordered. Further, just so Everybody Knows what we are doing, mr. Dunkin has joined the committee and subcommittee. Until a formal motion is made on the floor the parliamentarians tell me we have to treat him as a member but not yet on subcommittee of oversight investigations. He will be treated like all other members in the circumstance which means he will go last. As newest member of the committee he would go last anyway. We are just rubbing it in. I did want to let everybody else know what the status was so when they hear a motion on the floor they will understand that is what the parliamentarians told us we need to do. I assume he knows to as others getting us each coffee. Well make sure he is aware of those duties. We welcome members with us today pursue tonight house rules members not on the committee are able to attend our hearings. We are glad to have them but are not permitted to ask questions. I would like now to introduce our panel of witnesses for todays hearing. First we have the honorable robert, assistant secretary for preparedness and response at the department of health and Human Services. Welcome. Next is the honorable scott gotly who serves as commissioner of u. S. Food and drug administrati administration. Then we have ms. Kimberly brandt. Glad you are here. We have admiral steven red who is director of office of Public Health preparedness and response at centers for Disease Control. Thank you for being here. As a part of what we do in this committee we are holding an investigative hearing. It has been the practice of this subcommittee to take testimony under oath. Do any of you have objection to testifying under oath . Seeing none the chair then advises you that under the rules of the house and the rules of the committee you are entitled to be accompanied by counsel. Do any of you desire to be accompanied by counsel during your testimony . Seeing none i will swear you all in. Do you swear that the testimony you are about to give is the truth, the whole truth and nothing but the truth . Hearing affirmative answers from now i appreciate it. You are under oath and subject to penalties set forth in title 18 of the United States code. You may give a five minute summary of your written statement. Obviously, we will begin. Good morning members of the subcommittee. It is a privilege to appear to discuss our nations medical and Public Health response to a series of unprecedented nearly simultaneous category four and category five hurricanes that hit the u. S. Mainland and territories so far this season. Hhs as well as interagency partners of fema, dhs, dod have pushed boundaries in unprecedented ways to save lives and support communities and people impacted by the major hurricanes. I recognize in some regions in puerto rico and Virgin Islands people are still facing dire conditions. Recently saw that for myself in the devastation firsthand and can ensure you that hhs continues response at 110 and will continue to work as hard as we can until conditions improve. Since this is my first time testifying i begin with a brief description of my view on the role of this position. It was prettied almost 11 years ago in response to Hurricane Katrina. Its objective was to create unity of command by consolidating hhs Public Health and medical preparedness under one person. I had the privilege of serving as staff director of the subcommittee that drafted this legislation. The mission is simply to save lives and protect america from Health Security threats. Leads the Public Health and medical response to disasters in accordance with the National Response framework Emergency Support function number eight. Today the fronts facing our country are more lethal. My Main Objective is to improve National Readiness and response capabilities to 21st century threats. I aim to do that through four key areas. First provide strong leadership and create Natural Disaster Health Care System and sustain reliable Security Capabilities and finally advance innovative development. Hurricanes harvey, irma, maria and nate created unique challenges especially in puerto rico no place, mno person, no life was untouched. During my trip there i was overwhelmed by resiliency of citizens making do in difficult situations. Our strategy is save lives, stabilize Health Care System and restore health Care Services. In puerto rico we are still responding. In other areas recovery is underway. Here are many actions taken by partners. In order to save lives activated Natural Disaster medical system and deployed more than 2,500 personnel from 21 states and hundreds of other federal employees including corps personnel to communities impacted by the storms. In fact, in each of these storms we deployed teams before the hurricanes made landfall so they were ready to respond immediately. Cared for more than 15,000 patients in the affected states and territories. Hhs also sent 439 tons of medical equipment and supplies to the areas. Hhs declared Public Health emergencies before landfall of each storm. Cms proactively utilized empower tool to identify medicare and medicaid beneficiarys who rely on life maintaining medical equipment and people who rely on dialysis. We evacuated more than 200 dialysis patients from u. S. Virgin islands. Hhs activated the Emergency Prescription Assistance Program in puerto rico which provides free medications to disaster victims who cannot afford to pay. Hhs deployed Mental Health teams and activated Behavioral Health hotlines to people helping with psychological effects of these storms. I would like to show you a map. This illustrates comprehensive approach to provide health Care Services implemented. Together with our interagency partners as well as the Puerto Rico Health department. My overview of activities we took on behalf of americans in distress is just a fraction of what we actually did. I have not and could not speak to all of the work the assistant teams and Public Health Service Commission corps personnel did. They left their families, medical and clinical practices to render aid. We are committed to to the long period of recovery ahead. We also reflect on this by conducting comprehensive after action review to identify ways to improve our capacity to respond to future Public Health emergencies either naturally occurring or man made. I thank you for the opportunity to address these issues and am happy to address any questions you may have. Thank you very much. Five minutes for an Opening Statement. I appreciate the invitation to discuss response to hurricanes harvey, irma and maria. My remarks are focussed on the impact of maria on puerto rico because of the unique role fda has and the enormous magnitude of the devastation. First and foremost, our commitment is to the people of puerto rico as they begin the long recovery from overwhelming devastation. Fda also has a Broader Mission in puerto rico, a substantial portion of the islands economic base is compromised of facilities that manufacture medical products. There are currently more than 50 medical device manufacturing plants in puerto rico. They produce more than 1,000 different kinds of devices. To date we are especially focussed on about 50 types of medical devices. These devices are critically important to patient care because they may be Life Sustaining or life supporting. At the same time we are focussed on about 30 different important drugs and about ten biological devices manufactured on the island. 14 of these products are sole source meaning manufactured only in puerto rico. We have been working closely with our partners at fema, dhs and hhs. As well as logistics to move finished products off the island. Our interventions have evolved as nature of the risk has changed and response progresses. Early on we helped individual firms secure rights for planes. As days went on we started to get more actively involved in helping securities secure diesel fuel for generators. We have been actively engaged for helping facilities manufacture products critical to blood supply and secure small quantities of gases used in Manufacturing Processes. As Recovery Efforts proceed a lot of challenges are being solved through better logistics and no longer require active intervention. Thats the good news. We have processes in place to help guarantee fuel and medical gases and other critical components. There will be other challenges that rise as this crisis evolves. The one that concerns us the most is longterm power. Many generators werent meant to function for months on end. A lot of facilities cant return to full production on generator power alone. Most are producing 20 to 70 of their capacity. They wont be able to resume full production until they are back on the power grid. If they dont return to the grid by the end of this year we are concerned that we could face multiple potential shortages unless we can help the facilities shift more manufacturing off the island. With my remarks i would like to give you a perspective on the human factor that we are seeing every day where we see the islands residents taking off in heroic steps to keep supplies and critical products flowing and where firms are taking their steps as good corporate citizens to support these efforts. If we are going to avert major product shortages i want to take a moment to take note of the activities and to support them. First and foremost, i want to take note of the americans who reside in puerto rico. Medical product industry directly employs about 90,000. If we avert critical shortages it will be because of our fellow citizens who return to their post at this critical time as their own families were displaced. We owe them all an enormous debt of gratitude. I want to take measure of the good corporate citizenship. Even as we have watched some Companies Take extraordinary efforts to maintain production they took steps to support employees using facilities as a way to deliver direct assistance to those harmed by maria. Many of these manufacturing facilities is serving as Disaster Relief stations across the island and helping distribute aid to outlying towns. Companies are distributing gasoline to their employees and general relief items. Facilities have been using cafeterias to feed employees and families. One drug company told us they shipped thousands of generators to the island as part of hundreds of tons of relief aid. We know of companies that have created financial programs to help rebuild homes and resume their lives. Some of the programs include cash grants or match donations they accept across the globe as a way to help rebuild the homes. I want to take a moment to recognize these efforts. These kinds of commitments are a key part of helping puerto rico fully recover. We all need to