[House Hearing, 116 Congress]
[From the U.S. Government Publishing Office]
DEPARTMENTS OF LABOR, HEALTH AND HUMAN
SERVICES, EDUCATION, AND RELATED AGENCIES
APPROPRIATIONS FOR 2020
_______________________________________________________________________
HEARINGS
BEFORE A
SUBCOMMITTEE OF THE
COMMITTEE ON APPROPRIATIONS
HOUSE OF REPRESENTATIVES
ONE HUNDRED SIXTEENTH CONGRESS
FIRST SESSION
___________
SUBCOMMITTEE ON LABOR, HEALTH AND HUMAN SERVICES,
EDUCATION, AND RELATED AGENCIES
ROSA L. DeLAURO, Connecticut, Chairwoman
LUCILLE ROYBAL-ALLARD, California TOM COLE, Oklahoma
BARBARA LEE, California ANDY HARRIS, Maryland
MARK POCAN, Wisconsin JAIME HERRERA BEUTLER, Washington
KATHERINE M. CLARK, Massachusetts JOHN R. MOOLENAAR, Michigan
LOIS FRANKEL, Florida TOM GRAVES, Georgia
CHERI BUSTOS, Illinois
BONNIE WATSON COLEMAN, New Jersey
NOTE: Under committee rules, Mrs. Lowey, as chairwoman of the full
committee, and Ms. Granger, as ranking minority member of the full
committee, are authorized to sit as members of all subcommittees.
Robin Juliano, Stephen Steigleder, Jared Bass, Jennifer Cama,
Jaclyn Kilroy, Laurie Mignone, Philip Tizzani, and Brad Allen
Subcommittee Staff
___________
PART 8
Page
Oversight of the Unaccompanied Children Program: Ensuring the
Safety of Children in HHS Care.................... 1
Mental Health Needs of Children in HHS Custody............ 145
Investments in Medical Research at Five Institutes and Centers of
the National Institutes of Health........... 229
E-Cigarettes: An Emerging Threat to Public Health.............. 363
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
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Printed for the use of the Committee on Appropriations
U.S. GOVERNMENT PUBLISHING OFFICE
39-607 WASHINGTON : 2020
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COMMITTEE ON APPROPRIATIONS
----------
NITA M. LOWEY, New York, Chairwoman
MARCY KAPTUR, Ohio KAY GRANGER, Texas
PETER J. VISCLOSKY, Indiana HAROLD ROGERS, Kentucky
JOSE� E. SERRANO, New York ROBERT B. ADERHOLT, Alabama
ROSA L. DELAURO, Connecticut MICHAEL K. SIMPSON, Idaho
DAVID E. PRICE, North Carolina JOHN R. CARTER, Texas
LUCILLE ROYBAL-ALLARD, California KEN CALVERT, California
SANFORD D. BISHOP, JR., Georgia TOM COLE, Oklahoma
BARBARA LEE, California MARIO DIAZ-BALART, Florida
BETTY MCCOLLUM, Minnesota TOM GRAVES, Georgia
TIM RYAN, Ohio STEVE WOMACK, Arkansas
C. A. DUTCH RUPPERSBERGER, Maryland JEFF FORTENBERRY, Nebraska
DEBBIE WASSERMAN SCHULTZ, Florida CHUCK FLEISCHMANN, Tennessee
HENRY CUELLAR, Texas JAIME HERRERA BEUTLER, Washington
CHELLIE PINGREE, Maine DAVID P. JOYCE, Ohio
MIKE QUIGLEY, Illinois ANDY HARRIS, Maryland
DEREK KILMER, Washington MARTHA ROBY, Alabama
MATT CARTWRIGHT, Pennsylvania MARK E. AMODEI, Nevada
GRACE MENG, New York CHRIS STEWART, Utah
MARK POCAN, Wisconsin STEVEN M. PALAZZO, Mississippi
KATHERINE M. CLARK, Massachusetts DAN NEWHOUSE, Washington
PETE AGUILAR, California JOHN R. MOOLENAAR, Michigan
LOIS FRANKEL, Florida JOHN H. RUTHERFORD, Florida
CHERI BUSTOS, Illinois WILL HURD, Texas
BONNIE WATSON COLEMAN, New Jersey
BRENDA L. LAWRENCE, Michigan
NORMA J. TORRES, California
CHARLIE CRIST, Florida
ANN KIRKPATRICK, Arizona
ED CASE, Hawaii
Shalanda Young, Clerk and Staff Director
(ii)
DEPARTMENTS OF LABOR, HEALTH AND HUMAN SERVICES, EDUCATION, AND RELATED
AGENCIES APPROPRIATIONS FOR 2020
----------
Wednesday, July 24, 2019.
OVERSIGHT OF THE UNACCOMPANIED CHILDREN PROGRAM: ENSURING THE SAFETY OF
CHILDREN IN HHS CARE
WITNESSES
HON. DEBBIE WASSERMAN SCHULTZ, A REPRESENTATIVE IN CONGRESS FROM THE
STATE OF FLORIDA
HON. MICHAEL C. BURGESS, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF
TEXAS
HON. CLAY HIGGINS, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF
LOUISIANA
HON. DONNA E. SHALALA, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF
FLORIDA
LYNN JOHNSON, ASSISTANT SECRETARY, ADMINISTRATION FOR CHILDREN AND
FAMILIES
JONATHAN HAYES, DIRECTOR, OFFICE OF REFUGEE RESETTLEMENT
MARGARET HUANG, EXECUTIVE DIRECTOR, AMNESTY INTERNATIONAL USA
KRISH O'MARA VIGNARAJAH, PRESIDENT AND CEO, LUTHERAN IMMIGRATION AND
REFUGEE SERVICE
Ms. DeLauro. Good morning. Welcome everyone to the Labor,
HHS, and Education Appropriations Subcommittee.
Today's oversight hearing will focus on the Office of
Refugee Resettlement's Unaccompanied Children Program and its
reliance on influx facilities that do not adhere to State or
Federal standards of care for children. We have multiple panels
today, and I want to thank each of our witnesses for being
here.
We are starting this morning with testimony from several of
our congressional colleagues. After hearing from our
colleagues, we will proceed to a panel of senior officials from
the Department of Health and Human Services who are responsible
for administering the Unaccompanied Children Program. And
finally, we will proceed to a panel of civil society experts
with direct experience in child welfare and refugee services.
I will hold my opening remarks until the next panel, and my
colleague Congressman Cole will hold his remarks, opening
remarks for the second panel.
First, I would like to introduce Congresswoman Debbie
Wasserman Schultz of Florida, a member of the Appropriations
Committee and chair of the Military Construction and Veterans
Affairs Appropriations Subcommittee. I would also like to
introduce Congressman Michael Burgess of Texas, a member of the
Energy and Commerce Committee, as well as the Rules Committee.
Congresswoman Wasserman Schultz, your full testimony will
be entered into the record. You are recognized for 5 minutes,
and then, Congressman Burgess, again your testimony will be in
the record, and you will be recognized for 5 minutes.
Congresswoman Wasserman Schultz.
Ms. Wasserman Schultz. Thank you, Madam Chair. And I want
to thank both you and the ranking member for giving up an
opportunity this morning to share a little bit about our
experiences, in my case, for the opportunity to testify today
about my experience at the Homestead detention center in
Homestead, Florida.
I appreciated the opportunity to accompany members of this
subcommittee during a trip to the facility last week in my
South Florida backyard. I visited or attempted to visit this
facility four times now. I have only been allowed in twice.
I know the chairwoman submitted a request to the Office of
Refugee Resettlement a week in advance of our visit most
recently. This was all the time ORR needed to present a
prefabricated tour that painted the rosiest picture possible.
The red carpet was clearly rolled out for us. We were
accompanied by the Director of ORR, who is testifying today,
and the Deputy Assistant Secretary of HHS for Financial
Resources.
The private contractor who operates this facility ushered
us from one orchestrated stop to the next. It was tightly
regimented. Our interactions with the detained children were
limited. An employee always stood very close by. We were given
greater access to four student council leaders who were chosen
by the contractor.
A posted bulletin board had timelines dealing when staff
would notify ICE about kids approaching their 18th birthday.
These children had to be transferred out of Homestead and ORR
care, and we were told these young adults are arrested by ICE,
handcuffed, and sent to an ICE adult prison. Children often
dread this date. Many become suicidal as the date nears.
I came away with far more questions than answers, and I
believe many of you feel the same way. The most common answer
to our specific questions was, ``We will get back to you.'' I
will briefly mention a few of my biggest concerns.
We learned extremely troubling information about the
education program there. The private company running the
facility performs an academic assessment, one the company made
up themselves. We have no idea what standards they use, and
children are not taught by certified teachers or, frequently,
even by people with any teaching experience.
A second concern involves ORR's hurricane preparedness
plan. We pressed the agency to share its plan to safeguard
these children during a hurricane. ORR offered a briefing but
refused to share any written details.
We are in the middle of hurricane season in Florida, and
many of the structures there at the Homestead facility are
tents. In order to ensure the safety of these children, there
must be detailed and transparent evacuation and relocation
plans. Comprehensive Health Services will not even share the
plan with the Florida Division of Emergency Management.
Finally, while it was good to learn that ORR has recently
transitioned more than 1,000 children out of Homestead, they
achieved this massive downsize in just 2 weeks. I have been
calling for ORR to process children more quickly out of this
prison-like facility since the last Congress. This rapid
downsizing raises concerning questions. Why now? Why has ORR
not expeditiously processed these children long before now?
In January, HHS announced that it was expanding Homestead
from 1,350 beds to 2,350 beds after it claimed that ORR's
capacity was being overloaded. Then HHS expanded the facility
again in April, from 2,350 to 3,200. How can the agency reduce
its numbers so quickly now, and where do these children go? How
did ORR achieve this with such a limited case management
capacity? I have heard from advocate groups back home that
children have likely been shuffled to nonsecure ORR facilities
and not to sponsor households, but this remains unclear.
Additionally, I have been frustrated by ORR and DHS's
unwillingness to provide information on removal actions toward
sponsors and potential sponsors. I worked with our colleagues
on the Appropriations Committee to include language in the
fiscal year 2019 appropriations package that prohibits DHS from
initiating deportation proceedings against sponsors, potential
sponsors, or a member of a sponsor household based on
information shared by HHS.
This language was included to expedite the processing of
unaccompanied minors out of this prison-like facility and into
nurturing foster households. It is unclear if the
administration has complied with this language because it has
not provided information on the deportation of sponsors.
You can probably sense a theme running through my concerns,
an absolute lack of transparency. It is my hope that this
subcommittee will get solid, substantive answers from HHS and
ORR today. I commit to keep working with you to hold this
administration accountable. That is why I introduced the
Homestead Act of 2019 this past Monday.
The bill would allow Members of Congress to visit HHS or
DHS detention facilities without any prior notice. Congress
must assert its duty to conduct oversight of this
administration and ensure that children are treated with
dignity and humanity. ORR recently announced that it will
suspend sending children to Homestead, but we need to shut down
this temporary prison-like facility, one that is unlicensed by
the State of Florida and does not abide by State child welfare
standards.
When I looked into the eyes of these children, I could not
help but see my own children looking back at me. I shudder at
the idea of my child or anyone's child living the way these
poor children do. We just cannot turn our back on them.
Thank you again for the opportunity to testify today.
[The information follows:]
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Ms. DeLauro. Thank you very much. Congressman Burgess.
Mr. Burgess. Thank you, Chairwoman, and thanks to the
ranking member for having this hearing and allowing me to
testify today. And I am grateful that the Congress has
recognized that we are facing a humanitarian crisis on our
Southern border.
The unprecedented surge in the number of unaccompanied
children and family units crossing our Southern border this
year has stressed a system never designed to handle the current
volume. In May, over 144,000 people crossed our Southern
border, the highest number since the crisis began in 2014. Over
11,000 of these individuals were unaccompanied alien children.
These children endure terrible conditions to travel across
the desert. Sometimes they ride on top of a train to reach our
Southern border. They deal with cartels. They deal with
coyotes. They deal with gangs. They deal with human
traffickers.
When they arrive and they are determined to be an
unaccompanied alien child, they are transferred to the care and
custody of the Department of Health and Human Services Office
of Refugee Resettlement. Secretary Azar, Jonathan Hayes, the
Acting Director of ORR, and their teams are doing a good job
under trying circumstances for these children, with limited
resources and sometimes gross mischaracterizations of
individuals.
With a surge in arrivals, Department of Health and Human
Services does not have sufficient time to establish permanent
licensed shelter beds. So the Department of Health and Human
Services must care for these children as they arrive in the
hundreds every day.
Influx facilities like Homestead allow the Department of
HHS to care for some children and those who are expected to be
placed with a sponsor quickly for a shorter period of time. I
visited Homestead with several Democratic Members of Congress.
The conditions I found, the conditions I saw were comfortable
and age appropriate.
Children were provided three meals a day, plus snacks. They
were given new clothing, education, medical care, mental health
screenings and mental healthcare, outdoor time, and pizza
parties. When I heard the comments from other Members of
Congress at their press conference after this tour, I couldn't
help but wonder if we had visited facilities on different
planets, the wording was so different.
This crisis is receiving heightened attention and has
caused some Members of Congress to be highly accusatory.
Sometimes they do so without visiting the shelters or speaking
with the individuals about which they are making the
accusations. This exaggeration is inaccurate, unfair, and
inappropriate, and it is only making the job of caring for
these children more difficult. Members of Congress cannot make
such accusations and then demand immediate and unannounced
access to the facilities.
Now look, just recently we provided some needed relief in a
border supplemental bill, but even that legislation was called
a child abuser bill. So let us be very clear. The Office of
Refugee Resettlement is doing the job that Congress has asked
it to do, and they do not deserve the unfounded accusations
that are being leveled against them.
While the Office of Refugee Resettlement takes good care of
children to which they are referred, many remain with Customs
and Border Protection facilities for too long. The United
States Customs and Border Protection facilities are not set up
to house children. Placing a child in an Office of Refugee
Resettlement operated influx shelter is far preferable to
leaving a child for an extended period of time at an
overcrowded and ill-equipped Customs and Border Protection
facility.
Everyone has an interest in moving these children out of
the custody of Homeland Security agencies and into HHS area as
quickly as possible. State-licensed and small facilities are
the most ideal situation prior to family placement, but when
HHS does not have the capacity to accommodate the thousands of
minors arriving in these small-scale facilities, it is
preferable to move them into an influx facility and out of
Customs and Border Protection.
At least this way, they can access medical and legal
services and have access to child-appropriate activities and
education, rather than having them back up at overcrowded,
resource-constrained Border Patrol stations.
I also want to note that the Homeland facility was first
opened and operated as a facility in the previous
administration. Many of the services have been provided since
the previous administration. I do not recall the cries of
protest during the previous administration.
And just in my last moments, I do want to let the committee
know I have prepared a timeline of all of the different visits
I have made over the last 5 years. There are in excess of 10 of
those to ORR and Customs and Border Protection facilities. This
is not an issue that I take lightly.
But I also want to stress that our words matter, and we
have men and women who are on the ground doing a very difficult
job that Congress has asked them to do. And Congress will not
change the law. So the expectation is the job is going to
continue to be difficult.
I want to submit to the record a letter from Jonathan Hayes
written to another committee because of the false accusations
that were leveled against the men and women of his Department.
It makes it very difficult for them to do their job when they
were accused in an unfounded way by Members of Congress.
I thank you for the time. I will yield back.
Ms. DeLauro. Thank you both very, very much for coming
forward this morning and your remarks.
Mr. Burgess. May I ask unanimous consent to add these to
the record?
Ms. DeLauro. Unanimous consent, so ordered.
[The information follows:]
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
Mr. Burgess. Thank you.
Ms. DeLauro. If I can ask Congresswoman Shalala and
Congressman Higgins to take their seats.
Good morning. Let me welcome my colleagues here this
morning, and let me introduce Congressman Clay Higgins of
Louisiana, who is a member of the Homeland Security Committee,
as well as the Committee on Oversight and Reform. And also to
introduce Congresswoman Donna Shalala of Florida, a member of
the Education and Labor Committee, as well as the Rules
Committee. Congresswoman Shalala served as the Secretary of
Health and Human Services under President Clinton.
And to both of my colleagues, your full written testimony
will be entered into the record, and you are recognized for 5
minutes. Representative Higgins.
Mr. Higgins. Thank you, Madam Chair and members of the
committee.
I very much appreciate the opportunity to address you
today. I was advised that we should share our personal
experiences regarding the children that are being processed at
our Southern border and the means by which this is happening.
This is costing a tremendous amount of American treasure. You
men and women are responsible for the effective and efficient
management of the treasure that we seize. Therefore, it is
appropriate that this is reviewed.
Now I believe it is important that we note, as patriots all
regardless of our political affiliation, we are moms and dads
and grandmas and grandpas. And we have a compassionate approach
to how we care for the children of the world, regardless of
where they are or how they arrived here. Yet we have a mission
to maintain the sovereignty of our Nation and to stay within
the parameters established by our Constitution.
My experience with children that have been through trauma
in some manner in life is quite a unique perspective because I
was a night shift cop for 8 years during the course of my 12
years as a police officer. And at night is when things go
wrong. Mom is home. Dad is home. Hard day, money problems.
Frequently alcohol involved. Sometimes drugs. Things go wrong
in households right here in America from sea to shining sea.
The nightshift cops witness this firsthand.
I have a nickname in Louisiana. I am referred to commonly
as ``Uncle Clay.'' This manifested over the course of many
years from interacting with children on night shift that have
perhaps never had a positive interaction with a police officer.
I made it a habit to take and eat with those kids once order
had been restored, and I would ask them, ``Do you know who I
am?'' And they would be rather bewildered looking and say no or
you are the popa.
I would say, ``I want you to think of me as `Uncle Clay.'
We are going to take daddy away for a little while, and we are
going to treat him good, and when we bring him back, things are
going to be better. And we will always be here for you.''
Through the years, this grew.
So I went to the border. I have been to the border before.
I have brothers and sisters that are thin blue line report to
me regularly from the border. Send me texts and emails and
videos. I went to the border this last weekend specifically to
look at how kids were handled.
What I witnessed, if our endeavor is to provide
compassionate law enforcement under virtually impossible
circumstances, then the American men and women of law
enforcement on our Southern border have set a stunning example
for the world to observe.
With depleted resources and overburdened infrastructures,
operating at 200, 300, 400 percent capacity, these men and
women, primarily of Hispanic descent--Hispanic origin,
virtually all--mostly mothers, fathers, grandmas, and grandpas
themselves--they have done their best.
We visited a series of sort of the chronological process by
which a child is picked up in the field and processed through
in a matter of a couple of days through facilities, one of
which had been stood up for the last few months, an 800,000
square-foot facility, the Donna facility in McAllen, Texas.
Strictly for processing incoming family units, of course. That
includes children. Handled very effectively, incredibly
compassionately.
After a life of who knows what horror these family units or
children have fled from, they have arrived on American soil,
and they are treated well and processed efficiently. And up in
HHS, ORR--Office of Refugee Resettlement--the facility I
observed had a 6-to-1 ratio of professional social staff that
included medical supervision, et cetera.
I noticed that the building was unsecured to an extent
regarding exit, and I asked these professionals what stops
these kids from leaving? They said they want--they enjoy the
structure. First time in their life perhaps they have had some
structured environment where they are treated well, fed
regularly, have personal hygiene, et cetera.
They had 54 kids in the 60 capacity unit. Their average
time there was 32 days, and then they would move to a home, a
family home.
So, in summary, my fellow child of God and Republicans and
Democrats both, we are all doing our best to deal with the
situation. I believe the money, which is your question perhaps,
the money that is being invested is being invested quite wisely
in the care of children at the border.
We have broken the ice as a bipartisan bicameral Congress
regarding funding for the law enforcement professionals and HHS
professionals on the border. We should continue to do so and
keep in mind that these men and women are doing their very best
to maintain the sovereignty of our Nation while, at the same
time, their commitment as a compassionate and principled
American citizen.
Thank you for allowing me to address your committee today.
Ms. DeLauro. Thank you very much.
Congresswoman Shalala.
Ms. Shalala. Thank you for holding this hearing to ensure
the safety of our children.
I say ``our children'' because those who are in HHS's care
are our collective responsibility. On the wall of the HHS
building, which is named for Hubert Humphrey, is a quote from
Humphrey. ``The moral test of government is how that government
treats those in the dawn of life, the children.'' We are
judged, first and foremost, by how we treat our children, and
we have a moral obligation to treat these children as we would
treat our own.
As someone who has inspected the ORR facility in my
district's backyard--the Homestead facility--as someone who was
responsible at one time for ORR, I can confidently say very
simply that we are not doing good enough. We must do better.
The children housed at the Homestead facility are between
the ages of 13 and 17. Despite their youth, they have already
faced unfathomable hardship, including poverty and violence in
their home countries and the journey they have made to our
country. I have seen the prison-like conditions in which they
are kept. They are closely monitored, unable to leave the
compound, kept in military camp-like rooms, one of them with up
to 150 children per room, and barred from even hugging their
friends and siblings.
Some of these children have been forcibly separated from
their parents or other relatives or younger siblings without
explanation. And what is more, the Homestead facility is for
profit. Caliburn has received a no-bid $300,000,000 contract
extension. We are letting a private company make money off of
running a detention center for children. We have got to do
better.
In June, the Washington Post reported that the
administration is canceling English classes, recreation
programs, and legal aid for unaccompanied minors in their
custody. These are basic services that the administration is
legally obligated to provide unaccompanied children who are
detained in these facilities. So how did the administration get
around this?
Back to the example of Homestead, which is classified as an
emergency influx shelter. That means that the children are not
protected by the Flores Agreement, which sets limits on how
long children can be detained and sets strict standards for
conditions in which they can be detained. Because it is located
on Federal land, this facility is not covered by State
regulations on the treatment of children. These are loopholes
that leaves these unaccompanied children vulnerable to the
incalculable harms that are preventable.
These children are on their own in every unimaginable way.
So I thank the chairwoman supporting my amendment to Labor, HHS
that increases funding for legal services, child advocates, and
post-release services.
Its passage was a good first step. But again, we have got
to do better because these policies are impacting unaccompanied
children, and they are impacting children in my community that
live near Homestead.
Recently, nearly 1,000 public school children in Miami-Dade
took part in a letter writing campaign to the migrant children
being detained at Homestead, offering words of hope, love, and
solace. My local news station aired a story on the letters.
Thirteen-year-old Mattias explained, ``It is not fair because
if I am an immigrant and I feel accepted, how come other people
are being mistreated, held against their will? So I felt like
it is time for change. So I decided to write my letters.''
Fourteen-year-old Christian said, ``I am an immigrant as
well, and I could understand how it would feel to lose your
family. That is something tough to go through. I get that. So I
just want to help them.''
Miami-Dade County, where Homestead is located, is 53
percent foreign born, many of them children. So this is
affecting my community, both inside and outside the detention
center's walls.
A Miami-Dade Public Schools counselor warned, ``I don't yet
believe we realize the scope of the problem that has been
created by detaining these children. I do believe that our
students become more aware of what is happening at Homestead,
and there is a fear factor being played out for our students
who do live in the community.'' It will be years before we know
the full mental health impact of these policies on our
children. So this hearing has never been more urgent.
To close, I implore this committee to ask a straightforward
question to our colleagues at HHS. What resources are needed to
get these children to their sponsors faster? We have got to
focus on the outcomes. These children should be in their
sponsors' homes in 2 weeks or a little more, and the sponsors
must feel safe to come forward.
If ORR can't get these children to sponsors within a fair,
compassionate timeline, they need to tell us why. But more
importantly, they need to tell us precisely what resources they
need.
Thank you very much.
Ms. DeLauro. Thank you. I want to say thank you to both of
my colleagues for your testimony and for your concern about
what is a very serious issue.
Thank you very much.
Mr. Higgins. Madam Chair, I would like to ask, if it is
appropriate, unanimous consent to enter into the record some
photographs along with my transcribed testimony.
Ms. DeLauro. So ordered.
[The information follows:]
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
Ms. DeLauro. If we could now have the second panel come
forward.
[Pause.]
Ms. DeLauro. Happy to welcome here this morning the
Director of the Office of Refugee Resettlement, Director
Jonathan Hayes, and the Assistant Secretary for Administration
for Children and Families, both from the Department of Health
and Human Services, Assistant Secretary Lynn Johnson.
Thank you very, very much for being here this morning, and
welcome to you.
To start today's hearing, I would first like to describe
what has put us into this crisis. The surge of unaccompanied
children at our border is nothing new. It occurred as well in
2014 and in 2016. Without doubt, we have seen the increases
this year that have worsened the situation.
Make no mistake, however, that it is administration
policies that have brought us to the brink, a crisis created by
failed administration policies. In 2017 and 2018, the
administration initiated a zero-tolerance policy, which, as a
result, separated children from parents, adding to the numbers
of unaccompanied children.
The Department of Health and Human Services and the
Department of Homeland Security initiated a Memorandum of
Agreement using children as bait and scaring sponsors from
coming forward by rendering HHS as an immigration enforcement
tool. How has the administration done this?
Most chillingly, the administration introduced new
bureaucratic delays and onerous fingerprinting requirements on
sponsors. They began fingerprinting all members of the
household beyond those individuals applying to be sponsored,
thereby discouraging sponsors from coming forward, leaving
children languishing in Federal custody.
These failed policies strained the capacity of the network
of HHS's State-licensed residential shelters for children and
led to the opening of emergency influx facilities like
Homestead and Tornillo. Influx facilities are unlicensed
shelters, essentially warehouses for children. They are not
bound by State or Federal standards of care.
As the Appropriations Subcommittee which funds the
Department of Health and Human Services, we have been talking
about these intentional and harmful policy choices. We hosted a
hearing on the UAC program earlier in 2019. We hosted a
bipartisan private briefing with the Office of the Inspector
General at HHS. And just last week, we visited the influx
facility in Homestead, Florida.
Let me say that I was sorry that Ranking Member Cole could
not attend because of a prior commitment, as I know he wanted
to be there. But we extended the invite to our friends on the
other side of the aisle.
On our visit, we confirmed that the Federal Government is
using Federal property to skirt Federal standards of care. Why
are Federal facilities exempt? The guiding principle of U.S.
and international law concerning these children must be the
best interest of the child. Both the Flores Agreement and
international law say that we should be keeping children for
the shortest time and in the least restrictive setting
possible.
Visiting Homestead, we saw children under guard. Children
have no freedom of movement. They are always, wherever they go,
accompanied by a guide. They wear lanyards with barcodes. The
bedrooms have no doors. The bathrooms have no doors, only
shower curtain liners.
Visiting Homestead, we learned that they have only four
physicians, no psychiatrist, and only five certified teachers.
We saw the education facility, which is not conducive to
learning. The sound of a typical South Florida rainstorm
pouring down on this tent was deafening.
The din, the noise was so loud that the congressional
delegation was taken to another room to be able to have a quiet
conversation. Not an atmosphere which is conducive to learning.
Classrooms are structured. Children are silent. The teacher
teaches, and children learn. That is not what is happening at
Homestead.
What we also discovered was that the education curriculum
and the placement are not designed by the Florida Department of
Education, in conjunction with the Florida Department of
Education, or the Miami-Dade Department of Education, but by
the contractor who deals with the tools for education. We were
told by some children that they have been there 44 days, 56
days, 60 days when, in fact, they have family members in the
United States.
And yet we learned that over 1,000 children were moved to
placement with a sponsor in a 2-week period. Let us be clear.
This was not a matter of resources. This was a policy decision
by ORR. It made us ask if we can move these children this
quickly, why were we not moving them all along? Why did we have
chaos at the border and children not being able to be moved in
the appropriate period of time?
And we found the children are continuing to be separated
from family members--aunts, uncles, grandparents--who are their
primary caregivers. This is what we heard. That must end, and I
am working on legislation to address this.
We still do not know the level of information that is being
communicated between the Departments of Health and Human
Services and Department of Homeland Security and ICE. We need
to be sure that it is not putting the youngsters in jeopardy
nor their families. This is a concern for sponsors, who may not
be willing to come forward if they are threatened with
deportation.
We were shocked to see a checklist outlining the
notification process to ICE when a child is just days away from
turning 18 years old. The Office of Refugee Resettlement is not
an immigration enforcement agency. They should not be mailing
ICE 2 weeks out, 1 week out, 24 hours out of a child turning
18, and the child is picked up on their birthday.
And I don't make this up. One of the folks providing us
with the tour literally lifted up her hands, and she said,
``They are taken out handcuffed.'' Handcuffed. And where are
they going? What has become of these children? We need to know.
The mission of the Office of Refugee Resettlement is to
provide care and the expeditious placement for children with
sponsors. That is what we are trying to do. That is our job.
That is the agency's job.
And yet HHS is clearly not on the same page. They have so
obfuscated the goal of this agency that I believe they have
lost sight of their goal and their mission.
Secretary Johnson, in my office, you said you wanted to
create a ``business model.'' That is not correct. Nowhere in
the mission statement of ORR does it say we should be building
the capacity of detaining children for either short periods of
time or longer periods of time.
So let me say with the utmost and resolute clarity, we are
not going to be setting up an indefinite detention empire.
Instead, we must be taking the necessary steps to care for
children in the least restrictive possible setting and place
them in a safe setting with a family member or sponsor as
expeditiously as possible.
To do so, we must be responsibly closing down Homestead and
all influx facilities. We need clarity on Carrizo Springs. And
I am not interested in us starting up an influx facility at
Fort Sill.
Rather than focusing on beds and more beds, which the
administration continues to do, we need to be moving to a
system that does not require unlicensed influx facilities, and
we need to be discharging kids to a safe setting.
Second, we must end the memorandum of agreement between the
Department of Health and Human Services and the Department of
Homeland Security, which is a deterrent to people who would
otherwise be willing to come forward as sponsors.
Let me quote an ORR grantee who says, ``We are--'' And
again, it is a quote. ``--using children as bait for
immigration enforcement. It is alarming and cruel. And under no
circumstances is it justified.'' That is the MOA, and it needs
to be terminated immediately.
And third, we need to be prioritizing a safe discharge
process, as opposed to simply expanding detention capacity.
That should be our main goal, as it is the stated mission of
ORR.
The administration is now telling us that they want to
create the capacity to detain 20,000 children, up from the
current capacity of 12,000. Where did that number come from?
The peak has been 15,000 children, which occurred last
December. And instead of simply creating an unlicensed
detention complex, we need detailed plans about a discharge
process that gets children in and out of ORR's care as quickly
and as safely as possible.
To close, let me say that Congress has a legal and a moral
responsibility to conduct oversight of the UAC program and to
ensure that children are being taken care of. Our visit raised
more questions than it provided answers and reminded us that
our responsibility did not end with the emergency supplemental.
It began anew.
In fact, given the Trump administration history on this
issue, our responsibility as elected officials and as people is
heightened. We cannot allow systematic Government-sanctioned
child abuse on our watch.
Now I would like to introduce my colleague from the State
of Oklahoma, the ranking member of the committee,
Representative Tom Cole, for any opening remarks that he would
like to make.
