Testimony
of
Deputy Commissioner Marisa Raphael, MPH
New York City Department of Health and Mental Hygiene
before the
United States House of Representatives
Committee on Homeland Security
Subcommittee on Emergency Preparedness, Response, and Communications
regarding
Strategic Perspectives on the Bioterrorism Threat

April 22, 2015
Washington, D.C.

 Good morning Chairwoman McSally, Ranking Member Payne, and Members of the
Subcommittee. I am Marisa Raphael, Deputy Commissioner for the Office of Emergency Preparedness
and Response at the New York City Department of Health and Mental Hygiene. Our mission is to
promote New York City’s ability to prevent, prepare for, respond to, and recover from public health
emergencies. I have been privileged to serve in a leadership role in this field for more than a decade. On
behalf of Mayor Bill de Blasio and Health Commissioner Mary Bassett, thank you for the opportunity to
testify on New York City’s efforts to prepare for and respond to emergencies with public health and
medical consequences.
Public Health and Emergency Preparedness
I am here today to discuss the vital role that public health plays in detecting and responding to
emergencies, the importance of federal public health and healthcare preparedness funding, and examples
of how these investments have increased preparedness. I will focus on our most recent and ongoing Ebola
response and the Rapid Activation and Mobilization Point of Dispensing Exercise, called RAMPEx,
which the Health Department conducted in August 2014.
Our nation’s public health and healthcare infrastructure play a critical role in protecting our
citizens by quickly detecting acts of bioterrorism or naturally occurring outbreaks, containing the spread
of disease, and otherwise mitigating the public health impacts of emergencies. State and local health
departments along with their local healthcare systems play equally vital roles as that of first responder
agencies – we prevent illness and save lives. The Department currently receives federal emergency
preparedness funding from the Centers for Disease Control and Prevention (CDC) Public Health
Emergency Preparedness program (PHEP), the Assistant Secretary for Preparedness and Response
(ASPR) Hospital Preparedness Program (HPP) cooperative agreements, and the Department of Homeland
Security Urban Area Security Initiative (UASI) grant awards. As a result, the Department’s public health
and healthcare emergency response capabilities have been expanded, and we have made vital investments
in plan development, training and exercises, supplies and equipment, and skilled and experienced
personnel to respond to a broad range of emergencies. In New York City, a perpetual target for terrorism,
focal point for disease outbreaks, and victim of natural disasters, these investments have been critical to
shoring up our public health and healthcare system. I want to thank the Committee and Subcommittee for
their continued interest and recognition of the need for these critical federal programs.
Ebola in New York City
As the largest point of entry in the United States, we recognize the increased likelihood that a
naturally occurring disease in any area of the world can quickly spread to New York City. This was
demonstrated during our recent and ongoing response to Ebola. Beginning in July 2014, when it became
apparent that cases of Ebola were increasing in West Africa and that an individual with Ebola would
likely reach New York City, the City activated a highly detailed, coordinated and expensive multiagency
and multijurisdictional effort. The Mayor convened interagency preparedness meetings to discuss various
scenarios and ensure our healthcare system and first-responders were aware of their roles and familiar
with protocols. I would be remiss to not mention the over twenty agencies, including the NYC Health and
Hospitals Corporation (HHC), FDNY, NYPD and NYC Office of Emergency Management that worked
hand in hand with our team at Health and City Hall to ensure a coordinated response. Each city agency
dispensed invaluable expertise and leadership and I cannot emphasize enough how critical coordination is
in the face of threats like this.
To give you a sense of our preparation at the Health Department, we addressed hospital readiness,
risk communication and emergency transport, increased lab capacity, and community engagement. The
Health Department began developing detailed plans for disease surveillance, emphasizing early detection,
isolation and rapid notification, as well as plans to manage a person under investigation. Our public health
surveillance and epidemiology staff investigated hundreds of suspect cases; the Public Health Laboratory