do our part. Most of all i want to recognize the resilience of the people of puerto rico and their fidelity to Public Health mission. Fda has a long history of operating on the island. We owe the islands residents our long term commitment to a full recovery. Thanks a lot. I thank you for your testimony and now i recognize ms. Brandt. Thank you members of subcommittee, thank you for the opportunity to discuss efforts by the centers of services to respond to the recent hurricanes. Cms plays an intergral role. I have almost 20 years of experience and even with that perspective i was surprised of the involvement in the hurricane response efforts. This is a role our agency takes very seriously as evidence that cms administrator is in puerto rico assessing on the ground efforts in gaining valuable insights. Many people think of cms as a pair and as a regulator overseeing and enforcing standards for care delivered. While cms does not directly provide we do have a direct impact on the care they receive and the last several weeks have allowed cms to demonstrate the Important Role we can play. One of the most valuable Emergency Response tools is our ability to waive or modify Certain Program requirements which cms can do after the president declares a major disaster. Cms is using the full breadth of this authority to ensure our beneficiaries have access to the care they need so they can deliver high quality care to those who need it, when they need it and where they need it. We use waivers to allow medical providers to move patients between facilities and to expedite medicaid enrollment. Already we have approved nearly 100 waivers in total across the impacted disaster areas. Last month i joined on a visit to houston, texas where we were able to speak to several of those impacts including providers who demonstrated how important these were to them following an emergency. We want beneficiaries to focus on their immediate needs to provide urgent care without worrying about Reimbursement Policies and we heard during our visit what a difference those flexibilities make why cms is taking an approach in meeting and working with stakeholders on an ongoing basis to make sure we understand their needs and are able to meet them. One of the Top Priorities has been to provide access to necessary care to one of the most vulnerable groups, dialysis patients. One of the ways we have done this is using our authority to designate dialysis facilities located in locations impacted by the hurricanes that are not yet certified to serve as special purpose dialysis facilities. In fact, we were able to designate one of these facilities in florida before the storm hit to ensure that patients were dialyzed in anticipation of the storm. In puerto rico and the u. S. Virgin islands cms has been working closely with the Response Program to monitor conditions before, during and after the storms to predict the impact. Here are two examples of our combined efforts. Under the direction of one of our Commission Members we are working with these partners to track the operational status of dialysis facilities in puerto rico and their status with respect to fuel, water and other supplies as well as developing delivery schedules for the supplies necessary and to treat the nearly 6,000 patients on the island. Cms partnered with several partners to arrange support for approximately 120 patients evacuated to atlanta when conditions were no longer safe in the Virgin Islands. This included working with staff on the ground from day one to greet and medcally assess each patient as they arrived. Unfortunately, these events will not be the last health emergencies. Making sure providers are prepared for future disasters whether hurricane, wildfire is essential to insuring Patient Safety why cms requires all facilities to comply with basic health and safety requirements including Emergency Preparedness standards. The updates include a more comprehensive approach to Emergency Planning and requiring facilities to thoroughly address hazards. We require facilities to meet standards for staff and implement Communications System to contact patients, physicians and other necessary persons to ensure continuation of patient care functions. While much has been done there is much to be done particularly in puerto rico where over 50 of the population is covered through a cms program. Together we must continue to think creatively about ways to ensure we have access to needed care, supplies and prescriptions in the midst of emergencies and Natural Disasters. We appreciate the subcommittees interest in the efforts and look forward to irkiworking with you throughout the process. Good morning distinguished members of the subcommittee. I am rear admiral steven redd, director of center for Disease Control and office of Public Health preparedness and response. I appreciate the opportunity to be here today to discuss efforts and activities in response to the 2017 hurricanes. To address the impact of these hurricanes has provided Public Health support to coordinated, federal, state, territorial and tribal responses. The focus of the efforts have been in epidemiology and health surveillance, laboratory support, environmental and Occupational Health and health communications. On august 30, 2017, cdc activated Emergency Operation center to coordinate our response to Hurricane Harvey and subsequently we have expanded that activation to include hurricanes irma and maria. Since the end of august cdc has had approximately 500 Staff Members supporting the response. We have deployed over 70 staff to the 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, cdc deployed federal medical stations to serve as temporary, nonacute medical care facilities. Each federal medical station can accommodate up to 250 patients and includes cache of medical supplies and equipment. Hhs deploys medical teams to staff these facilities and cdc has deployed six of these to puerto rico, four to texas and two to florida. Cdc as used surveillance to monitor healthrelated data that may signal disease outbreak. Our National Syndromic Surveillance program has collaborated with disaster medical assistance teams to collect data on patient encou encounters and works closely with the American Red Cross to monitor data on shelter population so that Health Officials can respond quickly when that is called for. Surveillance during this response has indicated elevations in Carbon Monoxide poisoning. Identifying and controlling Public Health, diseases of Public Health importance in puerto rico and the u. S. Virgin islands are a priority. The Puerto Rico Department of health sustained significant damage during Hurricane Maria including damage to their laboratories. These laboratories are not able to conduct any Public Health tests. They are not able to confirm diagnosis of infectious or environmental diseases. Cdc is working to get the laboratories back in operation. In the meantime we have arranged for packaging and shipment of clinical specimens of suspected priority Infectious Diseases such as tuberculosis for testing. The first 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 effected areas to address Health Issues such as food safety, water issues including sewerage. We have provided guidance on injury prevention from debris and drowning. We helped with shelter assessments. We have provided guidance regarding safety of responders and we have developed and dissim sated key Public Health me messages. Cdc recognizes that the full recovery from the recent hurricanes will take time particularly in puerto rico and the Virgin Islands where the damage has been extensive. We are here to continue to provide that support. Thank you again for the opportunity to appear before you to discuss our response and Recovery Efforts. I would be glad to answer any questions you might have. Thank you all very much for your testimony. I will now begin questioning by recognizing chairman of the full committee for five minutes for questions. Thank you, vice chairman. I thank all of you for your testimony and the work that the people that you represent are doing in these terrible tragedies. We all know there is more to be done and it is hard in the aftermath to get it right. And we sure appreciate what you are doing. On behalf of the at large commissioner from puerto rico, thank you for joining us today. I know you are not able to ask questions as part of our committee rules, but i can on your behalf. So i appreciate your submitting some of these because i think they are really important to get on the record. I am going to start with you, puerto rico remains in the response mode of saving lives and stabilizing health Care Services. What major mile stones must be completed to go from response phase to recovery phase . I think it has been highlighted by members of the committee the power situation on the island does represent significant limitation. Right now we have about 60 of the 67 hospitals that are on the power grid and have reliable power. But there are 36 , total of 24, that still do not. That is an important benchmark. What do you think the timeline is to get them the power they need . I wouldnt be in a position to answer that. I think the u. S. Army corps of engineers is trying to move as aggressively as possible to do that. They have prioritized hospitals, Health Clinics and Dialysis Centers on the top of the list to reeelectrify. I think the intent is to get them up as quickly as physically and humanly possible. The other part of the sustainment is knowing about the operational status of the hospitals because some of them have physical damage, to ensure that they can basically resume full functionality. It is working closely with fema and with the army corps of engineers. Performed assessments to identify which ones need physical repair and then there are also issues that to supply restoration, things like oxygen, which i think is a matter of topical interest here. All right. Thank you. Rear admiral, thank you for being here and the work youre doing. Here is the cdc Dengue Branch in puerto rico being utilized during this recovery effort. I have one important for you. The Dengue Branch was affected just like every other location in puerto rico. As of october 10th the laboratory in operation, functioning at a low level under generator power right now. So i think its more in the affected response zone at this point. When do you think it might be up to full operation. I think some of the issues the doctor raised would be germane to the full activation and operation of the Dengue Branch as well. Particularly concerning puerto rico, department of Health Health labs. Today the labs are not able to conduct any Public Health testing including