Mr. Cole. Thank you very much, Madam Chair.
And I want to begin by thanking you for this hearing. I
think it is a very important hearing and timely. And you have
been engaged in this issue from its emergence, and I think you
are to be commended for that.
Before I begin, I want to remind everyone watching of the
history of the program we are talking about today and the
ongoing challenges regarding its implementation. Responsibility
for the care of unaccompanied children is relatively new. The
duty came to HHS as part of the Homeland Security Act of 2002.
Federal law requires the Department of Homeland Security to
transfer to HHS any unauthorized minor not accompanied by a
parent or legal guardian. This legal requirement means that
when Customs and Border Protection or Immigration and Customs
Enforcement apprehend a minor with an uncle, an aunt,
grandfather, grandmother, or older brother or sister, the law
defines the minor as unaccompanied and requires the transfer of
that child to HHS.
I understand there are many who believe these children
should remain with the adult relative they are traveling with.
However, that is not the law of the United States, and that is
not within the purview of HHS to change. That is within the
purview of Congress to change, if we choose to do that.
HHS and the Office of Refugee Resettlement, which oversees
the Unaccompanied Alien Children Program, does not separate
children from their parents. Let me repeat that. HHS does not
separate children from their parents and has not done so in the
past. HHS is only responsible for the care of children who are
unaccompanied, and this is a statutory responsibility given to
them by Congress.
I think it is obvious to everyone here that there are
significant disagreements between the President and the House
majority on matters pertaining to immigration policy, and I
know my Democratic colleagues are concerned about the
administration's action in this area. But disagreements over
the interpretation or implementation of immigration policy fall
squarely under the Departments of Justice and Homeland
Security. These policy discussions, frankly, are outside our
jurisdiction as a subcommittee.
Fiscal pressures associated with large numbers of
immigrants at the Southern border is not, as my friend the
chairman pointed out, a new phenomenon. In 2014, President
Barack Obama requested a supplemental appropriation to address
the urgent humanitarian situation on the Southwest border.
House Republicans, then in the majority, voted on a bill to
address President Obama's request in 24 days.
The majority waited roughly twice as long to give a vote to
the request for the humanitarian assistance by the Trump
administration. Frankly, in my view, that delay compounded--
that delay by Congress compounded the crisis at the border and
made things worse, not better.
In 2014, the year of President Obama's supplemental
appropriation request, HHS cared for over 57,000 unaccompanied
minors, an unprecedented number. By all accounts, in 2019 the
number of unaccompanied minors cared for by the Trump
administration will likely exceed 60,000, more children than in
any prior year on record. This administration inherited the
humanitarian crisis on the Southern border, one that has only
worsened in recent years.
The Congress recently approved a supplemental funding bill
to help alleviate the problem. And the bill included numerous
oversights, many based off provisions of the fiscal year 2020
House bill. The bill was by no means a blank check. The funds
are welcomed and critically needed, but securing additional
beds won't happen overnight.
The unprecedented surge in the number of unaccompanied
children and families crossing our Southern border this year
has stressed a system never designed to handle the current
volume of children. HHS cannot move minors into beds they don't
have.
In the meantime, HHS must continue to care for these
children as they arrive in the hundreds daily. The U.S. Customs
and Border Protection agency facilities are not set up to house
children. Everyone has an interest in moving these children out
of Customs and Border controlled custody and into HHS custody
as quickly as possible, and everyone agrees that State-licensed
and small facilities are the most ideal situation.
But when HHS does not have the capacity to accommodate the
thousands of minors arriving in these small-scale facilities,
it is preferable to move them into influx facilities, where
they can at least get medical attention, services targeted
toward youth, and have access to child-appropriate activities,
rather than having them back up at overcrowded, resource-
constrained Border Patrol stations.
I know that my friends at HHS are doing the best they can
to bring all facilities up to standards as quickly as possible,
and I want to commend them for the difficult work they are
performing and note that many of the same challenges were faced
by a prior administration. Frankly, HHS has had some successes
it doesn't get a lot of credit for.
Somehow in the testimony we heard earlier today, my
colleagues missed the fact that Homestead was actually
initially used by the Obama administration and that the current
provider was chosen initially by the Obama administration. And
frankly, the average stay there now, as I understand it, is
about 42 to 44 days. We would like it to be quicker, but that
compares to about 90 during the Obama administration.
So, again, this is a problem that all of us have had to
wrestle with before. I remember very well because I was
chairman of this committee in 2014. I remember working with
Secretary Burwell at the time on the challenges she had, and
Fort Sill was once again being used as a facility.
I want to thank the chairman here--I want to interrupt my
testimony and thank the chairman for inviting me to go
Homestead. I can assure her, and I know she knows this is true,
I would have gone had I not had the commitment. I would have
really gone.
I have seen these facilities before, but to be fair, most
of them were in 2014. Got scheduled trips coming up to some
facilities so I can be up to speed. But from what I can tell
and the testimony of the people I talked to, I don't find the
conditions dramatically different in 2019 than they were in
2014. I find the crisis eerily similar and the strained
resources all too familiar that we put HHS and ORR in a
situation to deal with.
So, again, I want to thank the chairwoman for having this
hearing. It is an important hearing. I want to thank the
witnesses for being here. I am looking forward to your
testimony.
And with that, Madam Chair, I yield back my time.
Ms. DeLauro. Thank you very much, Mr. Cole.
Now I would like to recognize the chair of the
Appropriations Committee, Congresswoman Nita Lowey.
Mrs. Lowey. And I want to thank you, Chairwoman DeLauro and
Ranking Member Cole, for holding this hearing.
And I want to thank the witnesses in each of the panels for
joining us today.
Last week, I, along with Chair DeLauro and several of my
colleagues, toured the Homestead influx facility in Florida. We
saw firsthand the results of the Trump administration's
policies, which directly led to backlogs and the use of massive
for-profit influx facilities like Homestead instead of children
being with their families.
I am very concerned that companies operating under no-bid
contracts are making profits by holding children for months on
end, to the detriment of those children and American taxpayers.
Children belong with families and loved ones, and facilities
like Homestead must be the absolute last resort.
Unfortunately for too many children, prospective sponsors
who would care for them in loving homes are faced with a
terrible choice--leaving these children in custody or
identifying themselves as viable sponsors at the risk of
themselves, their family, and their neighbors. Given the
administration's goal of stoking fear in immigrant communities,
no one is surprised that many sponsors are too frightened to
come forward, even with policies this committee has passed to
ensure that ICE cannot use data from ORR for deportation.
In fact, before I go on, I want to say that was not clear
to me, and perhaps you can elaborate on it, as to whether that
information that this facility Homestead had was kept privately
within that facility or shared with ICE. We seem to get
conflicting information, and I think it is very important that
we understand that. And this is what happens when an
administration at every turn seeks to divide the country and
play to its political base at all costs.
The purpose of today's hearing is to discuss the distinct
needs of these children and ensure the Federal Government is
abiding by our laws and our values. Ensuring that children
receive the proper care includes meeting physical needs like
clothing, bathing, nutrition, health screenings, and education.
It also means that we treat vulnerable children and families
fleeing the war and violence with decency, dignity, and
respect.
Upholding these responsibilities is a tall order,
especially with this administration. The lives and well-being
of thousands upon thousands of children depend, frankly, on
your agency fulfilling its responsibility.
I look forward to our discussion today, and I thank you.
Ms. DeLauro. I thank the gentlelady.
And Assistant Secretary Johnson, your full written
testimony will be entered into the hearing record, and you are
now recognized for 5 minutes for your opening statement.
Thank you.
Ms. Johnson. Thank you, Chairwoman DeLauro, Ranking Member
Cole, and members of this committee. It is my honor to appear
on behalf of the Department of Health and Human Services.
My name is Lynn Johnson. I am the Assistant Secretary of
the Administration for Children and Families, and I want to
start off by thanking this committee, your staff, for all of
your work in passing the recent emergency supplemental
appropriation for humanitarian needs.
Before joining this administration, I served as the
executive director of Jefferson County Human Services in
Colorado overseeing Head Start, workforce programs, career and
family services, child welfare, justice services, and community
assistance, which included Medicaid.
Prior to this position, I ran my own consulting firm. I
served as the chief of staff to Colorado Lieutenant Governor
Jane Norton, and policy adviser to Governor Bill Owens. Before
joining the Owens administration, I served with the U.S. courts
as a probation and parole officer. I carried a specialized
caseload of sex offenders and offenders with mental health
issues.
ACF administers the Unaccompanied Alien Children Program,
which is managed by the Office of Refugee Resettlement. ACF and
ORR are not immigration enforcement agencies. We do not set or
implement the Nation's immigration enforcement policies, nor do
we incarcerate children. ORR provider facilities are not
prisons.
Our program is a child welfare agency with a national
scope. Let me say that again. We are a child welfare agency
focused on providing care and services to an especially
vulnerable population. We are obligated under Federal law to
accept custody and provide care to any child who another
Federal agency determines is unaccompanied.
As Assistant Secretary, I have made it a priority to help
ensure that ORR fulfills its responsibility to deliver care
while working to discharge children to suitable sponsors as
quickly and safely as we can. We know families provide the best
care and structure for children, not the Federal Government.
ORR-run facilities, whether licensed or unlicensed, large
or small, are always better equipped to serve children than any
Border Patrol facility. Therefore, we have made it a priority
to obtain as much capacity as possible to help ensure that
children are transferred to an ORR care provider facility as
quickly as possible.
Unfortunately, the process for obtaining State-licensed bed
capacity is time consuming. The State licensing process can
take anywhere from 6 to 9 months. Care providers also must hire
sufficient staff, meet required supervision ratios under State
and Federal laws, conduct background checks on staff.
Staff must attend a variety of pre-employment training,
including trauma-informed care, program-specific training, and
trainings related to the duties of mandatory reporting. And
these are just a few examples of the issues that can add to or
complicate the timeframe of bringing these permanent beds
onsite. But it is our priority.
Of course, the Federal Government cannot force nonprofit
agencies to become ORR care providers, and we are facing
increasing difficulty in attracting new grantees in the current
environment. Some of our shelters face near constant protest,
and we are under a constant barrage of counterproductive
rhetoric. This includes gross factual misstatements by some
politicians. For example, comparing ORR facilities to
concentration camps, which are then repeated in the media, and
then that also scares our children we serve.
I am very concerned that such factual misstatements will
ultimately hurt our ability to deliver care. We cannot expect
qualified applicants to go through the grant process if success
means facing endless political attacks. Many of our grantee's
staff are counselors or social workers, and their mission is
strictly to care for children.
In our shelters, both permanent and influx, children
receive a wide array of services. And you heard this from
others before, that they are staying in their own beds, three
hot meals a day, snacks, showers, medical and dental care,
education, recreation, legal services. And they have asked for
more pizza parties and more soccer balls, and we have provided
that.
Just like you, I would prefer small, permanent shelters,
but I also prefer influx shelters over Border Patrol
facilities. My goal and that of our team is for ORR to succeed
in providing the very best model of care for children without
significant reliance on influx facilities, not just during my
tenure as Assistant Secretary, but into the future, regardless
of who is in the White House and regardless of who controls
Congress.
It is time not to have these crises. It is time to manage
this effectively. That being said, I am proud of ORR's UAC
program and my staff, and I am thankful for the hard work and
diligence of our care providers.
I am equally proud to report that right now, there are no
children pending placement over 24 hours in Border Patrol
facilities. And despite all of our changes in our testimony,
ORR does plan to have enough permanent licensed facilities that
we will not need to use influx as of 2020, at the end of 2020.
Thank you again, Chairwoman DeLauro and Ranking Member
Cole, because your hard work has helped us make these changes.
And I look forward to continuing them into the future and
answering your questions.
Thank you.
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Ms. DeLauro. Thank you very much, Secretary.
And Director Hayes, your full testimony will be entered
into the hearing record. You are recognized for 5 minutes for
your opening statement.
Thank you.
Mr. Hayes. Chairwoman DeLauro, Ranking Member Cole, and
members of the committee, it is my honor to appear before you
on behalf of the Department of Health and Human Services.
My name is Jonathan Hayes, and as the Director of the
Office of Refugee Resettlement, I manage the Unaccompanied
Alien Children Program. I became the permanent Director earlier
this year, and it is a privilege to serve in this role.
I am continually impressed with the level of commitment and
professionalism that I see in the ORR career staff and our
grantees on a daily basis, who carry out round-the-clock
operations in service of some of the world's most vulnerable
children. I have visited nearly 50 UAC care providers across
the United States over the last year so that I can see
firsthand the quality of care provided to these children.
Prior to my time at ORR, I worked for two congressional
Members for about 8 years. That experience provided me with
firsthand knowledge of the important oversight role that you
and your staff have to ensure that Federal programs operate
successfully. I am here today to report on the current state of
ORR's influx operations during this unprecedented time of high
arrival of UAC, including the conditions, services, and
standards at our temporary influx care shelters.
I would also like to express the Department's appreciation
and gratitude to Congress for passing the emergency
humanitarian aid package. Immediately upon enactment of the
supplemental appropriation, we restored the full range of
services for UAC, including those that we were unable to
provide during the anticipated deficiency due to appropriations
laws limitations.
HHS operates nearly 170 State-licensed care provider
shelters and programs, which include group homes, long-term
therapeutic or transitional foster care, residential treatment
centers, staff secure and secure facilities and shelters. Our
facilities provide housing, nutrition, routine medical care,
mental health services, educational services, and recreational
activities such as arts and sports, services that are very
similar to the domestic child welfare system.
Grantees operate the facilities, which are licensed by the
State authorities responsible for regulating residential
childcare facilities. While ORR's temporary influx facilities
are not required to obtain State licensure, children there
generally receive the same level of care and services to UAC in
State-licensed facilities.
We recognize that many of these children have experienced
traumatic childhood events and that migration and displacement
can cause ongoing stress. Care providers are especially trained
in techniques for child-friendly and trauma-informed
interviewing, assessment, and observation and deliver services
that are sensitive to the age, culture, native language, and
needs of each child.
Clinicians are able to do crisis intervention and group and
individual counseling sessions. If a child is found to have a
mental health need that cannot be addressed at any of our care
facilities, we will transfer them to a more appropriate
setting.
The number of UAC entering the United States during this
fiscal year has risen to levels we have never seen before. As
of July 15th, the Department of Homeland Security has referred
more than 61,000 unaccompanied alien children to us, the
highest number in the program's history. By comparison, HHS
received 59,170 referrals in fiscal year 2016, the previous
highest number of annual referrals on record.
HHS currently has about 10,000 children in our care, though
this number fluctuates on a daily basis. As of June, the
average length of time that a child stays in HHS's custody is
approximately 42 days, which is a dramatic decrease of 53
percent from late November 2018, when the average length of
care was about 90 days.
During my tenure at ORR, we have issued four operational
directives and revised our policies and procedures with the
specific aim of a more efficient and safe release of UAC to
sponsors. It is the expressed desire and goal of both the
political and career leadership of ORR to expand our capacity
in such a manner that as many children as possible can be
placed into a permanent State-licensed facility or transitional
foster care while their sponsorship suitability determinations
or immigration cases are adjudicated in the event there is no
sponsor available.
By December 31 2020, we anticipate that we will have
increased permanent State-licensed shelters, including foster
care, of up to a total of 20,000 beds, which almost doubles
current permanent capacity. In the short term, HHS aims to have
about 3,000 additional temporary beds available this fiscal
year at influx care facilities in anticipation of continued
high arrivals at the Southern border so that UAC do not remain
in Border Patrol stations, which are not designed or equipped
to care for children.
In conclusion, my top priority and that of my team is to
ensure the safety and well-being of children who are placed
temporarily in HHS's care and custody as we work to quickly and
safely release them to suitable sponsors.
Thank you for your support of the UAC program and the
opportunity to discuss our important work. I will be happy to
answer any questions that you may have.
Thank you again, Madam Chairman and Ranking Member Cole.
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Ms. DeLauro. Thank you very much.
Let me make one point of clarification, and I say this to
my friend and my colleague Ranking Member Cole. In the Obama
administration, the turnover was 35 days. It was 90 days last
year, as the Director has pointed out.
Director Hayes, in your testimony, you note that children
generally receive the same level of care and services as
children at a State-licensed facility. Quite frankly, not just
myself, but many others--many people on this dais--and folks
over and over again in recent weeks and months have noted that
these children are not receiving the same standards of care.
So my priority is to responsibly shut down Homestead to
eliminate the use of facilities that are not State-licensed.
When do you intend to close Homestead? Under what
circumstances, if any, would you choose to extend the Homestead
contract currently in place through November 30th?
I need you to move quickly as well because we only have 5-
minute periods of time. So thank you.
Mr. Hayes. Yes, ma'am, Madam Chair. I just want to
reiterate I, too, share your commitment to only utilize influx
shelters when absolutely necessary, and we want to see each and
every child, as we can, into a permanent State-licensed
facility.
Ms. DeLauro. When do you plan to close Homeland--Homestead?
Mr. Hayes. Homestead, the influx shelter, ma'am, we are
working as quickly and safely as we can right now to discharge
the children that are there to appropriate sponsors. As noted
in some of the opening statements, and that we----
Ms. DeLauro. So you are moving toward closing down
Homestead in the same way Tornillo was shut down. But shutting
down Homestead as soon as possible?
Mr. Hayes. Our team is working without delay to safely and
quickly move the children out of Homestead at this moment. We
have seen very safe and significant numbers, as we referenced
on the CODEL, yes, ma'am.
Ms. DeLauro. And it will be shut down then?
Mr. Hayes. I am not going to commit to actually closing
down the shelter at this time, but it is my desire to move the
children at Homestead right now out as quick as possible, yes,
ma'am.
Ms. DeLauro. Okay. And by the way, we have asked for a copy
of the Homestead contract. So we really need to know when you
are going to share that with the subcommittee.
Mr. Hayes. I will be happy to get with the team and make
sure that it is back to you just as soon as possible, ma'am.
Ms. DeLauro. The Homestead contract goes through the 30th
of November. What are the circumstances in which you would
intend to extend it? Are you planning to extend it?
Mr. Hayes. I am in constant coordination with both my
planning and logistics team, my Deputy Director of the
Unaccompanied Children Operations at ORR, to ensure that we
have as much capacity as possible in order to move children as
quickly as we can from Border Patrol stations into our care. It
would only be used----
Ms. DeLauro. Well, you are moving pretty quickly.
Mr. Hayes. We are, yes, ma'am.
Ms. DeLauro. When you have done in a month's time, it was
about 1,600, which again makes us all believe as to wonder why
we are not moving. In which case, I don't know, how many do you
have at Homestead right now?
Mr. Hayes. Ma'am, as of this morning, we have 894, as of
7:00 this morning.
Ms. DeLauro. You had 1,300 when we were there, 1,309, to be
exact.
Mr. Hayes. Yes, ma'am.
Ms. DeLauro. So you are moving. So we could move out
several hundred kids and really be done with this facility and
this warehousing.
Mr. Hayes. My commitment to you, ma'am, is that we are
seeking to move the children out of Homestead as quick as
possible into either sponsored homes----
Ms. DeLauro. Let me talk about discharge rates and the
impact of the Memorandum of Agreement. Operational directives
ORR issued December have helped to expedite, without question,
the discharge of children from ORR's care. They were only
necessary because, because of the Memorandum of Agreement.
Director Hayes, you noted that career staff proposed each
of the operational directives that have enabled ORR to place
children with sponsors more expeditiously. Question--and I need
a yes or no--what about the MOA? Did career staff recommend
expanding fingerprinting requirements to all adults living in a
sponsor's household? Yes or no.
Mr. Hayes. Ma'am, that was before my time at ORR. So I
cannot--I would be speculating if I answered that question.
Ms. DeLauro. Or sharing information on sponsors with ICE
for immigration and enforcement purposes, which is ongoing. Is
that coming from staff? Yes or no.
Mr. Hayes. Ma'am, the Memorandum of Agreement was set in
place before my time in the Office of Refugee Resettlement. I
cannot speak to the discussions or recommendations of career
staff prior to my time at ORR.
Ms. DeLauro. Okay. So, in fact, we have no--if you tell me
that the operational directives that you are now abiding by,
which went through to December and March and June, et cetera,
that came from your staff folks, not from--and prior to that,
you don't have any knowledge of where those--the policy came
from?
Mr. Hayes. That is correct. And I will say that I----
Ms. DeLauro. You were working at the time for the--as I
understand it, your job was as an Assistant or Deputy to the
prior Director. It seems unconscionable to me that you would
not know what the directives are, but let me move to Assistant
Secretary Johnson.
Have ACF and ORR discussed the potential impacts that
rescinding the MOA would have on discharge rates? Yes or no.
Ms. Johnson. No, we did not specifically talk about that.
Ms. DeLauro. You haven't? If not, will you look into for us
how this change could expedite the release of children?
Ms. Johnson. Yes. I will look at that.
Ms. DeLauro. Thank you. I just want to note before I
conclude that the written testimony from a witness on our next
panel, Krish O'Mara Vignarajah, includes data showing the
chilling effect of the MOA on the willingness of sponsors to
come forward. The number of sponsors who backed out of the
process increased sixfold after the MOA was implemented.
As I have said in the past, HHS needs to terminate the MOA.
Do you agree? Both. Go ahead. Do you agree? Yes or no.
Ms. Johnson. Congresswoman DeLauro, we agree that we have
got to take these operational directives and make the changes
that----
Ms. DeLauro. Yes or no, should we terminate the MOA?
Ms. Johnson. Yes, we should.
Ms. DeLauro. Director, yes or no, should we terminate the
MOA?
Mr. Hayes. I think the decisions that we made with the
operational directives show that that is the path we want to go
on, ma'am.
Ms. DeLauro. Should we discontinue the transfer of
information as it currently is because there is and should we
discontinue the MOA? Yes or no. You direct this operation. You
should know whether or not you want to keep this in place.
Mr. Hayes. Ma'am, I think if you look at each of the four
operational directives----
Ms. DeLauro. So you are not going to answer the question?
Mr. Hayes. I am not going to speak specifically to the MOA,
but I do support the four operational directives in order to
expedite the release of children to properly vetted sponsors. I
want to see the children back with their families.
Ms. DeLauro. I am going to take this as that you want to
continue the MOA and its current destructive effect on
discharging students.
Congressman Cole.
Mr. Cole. Thank you very much, Madam Chairman.
We are talking about Homestead. Let us talk a little bit
more about it. Mr. Hayes, can you tell me under what
administration Homestead was first opened and operated as a
facility to house and care for unaccompanied minors?
Mr. Hayes. Yes, sir. Homestead was chosen and the
contractor provided in December of 2015 under the Obama
administration.
Mr. Cole. And thank you. And the for-profit contractor
responsible for comprehensive shelter services, were they also
selected by the previous administration?
Mr. Hayes. Yes, sir. They were.
Mr. Cole. Okay. And during that time, was there any calls
that you are aware of for closure of Homestead or for dismissal
of that particular contractor?
Mr. Hayes. None that I am aware of, sir.
Mr. Cole. Okay. And I think that is important to establish.
There is a lot of continuity here.
Let me ask this as well. We have a lot of Members--I have
dealt with this at Fort Sill myself--that would like to show up
at facilities unannounced and have immediate right of
inspection. And there is a case to be made for that, but I also
know there is a whole series of legal challenges and problems
when that happens.
And I know how disruptive it can be. I saw a case where a
member of my own delegation did exactly that, was denied
entrance, appropriately so, in my viewpoint. It was actually on
a military facility. He was there for other purposes and went
over without telling anybody and started demanding to go.
So what are some of the problems--and I address this to
both of you. Maybe I would start with you, Secretary Johnson.
What are some of the problems that happen if Members don't
notify. You don't set up a procedure to actually come and
visit.
Ms. Johnson. Thank you, Ranking Member Cole.
Some of the problems that we have when Members just show up
at the door is that our staff, unlike those of us who work
every day with you or know of you because we work here in D.C.,
they don't know who is a congressperson and who is not. And we
have had several people who have protested or who are angry
with the immigration system or any other type of child welfare
system that we do.
People do come in and try to impersonate other people to
try to get in those doors. We want to make sure the safety of
those children is seriously the number-one priority. Letting
people just walk into the facility does not protect them if we
would have someone who is misrepresenting.
The other piece is that when someone, especially someone
who is in Congress, comes to a facility, the staff would want
to really be there to answer your questions. That means whoever
that staff is that we take off of serving kids is with the
congressperson, and we are not--we might lower the number of
children that are being cared for. That is not healthy for the
kids, and what we want to do is always be responsive to you
when you are touring one of our facilities.
And we appreciate the change to a 48-hour, 2 business day
change. I think that oversight is absolutely critical.
Mr. Cole. Let me ask both of you this. If the Homeland
facility were closed tomorrow, what would you do with the
population that is currently being housed and sheltered there?
Mr. Hayes. So, again, Ranking Member Cole, that is just shy
of 900. So, you know, we would move them into permanent beds.
But again, that would limit some of the permanent capacity that
we have immediate access to right now.
And just to note, sir and ma'am, we have not designated any
children to Homestead since July 3rd, and we have not
designated any children to any of our influx shelters since
July 17th.
Mr. Cole. And that was very much my experience with the
Obama administration. I remember talking to Secretary Burwell,
she said, look, we are trying to get kids out of there as
rapidly as we can. For a whole variety of reasons, one of which
they are a lot more expensive than if we can move them into
what we think are both more appropriate and more cost-
effective. I think that same imperative appears to me to be
very much at work here.
If we did--well, let me ask you this. We know we have had a
lot of challenges here. Were any of the challenges that you
faced a few weeks ago because you just were running out of
funds? In other words, Congress had not acted on the
administration's emergency request for 58 days. Did that make
things different or harder?
Mr. Hayes. I think the lack of appropriations definitely
created a high level of uncertainty amongst the program. And
that does make it very challenging for us to move in the
direction that Assistant Secretary Johnson and I would like----
Mr. Cole. Well, did you have to make reductions because you
weren't certain whether or not we would actually pass the
legislation and reduce your services to try and stretch out
your dollars.
Mr. Hayes. We did that as well, sir. As well as had to
scale back certain services in accordance with the Anti-
Deficiency Act.
Mr. Cole. I appreciate that very much. My time is about up,
Madam Chair. So I yield back.
Ms. DeLauro. Congresswoman Lowey.
The Chairwoman. Thank you for your testimony.
This committee, as part of the fiscal year 2019 spending
bill, included a funding prohibition that prevents DHS from
using information collected by HHS to detain, remove, or
initiate removal proceedings against the sponsor of an
unaccompanied child, and yet the original MOA between HHS and
DHS still stands, and many worthy sponsors are still terrified
to come forward, leaving children for extended periods of time
in shelters across the country. The Federal Government, and in
particular the Department of Health and Human Services, should
not in any way use vulnerable children as bait.
I went on that trip to Homestead, and this is the issue
that haunts me because we did not get the information directly.
Director Hayes, aside from information used to determine a
sponsor's fitness, such as a criminal record, does HHS
currently share information of potential sponsors with the
Department of Homeland Security?
Mr. Hayes. Yes, ma'am, we do. At the time of discharge,
once a child has been properly run through the sponsorship
process. When a child is discharged to a sponsor, we do send--
as I notified on the tour, Chairwoman DeLauro----
The Chairwoman. Excuse me. This is just shocking. I was
shocked when I heard it there. Given the funding restriction,
why is this happening? And are you aware of DHS using
information from HHS to detain or remove a sponsor of an
unaccompanied child? Is this arrangement or the perception of
such an arrangement creating delays for finding safe placement
for these children?
Mr. Hayes. So a couple of questions you ask, ma'am, and I
want to answer all of them. First off, to finish answering the
prior question, once a child is discharged from our care to go
to the family, to the sponsor, as they await their hearing,
they are then under the jurisdiction of the Department of
Homeland Security in order for them being referred back to the
Executive Office for Immigration Review for their court case.
The Chairwoman. Do you have a responsibility legally? That
is not my understanding according to law that HHS must transfer
all information to the Department of Homeland Security.
Mr. Hayes. I wouldn't say that it is all information,
ma'am. All it is, is where the child is going and who they are
going to be with. And so that they can--in order to get----
The Chairwoman. But who is the sponsor? So if the sponsor
is undocumented, you give that information to Homeland
Security?
Mr. Hayes. We do not share the immigration status of any of
our sponsors.
The Chairwoman. What information do you give them? It seems
to me that you can----
Mr. Hayes. We give them----
The Chairwoman [continuing]. You are not checking the
person's health, whether they are capable of supporting the
kids.
Mr. Hayes. We are.
The Chairwoman. But if they are undocumented, you give that
to Homeland Security. So are you surprised that sponsors are
not coming forward, that they are afraid to come forward?
Mr. Hayes. Ma'am, I just will add, again, when we discharge
a child to a sponsor, they then move under the jurisdiction of
the Department of Homeland Security and Department of Justice
for their immigration proceedings, and our responsibility ends.
We do not share that immigration status, and the immigration
status of the sponsors is not a major determining or automatic
disqualifying factor for us to discharge a child.
The Chairwoman. Of course not. But why do you believe that
the sponsors are scared to come forward? What do you believe
the impact is that fear has on the processing time to place a
child with its sponsor? We were talking to some of these kids
at Homestead----
Mr. Hayes. Yes, ma'am.
The Chairwoman [continuing]. And you just don't ask every
question. But I wondered, a young man who has been there for 56
days has a father who is working, has a paid job for 7 years.
Why is he still there? What other information?
Do you think that--do you have, and then we will have to
check on the law. You are saying that you have an obligation to
turn this information over to the Department of Homeland
Security?
Mr. Hayes. Once we discharge a child, they go under the
jurisdiction of the Department of Homeland Security, and we
simply share that information as to where they are so that they
can be further communicated with as their case goes through the
immigration court system.
And I just will add, I have no doubt that there are certain
sponsors that are concerned with coming forward. I am sure that
that exists. I would acknowledge that to you all today.
However, I think if you look at our discharge rate,
specifically over the last 4 to 6 months and how it has
improved, I would reject the argument that there is a
widespread pattern of sponsors, you know, too scared to come
forward. Because we are discharging children as quickly and
safely as we can with some of the highest discharge numbers
that the program has seen.
The Chairwoman. It seems to me, and I will conclude my
question because my time is almost up. It seems to me that--and
I think it was for the first part of our discussion at
Homestead, there was no admission that the information was
transferred at any time to Homeland Security. And after we kept
pursuing and asking those questions, we realized they do.
So it would seem to me we have to look at this law very
carefully because if you are going to place these children--and
to me, I am not even going to discuss the Homestead facility.
But if you are going to place these children in a home with a
family, which we all agree is the best place for them----
Mr. Hayes. Absolutely.
The Chairwoman. For the first part of our visit, we were
told that information is not transferred to Homeland Security,
and then it was clarified that it is.
Mr. Hayes. If I may, with all due respect, ma'am? I made
that comment in the command center, which was after our first
brief huddle in the ORR building. That was our very first stop,
and I shared that directly with Chairwoman DeLauro----
The Chairwoman. Let me end here at this point. It looks
like we have more work to do in that regard.