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 quickly became proficient in testing for Ebola to facilitate rapid diagnosis and delivered test results in
record time. We also prioritized community engagement, distributing over 100,000 “Am I at Risk?” palm
cards and speaking at over 115 public events to address the public health concerns of New York City’s
diverse communities. For example, our Commissioner personally went out into West African immigrant
communities and other vulnerable areas of the City to begin a dialogue about, not only of the risks of
infection, but also discussing issues of tolerance to ensure immigrants were being treated fairly.
Most notably, HHC proactively conducted extensive staff training at each of its eleven hospitals,
to be prepared to receive and screen individuals potentially exposed to the disease. Additionally, the City
chose to focus on readying Bellevue Hospital as the primary NYC Ebola treatment center. Bellevue was
selected because its “quarantine and isolation” unit has been supported over the past decade through HPP
funding and we could focus on enhancing existing capabilities by further training staff and hiring
additional personnel, as well as outfitting of isolation rooms to properly handle additional electrical and
laboratory capacity. The fact that Bellevue was the sole facility ready to receive and treat an Ebola patient
when that capacity was actually needed – and that it did so with successful outcome for the patient and all
the personnel who care for and supported the patient – is merely part of the remarkable preparedness and
response work overseen by Dr. Raju, HHC’s President.
Years of planning made possible through the previously mentioned funding gave the City the
capacity to quickly prepare and respond to the Ebola threat. On October 23, 2014, when the first
confirmed case in New York City was identified the City was in a strong position to respond because of
these federal dollars. Nonetheless, funding is still needed to reimburse the City for the costs incurred in
transporting, screening, treating and monitoring persons with or potentially exposed to Ebola.
Mass Prophylaxis Capability and RAMPEx
One of the biggest challenges we currently face is maintaining a permanent state of readiness
among city agencies and the healthcare system. This brings us back to the original impetus for the federal
preparedness funds – the September 11th attacks and the subsequent anthrax attacks.
The receipt of letters tainted with anthrax in multiple cities in 2001 led to a state and local
requirement to develop mass prophylaxis capabilities. PHEP funds support state and local health
departments to develop and execute plans for the mass dispensing of medication in response to a
biological attack. In the case of a widespread, aerosolized attack, all potentially exposed people must
begin taking antibiotics within 48 hours to prevent illness and death. While 48 hours is the target,
modeling has shown that the more rapidly medication is provided to the public, the more lives will be
saved. The primary method of rapidly dispensing medication is through Points of Dispensing, or PODs,
which are temporary emergency sites established to provide free medication to large numbers of people to
prevent them from becoming sick. Years of planning, training and exercises as well as our investment in a
team of experienced, highly skilled Health Department emergency managers culminated on August 1,
2014, when the Health Department conducted the largest no-notice emergency response exercise on
record: the Rapid Activation for Mass Prophylaxis Exercise, or RAMPEx. This exercise involved
notifying and mobilizing over 1,500 city employees and setting up and opening 30 PODs simultaneously,
and was funded by UASI.
RAMPEx tested all components of our mass prophylaxis response to an aerosolized anthrax
attack from the mobilization of our Receipt, Stage and Store (RSS) warehouse, to the coordination of our
command and control center and mobilization of PODs. RAMPEx definitively demonstrated our ability to
rapidly open 30 PODs citywide in less than 8 hours, with some fully set up, staffed, and ready to open
within 6 hours.