the ability to confirm diagnoses of infections and environmental diseases. What will it take to get them up and running. In their absence what is happening to do this kind of lab work . Yes, sir. So the restoring power is the first step. There is work with army corps to identify to bring laboratories up to power. There will ab second level of effort to determine what equipment can be salvaged and cant be salvaged. We dont know the results of that assessment until the power is back. So its going to be sometime. You dont know a time line on power. I think for generators were talking weeks at the most. They will be running on generators. Yes. Maybe less than that. So i cant say back on the grid but should be to the labs in a relatively short period of time. Meantime working with department of health in puerto rico to ship specimens to atlanta for testing. Thats where the first shipment has been. Are you comfortable perhaps to you and others on the panel with that kind of arrangement to do the lab testing. That is quick enough, adequate enough . Certainly not optimal, the best we can do at this point in time. I think what we really need is to be where those tests can be done in puerto rico and having the lab back up to full speed. But if its going to be weeks before that can happen, is there a temporary lab that can be flown in there . Weve had quite a bit of discussion on that. I think in general the the feeling is that getting specimens to atlanta for testing is going to be actually since its not going to be a very prolonged period of time, this is a temp orizing measure, not optimal but the best under the circumstances. You feel it works . Yes, sir. My time expired. Thank you, mr. Chairman, for the hearing and thank you for your testimony. Thank you. Now recognize the Ranking Member of the subcommittee from colorado. Thank you, mr. Chairman. I just want to remind the panel you know very well its been over a month since maria hit both the u. S. Virgin islands and puerto rico. Even now there was an article in New York Times, like going back in time Puerto Ricans put survival skills to use. Its a very powerful article that talks about how people dont have power, people are still eating canned foods. Elderly people are afraid to go outside because of gangs. And what it talks about is the way everybody is helping themselves is the neighbors are bonding together. Theres a fellow, the director of local nonprofit said most of the aid to neighborhood, which appears to be in san juan, not in the remote mountains, had receivers from private citizens and celebrities, quote, the government hasnt arrived here. As i mentioned in my opening remarks, having been on the committee having investigated katrina, its wonderful to reflect back on what weve done but more important to think about, a, how quickly we can do more. And b, what we can do to improve our efforts in the future. I just want to remind everybody listening to a lot of this tcm youd think everything was swell. I hope none of you intended to intimate that. I know were going to have a lot of questions about that. But commissioner gottlieb, i kind of wanted to hone in with you about your testimony. As you said, a lot of drugs and devices produced in puerto rico. Theres 13 of them, drugs, that are only produced in puerto rico. Is that correct . Theres more than 13. Theres probably somewhere in the nature of 40 sole source drugs but only 14 we think are critical insofar as they are medically important and cant find an alternative. About 14. Most of the plants where drugs are manufactured are relying on generators. Is that right . Thats right. I believe almost all if not all are on generator power. Generator. Now, i think you testified that this is not a longterm solution. Is that right . Thats right, congresswoman. There are some facilities with substantial generators and probably could operate for a sustained period of time. What do you mean by a sustained period of time . Some of them are very hardened. I dont want to say there are facilities that couldnt operate indefinitely on generators but thats the exception. Most facilities wont be able to operate for a sustained period of time. We get into the Second Quarter of next year stand these facilities arent back on the grid, were going to have concerns. Were trying to think how we can work with hhs and army corps of engineers to prioritize handful of facilities that are critical. The reasons you have concerns are twofold. Number one generators dont produce the kind of energy they theyd to produce these products number two. Even if you can produce it, its going to be a reduced supply. In most cases, i know of one firm producing at 100 output right now. They have dialed become certain portions of the facility. In most cases these facilities cant operate at 100 production on their generators and certainly cant 100 facilitators on generators. The other point is the generators themselves are going to break down. They are not meant to operate. They arent meant to operate these plants. Let me ask you quickly, on friday you released a statement that said fda is monitoring 50 types of medical devices manufactured in puerto rico, insulin pumps to pacemakers. Is this the kind kind of problems with drug manufacturers . Same challenge. Fifty devices were monitoring manufactured by 10 firms. In some cases device manufacturing is more energy dependent and facilities themselves need a more reliable flow from the grid. Even as these facilities back on the grid, if the grid itself is unreliable they might prefer to stay on generator power for long period of time. Many want dual feeds off the grid. Could be a while before they get the connection to the grid they need. Mr. Chairman let me say if anybody has concerned this is impacting all american families, my daughter who is a type 1 diabetic got a letter saying her new insulin pump was not going to arrive because of the problems in puerto rico. This impacting every american, not just americans in u. S. Virgin islands and puerto rico. Id like to ask unanimous consent to put New York Times article in the record. With that objection, so ordered. Recognize vice chairman of the full committee mr. Barton from texas for questions. Thank you, mr. Chairman. Want to extend my personal welcome to our newest member, mr. Duncan. Hes an outstanding member of the Republican Baseball Team i manage like mr. Ostello. Im sure hell do just as good if not a kber jbetter job on th committee. Good to have you. Look forward to the future with you. Mr. Chairman, i appreciate this hearing i know primary focus was puerto rico. We had a hurricane in texas, too. Were a little more developed as a state so our ability to endure it was possibly somewhat stronger. Having said that, theres still issues in texas. The first question i think will be to mr. Redd. There are lots in a normal year theres a lot of mosquitoes in the houston area. But given the amount of water that was sustained and still havent had a freeze, so we still have that issue, what cooperation, if any, has your agency had on helping to minimize that problem in the houston area specifically but the golf course generally . We operate as part of the combined federal response here. We work with dod from femamanaged response system to provide advice on what kind of Mosquito Control efforts would be most appropriate. Weve worked through that system. We dont do spraying ourselves but we provide that expertise on mosquitoes. As far as you know theres not an issue of not enough disinfectant insecticides. Thats correct. This is a problem that happens after virtually every hurricane which has a rain element to it. The types of mosquitoes that follow a hurricane typically arent ones that transmit disease. Theres pretty much a Standard Approach to that with cdc providing technical advice, dod providing the equipment and actually doing the spraying in consultation with the local Mosquito Control districts. Similar question. This would be to you, doctor. Lots of medicare patients in texas, golf course area, and many of them have had to go to hospitals for treatment. Under current regulations, does cms have the authority to reimburse these hospitals for the emergency treatment of medicare patients . Sir, since we have a representative from cms, ill ask miss brennan to thats my fault. I should have asked her to start with you. No problem, sir. Thank you. We are currently working with state officials to work with them on uncompensated care issues and to develop a plan so we can make sure to appropriately reimburse those providers. Is there anything the state of texas needs to supply cms to get that put together fairly quickly . Currently working with state officials for multistate waiver for federal matching dollars for uncompensated care pool. That would be for those people who have been displaced or need to receive care within the disaster area. So we are working with the state and hope for complete that in the foreseeable future. Im the cochairman of the texas congressional delegation harvey task force. My democrat cochairman is henry. If theres anything we can do let hess office or my office know, well make sure you get the information you want. We certainly will. Well keep you apprised of that, sir. Thank you. With that, mr. Chairman, i yield back. The gentleman yields back. Now recognize chairman of the full committee, from new jersey. Thank you. At a recent press event in puerto rico trump said he would give his administration a ten on his response efforts in puerto rico. I have to be honest with you what i hear from my mayors and Council People and people coming into my district from puerto rico, i would give at best a two on scale of one to ten. My concern is as i expressed a little in my Opening Statement, people are this isnt only an issue of whats happening on the island but also the people coming to the United States that have needs. I dont think they would be coming here if they werent if they were able to stay in puerto rico. Just as an example im looking at home news, which is my daily in new brunswick, one of the towns in my district, when the puerto rican governor visited with President Donald Trump on thursday to ask for aid, he said that without immediate help from the United States to rebuild the island, there would be a mass exodus to the mainland of the United States. And then we have a professor at rutgers, which is my district, who said the number of Puerto Ricans who will move to the garden state will likely spike once they determine they cant stay on the island longer if power and access to Running Water, food, and medicare do not improve. I obviously would like people to come here if they cant get basic necessities on the