Thank you, Madam Chair.
Ms. DeLauro. Mr. Moolenaar.
Mr. Moolenaar. Thank you, Madam Chair. And I appreciate the
hearing today, and I appreciate your testimony today.
Also just wanted to thank you, Director Hayes. I know you
and your staff conduct weekly phone calls with congressional
staff to keep us up to date on the status, and I appreciate
that, and I know the staff appreciates that as well.
I wanted to talk a little bit about kind of what the
lessons we have learned. When there was a surge in 2014, what
lessons were learned in that, and how are we applying those
lessons today? That is one question for you both.
And then also I want to talk a little bit about how we are
recruiting providers. That is something that, you know, how can
we get the message out. How can we improve that so that people
are getting the best care possible?
So if you would maybe start with kind of the lessons
learned from the previous surge and how we are implementing
that?
Ms. Johnson. Thank you, Congressman.
Lessons learned for me, I started in September, and so
things had already reached crisis stage when I arrived. I think
the biggest lesson I learned is that this doesn't just happen
in this administration. It happened in previous
administrations. And it even happened before, but not to this
extent.
That the lesson learned should be we should not wait and
then respond to surges in a crisis response management system.
We need to respond in a--we should be prepared because this
continues to happen over administration to administration.
We should be prepared to do it with conservative tax and
financial principles so that we are not wasting any dollars,
and we should always have these beds available so we are not
having to use influx and that we could put kids into loving
shelters and move them quickly to their parents. That was my
lesson learned.
Mr. Hayes. And I just would add, Congressman, I think one
thing that we have learned over the last number of years of
this program is that migration patterns are often extremely
difficult to predict, and so that is why Assistant Secretary
Johnson and Secretary Azar and I are committed to increasing
the number of permanent capacity State-licensed beds in our
network so that the use of influx beds is exceedingly rare.
That is our goal.
One thing that we have specifically done recently, you
know, how to look forward, and to how to expand that capacity
that we are speaking about and committed to at HHS. Just this
last Monday, I had a phone call with our whole grantee network,
the leadership of our grantee network, and I put forward our
desire and the goal of where Assistant Secretary Johnson and I
want to take this program.
And I told them that they are going to be partners in that
endeavor. And so if there are opportunities for them to
increase capacity at their current permanent shelters, please
let our project officer team know that. If they would like to
open up additional permanent licensed shelters, please let us
know that, respond to our Funding Opportunity Announcements.
And if there were other grantees and nonprofits and
organizations that have the capability to partner with us as
from a child welfare perspective that are not necessarily
providing a shelter for ORR right now, please bring that to our
attention and make sure that they are aware of the Office of
Refugee Resettlement's needs in the coming weeks and months as
we move forward with additional Funding Opportunity
Announcements.
Mr. Moolenaar. And are there barriers that you are finding
towards increasing the capacity?
Mr. Hayes. There are, sir. At the end of the day, the final
say on granting of a license and occupancy to a State-licensed
permanent shelter, even one that we fund and pay for as the
Federal Government through HHS, lies with both local officials
and the State officials through a licensing perspective,
occupancy from the local fire marshal and the local licensing
board.
And you know, we are--honestly, sir, we are experiencing
challenges, I would say, from both sides of the aisle. Some
Governors don't want, you know, illegal immigrants in their
States. I think there is an understanding that they might take
some of the resources away from the State, that HHS cares for
each and every one of the needs there.
And then also some from the left that don't want children
detained or locked up even in a 100-bed permanent licensed
shelter. So those are some challenges that we are definitely
facing, sir.
Mr. Moolenaar. And I know you mentioned ``quickly and
safely'' released to suitable sponsors. And I think that is
something those two, quickly and safely, that those don't
always work hand-in-hand. You want to make sure there is in
some way verification, in some way accountability for whatever
sponsors. Can you speak to that just for a moment?
Ms. Johnson. We do thorough background checks, and we have
been operating this program for a very, very long time. So we
do the background checks. We do home visits. We gather
information about the sponsor. And so we really worked hard to
make sure that this child is going to a safe home. And we do
this--we have got this down, and we do it as quickly as we can.
Mr. Hayes. And I would just add, sir, in closing that the
final say on the discharge of that child does fall to Federal
oversight staff, our Federal field specialist team and our
Federal field specialist supervisors. As they kind of look
through the entire case of that particular child and the
sponsorship care package and reunification package, again to
make sure that all the policies and procedures were followed
and that that is, indeed, the safest and best path for that
child to go into.
Mr. Moolenaar. Thank you. And thank you, Madam Chair.
Ms. DeLauro. Congresswoman Watson Coleman.
Mrs. Watson Coleman. Thank you, Madam Chair, and thank you
to the--thank you and thank you to the ranking member for this
hearing.
Thank you for being here.
We did have a very thorough visit, I think, at Homestead,
and I am grateful for that. I do think, however, it is
important that Members of Congress who have identification can
come to these facilities without first being--getting
permission to come in so that we can actually see what really
happens on a day-to-day basis.
I got a number of questions. Number one is the educational
offering that we saw at Homestead was really very disturbing.
The facility, in and of itself, was very counterintuitive to
learning. It was loud. It was noisy. You really couldn't hear
yourself think, let alone--you couldn't hear what people were
saying, let alone thinking. So I really think that that is a
particular challenge just being in those classrooms and
expecting those children to learn.
What happens if a child doesn't speak English or Spanish?
How does that child get to interact and be taught? Are there
other languages being taught, being spoken at Homestead, Mr.
Hayes? Thank you.
Mr. Hayes. Yes, ma'am. We do have translators available.
And I will just note that we do have a significant number of
children that come into our care that are not Spanish speaking.
We have a grantee in the Chicago area that has 38--the ability
for their staff to speak 38 different languages, and when our
intake team determines that or if a child were to arrive at
another shelter after, we will absolutely transfer that child
to a facility where we can communicate with them just as
quickly as we can.
Mrs. Watson Coleman. Thank you.
I know that the Homestead facility is an influx facility,
and so children don't necessarily stay there and shouldn't stay
there very long. But you have educational standards and you
have a curriculum, and none of it is curriculum or standards
that have been decided by the State of Florida as appropriate
for the educational offering.
And my question is why do you not use their standards and
their curricula?
Ms. Johnson. Thank you.
It is really critical to remember that the child that comes
over the border, sometimes they have never been in a classroom
in their lives. And sometimes they have been in 1, 2, or maybe
3 years of----
Mrs. Watson Coleman. Yes, I agree with that. But I don't
understand why you think that this for-profit company is more
capable of developing curriculum standards for these children
than those people who are sanctioned and educated and certified
by the State of Florida.
Ms. Johnson. The public school system's standards and
curriculum do not adapt to the situation that we have with the
children who have had no learning, and we want that child--it
is only 30 days--to have the type of learning so they can leave
the facility and be successful wherever they go.
Mrs. Watson Coleman. I think that is very----
Ms. Johnson. And that does not fit----
Mrs. Watson Coleman. Okay, thank you. I think that is a
very interesting concept.
Why is it that there are only five certified teachers at
Homestead?
Ms. Johnson. Thank you.
The teachers that we are able to recruit, we again look for
the Spanish speakers, those that have some social work
background, ability to do counseling and understand the
journey, the trauma-informed care. So we look for teachers who
can do a 30-day learning experience that, in addition to being
a teacher--and we do have some that are certified--we can move
forward.
The other piece with that is that many of the teachers are
not looking for an influx type of employment where in 30 days,
they might not have employment. Teachers may--they like the
long term.
Mrs. Watson Coleman. Okay. Thank you.
You mentioned that when there was a threat that you
wouldn't have sufficient resources, that you had to scale back
on certain services. Could you just list for me quickly some of
those services that you scaled back on?
Mr. Hayes. Yes, ma'am. They would have been education,
recreation, and legal services.
Mrs. Watson Coleman. So that leaves feeding and sleeping
and bathing perhaps. If you do not accept any more children
into Homestead and Homestead then becomes vacant, what is our
financial obligation to this facility when there are no
children there?
Mr. Hayes. It is on a contract, ma'am, and that is
something that we are working very closely with our team on. We
could modify that contract, and that is an ongoing operational
decision that we are having at the Office of Refugee
Resettlement.
And I will just promise to you and give you my word now. I
would agree, ma'am, that the education building that we went
into, that the noise level was something that was a bit of a
problem----
Mrs. Watson Coleman. Yes, okay.
Mr. Hayes [continuing]. In some of the curriculum. And I
will work with my team on looking----
Mrs. Watson Coleman. Mr. Hayes, thank you. You know, I am
really concerned about what our financial obligation would be
to a vacant facility. And so I don't need to know what you
could do. I need to know what you will do and what you legally
can do in that situation. And if you are not prepared to answer
that right now, we can through the chair accept that
explanation.
Mr. Hayes. As soon as we make a decision, ma'am, I will be
sure that Congress finds out through the Assistant Secretary
for Financial Resources and her staff.
Ms. DeLauro. Because Tornillo was shut down. There was a
contract. What was the amount, and what happened at the end of
that?
Mr. Harris.
Mr. Harris. Thank you very much, Madam Chair. And thank
you, Assistant Secretary and Director, for being here today.
First of all, you have got to realize, of course, it is not
your fault. This is Congress' fault. I mean, the bottom line is
this is a failure of Congress.
First, we refused to deal with the policies that
incentivize UACs crossing the border, and then we refuse to
fund you adequately. I mean, the bottom line is I think it
should be noted that when President Obama requested emergency
funds during his administration, it took 25 days to get those
funds to you, and this time, it took 58 days to get the funds
to you.
Now I am going to ask you, the bottom line is so when the
Republicans controlled it, we actually got funds promptly to
take care of the children. When the Democrats controlled it,
they whistled past the graveyard for a while.
In those additional 33 days that it took us--and by the
way, our 25 days was up, oh, that is right, in the middle of
the Memorial Day recess while we decided to go home instead of
taking care of the children issues at Homestead. Could you have
done something with funds, had those funds been released almost
a month earlier in terms of speeding the--what has occurred
since the funds were released, which is speeding the discharge
of these individuals from Homestead to other facilities or
places?
Could you have done a better job if we--if Congress didn't
whistle past a graveyard through its Memorial Day recess and
not provide the funds?
Mr. Hayes. Dr. Harris, we will always be able to do a
better job with the----
Mr. Harris. Sure. Of course, you can. This is crazy. This
is a failure of Congress.
Now HHS is not a law enforcement tool, but it certainly
should cooperate with law enforcement, shouldn't it? I mean, we
shouldn't put a wall between Federal agencies in terms of
enforcing the law.
And what I am getting at is, you know, human trafficking is
a huge issue, and we know that some of these unaccompanied
children are trafficked not only for human trafficking into
prostitution, but into gangs. And what I see here is most of
these children come from the Northern Triangle countries. That
is where MS-13--that is the base for MS-13. MS-13, a huge issue
in Maryland.
I would hope that we don't build a firewall between
agencies that would prevent the investigation of potential gang
trafficking and human trafficking into this country. Now look,
I am going to apologize that, you know, for the accusation that
somehow you are child abusers. Because child abuse is actually
a crime.
I am going to ask you, by the way, is the Homestead
facility subject to Florida State law?
Ms. Johnson. No.
Mr. Harris. So if a murder is committed, it is not subject
to Florida State law in the Homestead facility.
Mr. Hayes. No, our facilities are subject to all Federal
and applicable State laws, yes.
Mr. Harris. Of course, it is. And of course, you do realize
that child abuse is a criminal act under Florida law?
Mr. Hayes. Yes, sir. And the Florida Department of Children
and Families would investigate.
Mr. Harris. Correct. And that your--for instance, your
physicians and social workers are bound under law to report
child abuse.
Mr. Hayes. Yes, sir. As well as ORR policies and procedure.
Mr. Harris. Correct. In the past let us say 2 months, how
many reports have been made by your licensed physicians and
social workers under Florida law that child abuse has occurred
in the facility?
Mr. Hayes. I don't have that exact number, sir. But I would
be happy to get it back to you.
Mr. Harris. Is it a handful? I mean, because this is under
Florida law because, again, the allegations--and look, in
another room here, there are other baseless allegations being
made against the Trump administration and its officials. The
bottom line is that you were accused of child abuse, which is a
criminal act. And I want to apologize for that because there is
no basis for it. And I believe when you get me that number, you
are going to realize that there is no basis for systematic
child abuse occurring at this facility any more than systematic
child abuse occurs at a public school or other institution.
Now let us talk about a little bit about what we can do
going forward. Because this is in the past, we got you the
monies you need. The bottom line, and I want to bring up the
question because it has been said that we have to--if we close
this facility, how do unaccompanied children flow from the
border to a sponsor? How would that occur?
Mr. Hayes. So the process, sir, once a child comes into our
care and custody after being referred by DHS, we immediately
after processing them at the facility, again providing them
initially a hot shower, a warm meal, and the initial medical
exam. We immediately begin the sponsorship reunification
process to identify a sponsor, run the appropriate background
checks on that sponsor, and then discharge the child just as
quickly as possible.
Mr. Harris. Right. But if Homestead doesn't exist, where
would that child go?
Ms. Johnson. Our plan is that they would go to a permanent
licensed shelter so that they don't have to go to influx
facilities. But at this time and with the numbers coming over
the border, we have needed the influx. But they are dropping
now. We are watching the trends. We are watching the trends
from last year and the year before to find out is September
going to be high again? Is November?
So we don't want to change anything drastically until we
know that the new normal is.
Mr. Harris. I get it. Thank you very much.
Thank you, Madam Chairman.
Ms. DeLauro. I just might add that the bulk of the money in
the supplemental is for permanent licensed beds, understanding
your need. And that is what we did, so that we could close the
influx shelters down.
With that, Congressman Pocan.
Mr. Pocan. Thank you, Madam Chair.
And I just want to say Representative DeLauro's opening
comments reflect exactly how I feel from the visit and being
there. I think the thing that I took away was I would love to
figure out how we would never have a facility like this again,
period, given the conditions on multiple levels.
I mean, they are not the horrific conditions of the no soap
and toothbrushes. But for $750-plus a day, those are not
conditions that are acceptable.
I want to ask, so it looks like 1,400 children--because you
are now down to 890-something--in a matter of a few weeks have
suddenly been moved from there. I think the question that we
asked that day and hopefully have the answer now because it is
9 days later, how many of them were placed in homes, and how
many just are transferred to other facilities?
Mr. Hayes. So I actually did have the answer that day, sir.
We provided it to Chairwoman DeLauro and her staff.
Mr. Pocan. Okay. You can go ahead and say it.
Mr. Hayes. Looking specifically at those numbers of that
day as 900 that had been discharged in the 12 days you all were
referencing. About 810 were discharged to sponsors, you know,
family, close friends, and about 90 were transferred, either
due to the fact that there is no identified sponsor in the
country or they had medical issues.
Mr. Pocan. Sure. So I guess the question really is why all
of a sudden in a few weeks could you move that when for so long
those facilities are holding people at $750 a day? And let me
just say that conditions, the education. I don't think any of
you think that that really is education that is happening there
for that $750.
I taped the background sounds while we were there, and you
probably can't hear it there. It was a constant--let me turn my
volume up.
[Playing audio.]
Mr. Pocan. I couldn't hear the person with a microphone
that was about 8 feet away trying to--in a classroom because of
the background noise. There is no way that you are having
education occur with this kind of background noise.
The fact that mental health professionals, anyone who has
come leaving trauma in a country, violence is why they left in
the first place, went through a treacherous journey to get
there, and then being separated from their families, and then
the mental health in some cases is a Skype session with a
mental health professional in Texas?
I guess what I am getting at is people back home in
Wisconsin say how can this possibly cost more than the Four
Seasons or the Trump hotel, and yet the conditions are, you
know, bunk beds stacked in rooms, no education whatsoever, no
real mental health whatsoever. How does it get to be $750 a
day?
And at first you said, well, initially there is an expense.
This facility has been around, as we have pointed out, for a
long time. So there is no initial expenses we are still paying
for. How is it that we are not getting ripped off?
And then the second part to this is I talked to 4 girls--
one who had been there 75 days, two were there 60, one 45. The
one girl that was there for 60 days just the previous week,
they reached out to her brother who lives in the United States.
That means for 53 days, they didn't try to connect that person
to a family member at $750 a day.
What I am getting at is this is a very profitable venture
with very little incentive to transfer people. But all of a
sudden in a couple weeks, you transferred 1,400 people. So some
fire got put under the system.
But that is screwed up. And by every smell test that people
in Wisconsin live by, that doesn't make any sense. Can you
address the costs and specifically that issue of like people
sitting there for 53 days before they are finally trying to be
connected to a family member?
Mr. Hayes. Yes. So, again, I can't speak specific to
examples. So I don't know if there, you know, maybe that is
when she shared that she actually had a brother. We have seen
that before when children come into our care in custody, sir,
and they don't----
Mr. Pocan. Okay. How much does it cost? Because I want to
get one other question, and I got a minute and 9 seconds.
Mr. Hayes. Right. So the approximate cost at Homestead is
approximately between $700 and $750 a day, sir.
Mr. Pocan. How is that justifiable? I mean, given bunk
beds, not really educational opportunities, not really
teachers, Skype sessions with mental health.
Mr. Hayes. Influx shelters historically have cost more, and
I think it is important to note, Congressman, that when that
contract was originally awarded, two for-profit companies put a
bid for it and three nonprofits, and it was awarded in an open
and fair competition. It is not costing the Federal Government
additional money because it is for-profit.
Influx facilities----
Mr. Pocan. Okay, if I can just pause this because I do want
to go to another question. So it is still three times more than
the other shelters. I still think there is a real cost issue
that is totally indefensible, and we need to address that,
which is part of why these facilities should go down.
The question I wanted to get in my final seconds is we--and
Mrs. Lowey asked this question as well. On the--I am just
trying to find where this is now here. Well, actually, I am not
going to have time for this. I will leave it at this.
But I do have more questions. We gave you a list of 107
questions. Did we get the answers on those returned to us?
Ms. DeLauro. No. The answer is no. We worked on it, but we
don't have the answers.
Mr. Pocan. If I could, just 20 seconds, please, on this?
This is the question I was trying to get out is the
information, you said that they fingerprint everyone and that
information is given to Homeland Security. All the calls are
given to Homeland Security. And the question we had--that is
what you told us that day.
Because a question I had, you said you would get back to us
on, was what do they do with the information they get? And you
said you don't know, which I didn't expect you to then. But 9
days later, do we know if they use that information in any
other way?
Mr. Hayes. I would refer you to the Department of Justice
as to what they might do with the fingerprint results that we
share with them. But----
Mr. Pocan. I did ask you that question that day, and you
said you would get back to me at the end of the trip, which you
didn't. So now it has been 9 days later. Seriously, do you not
know what they do with that information?
Mr. Hayes. I believe, sir, we just have to agree to
disagree. I said that I would refer you to Department of
Justice and my colleagues on that specific thing. Our----
Mr. Pocan. Aren't you at all inquisitive, being in your
role, to what they do with that information? Like wouldn't that
be curiosity that if I give this information and they use it in
a detrimental way, that is why it is going to be harder to find
some of the placements?
I mean, I think that is a very fair question. I asked you 9
days ago.
Mr. Hayes. I think that is a fair question. I would also
answer one of your questions, sir, that we are not
fingerprinting moms and dads at this moment, nor are we
fingerprinting grandparents and adult siblings, provided there
is no red hits on the biographic background check. And I did
make that crystal clear that day.
So we are not fingerprinting every single sponsor. I just
want to clarify that.
Mr. Pocan. Right. But you still don't have--that is fine. I
will take it to the other Department.
Ms. DeLauro. The non-fingerprinting is what is allowed.
That could have been implemented many, many months before,
keeping in mind that Homestead has been open for a year and a
half. And only in the last few weeks have we seen the movement
of children.
With that, Congresswoman Roybal-Allard.
Mr. Hayes. Yes, ma'am. Due to the fourth operational
directive that we put forward. Yes, ma'am.
Ms. DeLauro. And I will just say I have got the yield time.
Ms. Roybal-Allard. Ms. Johnson, I want to talk a little bit
more about Homestead because in your written testimony, you
state that ORR care provider facilities are not prisons. Now I
believe that, based on my visits to licensed ORR facilities,
that that is true. But yet I have to tell you that throughout
our visit to the Homestead facility, it was obvious to all of
us that the shelter was run more like a prison than like a
child-appropriate housing.
And I understand the importance of supervision of these
children to ensure their safety, but these children are living
in overly restrictive conditions. For example, in addition to
the teacher, when we go into the classroom, there were four
other employees stationed in each corner of the classroom,
watching these children.
And in other ORR facilities that have I attended which are
non-influx, the children are in classrooms. They have one
teacher, and they move much more freely and independently in
that facility.
We have heard from child welfare specialists time and time
again that this kind of restrictive setting like Homestead is
extremely harmful to the children. And the chairwoman outlined
other areas where there is this lack of privacy. We saw the
children having to walk in the straight line, monitoring as
they were moving from one room to another.
My question is what of our policies stipulate the adult-to-
child ratio in these influx facilities, which appear to be
different than in your other facilities? And while ensuring the
safety of these children, how can this policy be modified to
provide a less-oppressive environment, as well as much-needed
privacy, as you have in your licensed facilities? What is the
difference? Why is it so--either one of you.
Mr. Hayes. If I may, Congresswoman?
Ms. Roybal-Allard. Either one.
Mr. Hayes. So the youth care worker ratio is the same at
both Homestead and at Boys Town, and I know a couple of your
committee staff went with us to Boys Town after the Homestead
tour last week. And there, we had the youth care workers also
sitting in the classroom with the teachers. So there is not a
difference, ma'am.
Ms. Roybal-Allard. But my question is that--but there is a
difference in your ORR licensed facilities. You don't have five
people in a classroom.
Mr. Hayes. No, I just described--we have the appropriate
number of youth care workers supervising both the children and
the teachers. You would have seen both youth care workers that
you saw in the four corners you referenced in Homestead. We
also have those at Boys Town and----
Ms. Roybal-Allard. I guess my question is when I have
visited your State-licensed ORR facilities, gone into a
classroom, there is a teacher there. The kids, you know, are
learning. But in Homestead, there was actually--if you counted
the teacher, there were five adults looking, watching these
children. And my question is why is it necessary at these
influx facilities to have that kind of surveillance of children
24 hours, where it is not done in your regular licensed ORR
facilities?
Mr. Hayes. What I am saying, ma'am, and I would want to
know exactly what shelter you went to where that was not
happening. Because, again, we immediately went to Boys Town,
which is a licensed shelter 30 minutes from Homestead, and that
is what is happening.
I will say this. If there are thoughts or, you know, some
direction that the members of this panel would like us to
consider, I am more than happy to take those back and have
discussions with our child welfare experts at ACF and ORR. But
a 1-to-8 child ratio for youth care workers and 1-to-12 for
case manager--I am sorry, 1-to-8 for case managers and 1-to-12
for clinicians are standard child welfare--standards in the
child welfare system.
Ms. Roybal-Allard. In classrooms? And they have to walk in
these straight lines? I mean, they can't move freely.
Mr. Hayes. There is structure at each of our shelters,
ma'am.
Ms. Roybal-Allard. I think we need to look at that, and I
think we need to work together to find a better way. Because as
I said earlier, child experts are telling us that this is not
healthy emotionally, mentally for these children to be treated
in this way. So let us work with the subcommittee to try and--
--
Mr. Hayes. You have my commitment. I would love to do that.
And again, the majority of our staff, both at our shelters and
at ORR headquarters, our child welfare experts and social
service workers, we share that commitment. Happy to work with
you and the committee, ma'am.
Ms. Roybal-Allard. Okay. And I do have another question,
but it would take much longer than my 5 minutes. So I will
wait.
Ms. DeLauro. Thank you. Congresswoman Lee.
Ms. Lee. Thank you very much. Thank you, Madam Chair and
our ranking member.
And thank you for being here.
First of all, I want to follow up on what Congresswoman
Roybal-Allard was talking about in terms of the structure. You
say they are not jails or prison. I say you are warehousing
children. It feels like a prison, okay? The structure and the
organization of Homestead feels like a prison.
Now given that it feels like one to myself, I am a clinical
social worker by profession, I know what it must feel like to
the children. And so in a case management plan, how do you
address that in terms of a child going through this system in a
warehousing prison-like setting?
First of all, the trauma, 100 percent of these children
have trauma, and I know we were told that they are assessed for
that. But you can assume and you know 100 percent have trauma,
and so 100 percent need clinical trauma-informed care.
How do you--they are not all receiving that trauma-informed
care. They are getting maybe counseling, maybe not, maybe a
week video session, maybe not. And then, as you move through
whatever case management plan that you have, how do you
deinstitutionalize these children as they move forward and move
on to their sponsors?
Because I know for a fact that when young people get out of
jail, you have to have a transition period so that they can
become--so the deinstitutionalization process works. So how do
you do that in the case management plan?
Ms. Johnson. Thank you, Congresswoman.
And as you know as a clinical licensed social worker, the
length of time in an influx facility is critical, which is why
we are working to reduce that length of time that they are
there. More critical is that we don't want them sitting in a
Border Patrol station because of that very trauma.
As probably when I got my social work degree, that what we
have learned about neuroscience, ACEs, trauma has changed
considerably in the last 10 years. We are hoping and training
our staff to deal with those issues.
The deinstitutionalization is in addition to dealing with
the trauma from the journey from home country and, you are
absolutely right, from sitting at a border and being in an
influx facility with all of the other children. We do know,
though, that those supports are very critical.
One very important piece. If someone is assessed with
serious trauma, serious mental health issues, they are not
placed in our influx facilities. They are placed in our
licensed permanent shelters that are specialties for just that.
Ms. Lee. Well, you can't tell me 100 percent of these
children don't have trauma-related mental health issues.
Ms. Johnson. No, I would say that many of those children
have trauma-related----
Ms. Lee. One hundred percent do.
Ms. Johnson. But very serious mental health issues are
moved elsewhere.
Ms. Lee. Yes. But you don't have mental health
professionals that have an expertise in trauma-related
psychotherapy to help 100 percent of these children.
Ms. Johnson. No. But they do have the training in trauma-
informed care. As you heard me say in my testimony, everybody
is trained----
Ms. Lee. But you don't have psychiatrists, psychologists,
clinical social workers to administer the trauma-informed
therapy for 100 percent of the kids.
Ms. Johnson. We do have access to all those mental health
requirements.
Ms. Lee. But not all of the children receive that?
Ms. Johnson. Not every day.
Ms. Lee. Okay. Now secondly, let me just ask you about this
contract. Well, first, Director Hayes, you said something that
was very interesting, and I would just like for you to respond.
You said some from the left don't want children, kids locked
up. What did you mean by that?
Mr. Hayes. What I----
Ms. Lee. Some from the left don't want children locked up?
Mr. Hayes. What I am saying is we have----
Ms. Lee. What did you mean ``some from the left'' don't
want children locked up?
Mr. Hayes. What I was commenting is that we have received
challenges from both sides of the political spectrum in the
history of this program.
Ms. Lee. From the right and the left?
Mr. Hayes. That is what I am saying, yes, ma'am.
Ms. Lee. That is a strange way to present testimony to this
committee, but if that is how you present it, some from the
left don't want children locked up, okay. I know children--I
know individuals who are not from the left who don't want
children locked up.
Mr. Hayes. What I was saying, ma'am, is that they don't
want any of our shelters, even our State-licensed shelters----
Ms. Lee. I understand. But I know people who are not from
the left who don't want children locked up.
Let me ask you a little bit about the contract since we
don't have it. I want to understand. It is a no-bid contract.
What is the profit margin? The daily rate is $750 per child.
That is, what, about a $1,000,000, depending on how many
children are there, a day. What is the profit margin? What is
the G&A rate on that, the general and administrative cost rate?
Mr. Hayes. I don't have the specific information on that,
ma'am, but will be happy to get back to you with that.
Ms. Lee. Well, let me ask you then is there an incentive to
make sure that these children are processed expeditiously or a
disincentive to keep them there so the contractor can make more
money?
Mr. Hayes. The answer is no to both of those, ma'am. It is
not our desire to keep kids longer than absolutely necessary,
nor do I ever want to put any of our grantees or any of our ORR
staff in a position where they are simply discharging kids for
the sake of discharging them.
Ms. Lee. Well, are there penalties if the contractor
doesn't perform based on the contract requirements, which,
again, we haven't seen. So we don't even know what the contract
requirements are in terms of the children.
Mr. Hayes. Right. It is not tied to length of care or
discharge rate, I can tell you.
Ms. Lee. What is it tied to?
Mr. Hayes. I would have to get you some more information on
the specifics of that contract, ma'am.
Ms. Lee. Listen, I was a Federal contractor, and I know
what these no-bid contracts are like. I know how you add on. Of
course, I couldn't add on.
But how is this contract performed, and when does it end?
And do you intend to--you didn't answer the chair's question
about when the contract is going to end and when we are going
to shut this down. So do you intend to add on to their contract
after November?
Mr. Hayes. Well, okay. So, yes, so November 30th is when
the current contract does end. Again, when it was originally
awarded, it was not a no-bid contract. There were five folks
that went into open competition for it.
And at this point, we are evaluating the needs for our beds
and the ability to take kids as quick as possible. Again, my
commitment is that we want to reduce the capacity at Homestead
down to zero just as quick as we safely can, and we would only
utilize any influx shelter in the event that there were no
permanent beds to place the kids in.
Ms. Lee. And no plans to get the contractor licensed, and
you don't know whether--and can they add on or not? And thank
you--can they add on to the contract?
Mr. Hayes. Those discussions are ongoing, and potentially,
looking at licensing any of our facilities that aren't licensed
is something that we are open to consider, ma'am.
Ms. Lee. Open to consider, but not required by the
contract.
Mr. Hayes. Well, again, it is not totally up to us at HHS.
Ms. DeLauro. Congresswoman Bustos.
Mrs. Bustos. I want to thank Chairwoman DeLauro for having
this hearing today and thank you to the Assistant Secretary
Johnson and Director Hayes.
I am going to continue some of the line of questioning that
Congresswoman Watson Coleman started regarding the education.
So just along those lines, most of us sitting up here are
mothers or I know, Mark, you don't have any children--or
grandmothers. And so, like, I know that each of us, when we
think about the children, we just think about how scared they
must be, how worried they must be about what is going to happen
to them going forth, all of the uncertainty that is in their
lives.
And part of me is thinking that education has to be like
the one respite from all of these worries. And as I was
preparing for this hearing today, I just was really surprised
at why the curriculum isn't something that would fall in line
with the State of Florida that has deep experience in educating
children. And I know you said that this is--the children are
different.
Why the teachers aren't--don't fall under the same level of
regulation that public school teachers would. And so I guess,
again, some follow-up questions to what Congresswoman Watson
Coleman asked. So does HHS or the Department of Education
review student curriculum at Homestead? Can you talk through
how that works and like what is being taught to these children?
