the greater the chance for disease to spread.

There are more than three million people in the city of Chicago, the third largest urban center in the nation. It is not at all surprising, then, that the city has the highest "burden of disease” of anywhere in Illinois--indeed, of anywhere in the Midwest. That fact alone might make it obvious that the city should receive special attention and special funding to combat disease. In fact, however, federal funding for public health defense has traditionally gone to state health departments, whose mandate is to provide public health services for the entire state--including many rural and sparsely populated regions. This "one-size-fits-all" approach may possess a certain logic in some areas of public policy, but when it comes to public health it has the effect of ensuring that centers of dense population, such as Chicago, receive the least amount of dollars proportional to their share of disease.

In the case of bioterrorism, the federal Centers for Disease Control has made a generous exception to this "one-size-fits-all" policy by directly funding Chicago, Washington, D.C., New York City, and Los Angeles. This wise investment in the nation's most populous cities will allow them to prepare for any terrorist catastrophes. In June of 2001, the Johns Hopkins Center for Civilian Bio-defense Strategies, in collaboration with three other institutions, convened a two-day exercise to simulate a covert terrorist attack using smallpox virus as a weapon. The name of the exercise, "Dark Winter," was ominously apt, for the simulation showed that in a worst-case scenario, such an attack could result in as many as one million deaths within a matter of months. It is worth noting that this nightmare scenario was predicted to occur following an attack in Philadelphia, Atlanta, and Oklahoma City--three cities with smaller populations than Chicago.

To be sure, terrorism (like infectious disease) is not confined to the nation's largest cities. But the vulnerability of cities like Chicago--and the magnitude and complexity of responding to an attack and containing it--is not determined only by the density of the population. It is also determined by the physical size of the city, the complexity of the city's health care system, the socioeconomic, linguistic and ethnic diversity of the population, the concentration of industry, the presence of two large airports (as well as rail transportation and interstate highways), and the daily influx of visitors from all over the world. These, and a host of other factors, make containment of an outbreak of deadly disease in Chicago vastly more complicated than a similar outbreak in a smaller or more rural setting. As only one example of this complexity, one may imagine the catastrophic potential of an undetected outbreak of highly infectious disease being carried all over the nation and the world by thousands of travelers leaving O'Hare and Midway airports.

Clearly, when it comes to bioterrorism, Chicago must be seen as a priority area requiring a welldeveloped response system. The city's international visibility, dense population, and importance as a center of transportation and commerce make it an all-too-appealing target. Indeed, an uncontained outbreak of deadly disease spawned by bioterrorists would easily threaten the larger surrounding region and the nation. For these reasons, we believe it is highly appropriate that the city of Chicago be funded directly by the federal government.

IMPORTANCE OF POLICYMAKING ROLE OF DEPARTMENT OF HEALTH AND HUMAN SERVICES

As I hope we have demonstrated this morning, the public health requirements for terrorism preparedness fall well within the broader, routine activities of public health, which take place in state and local departments, and at CDC and HRSA at the federal level. It is essential than any new federal department established for homeland security not fragment or compromise the bioterrorism efforts of HRSA and CDC, both housed in the Department of Health and Human Services. We understand and support the Administration's desire to have one entity which coordinates all terrorism-related activity; however, we believe it is integral to the building of public health preparedness capacity at the local level that the planning and implementation of federal policy remain within DHHS.

Mr. HORN. Thank you. Dr. Wilhelm, can you come here at the table.

Dr. WILHELM. Good morning. Dr. Diaz actually gave our combined departmental testimony.

Mr. HORN. Well, Dr. Wilhelm, you are a commissioner, and so if you would like to add anything, let us know.

Dr. WILHELM. The only thing I would emphasize again are the points of the complexity of a City such as Chicago and the others who receive direct funding-New York City, Washington, DC, and Los Angeles. It is extremely important that we use the funding to build our everyday systems to control communicable disease which are the exact systems that we would be using in the event of a bioterrorist attack.

Mr. HORN. You might want to bring the microphone a little closer. Thank you. Technology is slow with congressional committees. Go ahead.

Dr. WILHELM. My comment was the only thing that I would emphasize in the departmental statement that Dr. Diaz presented is the importance of direct funding to Chicago as well as the other cities-New York, Washington, DC, and Los Angeles, in recognition of the complexity and the density here in these major cities. What the funding is doing is it is strengthening our everyday systems and collaborations for control of communicable disease, which are the same systems that we would be using in the event of a bioterrorist attack.

Thank you.

Mr. HORN. Thank you. Dr. Schneider. Dr. Schneider is professor of medicine, chief of endocrinology section at the University of Illinois.

Dr. SCHNEIDER. Thank you. I appreciate the opportunity to present my comments on the role of potassium iodide, also referred to as KI, in the event of a nuclear or radiological terrorist attack. As an endocrinologist, I care for patients with thyroid disease. I have been studying the effect of radiation exposure on the thyroid since 1973. The studies have focused on the thyroid gland since it is the most sensitive organ to the effects of radiation. I have also served on advisory panels for a variety of studies, including those occurring in the Chernobyl region. Finally, until recently, I was the Chair of the Public Health Committee of the American Thyroid Association. My comments are also informed by my working with the expert members of that association.