island. The fact that the president would call this a ten is just absurd, in my opinion. So let me start with you, doctor, recent reports indicate nearly 80 of the americans on the island are without electricity. One mayor reported his citys ambulances had to respond to at least four calls where a patient who lost power for oxygen tanks or vents later had died. Other reports state hospitals have had to take in patients from medical centers where generators have failed. Ill tell you, when we had sandy, i think our power was out for two weeks, and it was impossible. I cant imagine going for months without power. So lack of electricity has created serious risk to the health of american citizens in puerto rico. Would you agree with that . Sir, the hole society there. So the answer is yes, there is a risk to the people. I appreciate your honest response. Last friday cnn report add million americans on the island, about 35 of all residents still lack access to Running Water. I understand without adequate Drinking Water or safe Running Water to provide basic hygiene affected populations run the risk of serious gastrointestinal and related diseases. Again, with sandy i only went a couple days without a shower and couldnt deal with it. So let me ask doctor i guess dr. Redd, would you agree if feerl a million americans lack access to reliable clean water that this poses a Major Health Concern . Yes, sir. Described the situation in puerto rico going back in time. Wired magazine reported breakdown in electricity and Telecommunication Systems had pushed puerto rico, and i quote, back a century or so. Just yesterday the fcc reported nearly 70 of the island cell phone towers are still out of service. Again, lack of communication, lack of cell towers. You cant even address emergencies if you cant communicate. Let me go back to you, doctor. Would you agree take functioning Communication System is also an tension component to reaching and communicating with Puerto Ricans to ensure Health Care Needs are met . Sir, it is. Weve done lots to ensure we have positive communication on the island either by radio, cell communication or land line. We gave them satellite phones when there was no communication on the island to keep positive contact. To your point about the generator, thats a fair one. Quite frankly, sir, weve created a whole system to basically address that. In fact, when i was there the first week after the storm, one of the hospitals where one of our dmat teams was located, colocated lost generator power. They had several patients in intensive care unit, a couple having surgery at the time, they were transported safely without loss of life not only to shelters where dmat teams were but transfer them in ambulances, medevac helicopters. To that point, we have gone to extraordinary steps to basically help i appreciate it. Let me issue one thing as the time runs out. The president said it was a ten, i gave it a two. Would you give me a number between one and ten. Im not in the business to give you marks but i can tell you were working 110 even today to help those people, help our fellow americans on an island. I appreciate that. Thank you mr. Chairman. Thank you so much. Now recognize gentlelady of indiana miss brooks for questions. Thank you, mr. Chairman. Thank you to all our pam members for being here. Dr. Kadlec want to talk more about National Disaster system youve described. I know youve only been on the job for a few months now. In fact, how many months on the job. 60 days. 60 days. A tough 60 days. Its been a baptism. Are there obviously you were very familiar with the Organization Prior to becoming in charge. There are reforms to the National Disaster medical system that youre already considering, or are there challenges youve already faced, whether its on the deployment, whether it is on the number of resources you have or the authorities you have . If so, what are they . Maam, all the above. I think one of the things this event demonstrated because of the extraordinary nature, to the representatives point, to go down there and see the devastation is pretty extraordinary. Ive made five combat tours in iraq and i never saw anything like what i saw in puerto rico, number one. Number two is, that would kind of simulate when we probably expect when we had Nuclear Detonation without fire or radiation. So the physical destruction to that island, as i said, affected everyone. The psychological and physiological effects are pretty extraordinary. To that point, we were stretched in terms of our dmat capabilities to deploy. I give a lot of credit to those physicians, paramedics, pharmacists in your states who deployed down there on numerous occasions. We had people at colorado who were at harvey, irma and now maria. The answer is we probably need creative thinking how to do that. We worked well with v. A. On that, probably with dod. Theres a lot of things we need to do to remove dependencies. Do mother may i for transportation. We probably need a larger supply capability. We need to move things faster and better. That said, we deployed before landfall. We had 150 people from our dmat teams in san juan riding out that storm. We have Extraordinary People degree extraordinary things. From your jurisdictions, there are american heroes. We probably dont give them enough credit and certainly dont give them enough resources. Dr. Kadlec with authorities, is it clear who is actually in charge of response efforts or do there need to be additional operational capabilities provided. Maam, thanks something were going to do after. I think we do pretty well but could do better, work with your staff to identify those things. Remove dependencies, mother may i, ambulances, air, transportation, a variety of things we need to resolve. Thank you. Miss brandt, again, i have some questions also provided. Prior to Hurricane Maria, according to my colleague, almost a physician a day would leave the island, would not be practicing an effected number of specialists left the territory, how is that impacting longterm and shortterm Recovery Efforts. I actually received communication from a constituent of mine whose cousin was a specialist overseas at the time that it hit, and she had difficulties getting back onto the island to help her people. So what is cms doing relative to the Physician Retention issue . Thank you for the question. That is hispanic that cms is very concerned about and very aware of. In terms of the retention effort weve been working department of health on the island and seeing what flexibilities we could do administratively to lift requirements that would make it easier for people to stay on the island or work with them to see what other types of programs we have that would provide incentives for physicians and other medical personnel on the island. But ultimately that is a decision by the government of the island. In terms of allowing people to come in to assist with the efforts on the island, especially in wake of what has happened, we have waived many different regulations and other authorities that we have that would have limited out of state or out of territory in this particular instance providers to be table to come in and provide care and working with department of health on the island to see what else we can do to ensure they have access to as many personnel as we can get them. Thank you for flexibility. My time its up. Thank you, gentlelady. Now recognize the young lady of florida, miss caster, five minutes for questions. Thank you, mr. Chairman. Over a month later folks in florida and all across the country are still reeling from the avoidable deaths in nursing facilities in florida. There are now criminal cases, civil cases. Were trying to figure out why in the heck floridas governor has deleted voicemails that came directly from the center to his cell phone. Theres an important pack story here. In 2005 after Hurricane Katrina and 215 deaths in Nursing Homes there, cms and everyone determined many Skilled Nursing centers are not prepared. You went to try to determine theres an alternative power source available. I understand that it will be november when a cms rule relating to alternative Power Sources for Skilled Nursing 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 Wasserman Schulz from florida and thank the florida delegation that has 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 med kaye ca medicaid beneficiaries. With respect to the rule itself, the rule went into effect last year. Well begin serving against it in november. The rule actually went into effect last year. Its just the actual surveys against it will go into effect starting next month. However, it is something that we think does go a long way towards addressing a lot of the concerns 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 do more. Some of the things it does that were pointed out as part of the problem at Hollywood Hills are ensuring 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 the facility and it doesnt go beyond that. Were also working to make sure that the appropriate staff are trained so they know what to do in the case of 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. Thank you. I encourage you to do that on expeditious basis because that timeframe is not acceptable. Miss brandt Health Services provided under medicaid provide Critical Role in health, families able to recover from Natural Disasters. Following katrina Bush Administration took a number of actions to ease barriers to Health Insurance coverage through medicaid. For example, cms allowed for temporary expansion of Medicaid Eligibility infected areas, moratorium on eligibility redetermination, 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 Maria . What if any difference will be there between puerto rico and u. S. Virgin islands and state on the 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. So 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. Good. 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. Even for future consideration. The first would it be beneficial to postpone medicare Enrollment Period to january 2018 . I asked this of miss brandt. Dpichb that 80 of the population is without 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 because we recognize many of them may have trouble meeting the current Enrollment Period. So that is viable . Yes. Okay. 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 we did 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. 92, 93 of 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. Weve been working a variety of different ways. Our dmat teams have caches they take, pharmaceutical supply. Weve done tailgate medicine. Weve actually gone into areas that are rural, remote and 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. Okay. 