Mr. Hayes. So the Department of Education is not involved
particularly at Homestead, but I know that our staff does work
very closely with the staff at Homestead and CHS that runs this
particular shelter. And again, I just want to recommit to you
that I did with Mrs. Watson Coleman that, you know, this is
something that I would agree that is an area for improvement
from both the actual facility itself, and it is something that,
again, if there are ideas and thoughts and suggestions you
have, we are definitely open to considering those in regards to
beefing up the education of these very vulnerable children.
We do acknowledge that they are vulnerable, that they are
scared. I think that is exactly why Congress, back in 2002,
moved the Unaccompanied Children Program from INS at Department
of Justice to HHS, specifically inside the Administration for
Children and Families. So we share that commitment to taking
care of some very scared and very vulnerable children who do
have a lot of uncertainty around them.
Mrs. Bustos. Do you have anything to add to that?
Ms. Johnson. I have toured several of our shelters and also
the influx facilities, and at one of the facilities, I watched
through when they were in their classrooms and they were
learning about homophones. And I couldn't tell you what that is
until after I left. I was like I am not sure for a child who is
only going to be here 20 to 30 days, that that would be the
priority that I would have on learning.
And so we had the conversation about what else gets that
child ready to move into the interior and live with their
sponsors, back with their parents, especially when they had not
had any education in the past. These kids were excited. They
were answering questions.
And in most of the classrooms I have gone to, actually, all
of the classrooms I have been to, the children were excited
about learning. I want to share--I do want to comment on one
thing. I am also a mother, and my heart goes out to every one
of these kids, but the excitement and the glint in their eye
because they know what is coming next and they are getting what
they believe is their dream is really, really exciting. And it
is a good thing that by law, I am not allowed to take every one
of them home because these are fantastic kids. And they get
excited to talk English, and they say to me, please, Miss Lynn,
talk to me in English. And I will say, talk to me in Spanish so
I can learn, too, and these kids are excited.
So from a mom, my heart goes out to every one of those
kids. I wish I could hug them all up, but I am exactly where
you are. We want the very best, and I always, in my previous
jobs and today, I always think this is what I would do for my
children if they were in the same situation. So whoever brought
that up I really appreciate that.
Mrs. Bustos. Okay. I am going to, because we have less than
1 minute left. I am also thinking about, again, how scared the
kids must be. We are in hurricane season in that region of our
country, and I know part of getting the kids out of the influx
center quickly is because we are in the middle of hurricane
season. Do you have an evacuation plan? If something is going
to hit, can you talk through what happens?
Mr. Hayes. Absolutely, and as a Floridian myself, ma'am,
that is something that I am very sensitive to. But not just
hurricanes, but any and all emergencies that might exist where
we need to potentially evacuate a shelter, whether it is
flooding in Houston or hurricanes in Miami.
The answer is, yes, we do have a plan. It has actually been
implemented before and executed at Homestead. Back in 2016 we
had to evacuate it. It is done. You may not be aware that we
have a planning and logistics team made up of emergency
management professionals that serve inside the Office of the
Director at the Office of Refugee Resettlement. This plan was
made in coordination with the Miami-Dade emergency management
folks. In fact, just last week my director of planning and
logistics met with the team down there. It is in close
coordination also with FEMA and with the assistant secretary
for preparedness and response at HHS.
And, again, whether it is a hurricane in Miami or flooding
in Houston, we have the ability to move the kids around in
order to get them in a safe environment. And, again, as we move
into the heart of hurricane season, as a Floridian, the size of
the census at Homestead was something that we were very much
tracking, and we are always going to make sure that we have
plans in place and the very best efforts that we make are to
ensure the safety of the children.
Mrs. Bustos. I am over my time.
Mr. Hayes. And if I might just add, we actually circulated
that plan earlier this morning to several members of Congress.
If you would like to get it, we would be happy to send it to
you.
Mrs. Bustos. I would. I know I would like to see it. I
think actually we would probably all like to take a look at
that.
Mr. Hayes. Absolutely.
Ms. DeLauro. Yes, and that was requested by Congresswoman
Wasserman Schultz. We were told at the time we couldn't get it,
you would set up a briefing. But I am pleased to know that we
can get it and it can be shared with every member.
Mr. Hayes. And Ms. Mucarsel-Powell as well.
Ms. DeLauro. Ms. Mucarsel-Powell as well, that is right.
Mrs. Bustos. I yield back. Thank you.
Ms. DeLauro. Just a quick point before Congresswoman Clark.
The ages of these children are 13 to 17. I am trying to think
of my grandkids. It is like the 8th grade through the 12th
grade, somewhere in there. And as far as we can discern in
terms of the education process, that these were kids not tested
to know at what grade level they go in or what is appropriate,
and I can't have you answer. I can do that in the second round.
You can't answer me because I won't take your time. But,
Congresswoman Clark, go ahead.
Ms. Clark. Thank you, Chairwoman DeLauro, and thank you.
Nice to see you again, Mr. Hayes. You told Dr. Harris that
Homestead is subject to State law, not licensing, but State
law. Is that correct?
Mr. Hayes. Yes, ma'am. Federal and State law does apply to
the employees and the staff, and we work very closely with the
Miami-Dade Police Department in FPS.
Ms. Clark. So if a child reports sexual abuse, that would
be investigated by Florida.
Mr. Hayes. That is correct.
Ms. Clark. And so there have been, according to your
numbers, 412 allegations of sexual abuse. Twelve percent of
those, a little under 12 percent, involve staff on minors. So I
have a couple questions. The Miami Herald says that the State
of Florida has not been permitted to enter Homestead to
investigate all the allegations of sexual abuse. Is that your
understanding? Can you explain that?
Mr. Hayes. That is not my understanding, and the Department
of Children and Families in the State of Florida has been
involved in investigations down there. So to the best of my
knowledge, they have access to and they are involved in that
process when appropriate.
Ms. Clark. Could you make a commitment to looking into
those allegations?
Mr. Hayes. Absolutely, Congresswoman. You have my
commitment to do that.
Ms. Clark. Okay. Are the staff who were involved in these
allegations, are they still there? I know this is not ORR
staff, but are the staff at Homestead still there?
Mr. Hayes. So in the last 4 years, there have been four
accusations that involved staff on UAC. Two of those were
determined to be unsubstantiated, one of those was closed
administratively by the State of Florida, and the other one,
and this actually happened in the last Administration, that
person was found guilty and they are currently in jail.
Ms. Clark. So I am looking at your numbers that said----
Mr. Hayes. I am specifically just speaking to Homestead, by
the way.
Ms. Clark. Okay. So the 412 allegations are broader than
just Homestead.
Mr. Hayes. I am not exactly sure what reports or what
numbers you are looking at, but I know that there is some
additional information that is forthcoming to Congress later
this month or early August that will address more of these
issues in regards to sexual abuse. I don't know if you want to
add anything, Madam Assistant Secretary?
Ms. Johnson. Yes, we are going to be providing all the
details and information on assaults and the questions about
those. One of the key things----
Ms. Clark. What is the timing of providing that
information?
Mr. Hayes. I think, again, I would say late July or early
August is my understanding, and if that is different from that,
I promise you we will get back to your staff.
Ms. Clark. So next week? In the next 2 weeks?
Mr. Hayes. That is my understanding, and if that changes, I
promise you we will let you guys know that just as quick as
possible, ma'am.
Ms. Clark. Can you let me know, I was there. I was able to
see this telephone that is preprogramed so kids can report, but
it is a rather open cubicle next to a ping-pong table. Does
that comply with their own regulations on reporting and
privacy?
Mr. Hayes. Yes ma'am, it does, and, again, I was there with
you and I pointed the phone out. And you are right, it is
preprogrammed to report any type of abuse as well as give the
children access back to home consular officers.
Ms. Clark. Okay. And you feel that is compliant with
privacy regulations.
Mr. Hayes. I do, but again, if you have suggestions on
improving that or modification on that, I would be happy to
discuss that with my team.
Ms. Clark. Okay. I want to go back to a question that
Chairwoman Lowey asked you about your legal obligations to
share information with sponsors on DHS. I appreciate Assistant
Secretary Johnson's comments on children may be excited about
their futures, but it was pretty startling to have it confirmed
by staff when I was at Homestead, the children who turn 18
while they are they are, that information is given to DHS 2
weeks before their birthday, and then they are shackled and
removed from the property. That was confirmed by staff when we
were there. I am sure you would also be able to confirm that,
Mr. Hayes. Are you legally obligated to share the information
on sponsors with DHS?
Mr. Hayes. It is my understanding that we are required to
through a statement of principles from the very early onset of
the formation the Department Homeland Security, because when
children are discharged from our care, our statutory authority
ends, and then they fall under the jurisdiction of DHS.
Ms. Clark. What about on sponsors? I know you are no longer
fingerprinting family members, but what about that information
on sponsors? Are you legally obligated to share that with
Department of Homeland Security?
Mr. Hayes. It is my understanding that we are not legally
obligated, ma'am.
Ms. Clark. So then why do you do that?
Mr. Hayes. We do not share fingerprints with the Department
of Homeland Security.
Ms. Clark. But you did everything until very recently,
right, or no?
Mr. Hayes. We quit in December with adult household
members.
Ms. Clark. Why was it done before December?
Mr. Hayes. I think you are referencing the memorandum of
agreement which, again, was put into place before my time at
ORR, so I can't really speculate on all that went into the
decisions behind that.
Ms. Clark. So there was no legal obligation, but that was
the flow of information. And I think as we talked about when we
were there at Homestead that maybe 2 weeks is not the time that
we should be focusing on these children turning 18. Have you
made any improvements in that time period?
Mr. Hayes. So personally, ma'am, again, I was with you on
that tour, and I thought that was an excellent idea, and the
team is working towards that. But as I said that day, you know,
if it was up to the grantee staff and the ORR staff, we would
let these kids stay with us until they are 19, 20, 21, if that
is what it meant. But, again, HHS' statutory authority over
those children ends on their 18th birthday. And because most of
the children are referred to us by DHS, they already know their
age, ma'am, and they know where, you know, we designate them to
because they bring them to us at our respective shelters.
So, you know, again, when they turn 18, they are no longer
children, and so they then go into the custody of Department of
Homeland Security.
Ms. Clark. In shackles. My time has expired.
Mr. Hayes. Any questions to that, I would refer to my
colleagues at DHS.
Ms. DeLauro. So much of this revolves around rescinding the
MOA, which we will keep repeating, and it should be terminated,
rescinded, and gone to protect the children and to protect
their families. To both of you, you have said that the ORR
wants a network of 20,000 State-licensed. But at its capacity,
ORR had 15,000 children in care, and the main reason you had so
many children in care was because of the excessively long stays
in care. Let us repeat that: 35 days in the Obama
Administration. Directives which you now have turned around, to
your credit, but there were directives that were put in place
which made these excessively long stays in care, and that was
because of the MOA. The fingerprinting requirements, and the
data sharing with DHS ground this process to a halt, created
chaos at the border and children in inhumane conditions, when
all the time we had the ability to move these children. My
question: what justification do you have for needing long-term
capacity of 20,000 permanent beds? Are you basing this on any
CBP projection data?
Ms. Johnson. Thank you, Madam Chair. The reason we are
looking at 20,000 beds is not because we are saying that is how
many we want to fill up. What we want to have are available
beds for one very critical reason. If a young girl comes in,
she is pregnant and has maybe a 2-year-old with her, and she is
with her brother, we want to be able to have the capacity to
put them together in a shelter and not have to say the child
goes to a younger children's shelter. We need to have some
flexibility in empty beds in order to get better care for these
children.
Ms. DeLauro. At the high point, we were at 15,000. You are
down to now, what, 11,000?
Mr. Hayes. Ten thousand.
Ms. DeLauro. Ten thousand. All the better. Numbers are
going down, and that is not to say that they couldn't, but in
2014 our experience was when those numbers went down, they went
down, it was through the September-October. They went down. I
got a chart of that. You know, I don't make that up. So where
is this 20,000 number coming from? You know, honestly, siblings
are separated all of the time. We tried in the 2019 Labor-HHS
bill to say that siblings could not be separated, but they are
separated. We found that when we were at Homestead.
A child had a sister, a brother, or so forth, they were
somewhere else, but that is no reason for trying to build an
empire of beds. The goal should be, the focus should be, and we
don't know where this number comes from. Who projected this
number? Where does it come, out of the thin air? What is the
statistical basis on our having this there? You know, what are
the resources? Quite honestly, the resources that you are
devoting to ensure.
Where is the plan? You have a plan for 20,000. Where is
your plan to ensure that children are placed with family
members as quickly as possible? What case management services,
Federal field specialists are part of your plan, and what
protections will you put in place so that this Administration
doesn't slow the discharge rate to a halt again? There is no
comparable plan. You are at 20,000, but there is no comparable
plan to move these children out as quickly as possible so we do
not have to have an influx facility.
I am just going to add one more piece here, which is about
Carrizo Springs. How is that contract structured with BCFS? Can
we get a copy of that contract? Influx facilities are supposed
to be temporary. I have seen one report that says 3 years, one
report that says 5 years. And do you see a path for State
licensing with Carrizo? And if not, why did you enter into a
multiyear lease? So let's start with your plan for discharge,
where the number 20,000 has come from.
Ms. Johnson. Based on looking at the trends over time and
the number of children that have been placed into the influx
facilities over time, should we have another surge in that same
way, we do not want to have to open up an influx facility. So
even if there are empty 20,000 beds, that is better than
opening up a new Tornillo or a new Carrizo.
Ms. DeLauro. You by your own words here have said the high
point is 61. You are talking to us about the numbers that are
going down. At the highest point, you had 15,000. Fifteen
thousand. And all of a sudden out of thin air comes a 20,000
number.
Ms. Johnson. If we were only to have 15,000 beds available
at that time, we would not have had the flexibility to address
siblings, pregnant teens, tender age because you can't place
those children in with teenagers. You have to move them around.
We need some movement.
Ms. DeLauro. You don't need another 5,000 beds to do this.
What you do need to do, which I understand, and I am surprised
you all haven't mentioned it, with your new grantee, you are
looking at an additional 3,000 permanent State licensed
facilities is what I have read about. So why are we not moving
in that direction? When is the next recruiting for, you know,
for grantees? But you have got now 10,000. You have got an
additional 3,000. That gives you 13,000 potential beds. Why are
we talking about an additional 7,000 when at the high point we
are only at 15?
Ms. Johnson. The permanent licensed beds are much less
expensive and are better for these children.
Ms. DeLauro. Yes.
Ms. Johnson. So if I don't have that additional beds
available in a surge, we are back to influx, and I never want
any Administration to have to go back there. In addition, may I
say, the operational directives that we have done are also
enhancing and moving the discharge rates.
Ms. DeLauro. Yes.
Ms. Johnson. We are taking these efforts. You just said it
yourself, we have 3,000 new permanent licensed beds coming
online. We are not ignoring the priority of licensed beds nor
the discharge.
Ms. DeLauro. I am not saying that. I want you to focus your
time and attention and any of the resources that we provide
here to moving in that direction as we try to in the House bill
on the supplemental, and what people want to say is that we
held back. We held back not because of we did not want to
provide the money. Every single day we talked about the
$2,900,000,000. What we wanted was the protections for these
children and a discharge plan, and those two pieces are what we
still want and what we still need. And we still do not have an
adequate discharge plan for how we are moving that. You talk
about a lot of beds, but let's talk about how we are getting
them out as fast as we can and make a difference so that we do
not have to have unlicensed facilities which are putting kids
and their families at risk. And I have gone way over time, so.
Mr. Cole. Thank you very much, Madam Chair, and those are
questions. They were questions that needed to be asked, so
please don't feel like you went over your time. I want to
actually build a little bit on what you talked of because I
have some of the same concerns, probably from a different
perspective. But I think you have those concerns as well. I
mean, I think you would agree, I think, with all of us up here,
regardless of perspective on the current thing, the best thing
is to get these kids out of your custody as quickly as possible
into an appropriately-vetted, you know, sponsor. Is that
correct? That is your policy? That is what you are trying to
do?
Mr. Hayes. Yes, sir.
Mr. Cole. And in terms of the surge capacity, and, I mean,
I sort of understand it. I have had to live through this in my
own district at Fort Sill, may have to live through it again.
We are hopeful since there is a decline in the intake right now
that perhaps you won't need to press that facility, but I
certainly understand your need to have them available if
something happens, you know. And I am not sure what that
appropriate balance is.
I think the chair raises a good question. I don't know
where that figure 20,000 came from either and I am not saying
that critically of you. But that would be helpful to this
committee if we got some sort of information on that, and I
would certainly support the chairman's efforts to do that. And
I hope you can enlighten us in that.
Second, I am very encouraged by this effort to also line up
when State-inspected facilities and beds are available again. I
think we all believe that would be better if we run into
another surge than what we have had to deal with with influx
facilities. And it strikes me that is your position, too. Am I
correct?
Mr. Hayes. Yes, sir, you are.
Mr. Cole. Okay. And is there any additional information on
both this target and what you see as the appropriate balance
between, you know, facilities that are permanent, you are using
all the time, others that would be licensed but would be
available on relatively short notice should you need them, and
finally and last resort always an influx facility? Do you guys
have some sort of plan laid out where you sort of think through
what the progression is?
And believe me, I say this with a lot of sympathy. I
understand this is an unpredictable thing. We have had the
budget up here. This committee has struggled really for years
trying to figure out what is the count going to be next summer,
what should we do, and know that, thank goodness, that whether
it was the last Administration or this, you had a certain
amount of flexibility and transfer authority. But even then, we
have gotten the mark wrong with the best intentions in the
world in having lived through one of these things before.
Mr. Hayes. So I just would add, sir, you know, first off,
it is up to 20,000 beds is our goal, not just this magical
number of hitting 20,000, but up 20,000. And I just will point
out more from an operational perspective, which is more my lane
as opposed to the assistant secretary's. And honestly, once you
exceed kind of that 90 percent capacity of your permanent
shelters, it does get very difficult to place children in
permanent capacity because beds come online and go offline for
various different reasons.
We might have a bedroom of, you know, 10 beds go offline
because one child in there is quarantined, for an example. And
all the UAC that come across the border that are referred to us
are not created equal, you know. If we have a teenage brother
and a younger sister, then that is going to be a very unique
shelter that we want to place them in because we do not
separate siblings at HHS. In fact, that will sometimes delay
placement because we want to work hard with our grantees and
our intakes team to find the most appropriate shelter for that
person.
So, you know, as we look at, you know, the high mark that
everyone's mentioned of almost hitting 15,000 children in care,
I would hope that if I hear the number that I have 15,000
children in my care as I did almost back in early December,
then I would hope that I would have had a minimum of 2,000
extra beds in order to help ensure that children will be able
to be put in a permanent licensed bed as they are referred to
us from DHS, and that we are able to do that as quickly as
possible within that 72-hour mark.
Mr. Cole. That is good, and that is helpful. Thank you.
Mr. Hayes. Yes, sir.
Mr. Cole. I have got very little time left, so I just want
to ask you, if I may, and either one of you or both can address
the question. But could you just for the committee's
edification explain some of the factors you have to deal with
when you are actually making a discharge decision? What process
has to have occurred before that? I am sure there are various
iterations of this depending on the type of person, the age,
the gender, you know, do they have special needs, et cetera, et
cetera.
Mr. Hayes. Yes, sir. One of the one of the key things that
our case management team focuses on is, you know, is the
sponsor able to meet the needs of this child, medical needs,
emotional needs, financial needs? Are they able to give them
shelter and food? Do they have the, you know, the ability to
help them, you know, get them plugged into the local community?
And also, you know, again just to those kind of things to make
sure that they are going into the safest environment possible.
We also do a very robust public records check on every
single sponsor. Even the moms and the dads, and more distant
family members and any of those family friends that the
families have said, you know, would like the child to go and
stay with this family friend they have a connection to, we are
doing FBI fingerprint background checks on them just, again, to
make sure that the child is going to the safest environment
possible.
So while it is a very streamlined process, there are a lot
of, you know, things that we work through. And I tell you, one
thing I would suggest is possibly maybe sharing the sponsorship
reunification package with this committee. There might be some
information that needs to be redacted on it. I would have to
check with our team, but that is something I am very much open
to, again, in coordination with my leadership at HHS.
Mr. Cole. Okay. Thank you very much.
Mr. Hayes. Yes, sir.
Mr. Cole. Thank you for the time, Madam Chair.
Ms. DeLauro. Thank you very much. I say thank you to the
ranking member. I want to just clarify, and to the credit of
HHS, last December there were 15,000 children in detention. And
because of that operational directive, almost within several
days, 4,000 children were released to a sponsor or to a
shelter.
Mr. Hayes. If I may, it was actually 8,000 in 30 days.
Ms. DeLauro. Well, to our point, if we can do that with the
directives that you are engaged in, we do not need to continue
the complexity of this detention system that we have, and that
we want to move people into the safest possible space
expeditiously. With that, Congresswoman Watson Coleman.
Mrs. Watson Coleman. Thank you, Madam Chair. The Homestead
facility has been in existence and in use since when, November
of last year?
Mr. Hayes. So the original site was chosen. The contract
awarded in December.
Mrs. Watson Coleman. I am not talking----
Mr. Hayes. I don't know exactly what month, but it was in
early 2016 when it was first operated with children.
Mrs. Watson Coleman. Is there any legal prohibition
stopping a facility of this nature becoming a permanent
facility, getting a license?
Mr. Hayes. No, there is no prohibition, ma'am, and that is
something I am open to consider. Again, again it would require
a partnership with the local State----
Mrs. Watson Coleman. And that is another question I want
ask you. Do you think that it makes sense that you had Federal
licensing regulations because the facilities that you are
talking about, even the permanent ones, are only housing
children, so they are technically Federal facilities, are
federally-controlled facilities, or federally-existing
facilities? Would it make more sense to have Federal licensing
requirements that were uniform across the Nation?
Mr. Hayes. You know, I would be happy to have that
conversation with you in coordination with the child welfare
experts at ACF, ma'am.
Mrs. Watson Coleman. All right. The facility, the Carrizo
Springs facility?
Mr. Hayes. Yes, ma'am, Carrizo Springs, Texas.
Mrs. Watson Coleman. Okay, it was open in 1 month and
closed another month?
Mr. Hayes. It is not closed, ma'am.
Mrs. Watson Coleman. According to this article I have, it
is shut down. So what does that mean?
Mr. Hayes. Well, I am not sure exactly which article. I
know----
Mrs. Watson Coleman. Are you shutting it down?
Mr. Hayes. First off, we have not placed any child at an
influx shelter since July 17th because we are below 85 percent
capacity.
Mrs. Watson Coleman. Are you shutting Carrizo down?
Mr. Hayes. I do not have plans to shut it down completely
at this time. I will say, ma'am, just real quick, it had 41
kids there this morning as of 7:00 a.m., so it is not shut
down, just to confirm that. I am not sure what the----
Mrs. Watson Coleman. So you have a $308,000,000 contract
with them through January?
Mr. Hayes. That is up to----
Mrs. Watson Coleman. Up to? But right now it is just the
$775 or $800 per child that you are paying?
Mr. Hayes. The estimate there is just over $600 right now
is initial estimates there.
Mrs. Watson Coleman. So you----
Mr. Hayes. It has capacity of about 1,100.
Mrs. Watson Coleman. So you said that there were no
children there, and now you are telling me there are 41
children.
Mr. Hayes. I never said there were no children there. I am
telling you as of this morning there are 41 children at Carrizo
Springs shelter in Texas.
Mrs. Watson Coleman. So where is this information coming
from in this article that you are shutting it down?
Mr. Hayes. I am not sure. We have had a lot of tours out
there. Again, I think maybe it is coming from the perspective
that, again, we are not placing children at any of our influx
shelters anymore. We are working to draw those down. And
because we are historically discharging children at high
numbers, you know, the need for children to remain there is not
an immediate need. Again, I don't know what is going to happen
this fall, though.
Mrs. Watson Coleman. Are there issues there regarding
health and safety violations, mold, structural issues, things
of that nature, unsanitary----
Mr. Hayes. No, structural issues, no. Once we initially
purchased that, there was some mold in some of the buildings,
but we brought in professionals----
Mrs. Watson Coleman. You mediated that.
Mr. Hayes. And we absolutely, positively remediated it
those issues before we had one child or any staff in there.
Mrs. Watson Coleman. Thank you. Let me ask you one quick
question.
Mr. Hayes. Yes, ma'am.
Mrs. Watson Coleman. The background checks that are done
for permanent staffers, is that the same as done for the influx
staffers, too? Do they go through the same rigorous----
Mr. Hayes. I can tell you that the FBI background checks
were done for the staff at Homestead and at Carrizo Springs.
Mrs. Watson Coleman. Okay. If a child is placed in your
facility and is 17 years old, 17-and-a-half, or whatever, do
you do any kind of planning for that child? Do you try to find
a sponsor before that child turns 18? Do you have any ability
to hold on to that child if you are actively engaged in the
search process rather than turning the child back over to ICE?
Mr. Hayes. The answer is yes and then no. Yes, we
absolutely focus with every fiber in our being to do as much as
we can for that child just as quick as possible. But as soon as
that child turns 18, our statutory authority ends at HHS. And
as I have mentioned several times on the tours and here today,
if it were solely up to our grantee staff and our ORR folks, we
would keep those kids as long as it took to find them----
Mrs. Watson Coleman. So then turn them over and you notify
ICE at certain periods. Is that like 30 days before they 18
years old?
Mr. Hayes. Again, they are referred to us from DHS, so DHS
knows their age when they come to us.
Mrs. Watson Coleman. Do you actively remind them this one
will be 18 in 30 days, this one will be 18 in 10 days? Who, you
got 24 hours?
Mr. Hayes. I would not describe it that we actively remind
them, but we do work on a plan with them because there are
certain different options that ICE can do. And, again, any
further questions about that, I will refer you to my colleague.
Mrs. Watson Coleman. And you have no idea what ICE does
with them when it takes them back into custody?
Mr. Hayes. Once they leave our custody, statutorily, they
go into the care of ICE. There are a lot of----
Mrs. Watson Coleman. You said something that I thought was
very interesting or either I read it in one of your testimonies
that when you place children with permanent sponsors, with
sponsors, that you do offer follow-up services, social
services, any other kind of, you know, navigation that is
necessary.
Mr. Hayes. There are some post-release services available.
Mrs. Watson Coleman. You do that even though the child is
no longer under your jurisdiction?
Mr. Hayes. Yes, ma'am, and I will just add, too, we have an
ORR call center that is operated 24 hours, 7 days a week. And
if any of our sponsors after the child goes into that care or
the kids have any concerns or they are struggling with some
issues, we can help find resources to help them out.
Mrs. Watson Coleman. Madam Chair, just one last question.
Thank you. Why does it cost 3 times the amount of money to
house a child in an influx facility versus a permanent
facility, even though that influx facility is in existence for
more than a year? Thank you, and after you answer that, I will
yield back. Thank you.
Mr. Hayes. So great question, ma'am. Thank you for asking
it. I would say, and I am just going to oversimplify, but I
think it gives us a high level of flexibility to both turn on
and turn off staff and capacity at these influx shelters that
does not exist at a permanent shelter. So with that flexibility
and that ability to, again, turn on beds and turn off beds in
order to bring the kids quickly and safety into HHS care and
custody does cost more than a standard licensed shelter because
we have very little, if any, flexibility at a permanent license
shelter. If the State licenses it to be 122 beds, we can't add
one more bed to that permanent facility without the State's
blessing through a variance.
Ms. DeLauro. Thank you. Before I turn to Mr. Pocan----
Mr. Hayes. I can't hear you, ma'am.
Ms. DeLauro. I am sorry. Notification emails to ICE are
sent, these are 18-year-olds--this was on the bulletin board at
the facility--14 days away from the 18th birthday, 7 days away
from the 18th birthday, and 24 hours prior to birthday. The
information is sent to ICE to let them know about the 18-year-
olds. Mr. Pocan.
Mr. Pocan. Thank you, Madam Chair. Yeah, actually a
suggestion, Madam Chair. I find it surprising that there is a
bit of a disconnect between the information you are sharing
with Homeland Security and then knowing what they do with it,
the fact that I asked you that day and again today and we don't
have exact answers what they are doing with it. Madam Chair, it
might be a good idea to have a joint hearing with Ms. Roybal-
Allard's committee because not only am I curious, but I hope
would you be curious, right? Because if I was a firm selling
people's data and they use it to scam people on the front end
of your business, that is one thing. But since our mission is,
as the secretary said, as a child welfare agency, I would want
to know because if the data we are sharing actually leads to
fewer people coming forward a sponsors, that affects the
child's welfare.
So I think you would all benefit from knowing that. I am
kind of surprised you don't already have that information, and
in the time you have been there you haven't asked for that
information. But I do think it would be helpful for the
committee and for you all to know, especially since some of it
isn't required by law. I really think that might be a good
suggestion.
Let me get back to that $750 a day because I have been a
small businessperson since I had hair, right? I was 23. I
opened up a small business. So when I look at what we are
paying, it still doesn't make sense to me because even if we
know we are going to have this certain number we are preparing
for, a permanent facility would be State licensed and have some
better standards overall. And if it is a third of the cost, you
really have to have some really highly-inaccurate projections
to not save money by having full-time facilities as opposed to
an influx facility that has been around as long as it has,
right? Because that amount of money for no real education, not
really providing mental health services--anyone would argue you
are supposed to at the level that we should--it just still
doesn't make sense to me that we would spend that kind of money
when all of a sudden in the last few weeks, all these people
got placed. That doesn't pass the smell test.
You know, for a long time, as you said, you have brought
the amount of days down considerably, but what is the incentive
to a firm to get people placed when they are making $750 a day?
And, again, they are a business, right? I appreciate some of
the nonprofit groups that are operating things and they have a
different mission. But when you are a business, your mission is
to make money, which means to continue to warehouse kids for as
long as possible because you are making money. And if you don't
have an incentive for them to actually place folks, that is
completely counterintuitive to the free market, period, full
stop.
So just respond to that. It just doesn't make sense to
continue to have a facility that you pay 3 times the rate with
worse conditions when there is no incentive for them to move
people. And they just proved, as we started looking at things,
suddenly 1,400 kids got placed in the matter of a month.
Mr. Hayes. So, again, specifically to your question, sir, I
think that has everything to do with the Fourth Operational
Directive. And what we are doing with that operational
directive, and this was a recommendation that I received from
the field out in Texas in one of my near 50 visits to our
shelters. It actually came from one of our case managers. And
that was, look, a lot of these children that come into our care
have grandparents and adult siblings, you know, that are very
close to them. So for a reason we have, again, based on the
recommendations from the child welfare experts in our field.
Mr. Pocan. Sure.
Mr. Hayes. So that is what I would directly attribute----
Mr. Pocan. So then if I can, just in conversation with you,
based on that directive, and I agree. That was a good idea, and
I am glad you implemented that. Why do we even need this influx
facility anymore, because now if that is directive, we can
utilize the permanent facilities much better that are a third
of the cost and have better conditions? Again, why have this
privately-run, for-profit, more expensive than the Trump hotel
or a Four Seasons operation when we could have a better
operation for a third of the cost?