The thyroid gland uses iodine to make thyroxine. Iodine is a unique component of thyroxine. As there is relatively little iodine in the diet, in order to make thyroxine, the thyroid has developed the ability to concentrate it. When the body is exposed to radioactive iodine, it is also concentrated in the thyroid gland. Giving a large amount of non-radioactive iodine, in the form of a KI tablet, can prevent this. The non-radioactive iodine saturates the thyroid and largely prevents it from taking up the radioactive form.

While it was known for decades that external radiation could cause thyroid cancer, it was not so clear for internal exposure from radioactive iodine. This uncertainty was erased by the unfortunate outcome of the Chernobyl accident. Among exposed children, hundreds of cases of thyroid cancer have occurred. Many of these cases have been unusually aggressive and some have been fatal. A terrorist attack on a functioning nuclear power plant could release radioactive iodine. A nuclear explosion would also release radioactive iodine, as did the bombs exploded in Japan and the above-ground tests conducted in the United States and in the Soviet Union. A dirty, conventional bomb or a non-functioning plant may not release radioactive iodine.

Following the Chernobyl accident, KI was widely used in Poland. That experience proved its safety and provided an important part of the data used to support the guidance issued by the FDA and the recommendations of the American Thyroid Association and others in favor of distributing KI tablets. Based largely on the Chernobyl experience, the American Thyroid Association recommends predistribution in a 50-mile radius around nuclear plants and stockpiling up to 200 miles.

I am pleased that both the legislative and executive branches of the government have acted and I am also pleased to see the growing list of States that have accepted iodine from the Federal Government.

Although there appears to be movement in the State of Illinois, the situation is less clear. First, reported comments from at least one State official indicate an under-estimation of the effects of thyroid cancer. Although often referred to as one of the "good" cancers to have, on occasion it can be difficult to treat and, as I mentioned, it can be fatal. Successful treatment includes removing the thyroid gland. Living without the thyroid gland is readily managed, but it is not without its difficulties and potential dangers. The second concern is that Illinois reportedly will use industrial support to purchase its supply of KI tablets. The rationale for this is not clear and raises the concern that Illinois will have policies that differ from its neighboring States and the rest of the country.

I thank you for the opportunity to address you.

Mr. HORN. Thank you, Dr. Schneider. That is a very helpful presentation because we have had a number of worries about the iodine.

And now we have David Kraft, director, Nuclear Energy Information Service, and we look forward to your testimony.

Comments of Arthur B. Schneider, M.D., Ph.D. submitted to the Committee on Government Reform's Subcommittee on Government Efficiency, Financial Management and Intergovernmental Relations for its hearing on Tuesday, July 2, 2002 in Chicago, IL

I appreciate the opportunity to present comments on the role of potassium iodide, also referred to as KI, in the event of a nuclear or radiological terrorist attack.

I am the chief of the Section of Endocrinology at the University of Illinois College of Medicine here in Chicago. Endocrinologists care for patients with thyroid disease. I have been studying the health effects of radiation exposure since 1973. My studies have focused on the thyroid gland, since it is the most sensitive organ to the effects of radiation. I have also served on advisory panels for a variety of studies, including those occurring in the Chornobyl region. Finally, until recently I was the chair of the Public Health Committee of the American Thyroid Association. My comments are also informed by my working with the expert members of that Association. The thyroid gland uses iodine to make thyroxine. Iodine is a unique component of thyroxine. As there is relatively little iodine in the diet, in order to make thyroxine, the thyroid developed the ability to concentrate it. When the body is exposed to radioactive iodine, it is also concentrated in the thyroid gland. Giving a large amount of non-radioactive iodine, in the form of a KI tablet can prevent this. The non-radioactive iodine saturates the thyroid and largely prevents it from taking up the radioactive form.

While it was known for decades that external radiation could cause thyroid cancer, it was not so clear for internal exposure from radioactive iodine. This uncertainty was resolved by the unfortunate outcome of the Chornobyl accident. Among exposed children, hundred of cases of thyroid cancer have occurred. Many of these cases have been unusually aggressive and some have been fatal. A terrorist attack on a functioning nuclear power plant could release radioactive iodine. A nuclear explosion would also release radioactive iodine, as did the bombs exploded in Japan and the above ground tests conducted by the U.S. and the Soviet Union. A "dirty" conventional bomb or a non-functioning plant may not release radioactive iodine. Following the Chorobyl accident, KI was widely used in Poland. That experience proved its safety and provided an important part of the data used to support the Guidance issued by the FDA and the recommendations of the American Thyroid Association and others in favor of distributing KI. Based largely on the Chorobyl experience the American Thyroid Association recommends predistribution in a 50-mile radius around nuclear plants and stockpiling up to 200 miles.

I am pleased that both the legislative and executive branches of government have acted and I am also pleased to see the growing list of states that have accepted iodine from the Federal Government.

Although there appears to be movement in the state of Illinois, the situation is less clear. First, reported comments from at least one state official indicate an underestimation of the effects of thyroid cancer. Although often referred to as one of the "good" cancers to have, on occasion it can be difficult to treat and it can be fatal. Successful treatment includes removing the thyroid gland. Living without the thyroid gland is readily managed, but is not without its difficulties and potential dangers. The second concern is that Illinois reportedly will use industrial support to purchase its supply of KL. The rationale for this is not clear and raises the concern that Illinois will have policies that differ from its neighboring states and the rest of the country. Thank you. I would be happy to answer your questions.