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. Mr. Got ltlieb, one more question. Medical access continues to be a challenge in puerto rico. Could you please update the committee both on 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 larger 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 thats 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 using comforts 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, ill tell you there is a number of medical product manufacturers who use oxygen, night again in their Manufacturing 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 bihar vard humanitarian initiative on humanitarian disaster aid including International Committee of red cross and one of the First Responders in 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 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 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. California one, california 11 from Orange County 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 dont 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 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, into the 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 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 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 the need. 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 lot more 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 queue. I went to a local school in one of the communities. They were going to close their doors october 23rd 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 authorities to move them down. Hell, yes. Having command posts on the ground in every municipalities, ngos, local mayors and everybody hold themselves accountable to address needs and realtime actions and cut mother may i, l like you suggest, get the food, medicines, realtime, addressing problems 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, trillion grids. Those are 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 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 effects. 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 took a 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 get go. 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 migrations and 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 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 you off, 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 would 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 as severe damage, if there had been a generator capability there that could have been stood up more quickly than whats going on now, those are the kinds of things that would have been able to bring the system back online 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 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. While i cant dispute the issues of field command post, i can say certainly, and with great authority, that throughout our efforts we were trying to work 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 ak s across not only department of health and Human Services we show here, solidarity with cdc, fda and cms and other but dod. The uniqueness of that is displayed in puerto rico that wasnt 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 in houston 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 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 pohospit personnel had it patients, haitian navy went out there to 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 to take vac of terrible events to see what we can do better. Thank you. Such a thorough response 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 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. Hospital stated it employs full time and parttime employees but did not state if a nurse was present when the paint 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, water. Weve talked about that. Of course more than a month after Hurricane Maria reported surgery is being done by cell phone flashlight. Theres 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 specific areas. 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 gen power at what of the hospitals. 0 on the grid would have regular power. Theres reliability as relates to 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 out there that are on the grid. Even those hospitals have generator backups. Okay. I want to turn for a minute to the Virgin Islands, dr. Kadlec. I understand Hurricane Maria tore the roofs off of the two 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, 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 thats there. Now were in the midst of basically deploying a western shelter 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 by army corps of engineers to either be repaired or replaced. I think in the case of saint thomas its going to need to be replaced. Weve provided immediate care, provided 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 and replace those 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 others now dealing with the fact that they are moving into an environment without power. In many cases without Running Water. Just to highlight a comment made earlier by admiral redd, there are 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, cant go home for whatever 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 one to make sure that when they 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 in to 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 been reported thane 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. Thats one way. The other way is if they would go to one of our dmat facilities colocated in seven of the regions in puerto rico, they can get medicines from there as well. We provide prescriptions or medications as required. Thats 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 who seek 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 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. So dr. Gottlieb, representative gonzalez that asked me to ask you, 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 its not business as usual as all. Thanks for the question, congressman. We would typically grant waivers, for example, if crops damaged in a 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 agriculture facilities and Food Production facilities to help them get back online. Weve done this in the last week or so even as our own employees down there have been devastated by the rushing. We have about 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 to say 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 two ten. 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 did occur on puerto rico. I yield back. The chair now recognizes the gentleman from california, mr. Peters for five minutes for 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 respective of prevention. I think a lot about what we might do with respect to preparing communities to deal with earthquakes or fires or floods. But from a health perspective, i havent really given it much 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 arms 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 east coast 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, its always going to be a circumstance that we may not be able to get 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, 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, the thing 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 has been 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 theyre 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 were 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 to better coordinate on the ground realtime with all the stakeholder snz. 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, 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 of unidentified 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. If you looked at that time, you hear the legend of hurricane galveston, 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 face many Health Challenges. The centers were breached, there were chemical spills, raw seuwae spills, toxic smoke fires that got out of control, flesheating bacteria took two lives. One in galveston, one in kingwood. A First Responder in my district was infected but 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 scandlinoaks. Talked to the parents, school kids come to class. One young man came very proud, the tornado hit my home. Knocked out my window as i was sleeping. Mom came back, and i said, man, hes doing great. She said, no, hes not. Hes great at school. A great story. I beat 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 by these events. Also, the adults. We went through days and days of tornado warning, flood warning, three nights, probably slept three hours in four 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 on everyone. Most of those effects are relatively short term for most people, and i think for people, when those effects are not short 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. 