Mr. Hayes. That is a great question, Congressman. So first
off, that is what we are doing. We are working to decrease the
census at Homestead just as quickly and safely as possible. I
don't know that I would support incentives for, you know, our
grantees just to discharge children as quick as possible. I
don't know that I would necessarily assign----
Mr. Pocan. I guess what I am saying is you wouldn't need
incentives if you had cheaper facilities that had better
conditions, right, you would be operating. But under this
current thing, when I talked to that girl who was there 60 days
or we look at the old rates of how long people were there, and
we saw you can move people just by being innovative, they have
no reason to be innovative. They have a reason to warehouse
kids because that is how they make money because they are a
for-profit venture.
But you are a child welfare agency to your very words. You
have an incentive to not waste taxpayers' money, and to make
sure the kids are in better facilities, and get them hooked up
with sponsors, but we haven't done that for the last year, year
and a half. So you are finally doing something towards it, but
I need to know that that is going to be a better direction,
Secretary, than what we have seen because I don't think the
last year and a half is something we ever want to use as an
example of how to move forward.
Ms. Johnson. Thank you. That is the goal, and you have
heard me say that over and over. The permanent beds and the
flexibility of permanent beds are critical. But you also heard
me say the time it takes to license a permanent bed, and it all
depends on the State, if they are willing to have our shelters
in their States, it takes time. We are now finishing up, as you
said, 3,000 new beds that have come online from May, and I am
hoping to have them on in the next 3 to 6 months.
And this is a continuing FOA. I am not closing it. I am
keeping this open so that we can continue to bring on permanent
beds. And the real goal of this, as you are all very aware,
with the FFPSA in child welfare, there is a reason to decrease
congregant care facilities. And if they already have a licensed
congregant care facility that provides the mental health are, I
would be very interested in those. So we want to encourage
States to let us use what has already been built and already
licensed, and those operational directives are absolutely
critical.
Mr. Pocan. One very quick final question. Would you make a
commitment, Secretary, because I am a little troubled that you
guys don't know exactly when you will share that data and what
gets done with it, because, again, it may not be in the
interests of child welfare. Will you make a commitment to
personally get some of that information so that we know what
you are doing with the data, whether or not it is
counterintuitive to child welfare?
Ms. Johnson. I would make the commitment to talk to DHS
about that, but I would really request that you ask DHS
directly. I wouldn't want them assuming what I do with
information they provide. I would rather not assume or take
just one person's word on what they do with it. So I would
highly request you ask my sister agency.
Mr. Pocan. Thank you.
Ms. DeLauro. Congresswoman Roybal-Allard.
Ms. Roybal-Allard. I am going try and get at least two
questions in, so I would appreciate very short, but pointed,
answers. I want to follow up on Congresswoman Clark and Watson
with regards to those detainees, those children that age out
and turn 18, because one day a person is a child in a
protective environment, and the next day they are put in
handcuffs like a criminal and taken to adult detention on their
18th birthday.
As chair of the House Appropriations Subcommittee on
Homeland Security, I find this not only disturbing because
there are alternatives to detention that are less costly and
more humane and dignified, but because I have been told that
one of the reasons that ICE takes these children into custody
and into detention is because ORR case managers fail to create
post-18 plans for these children while they are in ORR care.
And one example that I was given, and this was information
that came out in a Senate hearing was that in 2017, ORR failed
to give ICE 400 post-18 plans for these children that age out.
And I would like to hear why this is happening, and what is it
that prevents them from providing these aging-out plans which
would make them make recommendations to ICE that a particular
child would be eligible for alternatives to detentions or sent
to a sponsor and not to the adult facilities that they are in
now.
Mr. Hayes. Yes, ma'am, and I will just point out I am a
father of five, and I have a 17-year-old daughter, and, you
know, I share that concern that one day they are a child, and
the very next day they are adult. I would say, though, you
know, I feel like to some degree we are hearing mixed signals.
You all don't want us to coordinate with ICE, but now you want
us to coordinate with ICE. And so----
Ms. Roybal-Allard. No, no, wait a minute. Two entirely
different things.
Mr. Hayes. Okay.
Ms. Roybal-Allard. One is the sharing of information in
which ICE has gotten information on other people in the
household and have gone and rounded up members of the family
that has prevented sponsors from coming forward. What I am
talking about is providing a plan that is given to ICE where
ORR is supposed to recommend that child is eligible for
alternatives to detention, that they can be placed with a
sponsor and so on. So don't even mix the two.
Mr. Hayes. Okay.
Ms. Roybal-Allard. Don't even mix the two. So my question
is why is it that ORR is failing to provide these post
detention plans?
Mr. Hayes. So I am not aware of that specific report, so I
would like to see it. But you have my commitment I will go back
and meet with my team, and if we have any of our staff at our
grantees that are not meeting their moral obligation to do
everything in their power to benefit these kids, especially
ones that are going to be aging out soon, we will do everything
in our power to rectify that.
Ms. Roybal-Allard. You know, and I find it very disturbing
that when you have statistics like this where you are not
giving these plans that you are not even aware of it.
Mr. Hayes. I don't know where you are getting those
statistics, ma'am. That is why I would like to see that, and I
would absolutely commit to you today that I will look into that
as quick as possible with my staff.
Ms. Roybal-Allard. Okay. I still am surprised that you are
not even aware that these plans aren't being put together. Just
very quickly in the time that I have left, earlier this month,
the Miami Herald broke a story about a teenager who lived in
the United States for 15 years. After a routine traffic stop,
the uncle who was driving was arrested and put into ICE
custody. And the boy was eventually placed at Homestead in
spite of the fact that he lived with his mother in the U.S.
This is really disturbing because the mother, who was the legal
guardian, was not informed as to where her child was.
And, you know, I can only imagine the agony that the mother
felt when she tried to find her son. According to the news
report, she said, and I quote, ``I called his phone a thousand
times, called his uncle, called the police. Nobody picked up.
Nobody had answers. I thought that he was either dead or
kidnapped.'' And then days later, after the mother had
contacted, ICE, CBP, and a local immigration lawyer, and
finally ORR, when she read in the newspaper about Homestead,
she figured that maybe her son was there, she was able to
locate him at the Homestead facility. And she stated that the
only reason she was able to finally get a yes that he was there
was, and I quote, ``It wasn't until I lied and told them that I
knew my child was at Homestead that they confirmed.''
So under what circumstances would a child living with a
parent be referred to ORR? And is there some coordination with
ICE or ORR or DHS that encourages the transfer of children to
ORR custody after an interior enforcement action? And I just
want to say this is just one example. Let me give you quickly
another example. I spoke to a young girl in the Homestead
shelter who had been there almost a month. She had been
detained with her brother who was older. Her brother was with
the mother, and she was still at Homestead, and she said she
didn't know when she was going to be leaving. So when she was
detained, she was with her brother. The brother is with the
mother, but she is still in Homestead. So we know that she had
a sponsor and she had been there almost a month waiting to be
reunited.
So these are the incidents that raise, you know, all these
questions. Homestead, they make a lot of money by keeping
children. So can you explain what the process is and why this
is happening?
Mr. Hayes. If I may, ma'am, I would say on the surface what
you are sharing with me is concerning to me as well, so I share
that concern. What I have found, though, is, you know, I have a
lot of questions that come into my mind as well to lead me to
learn more about that unique situation. Was the brother an
adult? I don't know the answer to that question. If she was
with her brother and he is an adult, that is not considered a
separation. By statute, she is required to come into the care
and custody of HHS and we run through the sponsorship process.
So if there are some more specifics I will look at----
Ms. Roybal-Allard. Well, I think the more critical question
is that----
Mr. Hayes. The coordination?
Ms. Roybal-Allard [continuing]. He was with the mother.
They were detained together. He was with the mother and why
wasn't she?
Mr. Hayes. Okay. Are you saying he was with the mother when
they were all originally detained?
Ms. Roybal-Allard. No, no.
Mr. Hayes. Okay. So that is my question.
Ms. Roybal-Allard. She was in your Homestead facility----
Mr. Hayes. And he was----
Ms. Roybal-Allard [continuing]. And he was with the mother.
She knew where her brother was, and she didn't know why she was
still there----
Mr. Hayes. And they were probably, in theory, on the way to
the mother together, and they were detained. Then, again, my
assumption there would be that the brother is probably not a
child. He was over 18, and, therefore, she was required as a
minor to come into our care, and then we run through the
sponsorship process. So really the fact that she came in with
her brother is not really relevant in that fact. The question
is what we were doing to quickly vet and ensure that the mom
was capable to take the child. That would be the information.
But, again, there are questions that come to mind, and I am
happy to look into that particular situation. I know you
interacted with her, but I want her to be with her mom just as
quick as possible.
Ms. DeLauro. Congresswoman Lee.
Ms. Lee. Thank you very much. I wanted to go back to, well,
first, the contractor. I want to understand. Comprehensive
Health Services is the operator, right?
Mr. Hayes. Yes, ma'am, that is correct, Homestead as well
as several permanent network----
Ms. Lee. Okay. So Caliburn International, what is the
relationship?
Mr. Hayes. I don't know exactly when, but Caliburn has
purchased and owns CHSI.
Ms. Lee. Okay. So they own, okay, because I am looking at
one of their filings with the SEC, and I just want to quote
what it said. ``Broader enforcement in immigration policy is
driving significant growth. The company also warns investors
that the challenging and politically charged environment could
adversely impact our share price.'' Do you understand the fact
that this is a profit-making business and that it is driven by
their share price, and that they are there to make money? And,
in fact, I don't know if you have any other private companies
running these centers, but what do you think about that just in
terms of a profit motive company taking care of these kids?
Mr. Hayes. Well, again, we do have some other for-profit
providers out there other than just CHSI. I don't have those
specifically memorized. I know they are in the system. I would
just say that I have interacted very closely with the
leadership of CSHI specifically at Homestead. I have seen
nothing in any of the work that the staffers do that indicates
to me that they are driven by profit. I know that Comprehensive
Health Services does a lot of medical type care as well for
Customs and Border Protection. But, you know, other than that,
again, I go back to 2015 when that contract was originally
issued, it was an open and competed process against several
type of both nonprofit and other profit groups, and they were
awarded the contract.
Ms. Lee. You may not see that they are driven by profit,
but corporate entities are driven by profit, and so their
systems are based on the profit motive. I mean, that is just
how it works. And so, in looking at Homestead and the feeling
there, as I said earlier, it feels like a prison. It feels like
a jail. The systems that they have in place are warehousing in
a jail-like system. Why didn't they develop the systems based
on more of a boarding school system or something that is more
conducive to taking care of these kids until they can
transition out and then having a structure in place to, well, I
won't say ``expedite,'' but to process these children more
quickly if, in fact, that is their goal? And there is a
difference between a jail structure, which I think I saw there
personally, versus a boarding school structure.
Mr. Hayes. I just think we are going to have to
respectfully agree to disagree, ma'am. I would not classify
Homestead as a jail or a prison----
Ms. Lee. I am saying it may not be classified, but the
environment, the lining up, being told this, being told that,
the physical structure, you don't see that in a licensed
facility, and you don't see that in shelters where you have a
more conducive environment for the child's mental and physical
health.
Mr. Hayes. I think I would both agree and disagree with
you, ma'am, respectfully. I would say that I do think you see a
lot of structure at even our----
Ms. Lee. Structure is okay, but----
Mr. Hayes. But, yes, we had a high number of children at
our influx shelters. That is the purpose they serve in order
for us to be able to quickly move as many children as we can
into our care to prevent them from being at Border Patrol
stations.
Ms. Lee. But the feeling I almost got was, it almost
appears that these children could be seen as borderline
criminals. And that is not the message we want to send to these
children who are traumatized, who will hopefully be living with
their sponsors very soon.
Mr. Hayes. Absolutely.
Ms. Lee. And so by being treated by prison like, criminal
like, I still say that the case management system in place has
to have a big component that recognizes that as part of this,
and then says, okay, we have a program to deinstitutionalize
these children before they are released. I am saying released
before they are sent to their sponsors.
Mr. Hayes. ``Discharged'' is the term we use.
Ms. Lee. Discharged, yeah.
Mr. Hayes. Listen, we may agree on the environment at
Homestead, but I do share your commitment to doing what is best
for these children. And so with your background and your
expertise and your years of service in Congress, if you have
ideas how we could better set up our case management and
clinical social work, our team would love to sit down with your
team and hear some of your ideas.
Ms. Lee. Okay. Well, I would love to meet with you----
Mr. Hayes. Absolutely.
Ms. Lee [continuing]. To share ideas, and with the
organizations that we have talked to who have specific
protocols that they would like to recommend to you.
Mr. Hayes. I think that is a great idea.
Ms. Lee. Okay. Thank you.
Mr. Hayes. Yes, ma'am.
Ms. DeLauro. Let me give you a chance to respond.
Ms. Johnson. I would like to add on to that. For-profit or
nonprofit, we have our own monitoring guidelines. We have our
own audits. We have external groups that go in and look at what
is going on. So I would expect, as the assistant secretary over
this program, that it doesn't matter their compliance, whether
it is for-profit or nonprofit. They are to meet the standards
that we set, and that if they aren't, and we will continue to
look at that because we can always do better in everything we
do, we will move forward. But because they are for-profit, we
don't monitor them differently. We are still very strict in our
standards.
Ms. Lee. Well, you need to because they are for-profit, and
profit is the motive by which they operate under.
Ms. DeLauro. Thank you to you, Madam Secretary, and to you,
Director Hayes, for the time. It has been well over a couple of
hours, and you have been forthright in your commentary. Just
one point because you are going to leave and we have another
third panel coming up. I want to ask them to come up. But the
contract with regard to Carrizo, and if we could get that
contract as well as the Homestead, that would be terrific, and
thank you. We do look forward to working with you in various
ways.
Ms. DeLauro. I will repeat my hope is that, and just in
terms of summarizing, Secretary Johnson, you support
terminating the MOA, which is what you said. And my hope is
that, Director Hayes, coming around to that will be critical
for you, though I think, you know, you didn't answer that
question. But I think that that has been one of the most
serious and onerous policies emanating from that MOA that has
brought us to the brink of something that has been, yes, a
crisis, a humanitarian crisis. It did not have to happen.
Understanding what you have done in terms of rescinding
some of those pieces, let's rescind the rest of it, and let's
get these children with good standards of care and licensed
standards of care, and U.S. and international law standards of
care, as well as discharged as quickly as we can to their
families, relatives, and a placement that is safe while they
continue to go through the process. Thank you very, very much
for being here this morning.
We are going to ask our third panel to come forward.
[Pause.]
Ms. DeLauro. Thank you very, very much, and I want to thank
you for your patience, but I think it is important that we hear
from you. There is a record, and fortunately I wish there were
more of the members. But we have your testimony, and as I say,
that this information is part of the record, and so you can be
sure that it is distributed. So thank you again for your
patience.
Let me introduce our panel. Margaret Huang ho is the
executive director of Amnesty International USA, who recently
published a report, ``No Home for Children: The Homestead
Temporary Emergency Facility.'' You have advocated before the
United Nations as well as the Inter-American Commission on
Human Rights. Earlier in your career you served as committee
staff for the Senate Foreign Relations Committee.
And I would say this to you, Margaret. We are not going to
hold it against you that you worked in the Senate. Is that not
true, my colleagues? Okay, true. So thank you so, so much for
being here. And to Krish, I want to make sure I get it right.
Krish O'Mara Vignarajah. Yay, okay.
Mr. Vignarajah. It is a tough one.
Ms. DeLauro. President and CEO of Lutheran Immigration and
Refugee Services, LIRS, who has served as policy director for
First Lady Michelle Obama. In addition, served as senior
advisor of the State Department under Secretary of State
Hillary Clinton and Secretary of State John Kerry. At the State
Department, Krish coordinated development and implementation of
multiple programs, including those concerning refugees and
migration.
Now, I also understand that your dad is here. Is that
correct?
Mr. Vignarajah. He is indeed.
Ms. DeLauro. Where are we? Hello, yes. Thank you. Thank
you. Now I got to get this one right, too. Eliathanbi? Okay.
And so thank you so much for being here, and I know you sit
there with a great deal of pride, so it is wonderful to have
you here today. So and I would just say to both of you, your
full written testimony will be entered into the hearing record.
Ms. Huang, you are now recognized for 5 minutes.
Ms. Huang. Thank you so much.
Thank you for having me testify before you. My name is
Margaret Huang, and I am the executive director of the U.S.
Section of Amnesty International. We have advocated for the
safety and freedom of children seeking protection here for the
last years 20 years. Most recently, Amnesty International
published our grave concerns about the Homestead child
detention facility in Florida where thousands of children have
been warehoused as they await reunification with their
families.
Today's hearing is very timely and a critical opportunity
to examine the conditions in which migrant children seeking
safety here are being held, including the prolonged use of
influx facilities like the Homestead Detention Center. As a
starting point, under both U.S. law and international
standards, detention is never in the best interests of the
child and it should be avoided whenever possible.
In those rare situations when detention is truly necessary,
it should be for the shortest amount of time and in the least
restrictive setting.
The administration has increasingly relied on influx
facilities to warehouse children because of crises that it has
created. First, it continues to rip children apart from their
families at the border, literally creating unaccompanied
children who must then be placed in the custody of ORR. Over
700 families have reportedly been separated since the June 2018
order prohibited family separation.
A particular problem is the ongoing separation of children
from their adult caregivers and family members. In many cases,
these caregivers, grandparents, uncles and aunts, and adult
siblings, are functionally parents to these children, and the
separations are enormously traumatic. This is a stark violation
of those children's best interests.
Second, this administration is prioritizing immigration
enforcement over children's well-being. Under the Information-
Sharing Agreement that you so ably addressed earlier with the
previous panel, ORR is sharing information about the
immigration status of children's potential sponsors with DHS.
Originally, this included all of the adults in a potential
sponsor's home and we know that DHS is using this information
to target sponsors for immigration enforcement.
The Agreement forces sponsors to make an impossible choice.
Either they come forward and they free their child from
detention and they risk being deported or they stay back and
they let their children languish in detention.
After the Agreement was signed, the length of time that
kids were spending in ORR custody nearly doubled. Because that
policy has now been amended with operational directives, most
recently in June, today thousands of detained children have
been reunited with their families, and I've just come back from
both Homestead and Carrizo Springs and was informed by the
officials in those facilities that they attribute the sudden
release of these children to the change in policy. It is not
because it was not possible before.
To respond to this crisis of its own making, the
Administration has resorted to using warehouses, like influx
facilities, for longer and longer periods of time for some of
the most vulnerable people in its care.
Homestead is only nominally temporary because it's been in
operation for more than 16 months. Homestead is not a home.
It's an industrial line for the processing of mass numbers of
children. Children walk around with bar codes around their
necks in a highly-regimented setting. They fill out forms to
get the most basic of services.
Case management and medical treatment are inadequate. One
child we spoke with found out that he was HIV-positive while he
was at Homestead and he was kept in medical segregation for a
month.
Facilities this large warehousing this many children cannot
do right by the kids. Because Homestead is an emergency
facility, it evades state oversight and their employees do not
have to go through the same background checks as state-licensed
shelters do.
We must do better by these children who are coming here in
search of protection. First and foremost, children should not
be detained. Congress should prioritize funding policies and
programs that keep families together and reunite detained
children as quickly as possible with their sponsors.
Secondly, we must cease the protracted use of influx
shelters and close Homestead, which is not in the best
interests of the children. We have to prioritize funding
permanent state-licensed small-sized facilities instead and
only use those facilities when they're actually necessary.
Influx facilities should not be used for crises of the
Administration's own making.
Thank you for holding this important hearing today.
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Ms. DeLauro. Thank you very, very much for your testimony.
And now, Ms. Vignarajah.
Ms. Vignarajah. Thank you, Congresswoman DeLauro, Ranking
Member Cole, and distinguished members of the committee, for
the opportunity to testify.
The organization I lead, Lutheran Immigration and Refugee
Service, has a long history of successful collaboration with
the government through 80 years of work in refugee
resettlement, our care for unaccompanied children, and our
ongoing management of family reunification. We work with
partners, like Reverend Wilker from Lutheran Church of the
Reformation.
During last year's family separation crisis, LRS was one of
only two organizations asked by the government to help with
family reunifications. Neither LRIS nor our sister
organization, the U.S. Conference of Catholic Bishops, received
any government payment for that work, but without a moment's
hesitation, we stepped up to respond based on an unwavering
commitment to family unity and ensuring all God's children are
welcomed, protected, and offered love and warmth, not concrete
floors and Mylar blankets.
The term ``unaccompanied minors''' is seemingly meant to
give the impression that these children come to the border by
themselves. It masks the fact that some are unaccompanied
because we stripped them from their parents' arms. So it is my
duty to report that the assertion that family separation has
ended is not true. In fact, we have nearly 40 children who were
separated even after the policy supposedly ended, four of them
tiny babies, less than one year old. They were not
unaccompanied minors until our government made them so.
As a faith-based organization, we believe no child should
be separated from a parent in order to deter other parents. As
a faith-based organization, we believe no child should be held
hostage as bait in order to subject family members to
fingerprinting for immigration enforcement purposes, and so we
request the formal end to the Memorandum of Agreement between
the Department of Homeland Security and Health and Human
Services. We were heartened to hear the Assistant Secretary's
testimony on that fact.
We are trying desperately to reunite families and this
Agreement has significantly impeded parents and other sponsors
from coming forward and prolonged the time that vulnerable
children are separated from their family.
But our efforts to reunify families are much broader and
that is the focus of my testimony today. Right now, some
children are being housed in large shelter facilities that face
allegations of sexual and physical abuse. Some are kept in a
Walmart turned warehouse among nearly a thousand other
children. Others are in a federal influx facility where a 144
children sleep in one room with no state regulation and little
oversight.
So what if I told you what you know, that there is an
alternative, that I could provide many of these children with a
loving set of foster parents who could offer a child not just
shelter but a safe and stable home, that this care could help
the child reunify with their actual family safely and more
quickly, and that in the interim, these nurturing foster care
parents would help the child learn, read, play sports, tuck
them into a warm bed at night, and that this care would cost a
third or a half of the price of warehousing children?
As a parent or grandparent, wouldn't you choose the family-
like setting? And as an appropriator, wouldn't you choose the
setting that is better for kids, better for taxpayers?
Well, this choice isn't theoretical. It's the one
government faces every day when it places a child in a
temporary influx facility like Homestead rather than a family
setting like the care that LRIS provides.
This year, we've already cared for 549 kids. Yet as large
shelters grow, we have loving foster care parents today with
empty homes. Remarkably less than half of the care that we've
offered to the government is being utilized at this moment.
How is that possible? Well, here's what we're up against.
Right now, private prisons and for-profit companies account for
over 70 percent of the immigration bed facilities in this
country. We know the government's extraordinary logistical
burdens but caution against settling for the convenience of
for-profit influx and detention facilities.
These entities are not guided by the best interests of the
child but by the best interests of their shareholders.
As criminal justice reform has pushed private prisons out
of the American penitentiary system, they've turned to
immigration to turn a profit and profit they have. Caliber and
the company that runs Homestead earn $775 per child per day.
Since 2018, they've received contracts for $545 million.
Just as I was visiting Homestead, Caliburn was trying to
sell a hundred million in stock and said the need to house
migrant children is ``projected to drive growth,'' as
Congresswoman Lee pointed out.
Today's testimony has shown that they are not qualified to
care for children, let alone traumatized migrant children. So
rather than a Homestead, how about a home instead? For 40
years, LRIS has established proven models of family and family-
like care for unaccompanied minors until they can be reunited
with their families, a model of care that is small, safe, and
family-centric.
We ensure children receive trauma-informed care and that
all our foster parents and caseworkers are licensed by the
state and receive up-to-date information on the new child
welfare standards because we must never forget that these
children are not just in our custody, they are in our care and
while they are that burden of responsibility of protection, of
oversight, sits here with American leadership and the power you
wield.
Thank you.
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Ms. DeLauro. Thank you both very much for very powerful
testimony and thank you for your dedication, your commitment,
and compassion in dealing with this very serious issue.
Both of your testimonies highlight how toxic the MOA is for
the UAC Program. Just a couple questions in this regard.
Can you tell us more about the chilling effect the MOA
continues to have on the sponsor-vetting process, how this
results in children staying in ORR care far longer than is
healthy or necessary, and if HHS and DHS rescinded or
terminated the MOA, do you believe you would see an immediate
improvement in identifying sponsors? Please, I'll hear from
both of you. Go ahead, Margaret.
Ms. Huang. Thank you, Congresswoman. Thank you for the
question.
We know that hundreds, perhaps at this point thousands of
children have been released in the last month since the new
operational directive was issued in mid-June, and all of the
facility operators we spoke with, not just influx facilities, I
should note also permanent shelters we visited on our trips, as
well, they've all indicated that that directive had an enormous
impact on all of them. They were immediately able to see their
numbers go down. So it's very clear that the barrier is the
requirement of fingerprinting and sponsors being afraid to come
forward.
Unfortunately, we don't have data sufficiently from ICE
about whether it is in fact targeting sponsors, how many people
might have been identified and arrested because of the
Information-Sharing Agreement. So that would be information
that would be wonderful for Congress to seek.
I do believe that if we continue to see the removal of
these obstacles as we perceive them that we would see more
children unified.
When we visited the Carrizo Springs facility, all of the
children who were sent there were sent from other shelters,
from Texas and Arizona, and all of the children had Categories
1, 2, or 3 sponsors.
The day we were there, they learned that one of the
children's sponsors had decided they could no longer come
forward, which would make that child now a Category 4 child,
and so there are still issues, even children who have
identified family members here, if they're fearful of coming
forward, which many of them still have that fear. It is
actually forcing the children to stay much longer.
Ms. Vignarajah. So I'll add to that the data that we do
have. We provide the majority of reunification services across
the country and so we interact with potential sponsors on a
daily basis.
So we have data from four months before the MOA went into
effect and then three months afterwards, small sample size but
I think informative.
What we found was in terms of the number of cancelations
and no-shows, it increased from six percent to 33 percent, so a
third of these potential sponsors no longer came to our
facilities.
In terms of declining fingerprinting, it went from zero
percent, we had no declines, to nine percent, and, you know, I
know that in the prior testimony, there was some question about
what is the impact and why has it had such a chilling effect?
It's because the reality that we know that even from data that
was shared between July and November 2018, we had a 170 arrests
based on that information alone and so, you know, the chilling
effect that we are observing in our facilities is being
observed across the board.
So there's a public report that we put forth that indicated
that 75 percent of the survey participants in terms of
providers observed that fewer potential sponsors are now coming
forward.
Ms. DeLauro. I'd very much like to get that report, if we
can. Thank you.
Let me just ask a question to you, Krish. What is the LRIS
preferred standard of care for unaccompanied minors?
Ms. Vignarajah. So, you know, as I briefly touched on in
the testimony and I appreciate the opportunity to speak a
little bit more in detail, we very much believe that we can
provide a care model that is safe, small, and family-centric.
Our model is really centered on child welfare best
practices. It is designed around the recommendations of child
welfare experts. Truly, it is a labor of love for us. It is not
a for-profit center and so for us, the guiding principle is
what's in the child's best interests?
For LRIS, we have numerous partners in states really across
the country that operate the transitional foster care that I
mentioned, which is truly a family environment, as well as very
small group homes which are essentially family-like.
On average, our size is 12 children or less but the vast,
vast majority of our placements of children are in transitional
foster care in individual homes, and we believe that, to the
extent possible, and really we do have the capacity that we
should be affording every child, migrant or otherwise, with a
loving family environment.
Ms. DeLauro. Thank you.
With that, let me recognize Ranking Member Cole.
Mr. Cole. Thank you very much, and thank both of you for
your testimony which I read last night and enjoyed listening to
again today.
Ms. Huang, if I may start with you, obviously you've got a
study on Homestead. Now did you study it in the last
Administration, as well, when it was first established?
Ms. Huang. No, we did not, sir. In fact, I believe it was
even opened prior to the dates that were mentioned by the
director in the previous testimony. It was actually opened even
in 2012-2013.
Mr. Cole. Yeah. That's what I recall, as well. Any
particular reason why you didn't look at it then? It would be
very helpful, and I'm not being critical in this, if we had
kind of continuous study of what happened in what is clearly a
controversy.
Ms. Huang. It would be. I wish we had, but we didn't. We
actually requested to visit lots and lots of shelters in the
last 12 months. We've been given access to Tornillo. I visited
Tornillo last fall as well as to the two I've mentioned, and
we've requested and visited a number of permanent shelters.
We've not been granted any access to CBP holding facilities
at all----
Mr. Cole. Okay.
Ms. Huang [continuing]. Despite multiple requests.
Mr. Cole. Well, they're in very different categories
obviously.
Let me ask you this. A lot of your testimony is very
compelling about the separation of children and family members.
Currently, the law of the land, as I understand it, is if
you're not with a parent or a legal guardian, even if it's an
aunt, an uncle, you know, somebody that we would consider an
appropriate family member, is that a statute we should change?
How would we approach that?
Ms. Huang. Yeah. Actually, DHS has the discretion to keep
families together if they're identified as such. I think there
is a challenge if you're asking law enforcement officials to
make that determination and I can understand why we would not
want CBP to decide whether or not an adult and child traveling
together are the appropriate pairing, but there are child
welfare professionals who can make those determinations. That's
what in fact ORR does, and if we allow those people to
interview and to meet with potential families traveling
together, they could make that determination and in fact CBP is
not required to separate the child.
Mr. Cole. So would you--well, I think they would say we
don't know if this is really an aunt or uncle. We don't have
the appropriate papers. We don't know if this is something
where a child has been encouraged to identify this person who
may be a nefarious individual. There's got to be some mechanism
for the child's sake to check here.
So right now, I think it's probably pretty automatic, I'm
not sure, but I would assume that for Customs and Border Patrol
to do that.
Would it be better to keep them together and then turn them
over to DHS and where you would have this sort of option that
you described?
Ms. Huang. So ideally children should never be put in
detention. That's what we're aiming for and the goal would be
to try to keep the children with loved ones, with caregivers,
to be able to make that determination with appropriate child
welfare expertise, not by law enforcement, and then to enable
those children to be allowed to pursue their claims which I
believe most of these children have asylum claims, to allow
them to pursue those claims not in detention but in fact with
other means of showing up for their court proceedings, which a
very high percentage of them do.
Mr. Cole. That's correct, but again I'm just trying to--it
seems to me we've stumbled into a second crisis because we
didn't learn very many lessons from the first crisis. That is,
this is not news. Everybody up here said we've done this
several times and we seem to be reinventing the wheel over and
over and over again. Homestead's probably a pretty good example
of that.
And yet we also have some concern about--which I have the
same concerns my Chairman does over establishing regular
institutions and maintaining them because our aim is exactly
what you say, get them into an appropriate sponsor as quickly
as possible, not let them stack up, whether it's at a Border
Patrol facility or an HHS facility. Let's try to move these
people through to a more appropriate place for them to be.