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 RAMPEx helped identify critical planning gaps and solutions. First, all PODs were ready to open
up to 4 hours before medications from CDC’s Strategic National Stockpile (SNS) would arrive at New
York City warehouses. In an effort to close this gap, the Health Department has requested that SNS assets
be forward deployed in reasonable and useful quantities to NYC and other high-threat, high-density urban
areas that have demonstrated an ability to stand up PODs faster than SNS medications can be delivered.
The consequence of the failure to forward-deploy SNS assets may ultimately be measured in the numbers
of lives lost because of delayed access to medication.
Second, we have not met our POD staffing goals for both leadership and general staff. In NYC
alone, citywide prophylaxis distribution will require 33,000 POD staff to support 48 hours of dispensing
operations. In anticipation of “role abandonment” or failure to report, NYC has made great efforts to
recruit, pre-train, and assign staff to a POD site close to home. We are advocating for non-mission critical
federal staff, who live locally, to be similarly pre-identified and pre-trained to support POD operations.
There are many areas in which federal staff could be utilized to augment local response efforts during a
large-scale emergency, PODs being one such opportunity.
RAMPEx demonstrated New York City’s extensive medical countermeasure capabilities and
high level of readiness for this type of scenario, and the importance of federal preparedness funding to
sustain such efforts.
Importance of Federal Emergency Preparedness Funding
Our successful Ebola response and medical countermeasure exercise are a direct result of a
decade of federal investments in local preparedness. However, the greatest danger to our progress is the
decline in federal emergency preparedness funding. Preparedness is an on-going effort that must be
sustained over time. While the overall emergency preparedness and response funding should be increased,
funding allocations should also be based on risk to reflect the scale of threat, impact to high-density urban
areas, and complexity of response. These funds support the development, maintenance, testing and
continued improvement of these public health and healthcare capabilities and without these funds, lives
would be lost.
Federal funds have allowed us to build critical capabilities so that when faced with public health
emergencies, we have the tools necessary to protect the public. The Department relies on the dedicated
emergency preparedness federal funding streams of PHEP, HPP, and UASI to build and maintain these
critical public health and healthcare capabilities. Significant cuts to the PHEP award, combined with
similar cuts to the HPP award jeopardize NYC’s, and other state and local jurisdictions’ existing
capabilities and impede planning to address known gaps. I will speak to the cuts New York City has
endured specifically.
PHEP funding for New York City has decreased 35% from its peak in FY2005, which has led to
a 47% reduction in our public health preparedness and response workforce. The erosion of a skilled,
dedicated workforce including epidemiologists, laboratory technicians, and preparedness planners
threatens to compromise our ability to detect and respond to disease outbreaks. In New York City, for
example, the cuts have reduced the ability of the Public Health Lab to respond to after-hours lab testing
needs, which is critical to the 24/7 response needed for bioterrorism incidents and public health
emergencies such as pandemic influenza and Ebola.
Similarly, drastic cuts of nearly 40% to HPP have impeded preparedness and response efforts
necessary to shore up our nation’s health care sector. Healthcare system preparedness is essential to
responding to all types of public health emergencies. During the recent Ebola response, every hospital had
to be ready to identify, isolate and stabilize any patient with potential Ebola disease and a handful of
hospitals had to be ready to provide intensive treatment for a confirmed Ebola patient. There are 55

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 hospitals, 259 long-term care facilities, 303 primary care centers, 50 urgent care centers, and 101 dialysis
centers in New York City. Preparing a healthcare system of this size and complexity requires significant
resources, and as the funding has declined, NYC’s ability to fully prepare its healthcare system has been
compromised.
In the immediate months following a particular emergency, jurisdictions have occasionally
received one-time funding to supplement the PHEP and HPP grants. New York City is thankful to have
received such an allocation for our Ebola response. However, these singular funding allocations are not an
adequate substitute for sufficient and sustained base funding. There is also a critical need for a real time
funding mechanism to support public health emergency response. Currently, we must use federal
preparedness funds to cover response costs, however with decreasing budgets that are already allotted to
preparedness projects, this is unrealistic. Generally speaking, federal budgets designed to support public
health and health care system preparedness and response capabilities must be increased and sustained, this
is as true for New York City as it is for localities nationwide, particularly dense urban centers.
Chairwoman McSally and Ranking Member Payne, thank you once again for inviting me to
testify today. We are grateful for your and your colleagues’ work to protect our citizens. I look forward to
your questions.

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