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. One thing that unites us, beat l. A. I yield back. I thank the gentleman and now recognize the gentle lady from new york, ms. Clarke, for five minutes for questioning. Thank you so much, mr. Chairman. I would also just like to remind everyone that were talking about territories that are in tropical climate and that these are triisland territories. I hear people talk about puerto rico as if its a monolith. Theres also two others. Theres also Three Islands with respect to the u. S. Virgin islands. And that is st. John, st. Thomas, and st. Croix. So i dont want us to see this as a monolith because each of these islands have their own identity, their own inhabitants, and im not hearing enough of a deep enough dive into what is happening with the inhabitants of all of these territories. Because its not one singular event. Its an event that hit three separate geographic territories. Im putting that out there because im going to want to hear more about what is happening in terms of response to those territories. Were not hearing at all about how the people of st. John are receiving health care, the people of veecs are receiving health care. Were not hearing that information. That is just as important. I would like to start my question about the evacuation process. What assistance was provided to implement an adequate and efficient evacuation plan for those whose health are compromised . And was there coordination assistance provided to the local Health Departments in the wake of the hurricane to track evacuees who were sent to other islands and or the mainland . Maam, i can probably address that in deference to your question, i would highlight the map which we provided which identifies where hhs is based with providing augmentation support, st. John as well as st. Croix and the Virgin Islands, and we had a presence on vieques as well. To your point about evacuation, again, for the complexity of this event, and again, irma struck st. Thomas first, and for which we were doing some unprecedented things using cmss and power database, we actually were able to send in our map teams with urban search and rescue and identify dialysis patients on the island, which we recovered 120 of them. And then evacuated them to relative safety in puerto rico until maria hit. At which point in time, we evacuated them literally the day before, the day of landfall of maria. Evacuated those patients to miami to a medical shelter there where we could insure that they were being cared for. In the cases of other patients who were evacuated from the Virgin Islands, they were evacuated through atlanta, and again, receiving care through their, through local resources. And so throughout the intent here is not only did we evacuate the dialysis patients but sent them with a nonmedical attend nlt, a family member, so they would have someone to assist them along the way. At the present time, theres only been a handful of evacuations off the island to the mainland. There were two pediatric patients that were evacuated from san juan to miami soon after landfall. But what they have tried to do is basically maintain Health Infrastructure in puerto rico because were hopeful those people get better and they need to be closer to family and support units there. So the way we address the problem in puerto rico is we created these seven regional hubs of hospitals that we augmented with our disaster medical assistance teams. We took the benefit of a Level One Trauma Center in Central Medical in san juan, where we made it one, if you will, the eastern hub, Receiving Hospital for high acuity or intensive care patients and then used the u uss comfort as a western hub, a mobile hub that we could run from basically from the top down to ponce to collect patients depending on their acuity as required. And then have been able to use dod assets, both ground ambulances and medevac helicopters to provide response on the island and then using Naval Medical assets and rotary wing and fixedwing assets. There is a document you have that just sort of outlines all of that . Yes, maam. I can make that available. I also wanted to talk about the Public Health challenges of these islands territories. The islands will need the assistance of the federal government in the weeks, months, and years to come. What is the agencys position of the medicaid cap as it relates to the Virgin Islands with this already limited resources . And do you support a full federal contribution as the federal government did for katrina . Ill defer to ms. Brant. Thank you for that question. That is certainly something that were looking at, and were exploring whether or not we would have the flexibility to do that. But the federal match is set by congress. Its statutory. Yeah, im asking about your recommendation. Right now, you have these islands, right . Island territories where in one case, the u. S. Virgin islands, their major employment is through tourism. Right . No ones working. So are we requiring that government to come up with a match or are we going to suspend it and do a full federal contribution as we did for katrina . On the mainland. Excuse me for not answering directly. We are pursuing that. Were working with the office of management and budget to pursue that with congressional approval. Wonderful. Thank you. I yield back, mr. Chairman. I thank the gentle lady. Now recognize the gentleman from georgia, mr. Carter, for five minutes. Thank you, mr. Chairman. And thank all of you for being here today. I appreciate your presence. Im going to assume this goes to cms and thats ms. Brandt. Can you help me here . I know the situation exists with the nursing home situation in florida. Are you going to now require Nursing Homes to have generators . Is that going to be a requirement . Can you very briefly tell me how thats going to work . Sure, we actually have an Emergency Preparedness rule, which was finalized last year. That is going to be surveyed again starting next month, so thats when the state surveys go out. It requires generators. It requires Emergency Preparedness plans and training on a continual basis. Would there be any kind of reimbursements for Nursing Homes . I spent much of my professional career as a nursing home consultant. They are pushed for trying to stay solvent as it is. Is there going to be any kind of help for them or just another government mandate . Thats certainly something were looking at but i cant speak specifically to that at this time. Thank you. There was an article in the wall street journal the other day about the uss comfort the medical ship and how it was off the coast of puerto rico and it wasnt being utilized. I want to get your input on how we can do a better job in the future of making sure from what i understand, its a 250bed hospital on the water, but only 150 beds were being utilized at one time. Yes, sir. What can we do to make it better . Its costing us 180,000 a day just to have it there, and those people desperately off of puerto rico need the help. Yes, sir, and again, to allude to ms. Clarkes question before, part of our plan was basically use the comfort as a capability to deal with high acuity patients, intensive care patients. Particularly in circumstances where hospitals on generators would fail, where we would need to urgently transfer critically ill patients somewhere, and so we were basically using the 50bed icu on the boat and we understand and appreciate that, but it seems like we could have made better youssef it. Have we learned anything . Is there anything we can do to make it more successful in the future . Were in the midst of looking at how we can utilize it more, accept more of the stationary platform in one of the ports in puerto rico. Exactly. Make it more accessible. Thats been an ongoing conversation with the department of health in puerto rico to assess what we can how we can use that more to their needs. Okay. Thank you. Dr. Gottlieb, its my understanding that the fda can declare on a shortage list medications that are not available and that they can be compounded. Is that true . They can be compounded by pharmacies if theyre put on the fda shortage list . We dont typically look at the opportunity to compound as an alternative or solution for shortages. Our drug shortage staff would typically work to try to get the approved product back in supply and might look to help source the same product from overseas manufacturing facilities that might be inspected by fda. It is a case that in certain situations, you might see practitioners go to approved compounding facilities, facilities that are compounding within the confines of the statute to source certain products. Okay. So youre actually increasing access to alternative medications . Is that what youre trying to do . We have taken thanks to some of the newest authority that Congress Gave us with respect to the drug shortage and the ability to identify shortages further out from the actual occurrence of a shortage, we have been taking steps to try to mitigate the shortages that have occurred and also situations where we see the potential for products to tip into shortage. Were looking out a month, two months to see what could potentially happen if production doesnt resume and taking steps to, for example, move temporarily certain manufacturing out of facilities that might be damaged or not up to full production to facilities in other markets that could help supply the u. S. Market. Okay, i would ask you as you continue on your process for the memorandum of understanding, dealing with compounded medications, that you would take into consideration Natural Disasters and there would be exceptions put in there where compounding pharmacies could be utilized to get the medications to the patients in the case of Natural Disasters such as this. We would be happy to work with congress, as well, and it would be more appropriately addressed in statute, but i look forward to working with you on that. Ill be happy to work on that. One final question, ill ask you, is the cdc supporting vaccinations to prevent leptospirosis. I would defer to my colleague. Theres no vaccine for leptospirosis. What about treatment for that . Its very treatable. It works better the earlier the disease is identified, so earlier treatment is more effective. Is that being supplied to puerto rico now . It is. The antibiotics that used for treatment are theyre not pretty common . Theyre not anything special. Penicillin, tetracycline. Great. Tetracycline is not available as much as it ought to be. Depends on dr. Gottlieb will attest, unless youre getting it for fish tanks. Nevertheless, im serious. Nevertheless, it is a problem. But thank you very much. And thank you all of you again. I yield back. Now recognize the gentleman from new york for five minutes for questioning. Thank you, mr. Chair. As rancor on the subcommittee of environment, that reports to the Standing Committee of energy and commerce, i would say clean Drinking Water and is a major effort to focus, and im very appreciative the committee is responding to. We have recently reported a bill from subcommittee and then Standing Committee. So therefore, i want to address that concern, clean Drinking Water. There are many reports about a lack of safe Drinking Water in puerto rico. Unfortunately, neither fema nor the epa is before us today. So dr. Redd, im hoping that you might be able to share some insights into the water situation in puerto rico and the virgind islands. Recent news reports have stated nearly one third of puerto rico has no reliable access to Potable Water at home. Because of this, we have heard reports of people drinking and bathing in rivers and streams in puerto rico. Last tuesday, puerto ricos state epidemiologist announced that there have been some 74 cases of leptospirosis reported on the island so far this month. Puerto rico usually sees only 60 cases of this disease, as im informed, in a given year. Some reports have connected this outbreak to public use of contaminated water sources. So i ask, can you tell us about this whole concern, about leptospirosis and what are its symptoms . Certainly. Leptospirosis is a bacterial infection. Its acquired, as you described, by drinking or being exposed to water thats contaminated with those bacteria. They infect many species of animals. And animal urine is the vehicle for transmission of the disease. So situations where theres a shortage of Potable Water or exposure to floodwaters that are contaminated with the bacteria are the settings for exposure. Were working closely with the department of health in puerto rico to confirm or to determine whether those suspected cases actually are cases. We have specimens in the laboratory at cdc right now doing those tests. There is were aware of one confirmed case that was diagn e diagnosed in a patient at the v. A. So how large this outbreak actually is, if its an outbreak, remains to be determined. The best way to control the outbreak is to prevent exposure to the contaminated water. That really is an issue you started with, with wider availability of Potable Water, and early treatment for people who have symptoms of fever, weakness, exposure to those things. Then in the later stages, more characteristic is jaundice, yellowing of the skin because of liver damage. For the question about the extent of the water supply system, i might refer to the doctor on what the situation is proportion of people who have access to Potable Water. I can give you just basic lead down we have been following. 