How would we do that? I mean, with the estimates of the
crowd--you know, the folks coming very hard to predict. We've
had really pretty dramatic swings. If you went back to the
first year of the Trump administration, you'd see a dramatic
fall, partly probably because of the rhetoric of the
Administration, fear about coming.
I don't know if we have--and we have a different
composition of population now and partly that's clearly cartels
figuring out how to monetize the movement of human beings, in
addition to drugs and what have you.
So I'm just looking for suggestions here. What sort of
system would we need so that as these folks arrive--and by the
way, I don't hold the administration responsible for that. I
hold their home countries and cartels responsible for that. So
I don't say they created the crisis. They may have mishandled
the crisis. That's a fair point to make. I don't think you
could say they created it. They're not--you know, they didn't
do something to attract this population to the border.
So how would we have a system that works better than the
one we have now where we're not each time ad hoc and give me
just a little--I want both of you, if you'd care to respond.
Ms. Huang. So I do think that one of the ways that Congress
could be most helpful is really making the investments in the
reunification efforts.
Right now, there are insufficient numbers of caseworkers
working in all of these influx facilities. A lot of them
operate remotely. They're nowhere near the children that
they're trying to serve. There are not enough of the field
agents who actually investigate to find the sponsors and to
reunify them.
So there's a different approach and I know that
Congresswoman DeLauro referenced that, to have a plan that
makes investments in reunifying members. Even as you say,
Congressman, if an adult and child approach the border and
Customs and Border Patrol aren't sure if they're related, it's
understandable and appropriate for them to make sure that they
are before they're released together, but that process doesn't
have to take months. It doesn't have to take the amount of time
it's doing now.
So rather than investing in beds and these influx
facilities, which are incredibly expensive, a much better
investment is into making sure that that analysis is done, that
the care is given, that the children are being released as
quickly as possible into the care of those sponsors, and so I
think the challenge for us is that the investments have been
made more in the detention side, less in the reunification side
and that's what we really want to be seeing.
Ms. Vignarajah. It is a great set of questions and I think
the way I'd approach it is to look at it as a sort of sequence.
Phase 1 is really when we're talking about DHS custody.
What can we do to make less of a stark contrast between CBP
custody and ORR custody, and, you know, a few of the
recommendations--we included this in the Appendix knowing that
it's obviously not the purview or jurisdiction necessarily of
this committee is, you know, first, CBP is not following the
policy of standards that they themselves have always had on the
books, and I think that that is really important in terms of
the conditions of confinement right now are problematic and we
would just request that they actually review some of the
policies that they have in place, that there be independent
oversight of the facilities, which is natural in many other
settings, that we introduce state-licensed child welfare
experts into CBP facilities because right now we do have agents
that are just by the nature of their training ill-equipped to
be making determinations that are based on the best interests
of the child.
But I would also say, you know, it's about timely medical
care. There ought to be pediatricians. There ought to be nurses
in these CBP facilities. We also believe that we need to start
moving towards alternatives to detention. LRIS has been very
involved in piloting and showing the success of family case
management.
We know that there's been appropriation of funding for that
and we would just really request that that money actually be
moved to where it was intended.
In terms of that kind of middle area of when family
separations is happening, one of our recommendations is that we
don't get sufficient information because there is critical
information that is lost in translation and so one of the
things that we would really request is that in terms of the--
there's a 213 document that tries to reflect information of
it's not a parent, who is this individual, what is the
relationship?
Oftentimes we find that ICE and ORR aren't getting that
information. We're getting an individual with basically we have
a name, an age, and a home country location. With that, it
means that we're looking for a needle in a haystack and so any
cooperation in terms of helping us facilitate that
reunification process would be critically important.
Then the final piece just in terms of the facilities under
ORR's purview, first and foremost, obviously we've made the
case, I think, and there does seem to be bipartisan agreement
in terms of fostering and appropriating funding for, you know,
safe, small, family-like settings, but what we would also
recommend is that we don't continue to experience this roller
coaster.
We strongly believe that having the infrastructure of
guaranteed multiyear funding is critically important, but we'd
also stress that, you know, in terms of the ORR funding for
grants management, some of the issues we've seen as an
organization, even in the last couple months, is that we put in
indication that we would be able to take in a 108 additional
children two months ago. It was supplemental to a contract that
we already have. We actually got approved for a new contract
rather than the supplemental, which is just an example of
where, you know, look, it's not a thousand, you know, beds that
we're able to provide but it certainly is a 108 children that
could be under our care as opposed to in an influx facility.
I think one of the things we'd strongly encourage is that
ORR prioritize, you know, the grant management for facilities
like ours as opposed to the influx facilities, and then the
final point because, you know, I do take this point of what we
are seeing is in some ways not new to this Administration.
Our firm belief is that it doesn't matter if it's a
Republican or a Democratic Administration. We're helping
children. It's completely inappropriate on American soil. The
one thing I would note, though, is that, you know, to the
extent that I've looked at it, it is clear that under the Obama
Administration, there was kind of a more permanent part of
Homestead. It's called the Old Job Corps site, which is where
children were placed, whereas when I visited, and you probably
saw this, as well, the children are being placed in semi-
permanent structures and it is that uncertainty, you know, kind
of the non-permanent nature of that that does, amongst many
other concerns, raise red flags for us.
Mr. Cole. Thank you. Thank you. You were very indulgent
with the time. Thank you, Madam Chair.
Ms. DeLauro. No, thank you. I mean, your recommendations,
both of you, this is what we need to have. This was the
concern. We're willing to provide resources but not to continue
the current process which is failing and more than failing, the
repercussions on children are really staggering in so many
ways.
I have no problem calling into question policies of the
prior administration and that's why in this case, we are
looking at some more restrictions around the process that has
created a situation where we were trying to deal with increased
numbers of immigrants, but the policies have had a
significantly negative detrimental effect on children. So
that's, I think, what we have to acknowledge in both
administrations.
Let me just ask if you have a child with a Category 1 or 2
sponsor and that is parents or family, a family member,
grandmother--and, you know, look, I come from an extended
family. I understand that some of my aunts were like a mother,
you know, an uncle, a father. You know, when my father passed
away, my uncles stepped in. They all helped take care of me.
That's what so many families are about today.
So if you have a child with a Category 1 or 2 sponsor, once
the sponsor has been identified in your view, how long should
it take to place the child safely? No one is suggesting cutting
corners or doing it safely in your views. Go ahead, Margaret.
Ms. Huang. We believe that 2 weeks should be sufficient----
Ms. DeLauro. Two weeks?
Ms. Huang [continuing]. In that situation, yeah, and
certainly under the Flores conditions, we believe that it is
possible to be much shorter than the timeline it's taking now,
but you all are the experts placing, so you should answer that
question, too.
Ms. Vignarajah. Yes, and I should, you know, on that point
flag that I know there's a lot of discussion around length of
stay and I want to just clarify that we shouldn't put all our
eggs in that basket in the sense that length of stay reflects
the amount of time for those children who are actually
discharged, right?
So if we have an instance of 10 children, one child is
discharged in 10 days, nine children actually remain in custody
for a hundred days, your length of stay would be 10 days when
in fact if you would actually contextualize it, it would be 91
days at that snapshot period.
So one of the things I want to flag is that, you know, I
know there was some prior discussion about, well, under the
Obama Administration, it was X days. Under this Administration,
it has declined. As child welfare experts, our concern is
making sure that we have as short a window as possible but
knowing that background checks are in place for a reason and,
you know, we are a little bit concerned about the fact that,
you know, right now under the new regulations, this
Administration doesn't even require, you know, a bona fide
relationship being established.
There were reasons why those checks were put in place
because we had instances of trafficking happened not 20 years
ago but just two years ago and so I think that's where for us,
you know, I think two weeks is a good aim but, candidly, for
us, as long as we can get sufficient paperwork to support that
this is in fact, you know, a family member and that we have
conducted all the safety checks, we believe that it's possible
to even do it in shorter amounts of time.
Ms. DeLauro. The bureaucratic snafu around--you know, I
understand two weeks in the shortest particular time. Why then
would it--why would it be taking so long in some of these
instances?
I understand what you're saying. Why is it taking so long?
And clearly it didn't have to take as long. We're witnessing
within the last several weeks, yeah, that there is movement,
there's real movement, and so there is--from your perspective,
there is not a reason other than bureaucracy, there is no
reason to hold up this process in getting these kids to family
members, parents or relatives of some sort.
Ms. Vignarajah. And I think, you know, the few points I
would stress in terms of how can we reduce this time period to
ensure the reunification of family is, you know, first, in
terms of the reunification services we have where oftentimes
with the potential sponsor, that's the first interaction with
any kind of immigration entity.
It is quite clear that for many of these sponsors, it is
critically important to have an in-person resource who can walk
them through what is frankly, as this hearing reflected, it's a
complicated process for any individual, even who, you know, has
a mastery of the English language.
You know, second, I do think that we need to invest
resources in making sure that the paperwork is available not
just in English but in also the first language of the sponsor
because we found that to be a hurdle in terms of why the
paperwork is taking so long.
Third, obviously we've talked about the MOA in terms of the
chilling effect, and then, fourth, as I've mentioned, we need
to strengthen the information-sharing between DHS, ICE, ORR,
and then the implementing organizations so that we can expedite
that process.
We can do it. It's just a matter of streamlining and having
better coordination between the different entities.
Mr. Cole. I'm really probably at that point, I have more
observations than questions that would take a longer period of
time, but I do want your thoughts on a couple of items because
having lived through one of these things as the chairman and
now having lived through another one as the Ranking Member, I
don't want either of our successors to do this again.
So to me, part of the big problem is how do you set up a
system that allows us to handle something that might not be
predictable on an annual basis but is certainly something we
know we're going to probably face again? It's almost like
planning for a hurricane. You don't know when it and how but
you know there's going to be hurricanes.
So there needs to be a better system than what we've had
and I say that with no criticism of anybody involved. I think
they've handled the situation broadly as well as they could as
they've gone on, but we've got to do a better job in Congress
and as whoever the Administration is of thinking through what
do we do when something like this happens.
So toward that end--and I will tell you one of my problems,
I sit on the Rules Committee and we had a piece of legislation
coming through that was getting ready to lay down a lot of
requirements in terms of the border control and what do you do
when you have an unaccompanied minor, perfectly appropriate for
us to be talking about. There wasn't a single dime of
authorization for more money, not a dime.
So we're going to consider something, probably pass it
through the House, it won't get through the Senate, would never
be signed by the President, but if you're going to do this,
it's going to take resources, and particularly if you're going
to change the nature of the Border Patrol.
I mean, even some of the suggestions you had about the
types of additional personnel you would have at the border,
they're really not designed by and large to be legal points of
entry. They are Border Patrol. They're actually there to stop
human trafficking, to stop drugs, to stop folks coming into the
country illegally, and how you combine and give them the
resources--we had the same, honestly, struggle when we did the
authorization recently.
One of the points of contention was the Majority didn't
want to give any additional money to the Border Patrol because
they thought it would be used for Border Patrol purposes as
opposed to being used for the kids. So I understand the concern
there, but at the end of the day, you've got to get passed
that. They either have the resources to do the things you
suggest or they don't. They stay exactly like they are and
that's probably going to take authorization language and its
stuff beyond our ability in this subcommittee.
But I would just again ask both of you, and I don't ask you
to respond today, I know you guys think about this issue on
every day, literally you're trying to figure out what's the
best policy, and what we really need is, okay, if you're going
to change the nature of the Border Patrol where they can handle
these types of situations better because again the population
they're dealing with has changed in its character in a
relatively brief amount of time and we're not getting single
males from Mexico now. We're getting family units and
unaccompanied minors.
You know, cartels, which used to be primarily engaged in
drug trafficking, are now beyond human trafficking. I mean,
this is not necessarily--but this is slowly facilitating
illegal immigration.
So what do you need differently that you didn't have before
and as appropriators, we always ask that, and how much will
that cost us? So any thoughts you guys have on that would be
gratefully received either here or at a later point.
And then the second thing is this, you know, what are--I
think part of the conflict here between the parties is a sense,
okay, is this open borders, anybody can come that wants to come
and have to be received and give them resources, or, you know,
what do we really do in terms of cases where, you know, people
are legitimately--they're coming for economic opportunities as
opposed to asylum?
It's that appropriate legal balance, which, you know, we
have not been able as a Congress under either Democratic or
Republican control and with either a Democratic or Republican
Administration to really come up with something that we could
get through anyway.
That becomes the second problem. What's the appropriate
legal framework that we have to have to deal with these crises?
I guess the final point I would make, if we don't have a
system, these things are going to just inflame public opinion
when they happen. There has to be some agreed-upon system
because they turn into political issues whether people meant
them to or not. They simply do, having watched this twice, and
therefore we need some sort of bipartisan policy.
It assures the American people, okay, when something like
this happens, we have a plan that we've agreed upon and vetted
and put into law that, okay, and this is how we're going to
handle it. This is what we're going to do. So again I do think
a lot of this has been reinventing the wheel and there have
been some policy initiatives I certainly didn't agree with and
the child separation policy I think has been an enormous
mistake and I think has poisoned the debate and the discussion
a great deal, you know, again but I don't blame anybody for
being against that. I was against that and said so at the time.
You just don't do it.
Then, finally, I guess I should say this last thing I would
just say this whole knotty issue of who you're traveling with,
you know, it's pretty easy if it's a parent or legal guardian.
It really gets murky pretty fast after that, particularly if we
have some reason to believe that, you know, a child may or may
not be telling the truth in the sense they may feel intimidated
into not telling the truth and again a lot of these, they're
not young children. They are adolescents for the most part,
they're teenagers, but they're certainly still susceptible to
manipulation and intimidation in traveling with an adult and
they've undoubtedly been told, okay, this is what you say when
we get to this point.
There's got to be some direction we can give the Border
Patrol person who is the first encounter. This is your
sequencing. This is what--if it's this, do this. If it's this,
do this. If it's this, do this, and then you've got to have it
corrected pretty quickly within--because I agree very much with
your point. I don't know that--I don't want these folks making
that final decision. I don't think they want to make this final
decision. They would love--okay. Let's facilitate this into an
environment and with an appropriate set of childcare experts
and what have you that could then make that decision. Just give
us a place to move these children where they can get
appropriate care and people other than just us that are
enforcing law on the border are making the final decision and
disposition about where the child goes.
Just for what it's worth, those are my thoughts.
Ms. Huang. Thank you so much for those observations. I
think there's a lot to respond to and will definitely try to
provide you with some additional information.
MSC is monitoring the refugee crisis not just here in the
Americas, in our country and in the Americas, we're actually
monitoring it globally, and today there are more than 70
million displaced people around the world, which is just an
extraordinary number, nearly 26 million who've been identified
as refugees, and that's not counting the asylum-seekers. Those
are people who've been identified by the UN agency.
So you're right to anticipate that this is not the last
surge, the last crisis, the last influx that we will have. We
will continue to see more of this because what is driving
people to make those moves is not singular, it's not a one-time
thing, and it is larger patterns of violence, of civil
conflict, of environmental degradation, of famine, things that
are clearly causing different people to feel that they need to
leave.
I think it is clear that we're not seeing the same economic
imperatives of migration patterns now. We're seeing something
very, very different, and the response therefore has to be very
different. It's no longer about having a legal framework that
takes into account economic priorities. It's about having a
legal framework that recognizes our obligations to asylum-
seekers and to protecting people who are so vulnerable and
seeking refuge. That's a different framework.
Part of the problem is we've struggled with how to shift
our policies from anticipating people who might be coming
seeking work to people who are fleeing and looking for a safe
haven.
So it's not an easy thing to switch on and off. It's
something that we have to do collectively, but it's very clear
that that is the future direction for all of us and that we
have to be doing a better job.
I just wanted to note that on the notion of determining
whether a child is traveling with an appropriate caregiver, for
so many of the people who are fleeing now as part of this
pattern, children have been left behind by parents. Parents may
have come in the past seeking economic opportunity. The people
bringing them now are often not the parent and so it's a
recognition again of what this crisis is, the reason that
they're traveling with non-parents and many of them don't have
a legal guardian because that's not even plausible from some of
those countries, is because of the circumstances that are
driving it, and I think being responsive to that and thinking
through policies that would recognize those facts and help
create the appropriate setting is the most ideal.
But I think we're all looking for the same thing. If we can
reunify families as quickly, as safely as possible, that is
always in the best interests of the child, and I know that's
been a driver for this committee. So thanks.
Ms. Vignarajah. All excellent questions, so I'll try to
very quickly respond in turn.
On the broader point, you know, I, of course, realize that
it's easy to say, well, we should fund X, Y, and Z, but your
responsibility is to figure out how do we find funding for it,
and that is where----
Mr. Cole. That's actually now the Chair's. [Laughter.]
Ms. DeLauro. A willing Chair.
Ms. Vignarajah. And I have full faith she will be able to
do so.
But that is where, you know, obviously we've talked a
little bit about our cost structure versus the influx facility
cost structure, but even when you look at detention facilities
versus alternatives to detention, you are literally talking
about something around 350 versus $15.
When we've shown that it is better for the family, better
for the children, 99.7 to 99.8 percent compliance in terms of
showing up for an ICE hearing, an ICE meeting, or your
immigration court hearing, and so our point is that we can find
the cost savings that will pay for all of this.
But part of it is making the sound investments now so that
we don't have to all of a sudden, you know, in a rush stand
something up, like Homestead, and I think that's where, you
know, for me, it's about looking at the fact that, as you said,
we had some notice. Obviously it wasn't like this happened over
a two-year time span, but we did have some notice.
If you look at January, we knew that we had facilities for
3,000 members of families. We received 28,000 members of
families and that to me was something that we saw even last
year and I just don't think that we prioritized making sure
that we had facilities responsive to the urgent needs of
children and instead we implemented more of a militarized
response which we know, of course, costs, you know, a lot more.
I think what I would say is that in terms of the planning,
we do have to be a bit creative when we face these situations
that, you know, we didn't plan for. For LRIS, what we've done
in terms of our border work is that we've really taken a
leadership role in Arizona as well as in New Mexico. That has
been based on the churches who have stood up basically, you
know, pop-up shelters, but we can do that in the context of
providing the scale of beds we need, in the sense that we've
got congregate care that can no longer be providing care for
domestic children.
There are partners like us who have the expertise in terms
of how to address children who are coming from other countries.
It is why we've been incredibly aggressive in part because when
I visited Homestead, I said to my team, look, we can stand here
and criticize from the sidelines or we can actually find a way
to be a part of the solution which is why in short order we
will actually be proposing that we have 600 placements for
children in our facilities because we know that we do need to
scale up and be creative.
But the other piece of it is that, you know, when you look
at even the infrastructure we have for refugees, so some of our
work is refugee resettlement, because we operated just a couple
years ago at a time where the resettlement agencies were able
to bring in and help a 110,000 refugees, now we're at 30,000.
If we can be creative in identifying opportunities like that
and repurposing them, I do think there are ways in which even
today we would not need temporary influx facilities.
On the question of the legal framework, look, I appreciate
your comments in terms of taking this out of the political
pinball machine because it's true. I don't think anyone is
really advocating for open borders and until recent rhetoric, I
don't think anyone was advocating for closed borders. That was
not what America stood for, and I say that as someone who fled
a civil war when I was nine months old. My parents brought me
here from Sri Lanka.
But I can tell you that coming from a country divided along
religious lines and being able to come to a country where there
was a response of people welcoming us, who were Lutheran and
Catholic and Jewish and Muslim, that has always been America
and that, I think, is--you know, there is great area.
Of course we need comprehensive immigration reform, but in
terms of the policies we have in place, they are responsive
even to the climate that we're dealing with right now. When you
look at the legal right to asylum, 88 percent of people who are
coming across the border are meeting that initial threshold of
a credible fear. We know that they're not coming here with
whimsical claims.
In terms of, you know, this metering policy that has been
recently instituted, when you think about the deaths that we
have seen in recent days, and I say this as the mother of a
two-year-old, when, you know, Valeria and her father died
crossing the Rio Grande, it wasn't because you had an ill-
suited father who made a decision on whim. It was because he
was told when he went to a port of entry that he couldn't come
across because the door wasn't open at that time and when he
realized that he would have to remain in a foreign country that
is incredibly dangerous and that would have to be for at least
20 to 30 days, he took what is an act of desperation.
I think that that's where, you know, when I see the
progressive sequencing of that golden door closing, first with
the metering, then now with the interim final rule, again this
is a strategy where we have a lot of the legal safeguards we
need in place, meaning that right now under kind of our border
control, if you have a firm offer of resettlement, you're not
allowed to claim asylum here in the U.S., and likewise we can
establish third party arrangements with other countries. We do
it with Canada, but the reason why we don't do it with Mexico
or Guatemala is, first, it doesn't meet the threshold of being
a safe country and, second, there hasn't been any undertaking
of does the legal system exist that would actually be able to
offer asylum?
Finally, you have to still establish a negotiated
agreement. The fact that the Administration pursued agreements
and ultimately was not able to sign on the dotted line with
Guatemala and Mexico, you can't announce an interim final rule.
It's not just not legal and not within the framework that
Congress smartly articulated, there's also no way to actually
put it in place because you have countries that have been
unwilling to actually take on that responsibility and so that's
where I just think that there are opportunities to have
bipartisan conversations because I would tell you we operate in
39 states, some of the most red and some of the most blue, and
there is agreement. There is a way for us to have a workable
system in place.
Ms. DeLauro. I honestly wish we had the entire subcommittee
on both sides of the aisle to be able to listen to you.
I think one of the things that comes to my mind when I
think about this is that if you start from the premise that
immigration and immigrants are bad people, are trying to game a
system, are trying to enter a country, you know, your word, as
a whimsical reason, and that the tone that is set on the whole
immigrant experience is so--in my view, I will use the word
``polluted.''
You know, I am the daughter of an immigrant family. My
father came in 1913 and the immigrant experience oftentimes
gets romanticized in our country. It has forever been a very
difficult experience and sometimes we lose track of the fact
that we did have a government who said people could come from--
first, when they came, it was whether or not at Ellis Island if
you were physically all right, we embraced you, we embraced
you.
Then we went through a period of time when we didn't want
people from Southern Italy. We didn't want people from Eastern
European countries. We began to sift out who it was that we
wanted to be here and we can go through the history of
immigration policy here, but we are at a time and I just say to
you, Tom, you cannot have the whole experience for people or
denigrate people who, for one reason or another, whether they
were or now or in the past coming for economic reasons, they
did. Why did my forebears come? They came for economic reasons,
you know.
I understand my grandmother cried when she came because it
was so beautiful in Amalfi, Italy, and it wasn't quite as
beautiful in the United States of America or they found that
the roads were not paved with gold but that they were going to
have to pave the roads. They came with a hope and so forth and
people have that same hope and drive and, quite frankly, Tom,
we do not have an environment and that's not everyone. That's
not everyone.
But there are those who want to just characterize this
experience and characterize the people who are coming, some out
of desperation because we know that's the fact and violence,
etcetera, and trying to escape the violence, but that is a bad
thing and that's not something that is acceptable any longer in
our country and that we are going to have a militarized
response to this. That sets a tone.
It sets a tone, and I think it's incumbent upon us to
reverse that tone, and when someone can say that the border
separation policy was understandably knowing that if you took a
child from a parent, that that was going to create such
heartbreak, that that would deter you from coming, that was at
the base of that policy. That's what we are trying to say is
wrong and that that has to be corrected and if that is
corrected, then we maybe can look at the way we are dealing
with people in an unmilitarized way and in a way that says we
have nurses and pediatricians and the kind of casework people
that are needed in order to make this process work or that--you
know, our own law says you can seek asylum anywhere in this
country. You can come from anywhere to seek asylum, but we have
so--excuse me--bastardized that view and so what we've done
with it as to create a problem of metering or other pieces of
legislation that turned this into such a tragic set of
circumstances for people.
You know, it is about resources. What are the kinds of
legal services that we are providing for people? You know, we
found out at Homestead, because they're 13-to-17-year-old kids
there, they read the Know Your Rights. I have a 15-year-old
granddaughter, a 14-year-old granddaughter, a 12-year-old
granddaughter and grandson. You take a manual and read them
their rights. They don't know what they're listening to. Who is
there to provide legal counsel for people to represent their
interests? What are we doing about a child advocate program, of
expanding a child advocate program?
What are we doing about the services that we provide for
post-release, you know, for these kids or for their families?
That is the road that we ought to be investing in instead of
saying we need 5,000 more beds. We wouldn't need the beds if we
are--and, you know, we had a case management system, Tom. We
did. It was working. 90 percent of the people were showing up
for the hearings. 2016 that was ended.
Let's think about--you all, not us. We are political
people. We do. We come from a different perspective, different
spectrum, et cetera. You can be of such critical importance to
influence in the kind of public policy that we can engage in
and if we can't agree, you know, we have a lot of very
reasonable people on both sides of the aisle, that I think if
we had the kind of counsel that you all could provide that we
can't initiate legislation that could help to make a
difference.
I want to make a speech. There are lots of questions, but I
think we're at the point of no longer any questions.
Mr. Cole. Can I add one word, Madam Chair?
Ms. DeLauro. You can add any point, Mr. Cole.
Mr. Cole. We will get an exact count of the reasonable
people we have on the budget vote later this week.
Ms. DeLauro. Hear hear. Hear hear. But you know what I'm
saying. We can come together to do this, but it starts with a
vision. It starts with a philosophy. It starts with a value
system that says this is what we believe the United States of
America should be about. We believe in that. You do.
Thank you so much for staying as long as you did today and
for your testimony but more than anything else for your
determination, your commitment, and your compassion every
single day. Thank you, thank you.
Let me formally close the hearing. Thank you.
[Answers to submitted questions follow:]
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
Wednesday, September 18, 2019.
MENTAL HEALTH NEEDS OF CHILDREN IN HHS CUSTODY
WITNESSES
JONATHAN HAYES, DIRECTOR, OFFICE OF REFUGEE RESETTLEMENT, DEPARTMENT OF
HEALTH AND HUMAN SERVICES
JONATHAN WHITE, COMMANDER, PUBLIC HEALTH SERVICE COMMISSIONED CORPS,
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ANN MAXWELL, ASSISTANT INSPECTOR GENERAL, OFFICE OF INSPECTOR GENERAL,
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Ms. DeLauro. The subcommittee will come to order.
Good morning to all and welcome to the Labor, HHS, and
Education Appropriations Subcommittee.
We are here today for another oversight hearing, and this
time with administration officials and members of the
Department's Office of Inspector General, to discuss the
recently released report on the mental health needs of children
in the care of the Department of Health and Human Services
Unaccompanied Children Program.
I want to thank our witnesses for being here today: Ann
Maxwell, Assistant Inspector General, Office of the Inspector
General, the Department of Health and Human Services; Jonathan
Hayes, who is the Director of the Office of Refugee
Resettlement, the Department of Health and Human Services; and
Jonathan White, Commander, Public Health Service Commissioned
Corps, Department of Health and Human Services.
This hearing is really part of our oversight
responsibility, which we take very, very seriously. We must.
Considerable taxpayer resources are at stake, and something
even more precious is at stake, and that is the mental and the
physical well-being of children.
That is why the Office of the Inspector General's new
report was so alarming. It confirms our worst fears, that
intentional policy choices by this administration created what
I would call a mental health crisis, which the Office of the
Inspector General said that Health and Human Services and the
Office of Refugee Resettlement failed to address. It is a
crisis of deliberate government-sanctioned child abuse. We must
stop the trauma inflicted on these children. So I believe the
administration must quickly implement the OIG's proposed
recommendations, which are included in the report.
The Administration for Children and Families has concurred
with each of the recommendations, but words alone are not
enough. The gaps created a mental health crisis as children are
still dealing with the effects.
As Ms. Maxwell summarized on page 8 in her testimony, and I
quote: ``Policy changes in 2018 exacerbated existing
challenges, as they resulted in 1) a rapid increase in the
number of children separated from their parents after entering
the United States, many of whom were younger, and 2) longer
stays in ORR custody for children,'' end quote.
Those policy changes in 2018 were the administration's zero
tolerance family separation policy, which ripped children from
their parents, and the administration's grossly intentional
changes to fingerprinting and screening requirements that
ground discharge to a halt. As a result, a child's average
length of stay in government custody nearly tripled, from 35
days to 93 days.
The numbers have improved since the administration began
implementing its four operational directives in December to
reverse their changes to the screening process. I will note
that those changes followed a consistent drumbeat for
accountability from the subcommittee. Now we need to see the
agency's plan to improve the discharge process, so that we are
able to get children in and out of ORR's care as safely and as
quickly as possible so they do not experience toxic stress and
mental trauma. We do not only need a plan for bed capacity.
And, as I understand it, the onus with respect to discharge
is on the grantees, and that is the contractor is responsible
for the discharge consistent with policies, ORR policies and
regulations, but the contractor is responsible.
So ORR must then have policies in place that get children
in and out of the facility as quickly as possible, because when
Homestead, which is an influx facility, is charging $750 per
night per child, the motivation to move these kids may not be
as strong as it needs to be.
There must be change, because, as the OIG concluded,
children have been suffering because of these intentional
policy choices. Ms. Maxwell wrote in her testimony on page 9,
again, I quote: ``Children who experienced longer facility
stays exhibited higher levels of defiance, hopelessness, and
frustration, along with more instances of self-harm and
suicidal ideation,'' end quote. Also in her testimony on page
8: ``Separated children exhibited more fear, feelings of
abandonment and post-traumatic stress disorder than did
children who were not separated.'' And the OIG's report on page
10 also described how some separated children expressed acute
grief that caused them to cry inconsolably.
In another story, the OIG's report shared that, quote: A 7-
or 8-year-old boy who was separated from his father without any
explanation as to why the separation occurred. The child was
under the delusion that his father had been killed and believed
that he would also be killed. This child ultimately required
emergency psychiatric care to address his mental health
distress. This is terrible. And then the administration failed
to fully or adequately treat it.
As the OIG report spotlighted in its executive summary:
Quote: Facilities struggle to address the mental health needs
of children who had experienced intense trauma and had
difficulty accessing specialized treatment for children who
needed it. Overwhelmed by the deluge, clinicians reported
caseloads more than doubled what they should have been. And
unprepared for the younger children, those mental health
providers who were available were primarily prepared to serve
teenagers, not the mental and the social needs of preschoolers,
who cannot communicate their backgrounds, their needs, or even
their pain.
So, as I read the OIG's report and testimony, the
administration's intentional policies traumatized youngsters
who then did not receive the proper care they needed. And I
will say it very honestly, I believe it is twisted and it is
shameful.
Let me add that we do not know the mental state of the
children who were separated in 2017. That is a matter that is
still in the courts. And understand, we only know about the
2017 children because of the Office of the Inspector General
and the ACLU.
And it is really very interesting to me as to at the time
of July 2018, who made the decision to certify a list that was
inaccurate? It was 2018, not what happened in 2017. What was
the role? I don't know, Mr. Hayes, about your role. What
factors went into making that decision?
Now, we can also assume that the trauma of these children
mirrors that of the children that the OIG identified in this
report. It should add to the urgency we feel to stop the
trauma. ORR is a child welfare agency, and we must be ensuring
it is upholding its mission, which brings me to the OIG's
recommendation.
One recommendation from OIG is that ORR should take all the
reasonable steps to reduce the time that children remain in
ORR's care. I wholeheartedly agree. In fact, I will reiterate
what I have been saying to this administration for months:
Rescind the memorandum of agreement between the Department of
Homeland Security and the Department of Health and Human
Services.
With respect to the agreement, the subcommittee has heard
from outside witnesses and ORR grantees, who said it continues
to scare away potential sponsors who otherwise want to take
care of a child, but are too afraid to come forward. In fact,
at our July hearing, Assistant Secretary Johnson agreed with
the subcommittee that the memorandum of agreement should be
rescinded.
Since there has not yet been any action, it would appear
that the responsibility to rescind the MOA is in the hands of
the White House, because if the administration wholeheartedly
agrees with the OIG's recommendation here then the
administration must rescind the memorandum of agreement
immediately.
Another recommendation from the OIG is that ORR should
identify and disseminate evidence-based approaches to
addressing trauma. Again, I wholeheartedly agree. This
subcommittee has repeatedly provided resources for the care of
children in the appropriations bills that the House passed the
last 2 years and in the emergency supplemental bill.
With respect to the 2019 appropriation, I want to say a
thank you to Ranking Member Tom Cole, then Chairman Cole, for
accepting, by voice vote, my amendment to provide funding for
SAMHSA, the Substance Abuse and Mental Health Services
Administration, through the National Child Traumatic Stress
Network, in what was a total increase of $10 million for the
network, $4 million of which was for these children. And I just
say clearly today that we need more funding to the Stress
Network to deal with this issue.
We are committed to ensuring ORR and HHS are upholding
their mission to care for children, not to act as a tool of
immigration enforcement, which is why we need to see the
administration quickly implement the necessary changes,
including the OIG's recommendations.
Children did not just arrive at our border. They suffered
by our hands and they are suffering still due to the long-term
mental health trauma. That is not something that we can ignore
or that we can sweep under the rug. We need to stop the pain
and the suffering. Caring for the most vulnerable is the most
sensitive of our duties as members of this body and as a people
of this great Nation. There can be no greater sin than allowing
ourselves to live by a lesser standard.
So, to close, I want to say a thank you to the OIG for this
report, for your work. I look forward today to hearing more
about it, hearing from the administration, and I hope to learn
from HHS how you intend to take--to prevent the traumatization
of youngsters as a result of--the way I characterize it--the
administration's cruel and heartless immigration policies
moving forward.
First, let me introduce my Republican colleague, the
ranking member of the subcommittee, Congressman Tom Cole of
Oklahoma, for any remarks that he would like to make.
Mr. Cole. Thank you very much, Madam Chairman. And I am
going to depart from my prepared remarks for just a second,
because I want to begin with four thank yous.
And the first one is to you. Your focus on this issue has
been unrelenting and I think appropriate. And while we may
disagree over this or that interpretation, the fact is you have
kept this committee focused where it needed to be, on the
welfare of these people, and you deserve all of our thanks. It
is the right way to do oversight, and you have done it.
I want to thank the IG. You know, we have IGs because we--
you know, my mom used to have a wonderful saying, you are
friends with the people that tell you what you need to know,
not what you want to hear and I think, Ms. Maxwell, you told us
what we needed to know and not necessarily what we wanted to
hear, but I think that is your job and you did it very well in
this case and I appreciate it.
I also want to thank Director Hayes. I had the opportunity
to travel to the border region with him over the August break,
and I see a lot of effort to implement some of the changes and
to be responsive to criticism and to correct the situation that
we all agree.
And finally, to a much maligned Congress, I want to give a
thanks to the Congress. It took us a little too long, but we
finally gave the administration the resources it needed in the
emergency supplemental. And it hasn't solved every problem, but
I can tell you things are a lot better than they were 90 or 120
days ago, because Congress acted.
Again, it took us 6 weeks. We did the same thing for
President Obama in 2003, but in the end it was a bipartisan
action by Congress that provided the resources that began to
let us address some of the problems that Ms. Maxwell has very
appropriately and I think wisely pointed out. We still have a
long way to go, but this was a promising start.
So, with that, Madam Chair, I want to welcome our witnesses
for the subcommittee's third hearing on Unaccompanied Alien
Children Program. Today we are here to focus on the mental
health needs of children in the care of the Department of
Health and Human Services.
Before we begin, I want to focus a little on the history of
this program over the past few years. In 2012, this program
received an appropriation of $169 million. This past year, the
fiscal year 2019 appropriation, this committee provided more
than $1.3 billion. In just 7 years, the appropriation for this
program has grown by more than 670 percent. So there certainly
has been a focus on it here.
In 2012, the Department of Health and Human Services'
Office of Refugee Resettlement had over 13,000 children
referred to them by the Department of Homeland Security. In the
current year, HHS has had over 60,000 children referred to them
for care. By the end of the fiscal year, HHS will likely have
cared for over 70,000 children, more children than in any prior
year. Again, in just 7 years, an increase of 370 percent.
Pretty staggering.
Both a Democratic and a Republican President have requested
supplemental appropriations in the billions to support
unanticipated arrivals of teenagers at our southern border. HHS
now routinely cares for tens of thousands of children who
travel thousands of miles, most coming from El Salvador,
Guatemala and Honduras. Objectively, this is a crisis and one
that needs a comprehensive bipartisan solution.
Federal law requires the Department of Homeland Security to
transfer to HHS any unauthorized minor not accompanied by a
parent or a legal guardian. This legal requirement means that
when Customs and Border Protection or Immigration and Customs
Enforcement apprehend a minor with an uncle, an aunt, a
grandmother or grandfather or older brother or sister, the law
defines that minor as unaccompanied and requires transfer of
that child to HHS.
I understand there are many who believe these children
should remain with the adult relative they are traveling with.
However, that is not the law of the United States, and that is
probably something we should look at.
I also want to address the topic of the zero tolerance
policy implemented by the Department of Justice in 2018. The
administration has made several attempts to stem the flow of
migration happening to our southern border. The zero tolerance
policy was clearly a mistake, and I am glad that the President
quickly ended it, the implementation of it, but the
consequences continue.
And while we may all disagree on the merits of such a
policy, we can all agree HHS does not play a role in the
establishment of immigration policy. HHS does not separate
family. HHS does not separate children from their parents. HHS'
responsibility is to care for children referred to them by DHS
and to find suitable sponsors. And in that area, we have made
considerable progress.
As I said, many of these children are coming to our borders
through Mexico from Central America. It is no surprise that
such an arduous, dangerous journey is traumatic. Many of the
children left family members, poverty, and dangerous conditions
to come here. Once apprehended by DHS, the children are turned
over to HHS to begin the process of finding a sponsor.
For the short time the children are in HHS' care, they are
provided with vaccinations, mental health screening, education
and legal information. Referral to mental health services can
be a part of that process.
The Office of Inspector General highlighted the challenges
with meeting the mental health needs of the children in care. I
want to point out that a significant portion of America,
frankly, also faces the challenge of accessing mental health
services. According to the Health Resources and Services
Administration, 34 percent of the American population lives in
a mental health professional shortage area. My own district
alone has 22 such designated areas.
The challenges facing adequate access to mental health
services is something many areas are having to deal with. I
will just add parenthetically, when I was fortunate enough to
be chairman of this committee and we had passed 21st Century
Cures, there were a lot of mental health provisions in that.
And the Member most responsible, the former Member,
Congressman Murphy, came to visit me and I said, look, you have
got multiple things here. I can't fund them all. You know, they
are going to give me a finite amount of money, I am not an
authorizer, I got to live within a budget. Pick one or two
things. And he hesitated for a minute. He said, the number one
thing is we just need more mental healthcare professionals.
Anything you can do otherwise, we are just competing back and
forth for a very small pool of professionals. And so we need to
invest more in creating literally the healthcare professional
service corps that we need.
I also appreciate the desire for HHS' role in the care of
these children to be expanded. However, given the unprecedented
surge in the number of unaccompanied children crossing our
southern border, HHS' primary focus should be the establishment
of State-licensed and small facilities to care for children
until placement with a sponsor is possible. And, again, I want
to commend you, Mr. Hayes. You have done a lot more of that in
the last 60 to 90 days, and that has been very helpful.
I know that my friends at HHS are doing their best that
they can with a challenging situation. I want to commend them
for the difficult work they are performing, and note that they
are facing many of the same challenges faced by the prior
administration. It is my hope that this committee will work
with them in a bipartisan fashion to provide the resources
needed to confront this urgent challenge.
With that, Madam Chair, I yield back my time.
Ms. DeLauro. Thank you very much, Congressman Cole.
I would like to yield to the ranking member of the full
Appropriations Committee, Congressman Nita Lowey of New York.
Mr. Cole. She is the chairman.
The Chairwoman. What did you call me? You can call me
anything you want.
Ms. DeLauro. I said the chair of the Appropriations
Committee.
Mr. Cole. No, you said the ranking member.
Ms. DeLauro. Make no mistake, she is the chair.
The Chairwoman. I thank you, Madam Chair, my friend for a
very long time. I want to thank Chair DeLauro and Ranking
Member Cole for holding this hearing. And I thank Assistant
Inspector General Maxwell, Director Hayes, and Commander White
for joining us today.
The fact that we are here again today is a clear example of
how damaging and cruel the Trump administration's actions have
been on the mental health of vulnerable children. This could
have been largely avoided. Children belong with their parents.
Now, many of us have read this article in the New York
Times, July 30, 2019, and it says: In testimony before Congress
earlier this month, the Border Patrol's Chief of Law
Enforcement Operations, Brian Hastings, said the agency has
established that its agents may elect to separate a child from
a parent if there is a determination that the parent or legal
guardian poses a danger to the child, is otherwise unfit to
care for the child, has a criminal history or a communicable
disease, or is transferred to a detention setting for
prosecution for a crime other than improper entry.
Seventy thousand children have been separated from their
parents. I am going to say a few more words, but I find that
astonishing. Two months ago, Chair DeLauro and several of our
colleagues visited the Homestead influx facility. As I looked
through the Inspector General's report on mental health needs
of these children, it is clear we were not provided a full
picture of ORR's challenges.
I am deeply concerned with the Inspector General's finding.
Some of these include clinician shortage problems with access
to external and specialized care and a lack of preparedness
among clinicians to treat the level of trauma in these
children.
What causes me even more concern is what we still don't
know. Now, I just want to repeat this again, because--okay. I
have just been corrected by my distinguished chair. Okay. I
just want to conclude by saying, whether it was 70,000 or this
number is wrong, I am not going to debate that now.
But my prime concern. No matter how clean Homestead was, no
matter how many smiles were on the face of everybody, no matter
how many books they were given to read, no matter how many toys
they were given to play with, I just feel very, very strongly
that children belong with their parents. And to leave it to the
Border Patrol, who may elect to separate--a Border Patrol
person, who may make the decision to separate a child from a
parent, that Border Patrol person is making a decision as to
whether the parent who brought the child here should be taking
care of the child, better putting it in a facility away from
their child.
This just doesn't make sense to me, and I cannot believe--
and we met many of those children. I cannot believe that the
parents of all of those children were unfit to take care of
that child while they are waiting for a hearing. So let me just
say it is clear, although we visited this facility and we saw
some good things, but we saw many things that had to be
corrected.
I just want to conclude again, because as good as your
clinicians are, and they may be fine people doing the job, you
can't tell me that thousands and thousands of children are
better off in a facility, as clean and as smiling the people
are, than being with their own parent. So that is really my
point.
Ms. DeLauro. Thank you very, very much, Madam Chair.
We now are going to proceed to the opening remarks from Ann
Maxwell, again, Assistant Inspector General, Office of the
Inspector General of the Department of Health and Human
Services; followed by Jonathan Hayes, Director of the Office of
Refugee Resettlement, Department of Health and Human Services;
and we are also joined by Commander Jonathan White, U.S. Public
Health Service Commissioned Corps, who will be available to
respond to questions.
Ms. Maxwell, welcome and thank you for being here today.
Your full written testimony will be entered into the hearing
record. You are now recognized for 5 minutes.
Ms. Maxwell. Good morning, Chair DeLauro and Ranking Member
Cole and other distinguished members of the subcommittee. Thank
you for the opportunity to discuss OIG's ongoing oversight of
the Unaccompanied Alien Children Program administered by the
Office of Refugee Resettlement.
Today, I will be focusing on our findings regarding the
challenges ORR-funded facilities face in addressing the mental
health needs of children in care. These facilities serve
migrant children who arrive in the U.S. on their own or who are
separated from their parents by immigration officials. These
children have often experienced intense trauma before coming
into ORR care, which is why prompt mental health treatment is
not only required by ORR, but is essential for a child's well-
being.
My testimony reflects what we heard firsthand from facility
staff across the country about the obstacles they face. We were
told that there are a number of systemic challenges that make
it difficult for staff to address the mental health needs of
children. These include the ability to employ and support
clinical staff.
Mental health clinicians reported heavy caseloads. They
also asked for more training and support to treat traumatized
children. In addition, staff face difficulties in accessing
specialty care, such as psychologists and psychiatrists, to
treat children with greater needs. In one example, the only
bilingual specialist the facility could locate was in a
neighboring State.
Finally, staff reported lack of therapeutic placement
options within the ORR network that were equipped to treat
children who needed a higher level of care. This was especially
acute for children who needed secure therapeutic settings due
to their history of behavioral problems.
To address these systemic challenges, we recommend that ORR
leverage the expertise and resources within HHS and the broader
mental health community, to ensure facilities have sufficient
clinical staff who are fully supported and able to access the
needed specialty care for children. These systemic challenges,
according to staff, were exacerbated by policy changes made in
2018.
In the spring of 2018, the Department of Homeland Security
formally adopted the zero tolerance policy of criminally
prosecuting all adults for illegal entry and placing their
children in ORR facilities. Facilities reported that addressing
the needs of children separated from their parents was
particularly challenging, because the children exhibited more
fear, more feelings of abandonment, more post-traumatic stress
than children who were not separated.
One medical director told us that separated children would
present physical symptoms as manifestations of their
psychological pain. These children would say their chest hurts
even though there was nothing wrong with them medically. One
child even said, every heartbeat hurts.
These children didn't understand why they were separated.
As a result, some were angry, believing their parents had
abandoned them. Others were anxious, concerned for their
parents' safety. One 8-year-old boy, who the chair talked
about, was separated from his father, was under the delusion
that his father was killed and that he was next, and he
required emergency psychiatric care.
Caring for separated children was additionally challenging,
because they were often younger than the teenagers the facility
were used to serving. Staff reported younger children had
shorter attention spans, needed greater supervision, and more
commonly exhibited defiance and other negative behaviors. They
couldn't always accurately communicate. The little ones, as one
program director said, don't know how to express how they are
feeling.
There were other policy changes in 2018 as well, and these
involved the process for discharging children to sponsors. ORR
added new screening requirements and started sharing sponsor
information with immigration officials. Staff noted that these
changes led to longer stays in care for children, and that had
a negative effect on their behavior and their mental health.
They said, even children who entered care with good coping
skills became disillusioned as their time in care dragged on,
resulting in higher levels of hopelessness, frustration, and
more instances of self-harm.
While the policy changes made in 2018 have largely been
reversed, facilities continue to serve separated children as
well as children who are not quickly discharged from care. To
address these continuing challenges and to ensure that children
are not unnecessarily harmed, we recommend that ORR continue to
reassess whether its current policies are negatively impacting
children in any way and adjust as needed. We also recommend
that ORR establish guardrails that ensure that future policy
changes prioritize child welfare considerations above all other
competing demands.
Thank you to the committee for the opportunity to present
this information and your ongoing support of our oversight. It
is greatly appreciated. I am happy to answer any questions you
have.
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Ms. DeLauro. Many thanks.
Director Hayes, welcome back. Thank you for being here and,
again, your full testimony will be in the record. And so now I
will recognize you for 5 minutes.
Mr. Hayes. Thank you, Chairwoman DeLauro, Chairwoman Lowey,
and Ranking Member Cole, members of this committee. It is my
honor to appear today on behalf of the Department of Health and
Human Services. My name is Jonathan Hayes, and as the Director
of the Office of Refugee Resettlement, I oversee the
Unaccompanied Alien Children Program.
I am joined today by Commander Jonathan White, an officer
in the U.S. Public Health Service who is currently assigned to
the Assistant Secretary for Preparedness and Response at HHS.
Commander White served as the Federal Health Coordinating
Official for the interagency mission to reunify children
separated from their parents in ORR care as of June 26, 2018.
He also previously served as a deputy director at ORR. He has
not prepared testimony, but is here to answer your questions.
Thank you for the opportunity to discuss with you today the
HHS Office of Inspector General report titled ``Care Provider
Facilities Described Challenges Addressing Mental Health Needs
of Children in HHS Custody.'' HHS is committed to addressing
the mental health needs of the UAC in the care of ORR. We
welcome the report as we continually improve the mental health
services provided to the children in our care.
ORR operates nearly 170 State-licensed care provider
facilities and programs in 23 different States. ORR has
different types of facilities in order to meet the different
needs of the minors in our care. In addition to our traditional
State-licensed facilities, ORR also operates influx care
facilities which receive UAC when ORR's licensed bed capacity
is strained by surges of referrals or in a case of a natural
disaster or other emergency.
HHS has detailed policies for when children can be
sheltered at a temporary influx care facility. Mental health
services are available at all of our facilities. ORR policy
requires, at a minimum, that UAC and ORR State licensed
facilities receive an individual counseling session and two
group counseling sessions with a clinician every week.
Additional mental health services are available as needed.
The children in ORR care have a unique set of needs. We
provide services to children from a wide range of backgrounds
and cultures who speak a variety of languages. As documented in
the OIG report, many of the children placed in ORR care have
experienced severe trauma. The mental health professionals
working with the children must be bilingual and be qualified to
assist traumatized children. Yet, the OIG report acknowledges
the general shortage of qualified practitioners nationwide.
The qualification requirements create difficulties in both
recruiting on-site staff as well as finding referrals for
additional services in the communities around the facilities.
One challenge identified in the report is that some clinician
staff told the OIG that they are often unprepared to assist
children with the severe trauma experienced by UAC.
Treating children with severe trauma is complicated and is
only made more complicated by the relatively short time of
children residing in ORR care. Some clinicians told OIG that
they were concerned about asking children to revisit their
trauma when it was unclear whether the child would be in our
care long enough to make progress in addressing their trauma
fully.
ORR's mission remains to unify children with a suitable
sponsor as expeditiously and safely as possible. For this
reason, most children do not stay in ORR care for very long.
Based on the clinical expertise of the mental health
professionals on staff, the focus of mental health services has
been to stabilize children and to provide them with a sense of
security. However, program staff assess each child's mental
health needs and provide additional services, as appropriate.
ORR is working to provide clinicians with tools to
strengthen mental health services. Recently, ORR collaborated
with the National Child Traumatic Stress Network, or NCTSN, to
develop a four-part webinar series on addressing trauma in UAC.
ORR is continuing to work with the NCTSN to develop additional
resources. ORR also offers post-release services to some UAC.
If a child needs additional mental health services after
they leave ORR care, a post-release services caseworker will
work with both the child and the sponsor to find services in
their community. ORR is working to expand the number of UAC
that receive post-release services.
I believe that a child should not remain in ORR care any
longer than the time needed to find an appropriate sponsor for
the child. A central part of ORR's mission is to discharge
children from our care as quickly as possible while still
ensuring the safety of the child. At the time that OIG
conducted its visits, the average length of care was 83 days.
It is now 50 days, a 40 percent reduction. ORR will continue to
assess the efficiency of its operations, to improve the process
for release and reduce the time that a child remains in our
care and custody.
My top priority and that of my team is the safety and well-
being of the children in the temporary care of HHS. We welcome
this report, because it explained the services that ORR
currently provides and identified the obstacles that we face in
providing those services. My team is ready to face those
obstacles and overcome them, with help from our partners and
with the continued support of Congress.
Thank you for the opportunity to discuss our important
work. Commander White and I will be happy to answer any
questions that you and your committee may have. Thank you,
Chair DeLauro.
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Ms. DeLauro. Thank you very, very much.
I will get right to the questions here. Ms. Maxwell, you
note that the policies that traumatize these children have
largely been reversed, and I just pick up your quote at the end
of your remarks. But you say that facilities still face
challenges addressing the trauma of separated kids and that we
ought to pay attention to that and to the deteriorating mental
health of the kids who remain in care.
The policies have been reversed. What are still the
challenges and what are the policies that ought to be examined
going forward?
Ms. Maxwell. Thank you, Chair, for allowing me to clarify
that point. Yes, the additional challenges that facilities
faced in 2018 continue to be a concern despite some of the
policy reversals.
First of all, facilities continue to provide care for
separated children. So the court order, as you mentioned, that
stop most separations allows for separations under certain
conditions.
Ms. DeLauro. There are separations.
Ms. Maxwell. Absolutely. And the Federal Government
recently certified to the Court that there were 911 children
separated from a parent over the last year. In addition, with
respect to lengths of stay, ORR did reverse additional sponsor
screening requirements and the length of stay fell. However,
they continue to share information about sponsors with DHS,
according to the 2016 MOA and, again, as you mentioned, there
are concerns that that has a chilling effect on finding
sponsors, which is why we recommend that ORR review all of its
current policies to see if they present any unnecessary
barriers to releasing children to appropriate sponsors and
adjust them as necessary.
Ms. DeLauro. Thank you for the clarity on that issue.
Let me move to exhibit 2 on page 12 of the report shows how
the number of young children referred to ORR sharply increased
as a result of family separation, and I want to put this
information into the record.
ORR facilities typically serve teenagers. So answer to this
question: Did facilities and grantees have the right tools to
adequately provide mental health services for younger children?
Ms. Maxwell. Not according to the clinical staff that we
spoke to. They told us that they, as Director Hayes had
mentioned, that they expressed their concerns about being able
to treat children who had encountered intense trauma before
coming into care. Now, this is a concern they had in terms of
treating all children. They noted it was additionally
challenging treating younger children, who had different needs
and different therapeutic needs, and had less attention span.
So we recommend, again, that ORR help these facilities,
help the clinicians by identifying and disseminating evidence-
based, trauma-informed, short-term therapy for children of all
ages.
Ms. DeLauro. Thank you.
Commander White, earlier the subcommittee held a hearing
with Dr. Altha Stewart, who is president of the American
Psychiatric Association. Told us about toxic stress. Highly
stressful experiences like separation of children from their
family is resulting in toxic stress, can cause irreparable
harm.
I respect the testimony that I have heard that you have
provided in previous hearings and the warnings that you gave to
HHS officials about the traumatic impacts of family separation
and the effect on children.
Let me just ask you, with your medical background, with
what you know about the children who end up in ORR's care, what
can you tell us about toxic stress that affects these children
as a result of the trauma they have experienced in their
countries of origin, during the journeys to the United States,
and as a result of family separation?
Mr. White. Thank you, Madam Chairwoman. So, to be clear,
the UAC program has long been trauma-informed and is designed
to serve unaccompanied children. That is an enormous challenge.
It is an enormous challenge. But it is dwarfed by the unique
challenge of separated children. And, as I have testified in
front of other committees and I will say again today, it is in
my professional judgment impossible to build a program that can
respond appropriately to the needs of separated children.
The only way to address that trauma is prevention. And this
speaks to the need for a coherent legislative fix to define
those conditions under which it is permissible to separate a
child from a parent at the border, to have appropriate rights
and remedies for parents who experience that.
The UAC program is the right place for children who enter
the United States unaccompanied, but neither it nor any other
Federal program I could imagine can respond to the recentness,
the severity, the toxicity of the trauma of separation from
parents, particularly when the clinicians themselves will be
seen by the children as part of the very system that separated
them.
Ms. DeLauro. Thank you. I am going to go for the last
comment here. You have exhibit 3, page 13 of the report: Length
of stay in ORR custody spiked after HHS signed the MOA with
DHS. So, Ms. Maxwell, according to the mental health clinicians
your investigators interviewed, what are the mental health
effects on children saying in ORR custody longer as a result of
the memorandum of agreement?
Ms. Maxwell. What we heard from clinicians in the field
were that children who did not initially exhibit mental health
or behavioral issues began reacting negatively the longer their
stay wore on.
Ms. DeLauro. So the longer children stay in care, the
longer they are traumatized. Let me make a final comment here.
As long as the MOA is still in place, there are sponsors who
are terrified of coming forward. It was at our July hearing
Assistant Secretary Johnson agreed that HHS should be
terminated. As long as this MOA is in place, HHS is
unnecessarily extending ORR custody for children, which further
traumatizes them. The MOA must be rescinded.
Congressman Cole.
Mr. Cole. Thank you very much, Madam Chair.
Ms. Maxwell, let me start with you, if I may. You had some
really valuable, I think, and very helpful information on the
damage done, in terms of family separation to young children.
We obviously have a larger population that is
unaccompanied, and so they don't review that, but if you could
distinguish, and the last testimony actually probably did a
pretty good job of this, but that second population which we
are dealing with in very large numbers, what are the
differences that you see between, obviously, family separation,
which I think we all agree was a bad mistake, and, obviously,
the more normal situation that we are now dealing with of
unaccompanied children? Are they traumatized to the same
extent?
Ms. Maxwell. Yes. Thank you for that question. Yes, our
report largely deals with the entire population of children
that the ORR facilities have to provide mental healthcare. Most
of the challenges that we heard about were, in fact, systemic
challenges that affected all the children in care. And we heard
again and again that all the children in care suffered, you
know, severe trauma in home country, during the journey, and
that some children experienced the additional trauma of
unexpectedly being separated from their parents.
But as we move forward with our recommendations on
practical steps that ORR can take to address these systemic
challenges, we have designed them such that they would help
improve the mental healthcare for all the children that ORR
facilities are responsible for caring for.
Mr. Cole. Thank you.
Director Hayes, could you give me some idea of the steps
that you have taken to respond to some of the suggestions and
recommendations that the IG has placed in front of you?
Mr. Hayes. Yes, sir, Congressman, I am happy to. So, again,
we are working on a number of things in response to the OIG's
report. We already are working on developing an intern program
with colleges and universities in order to place interested
students in ORR programs, with hopes that they will one day
come and join us as professionals postgraduate. Additional
funding for continuing education to license clinicians as a
retention strategy is also something that we are undertaking.
We are working to expand our presence at job fairs across
the Nation in order to find needed clinicians and case managers
to work in our facilities, although I will note that a number
of those job fairs have been protested and some of the staff
verbally--potential staff verbally threatened, and so that is
not helpful.
We have also partnered with the National Child Traumatic
Stress Network, the NCTSN, to develop a four-part webinar
series, as I referenced in my testimony, on trauma in the UAC.
And in April of 2019, we also hired a board certified
adolescent and adult psychiatrist that is employed inside of
the Division of Health of Unaccompanied Children at ORR.
Mr. Cole. I commend you for those steps.
Let me go back very quickly to Ms. Maxwell. Do you have a
mechanism to follow up? I think there is a good faith effort
going on at ORR to try and respond, but, you know, it is
important, obviously, that we have, as you provided us, sort of
an outside view to make sure that that process continues.
Ms. Maxwell. Absolutely. Thank you. We are happy to see the
steps that ORR has already committed to, some of which they
have already undertaken. So that is a good start. But yes, our
process is to always follow the recommendations and be in
conversation with the Department, to ensure that all of the
commitments that they made are fulfilled and are fulfilled to
sort of the spirit of the recommendation as well. So we will
continue to work with the Department to make sure.
Mr. Cole. And I hope you, as I know you will, stay in touch
with this committee because, obviously, at the end of the day
we have got a resource requirement here.
Let me go back to you, if I may, Director Hayes. It has got
to be extraordinarily difficult to get the personnel you need.
We know that, as I mentioned earlier, just in terms of mental
health for the entire population. In this case, you need
bilingual professionals, I would suspect, in many cases. There
can't be a ton of those, particularly in a lot of the areas
that you have your shelters. So, I mean, number one, what are
you doing? What level of success are you having?
Mr. Hayes. So thank you, Congressman. Yes, to your point,
you know, the Flores settlement agreement does require the
majority of our shelters to be in the area where the majority
of the children are apprehended: Southeast Texas, the northeast
corridor, southern Florida and southern California. And so, you
know, there is a challenge in those areas to identify and
retain some of the licensed clinicians that we need. We are
looking to expand outside of some of those areas.
We work very closely with keeping the committee staff
informed on our efforts to look into larger metropolitan areas,
where we can have some of these smaller and medium-size
shelters and then, you know, hopefully tap into a fresh, you
know, pool of clinician staff, although we are seeing some
resistance to that even right here in our own backyard in DC
and Northern Virginia.
You know, again, at the express desire of Congress to open
up more smaller and medium size shelters that are licensed, we
are seeking to do that and not really receiving a lot of
support, actually opposition by both D.C. and Northern
Virginia.
So we will continue to look in other areas and expand
outside of that, but we can pull, you know, from the local
community the needed licensed clinicians and case managers and
youth care workers and other support staff that we need.
Mr. Cole. Thank you very much. As I advised you, Madam
Chairman, I have to step out, but I will be back. Thank you.
Ms. DeLauro. Thank you so much.
Chairman Lowey.
The Chairwoman. I too want to apologize. I am called to
another hearing.
I just wanted to thank you all for your thoughtful
comments, and particularly, Jonathan White, when you talked
about the severity, toxicity separation of children. And I just
want to read this quote again, because, as a mother of three,
grandmother of eight, I can't imagine that these children who
were brought here by their parents for whatever reason are
being separated.
So the New York Times is saying: Since the President
officially ended family separations, authorities have removed
more than 900 children from their families. More than half of
the children, 481, were under the age of 10 at the time of
separation; 185 of those were under the age of 5. The
administration is still doing family separation under the guise
that they are protecting children from their parents, even
though the criminal history they are citing is either wrong or
shockingly minor.
So I want to thank the chair for having this hearing again.
Thank you for your good work in trying to do the right thing,
but this policy is outrageous, and I do hope that we can all
work together to change it. Thank you.
Thank you, Madam Chair DeLauro.
Ms. DeLauro. Thank you, Madam Chair.
Congressman Harris.
Mr. Harris. Thank you very much. And thank you, Madam
Chair, for calling the hearing about, you know, mental
healthcare.
So I need to ask--and I don't know. I guess maybe I am
going to read it there. Commander White, right? Yes, it is not
on there. It is on your arm. Oh, yeah, it is in small print. I
am too old to read that far.
You are a licensed clinical social worker. You understand
the lack of mental health professional availability in the
United States. In fact, as the ranking member had said,
according to, I believe it is an HHS report, the designated
shortage, there are 111 million Americans who live within
shortage areas, designated shortage areas. Sixty percent are in
rural areas.
My district is largely a rural area. So I am going to
estimate that I have tens of thousands, if not hundreds of
thousands of people who live without adequate mental health
coverage. Is that something that you appreciate, that there are
a lot of Americans who don't have adequate mental healthcare?