25 out of the 115 public Drinking Water facilities are out of service. So again, thats an intense issue of concern, and again, prioritization in terms of reelere reele reelectrification, but facilities are out of service. So that gives you a rough estimate of what the situation for water is. But if thats being followed by the u. S. Army corps of engineers. Back to the disease itself, is it normally treatable . It is treatable. It does have a significant mortality rate for severe cases, 5 to 15 mortality. Its a serious disease that we need to take steps to try to prevent, and when its recognized, treat promptly. And how critical is it that patients be treated in, you know, in a matter of days or hours after . Well, the sooner like many bacterial infections, the sooner treatment can be started, the more effective it is. So early recognition is very important. And some of that has to do with access to medical care. And are there any other diseases or hazards associated with drinking and bathing in rivers and streams, particularly after these heavy rains and floodings that we saw in puerto rico . Are there other Health Concerns . There are. There are. So the conditions that can cause gastrointestinal illness are going to be more common in floodwater, waste water, that has sewage in it. There are also Skin Infections that could be more common when people become exposed to that. So really, its a variety of diseases, as well as something thats been alluded to earlier, the inability to wash hands, do things that will have many other beneficial effects. Thank you very much. I yield back. I thank the gentleman, and appreciate everybody bearing with me. I am going to reserve to go at the end, now recognize mr mr. Bilirakis from florida for five minutes for questions. Thank you. Thank you, mr. Chairman. Thank you for allowing me to sit in on the subcommittee. Secretary, does the Hospital Preparedness Program currently allow states to use grant funds to help defray costs associated with procurements of generators for assisted living facilities and Skilled Nursing facilities to support the development and sustainment of Regional Health care coalitions . So, the way the grants are structured, its for Health Care Facilities and for coalitions there of. So as part of a plan of a coalition, that could be considered as part of it, but we dont dictate that as being part of it. Were looking at to identify how these hospitals and Hospital Systems can become more resilient. But in fairness to your question, sir, if i may get back to you on that, i can give you more fulsome follow up on that. Thats very important. To see whether its permissible, because again, in our area, there are small nursing facilities, but also alfs that dont have generators. Thats a priority. Thats what im concerned with. Ill get back to you. Maybe they have ten patients or less. And weve got to make sure they have their generators, the backup. Ms. Brandt, last friday, the committee sent a bipartisan letter to the owner of the Rehabilitation Center at Hollywood Hills in florida, raising concerns, again, about the nursing home in florida, where 14 im sure youre aware of this 14 residents eventually died after the facility lost air conditioning. In the wake of Hurricane Irma. There was apparently a fully functional hospital across the street. Unbelievable. And according to the Florida Agency for health care administration, the facility administrator and medical professionals didnt know to call 911 in an emergency. I just cant i cant understand this. Whats wrong with these people . How could a nursing home be so unprepared for a medical emergency that 14 residents lost their lives . Especially when there is a hospital across the street. Can you answer that question, please . Well, thank you for the question. And as youre aware, Hollywood Hills has been terminated from participation in the midcare and medicaid program. We make Patient Safety our number one priority for the residents of all of our medicare and medicaid facilities, and this was a complete management failure at Hollywood Hills, which is why they were terminated. They did not meet our conditions of participations for keeping the temperature at a reasonable level. They did not provide adequate care to the patients. As you mention, there was a hospital right across the street, so they had several levels of what we call immediate jeopardy for patients, which is why they were terminated. Okay, who is ultimately responsible for their safety . In terms of the Patient Safety, the facility has the responsibility and the management at the facility has the responsibility to insure theyre meeting Emergency Preparedness requirements, that theyre providing adequate care to the patients, and we survey and hold the facilities accountability to those requirements. Okay. Thats very important. The accountability, obviously, the supervision is so important. What can cms do to insure a tragedy like this never happens again . Well, one of the things that we have done, as i mentioned in my Opening Statement and the written testimony, is we have instituted a Emergency Preparedness role that requires they have a plan, that they train on the plan and make sure all employees are aware of it, and that they have adequate backup in place to allow, you mentioned the discussion of generators and other things, insure that they have adequate Power Supplies and other things to insure that patient care can be provided and that they have a plan for where the patients can go if it cannot be provided. What about puerto rico now . I understand that there are Nursing Homes operating without air conditioning. People are very unsafe. Who is responsible for this . Who is supervising this . Is it cms, hhs . And obviously, its unacceptable. Can you respond to that . Well, so in situations like in puerto rico where you have an almost unheard of position where you have no water, you have no power, you have really no ability to provide, we work with all of our partners. The doctor and the team as well as the fema teams and everyone on the ground works with not only federal and state but also the territory officials in puerto rico to pull together and get patients to a safe place. If they dont have the ability to provide that care, then we Work Together to get them transported to a safer place such as the evacuees that the doctor was talking about earlier from the virgind islands. Thank you very much. I appreciate it. Ill yield back. I thank the gentleman. Now recognize the mr. Green, the gentleman from texas, for five minutes. Thank you, mr. Chairman. And coming from the houston area, again, a very urban area, i heard today that we had our second death from the flesh eating bacteria in galveston county, one to the south of us where im at, but also to the north we had a 77yearold lady in the kingwood area who passed away. We have some great medical facilities and that gentleman was at utmb because its infectious disease. Has that been prevalent in puerto rico or Virgin Islands . I know we have a lot of standing water early, we did have. And i would like to ask this of cdc. Im not aware of cases that have occurred in the other hurricaneaffected areas. The condition that youre describing is pretty infrequent in the u. S. About 600 to 700 cases per year over the last four or five years of that disease occur. Its not common, but the exposure to flood waters is a risk factor for that condition. Okay. Thank you. Hurricane harvey created so many serious environmental and Public Health issues, including evidence of compromised Super Fund Sites and tox ic spills, chemical fires and high levels of air pollution. Epa confirmed in the aftermath of Hurricane Harvey, we have a location called a waste pit in Harris County that is now in the congressmans district, but it was in my district, it was in ted poes district, so we changed those, but our constituents still contact all three of us. The analysis found that it was concentrations of 2,000 times higher than the level in which the epa required a cleanup. And the epa administrator was there literally two weeks ago to visit that site, and the decision has been made to permanent clean up that facility there in east Harris County. I was glad of that. Dr. Redd, what are the types of risks associated with substances such as this . Its a dioxin facility. Dumped there in the 60s by a paper mill. We have responsible parties, in both the state of texas, the city of Harris County and city of baytown thats there, put signs up in english, spanish, and vet numees not to eat the crabs or fish. When i go out there, you cant find anybody who doesnt have a fishing pole because the signs say if youre an expectant mother or a small child, you shouldnt digest these crabs, but a lot of people still do. What are the types of risks that are associated with that, other than that problems with eating it . I would like to respond to that question in followup. I dont want to say anything thats incorrect, and i think especially with the levels that were seeing in that setting. Okay. Like i said, were going to the decision has been made to clean it up. But my concern is a lot of my constituents who go out there and fish and crab, and i keep explaining to them, you need to Pay Attention to those signs. According to the Houston Health department, there were millions of contaminants in flood waters covering most of the city. Arsenic, lead, heavy metals were repeatedly found. Dr. Redd, following Hurricane Harvey, what role did the cdc play in warning affected communities of possible waterborne risk and other Public Health risk . In general, in that part of the response, we were working in support of the epa. The kinds of things that we would do would be to try to make the kinds of warnings that you described, make sure people know those things. So really Public Health communications because of the flooding. Okay. Additionally, not just from the industry but about 50 Drinking Water systems were shut down following Hurricane Harvey. And more than 160 systems issued boil water advisories. This is an issue also were seeing in puerto rico, which still is issuing boil water notices. However, given the lack of power, some people are not able to boil their water. Dr. Redd, given that boiling water may not be an available option, what are some of the hazards of drinking potentially contaminated water without boiling it, and how does the cdc communicate these hazards . Now, we may be over it, i hope, at least in southeastern texas, but again, in the Virgin Islands and puerto rico. So, the hazards that one would be exposed to Drinking Water that could be contaminated with sewage would be the things we talked about before. Gastrointestinal illnesses, the inability to do hand hygiene that prevents a lot of other diseases. And if theres a Super Fund Site contamination exposure to some of the materials in those waters, i think just to bring back one other point, thats one of the reasons that having the Public Health laboratory in puerto rico online again is so important, is so that testing can be done. And when water is safe to drink, it will be easier to confirm when that testing is available. Thank you, mr. Chairman. I know im out of time, but you know, every year, the upper texas coast, i mean every seven or eight years, we get a hurricane or a Tropical Storm, so you know, hopefully it will be that long a time, but are we learning any lessons from Hurricane Harvey, both in southeast texas, louisiana, that could be applied in puerto rico or the virgind islands now or hopefully were learning to be better prepared, particularly for our water systems. When they shut down, thats really a human need that we have to have. And doctor, you had mentioned that. Thank you, mr. Chairman. I appreciate that. And thank you. That being said, i now recognize myself for five minutes. And this will be the end. So youre almost done. Dr. Gottlieb, black mold. All of the areas we have talked about, Everybody Knows theres going to be some black mold issues. Heres one issue im not sure most americans know. What are the symptoms . If you see it, youre going to do something about it or try to do something, but oftentimes its a hidden concern. So what should be people on the lookout for . You want to take it . I defer to cdc if thats thats fine. Youre absolutely correct, chairman, that flooding leads to mold contamination. There are two different hazards from exposure to mold. One is the worsening of allergic conditions. That can be quite serious in the case of someone who has asthma who is sensitive to mold. The other is particularly for people who have weakened immune systems. Infection for mold. It also can be very serious. How are they going to know . I recognize the seriousness. What are they going to be seeing . I think when Building Materials have been damaged, i think if mold can grow on it, it will. So really, its a question of remediation. In other words, porous systems, removing those systems and rebuilding. And for surfaces that arent porous, cleaning them. Thats the guidance in those areas, is what cdc has been providing, working with the Texas Department of health. All right. I guess im concerned if you dont see it and dont know its there, i mean, i know that youre going to start having some rasping, particularly if you have asthma, but what if you dont, or what if you dont know about that . Isnt that one of the first ways you tell, you start having some chest congestion . I think for areas that have floodwaters, you can tell where the flood water has been, and you just do the remediation. All right. Doctor, its been a month. We have any hospitals in puerto rico that are not accepting patients . Sir, there are about if i remember correctly, about three that were closed. So there are some that have been that arent open. Physical damage to the point where they could not the ones that are open, are any of them refusing to accept patients . Sir, on a daily basis, i dont know what the census is, but it could be the circumstance where they divert patients. We talked about dialysis before. Any other specialized treatments that are currently unavailable at various hospitals . Dialysis is available through the 46 of the 48 clinics on the island. Depending on the hospital, there may be some services that are not available, so i cant give you affirmative. Let me ask you this. Because i read a report somewhere that even though dialysis was available, they were cutting short the treatment time period from what it normally would be. Is that still the case . Sir, it is, and were looking to actually work that problem out in terms of lowering the stress on some of those clinics. Where they see fewer patients or defer patients to places thatt have more functionality. That brings up the comfort the u. S. Navy ship comfort. Its sitting out there, hasnt had a whole lot of patients. What is, and this is a question my colleague addressed earlier. What is the approval process or the admission process to get on or to be approved for the comfort . Yes, sir, the plan is very simple, that the island was kind of not cut in half, but based on the swath of the hurricane that came through, westward side, eastward side, on the east side, referrals of any high acute patients, intensive care patients, that need to be made from hospitals that are on the east side of the island, we go to central medico, which is their Level One Trauma Center, that would be done through ground or rotary wing transportation. The determination of whether the patients would be moved there, same as to the comfort would be based on decisions by clinicians at central medico that would review and talk to the doctors at the local hospitals to say, what is this patient suffering from . What kind of care do they need . What kind of service do they need . And i appreciate it. Based on that, they would be transferred. One of my concerns, i recognize some might argue that its good that you havent sent more to the comfort. I think we have an asset down there were not using. Dr. Gottlieb, biggest longterm concern you have both for puerto rico and otherwise. Whats your biggest concern that fda may be having . The biggest longterm concern right now from a Public Health standpoint is that we may face product shortages of medical products heading into the first quarter. Were going to do everything we can to head them off. My biggest longterm concern for the island of puerto rico is if we dont do our jobs in helping the facilities stand back up in a timely fashion, we could start to see some of the production move out of the island, and i think that would put a strain on the puerto rican economy, so part of our solidarity to the people of puerto rico is make sure we can maintain that production down there. Its an important part of the island. I appreciate that. I yield back. Just follow up on that, also, it would take away good jobs from the island if those facilities start to close down, is that right . Right, about 90,000 people are directly employed by the industry. These are highpaid manufacturing jobs relative to other manufacturing jobs on the island. An important part, depending on the estimate, 20 to 30 of the gdp of puerto rico. A very important part of the island. I want to, in conclusion, i want to thank all of the wenlszs and the participant today. I remind members they have ten Business Days in which to submit questions for the record. The witnesses all agree to respond promptly to the questions they receive after the hearing from members. I have to say, i learned a lot. This was a good hearing. Thank you all for participating. You all contributed greatly, and i think i have a better understanding. I do look forward and maybe you all should suggest where we should go, but i look forward at some point to the committee and the subcommittee perhaps visiting the islands to see what weve got or and perhaps as well the other areas that have been affected by the recent hurricanes. With that being said, committee is adjourned. If you missed any of this hearing, you can see it in its entirety on our website. The Houston Chronicle reporting the Texas Senate Finance Committee is holding a hearing in austin to look at how funding is used to deal with relief and Recovery Efforts there. Additional additionally, the committee is evaluating the storms longterm impact on the texas economy. Another committee tomorrow is looking at local, state, and federal coordination full relief efforts. Later today, a hearing on the laws and regulations that govern political ads on social and traditional media. Live coverage starts at 2 00 p. M. Eastern. You can also watch online at cspan. Org or listen with the free cspan radio app. The cspan bus is traveling across the country on our 50 capitals tour. We recently stopped in frankfort, kentucky, asking folks, whats the most important issue in their state. Hi, my name is gerald. I live in frankfort, kentucky. One of the more important issues in kentucky right now is public pensions. Legislators are here in kentucky getting ready to call a special session to try to fund our special excuse me, our pensions. And its very important to all of the Public Sector workers and all of their families. We have a coalition called the Kentucky Public Pension Coalition which includes firefighters. Police officers, state workers, reteared state workers and various other members who have joined us and are partnering with us. Its very important and our coalition is trying to fight and make sure that the legislators here in kentucky do the recognize thing and find a Funding Source for our pensions. My name is jerry freeman. And one of the biggest issues of this state is the drug problem. Even in rural kentucky, the drug problem is rampant. So thats definitely one of the biggest issues. Hi, my name is dede. I work for the commonwealth of kentucky. And the most pressing issue right now in the commonwealth is the employees retirement. Voices from the states on cspan. British Prime Minister theresa may updated members of the house of commons recently on the status of brexit negotiations and her meetings with European Union leaders in brussels. The prime