Mr. White. Congressman, there is no doubt that nationwide,
all of the evidence that we have and everything that our
Department has produced for many years affirms there is not
enough mental health workforce. There are also particular
deficiencies for many geographic areas.
And in the case of the children we serve, there are also
additional challenges, both for those children and for anyone
who needs culturally and linguistically appropriate services
that those with mental health needs from Central America would
have. These are national problems. They are amplified for us
because these children are a Federal responsibility, but this
is a giant problem.
Mr. Harris. Sure. But, you know, as policymakers, I mean,
we always have to balance, you know, when we have a limited
resource like health professionals, where are we putting them?
Now, it says I guess in the IG's report that--and I guess this
is true--ORR requires each facility employ at least each one
mental health clinician for every 12 children in care, a ratio
of 1 to 12?
Mr. Hayes. That is correct.
Mr. Harris. Wow. In Baltimore City, remember where there is
one murder a day, where I will bet you almost every student
knows someone who has been killed or some family who has had a
murder a day, the ratio of counselors in schools, mental health
counselors to students is 980 to 1. Twelve to 1 sounds pretty
good.
I mean, is that--I mean, how are we getting to that goal?
Because I don't know, you must be doing tremendous recruiting,
because we can't recruit into inner cities in Maryland, where
we have students who unquestionably have the need for mental
healthcare, unquestionably.
So where does 12 to 1 come from? Because it seems like it
is a pretty low ratio compared to the 980 to 1 that are in
Baltimore City schools and the 250 to 1 which is recommended
nationwide for school counselors. And, again, Baltimore City
has more problems. You know, these children are exposed to
trauma every day on their streets. It is a lawless environment.
The President is absolutely right about Baltimore.
Where does the 12-to-1 ratio come from?
Mr. Hayes. So, Dr. Harris, the ratios of 1 to 12 for
clinicians, 1 to 8 for youth care workers, and 1 to 8 for case
managers is inside the ORR policies and procedures. Perhaps my
colleague Commander White can speak to some of the historicity
behind that, but that is specifically spelled out in our
policies.
Mr. Harris. And you hit that ratio? I mean, you do have a
12-to-1 ratio?
Mr. Hayes. We do, yes, sir.
Mr. Harris. Congratulations, because it is much, much
better, much, much better mental healthcare than exists in
other high-risk populations, again, like Baltimore City
schools' students.
There are two categories of children who are--general
categories: Ones who have been separated by their parents,
because they are unaccompanied children. I mean, some relative
of theirs decided to send this child across a trek to sep--you
can't call it self-separation, because these children had
nothing to do with it. Then you have the family separation that
occurred at the border under laws.
What is the ratio, what is the highest it has been and what
is that now of those two, I will call them patient groups? I am
a doc, patient groups.
Mr. Hayes. So, Congressman, I don't have the specific
numbers. I will be happy to work with your team, you know, to
get the specifics of it. But I can state, you know, the
overwhelming majority of the children that are in our care, the
absolute overwhelming majority are not children that we
consider separated by law, meaning they came across the border
either unaccompanied or with someone other than, you know, a
mom, dad, or----
Mr. Harris. The overwhelming majority. So how do I explain
to the people in my district who don't have mental healthcare
that we have a 12-to-1 ratio in these facilities when the vast
majority of children are there because their parents chose to
separate them or their relative chose to separate them?
And I don't have--and that is a rhetorical question; you
are not going to answer that. I tell you, 12-to-1 ratio is
great. I congratulate you on being able to find those
professionals, because we can't do it in my district.
Madam Chair, I yield back.
Ms. DeLauro. Congresswoman Roybal-Allard.
Ms. Roybal-Allard. For a long time one of the things that
has troubled me is the overuse of psychotropic drugs in our
foster care system. So when I read press reports indicating
forced use of these drugs in ORR custody children, I found it
to be extremely disturbing.
And while the OIG report showed the percentage of children
in ORR custody who had been prescribed psychotropic medications
was lower than in the general population, there are still 300
or more children currently prescribed medications that can have
significant impacts on their psychological development without
any family involvement or consent.
Ms. Maxwell, what percentage of the children reported to be
taking these psychotropic medications in your report came into
ORR custody already on these medications, and did your report
quantify how many of the children receiving psychotropic
medications were taking two or more medications?
Ms. Maxwell. Thank you for that question. We do not have
those specifics. So we were talking to their case managers and
the medical coordinators that prescribe those medications, and
we have the statistics about who was taking medications in
care. And, as you mentioned, it was about one in 30. About 300
children in the 45 facilities we visited were on those drugs.
Ms. Roybal-Allard. Commander White, I think this is a very
serious issue, particularly in terms of, you know, followup,
children who are on these drugs and then are released. It can
have serious consequences if they aren't monitored and either
continue with the medication or are brought down from it.
Since OIG did not independently review the medical records
or assess the appropriateness of the medications that were
prescribed for these children, who would be the proper person
or agency to go and make these reviews?
Mr. White. Just a moment. I will actually defer to Mr.
Hayes, as the director, because policies have evolved since I
left ORR. But within ORR, there is a team of the Division of
Health for Unaccompanied Children. They are career public
health service officers like myself. They are board certified
pediatricians, epidemiologists, pediatric psychiatrists and
nurses.
And the supervisory role for the care, medical care of
children and also the processes whereby children are discharged
with a plan for continuity of care is ultimately their
responsibility. But I will defer to Mr. Hayes to talk about the
current policy.
Mr. Hayes. Yes. So Commander White answered that question
accurately, ma'am. That is how I would have answered it as
well. And I will just state that when I became the acting
director at the very end of 2018, I delegated those medical-
type decisions to our deputy director of our children's
programs and her medical team as the both medical and child
welfare experts.
Ms. Roybal-Allard. And so how often does that person review
the medical records of these children to make sure that they
are prescribing the appropriate amount, and when the children
are released, that their follow-up records are also
appropriately done?
Mr. Hayes. Yes, ma'am. So, Congresswoman, specific to
medication prescribed, I don't have details into that. Again,
that is something I would defer to the--you know, to our
medical doctors on staff.
But I would say that the professionals that Commander White
mentioned, that is an ongoing daily discussion across a myriad
of issues with all of the medical professionals at each of our
shelters, a coordination effort back and forth with the
division of health of unaccompanied children here in DC. So it
is an ongoing process.
Ms. Roybal-Allard. Okay. So when a child is released, then,
does that medical expert then review the record and the plan
for that child when that child is released on a case-by-case
basis? How does that work?
Mr. White. Ma'am, particularly for minors who have higher
acuity medical needs, including higher acuity behavioral health
needs like you are talking about, it would be standard to have
a member of that team work with the treating physician and
treating medical team in the child's program on a plan for
effective transition for continuity of care as the child exits
the program. That is ultimately bounded by the realities of
what kinds of care actually exist out in the community, which
is something we don't control, but absolutely, yes, that is a
very high priority for physicians on that team.
Mr. Hayes. And if I just may add, Congresswoman, you know,
that could be a situation where if there is a strong medical
need, that would be something where our grantee team and our
project officers would work for some post-release services to
identify some community-based resources to Commander White's
point, again, to ensure that continuity of care.
Ms. Roybal-Allard. Okay. Does the insurance--if, say, a
sponsor--they are released to a sponsor, are those medications
covered by insurance? Maybe not every insurance company, but--
--
Mr. White. So different sponsors will have different
degrees of family access to the healthcare system. We in HHS do
not fund ongoing access to healthcare. We are not appropriated
to fund ongoing access to healthcare for discharged minors.
Minors are discharged with a supply of medication, a
referral to services in the community. And part of the case
management plan with the sponsor and the child is to identify
how they will get those needs met in the future. But the
broader healthcare system is as it is.
Ms. Roybal-Allard. Okay. And--oh, I am over. Okay. Okay. I
have got plenty of questions.
Ms. DeLauro. Congressman Moolenaar.
Mr. Moolenaar. Thank you, Madam Chair. And, again, thank
you for having this hearing.
And I want to welcome all our guests, and I want to thank
you, also, for reappearing before the committee and
participating in this way.
I wanted to, you know, just build on some of the discussion
that has already occurred on the, you know, the health
professional shortage areas. Obviously, we are concerned about
people getting good access to mental health services, and, of
course, these children, given what they have been through,
would want to really make sure they are well served.
And, you know, the ratios that we were talking about, you
know, as some of our colleagues have mentioned, it is a
challenge all over the country. And my hope is that ORR has
been working with colleagues in HHS to kind of look at what we
are learning on a national scale and applying it to this
situation as well in order to, you know, expand these resources
and make the most.
One area, and just in context of my district, is in rural
Michigan. We actually have 62 health performance professional
shortage areas, which is pretty significant. So we are dealing
with this in rural Michigan. A couple of things we are looking
at is, you know, kind of innovative ways to partner with State,
Federal, and local agencies to maximize the resources.
Another thing we are looking at is telemedicine and, you
know, technology where, you know, people don't have to travel
great distances, and you are able to--have you looked in this
situation at the use of telemedicine, where it may be
beneficial? Where it wouldn't be helpful? Because I am viewing
that as a tremendous way of, you know, giving people the
resources they need and specified treatment. But I want to get
your perspective on, you know, what the potential is for that?
Mr. Hayes. So I don't have specific numbers, Congressman.
But I will say that we do utilize some telemedicine practices
inside some of our shelters to help, you know, meet some of the
ratios that are required. So----
Mr. Moolenaar. And do you feel that--you know, I know it
requires technology, it requires, you know, in our case, rural
broadband access in every area. But what strikes me is you are
talking people who speak different languages, people who have
different cultural--and the idea that you could tailor that and
have professionals from all over the country being available
to--that could be helpful. But, you know, I don't know the
limits of that.
Mr. Hayes. Well, Congressman, I just--you know, one of the
things I pointed out in my testimony, and as did Ms. Maxwell,
you know, one of our requirements is that you are a bilingual
to be one of our grantee staff, and, obviously, have just that
cultural understanding of, you know, where the children have
come from as well. So that is a requirement. So that actually
even further narrows the window of licensed clinicians that we
have available, you know, again, having to both meet our
educational standards, and experience standards, but also be
bilingual.
Mr. Moolenaar. Are there any resources you would need to
expand opportunities for telemedicine?
Mr. Hayes. You know, I am sure there could be some, sir. I
don't really have any at the top of my head. I would be happy
to circle back with you.
Mr. Moolenaar. Okay. I would be very interested in that. It
is something we are dealing with in rural Michigan, and we are
kind of seeing areas where it has tremendous potential, areas
where it may not so much. But, you know, I think--and the other
question I had, are you looking at sort of partnerships with
States and local entities that could help improve the
situation?
Mr. Hayes. So I would say one thing. I am going to go, you
know, back to the division director of health for unaccompanied
children and ask the telemedicine question, and, so, we will
get back to you on that.
My goal and the goal of Assistant Secretary Johnson and
Secretary Azar is to increase our permanent network capacity so
that we have available permanent State-licensed beds for all
the children that are referred to us from our Federal partners.
And to that end, that requires a partnership with the local
and State governments, and we welcome local and State
governments to partner with us in this mission to care for
these very vulnerable children. And, again, we are seeing some
resistance to that with certain communities, and I wish that
wasn't so, because we want to be able to have, as directed by
Congress and is the expressed desire of the leadership of HHS,
as many State licensed permanent beds available to meet the
needs of these kids without having to rely on emergency influx
beds.
Mr. Moolenaar. Okay. Thank you very much. I yield back.
Ms. DeLauro. I am going to take the prerogative here before
I introduce Congressman Pocan. I would just say that if we had
a discharge plan that was adequate and move these children out
quickly, as we said earlier, that the longer they are there,
the more traumatized they are. It is not about building the
capacity for beds. It is about building the capacity and a
discharge plan to be able to get them out of the system in a
safe place, as the mission has said, expeditiously as possible.
I might also add that if you want to increase
professionals, increase the reimbursement rates, stop private
contracting, and look at some of those issues in terms of
increasing professionals, and in terms of the amount of
services and the dollars where you can find opportunity for
different kinds of services for the children who are there,
including mental health services. We just appropriated $2.9
billion, there ought to be room in there to be able to fund
some of these efforts.
Congressman Pocan.
Mr. Pocan. Thank you, Madam Chair.
And thank you all for being here today. I appreciate it.
You know, this is certainly a sad stain in our Nation's history
of what has happened with this period, and we are not through
it yet. So we appreciate you all being here today.
Mr. Hayes, I have a question for you. It is a yes-or-no. Do
you agree that the Trump family separation policy has had a
negative impact on your agency's ability to meet its legal
mandate to provide mental healthcare to unaccompanied children?
It's a yes-or-no.
Mr. Hayes. Could you reframe or repeat the first part of
that, sir? I am sorry.
Mr. Pocan. Sure. Do you agree that the Trump family
separation policy had a negative impact on your agency's
ability to meet its legal mandate to provide mental healthcare
to unaccompanied children?
Mr. Hayes. I agree that the separation of young children
from their families created a difficult environment at the
Office of Refugee Resettlement, which I stepped into in June of
last year, sir.
Mr. Pocan. Yeah. I appreciate that because, you know, when
we read the report--and I know you have obviously read the
report--and, you know, hear things like, you know, having to go
to a neighboring State for a bilingual specialist, I mean,
clearly we know where these kids are coming from. Like, this
should've been--it is not even a 101. It is kind of a remedial
level of providing assistance to folks.
And, you know, again, it is just very sad that this
happened when you hear about a 7- or 8-year-old child thinking
they are about to be killed because of this policy. You don't
get much worse, I think, as far as government policy doing
things like this.
Yeah, I have a question just to kind of bring it back. So
we all went to Homestead, and we appreciate your time there,
and since then coming to the committee. But to get back to why
and some of the conditions that put children in this place,
people back home still, to this day, cannot understand how we
spend $750 a day to house children for really long periods of
time until we made some policy changes recently. And we had
33,000-plus kids at Homestead, when for $750 a day you could go
to Four Seasons, any Trump Hotel, which I am sure he would have
enjoyed.
The fact that we finally got the children out very quickly
just doesn't pass the smell test back home why it took so long.
For so long, people were making a lot of money in a private
facility at $750 a day, and then suddenly we are able to move
folks.
But at the very end, there were a couple hundred kids that
were literally, in the middle of the night, whisked away. Can
you address that couple hundred children that in the middle of
the night were whisked away on the final day?
Mr. Hayes. Yes, sir. So one thing, I think you referenced a
number of well over 3,000. There was a----
Mr. Pocan. Was it 2,700 or something?
Mr. Hayes. The highest number was around 2,620. I don't
know the exact number.
Mr. Pocan. 2,620, Okay.
Mr. Hayes. That was the highest--I just want to clarify
that.
Mr. Pocan. A pretty disgusting number, nonetheless,
correct?
Mr. Hayes. Well, again, you know, it was based on the
numbers of children coming across the border.
Mr. Pocan. Due to the policy that we have all agreed has
put us in a pretty awkward place.
Mr. Hayes. No. These are numbers that started in January of
this year, and it escalated up until June until when the
referrals dropped. And the reason I am answering that way,
Congressman Pocan, is because that was one of the effects on
the ability to, you know, to empty out Homestead, which is the
sheer drop in mid-June of referrals coming across the border.
Mr. Pocan. Well, just because one of the girls I talked to,
you know, she had been there 60 days before--the week before
they finally reached out to her brother. So for 50-some days, a
company made a lot of money not doing their job, which was to
try to place that person outside. And, again, when I tell that
story back home, people can't understand it. But the 200 people
whisked away, I am just trying to figure that out----
Mr. Hayes. Right.
Mr. Pocan [continuing]. Because it is something that is a
question for a lot of us.
Mr. Hayes. So I asked for the percentages of kind of the
last, you know, 30 to 45 days at Homestead, and----
Mr. Pocan. The last night. We are talking about the middle
of the night, the last couple hundred.
Mr. Hayes. I answered that, sir. Well over 80 percent of
the children that were discharged from Homestead were released
to their family or sponsors.
Mr. Pocan. Right. That wasn't my question though. My
question was----
Mr. Hayes. But then the ones that were transferred, the
roughly 15 to 17 percent, they were transferred----
Mr. Pocan. What I am asking for really specific, please, if
you could address that is, we are just wondering, a couple
hundred children between like, what, 2:00 and 6:00 in the
morning were taken out of the facility the last day? That is
odd, right?
Mr. Hayes. No, it would not be odd, sir, for this reason--
--
Mr. Pocan. It is not odd. Interesting, Okay.
Mr. Hayes [continuing]. If we are going to transfer them to
another shelter, which is what we did, for medical reasons or
because they had no identifiable sponsor in the U.S., we would
rely on commercial transportation at times, and that might
involve an early morning flight if you are traveling
transcontinental.
Mr. Pocan. So that was what happened to the final 200?
Mr. Hayes. Again, I don't know every single specific, but I
can guarantee you, that that is most likely what happened. A
lot of times our staff will escort these children on very early
morning flights so that they arrive at a more appropriate time.
Mr. Pocan. Sir, just because I have got 30 seconds, is
Homestead completely empty of children right now?
Mr. Hayes. It is as of August 3.
Mr. Pocan. And what are we spending to keep it empty at
this point?
Mr. Hayes. I don't know the exact number, but I do know
that we reduced the support capacity from the 2,700 down to
just 1,200, and so, a lot of the staff were let go.
Mr. Pocan. So are we paying equivalent of 1,200 kids a day
to be there, or are we just paying a maintenance? I am just
trying to get an understanding of what we are spending.
Mr. Hayes. It is a fully active shelter at this time with
the ability to take----
Mr. Pocan. So we are spending $750 a day on 1,200 imaginary
people?
Mr. Hayes. It is not $750, but yes, sir, we are.
Mr. Pocan. What is the total, just so I get it?
Mr. Hayes. I think it is about $600.
Mr. Pocan. $600 a day----
Mr. Hayes. We are.
Mr. Pocan [continuing]. For 1,200 invisible, imaginary,
nonexistent human beings at Homestead right now, every single
day?
Mr. Hayes. Well, it is the beds, but, yes, sir, to keep
them available.
Mr. Pocan. But why 1,200 if we have no one there? Couldn't
we say 100 people that aren't there?
Mr. Hayes. 100 kids or----
Mr. Pocan. Imaginary people. There is imaginary people
there right now. There is no one there, but you are spending--
again, I have to explain back home--even $600 a day you are
still at the Four Seasons or the Trump Hotel--why we are
spending that much, but now, not to even have a child not
getting mental healthcare. This is not to even have anyone stay
there.
Mr. Hayes. Congressman, I think one thing you and I can
agree on is that this is a very expensive program to operate.
If that is the point you are trying to make, I would agree with
that. I would just state that if we remove the staff at
Homestead, what I was told by my planning and logistics team
and the senior career professionals at ORR, you are looking at
a minimum of 90 to 120 days in order to reactivate the staff
back for that.
And, again, given the extreme uncertainty of referrals
coming across our Nation's southern border and how many kids we
might have to care for, that wasn't really a switch that we
were ready to turn off at this point.
Mr. Pocan. But some of that referrals is caused by the
President's policies, I would just add. My time is out, so I am
sorry. Thank you.
Mr. Hayes. Thank you, sir.
Ms. DeLauro. Congresswoman Bustos.
Mrs. Bustos. Thank you, Chairwoman DeLauro. And thanks for
holding this hearing and for the points that you have made.
Thanks to the Office of Inspector General for taking a look
at this.
You know, the three of us, we are having these little side
conversations up here. Congresswoman Frankel to my left, who
has a grandson who is less than a year old, Congresswoman
Watson Coleman, who has a grandson who is 6 years old----
Mrs. Watson Coleman. Daughter.
Mrs. Bustos [continuing]. Granddaughter who is 6 years old.
I have got two grandkids myself, and we are all just up
here listening to these words: Hopelessness, feelings of
abandonment, fear, severe trauma, and we are all picturing our
own grandchildren being in these situations and we are just
heartbroken. And when we look at this report and every page we
turn, just heartbreaking.
And I don't care who is in the White House. I don't care if
it is a Democrat or Republican. And I don't care who is sitting
up here, whether we are Democrats or Republican. This is just
heartbreaking to listen to this.
Commander White, I was looking at your bio. You are a Ph.D.
licensed clinical social worker, career officer with the U.S.
Public Health Service. Have you gone to these facilities and
seen what is going on there and--I am just--I want to get like
this--and have you also--Ms. Maxwell, have you seen this up
close and personal?
Mr. White. Congresswoman, I was the senior career official
over the UAC program previously. And prior to that, going back
to 2012, I have been the emergency management official used in
every one of the influx crises. I know these programs and their
services pretty well from firsthand.
I have also been, in 2014, in the border stations, and I
know what it is when we don't have bed capacity available for
children in time. And that is the other part of the story that
is also very important when we talk about beds not being used.
And, yes, I have seen these programs and know them well.
Mrs. Bustos. So maybe you can talk us through, you know,
when it is not a visit that has been preplanned, and as I think
it was Congresswoman DeLauro was saying that, you know, you
walk in and you see smiling kids when this is a planned visit
by Members of Congress. What do you see? Tell us what you are
seeing.
And then my other follow-up question to that, because we
get our full 5 minutes here, which is never enough time to have
a decent conversation about all this, what are the long-term
consequences of the kids who are living through the severe
trauma, the angry feelings, the anxiousness? What are we going
to see when these children are teenagers, and what are we going
to see in our society as a result of what the government has
done to these children?
Mr. White. So what you see when you are in a program on a
regular day without Members of the United States Congress there
is not, in my experience, very different from what you see on a
tour except that the staff are much more nervous when there are
Members of Congress there.
The children that you see and the environments in which you
encounter them are what you would also see in domestic
congregate child welfare settings licensed by the State
because, that is what they are.
The children, as you talk to them and work with them,
represent a range of experiences. Many of them have sustained
extraordinary--extraordinary histories of trauma in home
country, in transit, and, in some cases, in the United States.
Separated children are intrinsically different, however, in
that the traumas they have sustained are both extraordinarily
severe and they are currently ongoing. And we are part of that
traumatization in the United States Government, which is
different than being the response to that traumatization.
Long term, the consequences of separation, for many of
these children, will be lifelong. It will involve both
behavioral and physical health harm that all the best available
evidence we have on trauma and toxic stress, including that
that focuses on children separated from their parents, would
suggest will be both severe and very difficult to manage, even
with high levels of clinical care.
Mrs. Bustos. And all this could be prevented if the United
States Government in this administration, didn't have these
kind of policies that is allowing these children to go through
this kind of trauma?
Mr. White. Separation, other than for strict cause, is
preventable. However, Congress has not passed legislation of
any kind to define the conditions under which separation may
occur. And as I have asked previous committees, I will say
again, that is a gap in law, and it is one that this Congress
could, and, I would submit, should address.
Mrs. Bustos. Okay. I am down to 3 seconds, so thank you for
those answers. Appreciate it. I yield back.
Ms. DeLauro. Congresswoman Frankel.
Ms. Frankel. Thank you. Okay. My little sponge here fell
off. Okay.
Mr. White. We can hear you, ma'am.
Ms. Frankel. You can hear me? Okay.
Thank you all for being here really. And, you know, I
really can tell from your expressions and what you are saying
that all of you are very sincere about trying to correct the
very terrible situation, which I know none of you really
caused.
But I just want to echo, before I ask my questions, what my
colleague here, Mrs. Bustos said, because, right, you know, I
am a new grandmother. And when I just think of the brutal,
cruel policy of taking children from their parents, and to me,
this is just government child abuse. It is child abuse.
I want to start, because I want to emphasize what
Representative DeLauro has been talking about, which is the
agreement with HHS where HHS has agreed to share personal
information of potential sponsors with agencies that can
actually go to a home and, perhaps, take a--seize an
undocumented citizen.
And I think what we experienced when we were at the
Homestead--we all went to the Homestead facility, is that one
of the feelings that we got is that--one of the big reasons for
the delay in getting these children back with any member of
their family was because of the fear, the fear that by giving
an enforcement agency the ability to go to a home and then pick
up an undocumented citizen.
So, Mr. Hayes, I just want to know whether or not--what, if
anything, are you doing about trying to get this agreement
rescinded?
Mr. Hayes. So I just would say one thing, actually to
correct Commander White. I don't believe the staff at the
facility in your district was scared of you. I think they
actually looked forward to you coming to the shelter, ma'am
Ms. Frankel. I agree. I agree.
Mr. Hayes. They even had your picture up on the wall, so--
--
You know, I think one thing is clear. I think there is some
confusion around the information that is shared. I think it is
important--I noted this on the tour at Homestead and as well at
my last testimony here, is that going back to 2004, every time
a UAC is discharged from ORR, they then go to the jurisdiction
of the Department of Homeland Security and that discharge
notification form does go to DHS with the sponsor's information
and the child, because it then, you know, falls on DHS and
Department of Justice to keep them apprised of their court
proceedings. So I just think that that is----
Ms. Frankel. No, I understand. But look, because I have
some more questions.
Mr. Hayes. Yes, ma'am.
Ms. Frankel. Look, here is the point we are trying to make
is that that process is keeping children and families
separated.
Next question----
Mr. Hayes. May I----
Ms. Frankel. Can I----
Mr. Hayes. Yes, ma'am.
Ms. Frankel. Well, I want to ask another question. There is
a new policy, I understand, that the President has put in place
that now prohibits people seeking asylum to come into the
country so they get stuck in Mexico. Is that correct? Is that
going to affect the number of the undocumented children coming
into the country?
Mr. Hayes. I think the impact is unknown. There are a
couple of things that are ongoing with some of the asylum laws,
and, again, HHS is not an immigration enforcement agency. I
know we did issue a Dear Colleague letter where certain
components of that we don't believe will impact the, you know,
folks that are eligible to come into ORR care, both on the
refugee resettlement side and----
Ms. Frankel. But they have to come into the country first,
right? Is it going to be hard--the reason I ask this question
is because Mr. Pocan asked about spending a lot of money on
invisible people. I am just wondering, are you actually
expecting more undocumented individuals to get in here, given
the new policy?
Mr. Hayes. Right. Yeah. While I will acknowledge that the
chairwoman is correct, our referrals number are low. But if
historical trends--and I would yield to Commander White here in
a second as well, but if historical trends hold true, the
expectation should be that as we move into these cooler months,
there is a pretty significant chance that the referrals will
increase, and most certainly as we get further into November
and December, an even greater chance.
Commander White.
Mr. White. I did just want to say this, and I will keep
this brief out of respect for you, ma'am. Every influx crisis
in the history of this program--and in fairness, I have been
deeply involved in response to all of them. So I have some
experience to speak from. Every one of them was preceded by a
period of reduced referral and pressure to reduce capacity or
stop expanding capacity.
And I have asked colleagues on the career side, on the
appointed side, and I will now ask Congress, can we please not
make this mistake again of thinking that every time it goes
down that that is, like, the future. This is an oscillating,
highly volatile system, and the best way to keep children out
of the--off the floors of border stations is to not react when
there is a downturn and say, Oh, look, that is the end of
migration highs.
Ms. Frankel. Let me just say two points that I guess--
because I am running out of time here. But one thing that we
found on our visit is that children who were reaching the age--
they were getting to an age where----
Mr. Hayes. Age out.
Ms. Frankel [continuing]. They were going to age out----
Mr. Hayes. Yes, ma'am.
Ms. Frankel [continuing]. A terrible stress on them because
that meant they were going to be incarcerated.
And the second thing is, I think what we have to remember
that these children, once they are released or to a family or
whatever, you know, a lot of damage has been done and now they
are out in our community. And my question is, is there follow
up? Do they get mental health services, or is that it?
Mr. Hayes. Yeah. So whenever a child is discharged--two
separate questions, ma'am. So we do have children that do age
out. Once you turn 18, the statutory authority at HHS ends
inside the ORR UAC program. Our teams work very closely with
the local ICE officials to come up with a post-18 plan. And as
I said on the tour, if it were solely up to our grantees and
the ORR career staff, the kids could stay with us until they
were 22, but it is not our decision.
Ms. Frankel. No. No. They are going to----
Mr. Hayes. We do work very closely, and a lot of times they
are released in that post-18 plan on their own recognizance. I
would just add, as far as the second--what was the second
question you asked?
Ms. Frankel. What happens once they are released? They have
this trauma. Yeah.
Mr. Hayes. So there is a 30-day follow-up call from our
team, and if there are post-release services that are
recommended by the team, again, we work with a particular
project officer at ORR with approximately 11 grantees to
identify post-release services that might be available within
the community.
Ms. Frankel. Thank you.
Ms. DeLauro. Congresswoman Watson Coleman.
Mrs. Watson Coleman. Thank you very much. Thank you for
being here.
And, Madam Chair and Ranking Member, thank you for hosting
us here in this very important committee meeting.
Before I start asking my questions, I need to make a
comment. There was a comment made up here by one of my
colleagues, and it had to do with--I found very offensive. And
what it suggested was that parents are making a choice to be
separated from their children, and I just cannot believe that
that is the truth in any way, shape, or form.
I am a grandmother, and I am sitting up here listening to
what these young children are going through. My granddaughter
is 6 years old, and it breaks my heart. Not only does it break
my heart for the child, it breaks my heart for the parent or
the relative of that child. And I just think that we are in the
wrong--we are moving in the wrong direction here.
Do we or do we not have a no-separation family separation
policy now? Let me ask you, Mr. Hayes.
Mr. Hayes. So----
Mrs. Watson Coleman. Is that a yes or a no?
Mr. Hayes. Yeah. So based on my understanding, the
President did issue an executive order stopping family
separation as a result of the zero-tolerance policy
specifically for an immigration violation. However, separations
do continue for other reasons and have----
Mrs. Watson Coleman. Such as?
Mr. Hayes. Such as past criminal activity of the parent,
legitimate child welfare concerns. There is a myriad of issues.
I would be happy to get you a list of the different categories
that fit into that. But I think it is important to note that
there have been separations in the entire history of this
program.
Mrs. Watson Coleman. So you were very successful in
reducing the census at your facilities extremely.
Mr. Hayes. Yes, ma'am.
Mrs. Watson Coleman. And I would like to know specifically
what were some of the things that you did to facilitate that
release, and are those things part of an ongoing policy now?
Mr. Hayes. They are, ma'am. I issued four operational
directives, so the first one, about 3 weeks after I was named
the acting director at the end of November. The first
operational directive ended the household member fingerprint
checks, which the counsel of my senior career staff and child
welfare experts did not deliver any new or additional
information that would cause them to change the decision to
discharge that child to his or her family member.
The second operational directive was in March of this year,
ma'am, and that was in regard to the moms and dads that are
seeking to sponsor their children. We quit fingerprinting them
as well, provided there was no red flag or hit on the public
records check or sex offender registry check in that.
The operational directive number three had to do with the
immigration status checks. We suspended the reconciliation of
the ICE background checks, results from our sponsors. We rely
on the testimony and communication with each sponsor. The only
thing we ask is that if a potential sponsor is undocumented and
here without status and could potentially be deported, is there
a safety plan, meaning who will the child go to if you are
deported?
And then the fourth operational directive was also done in
June of this year where we are--still to this time, but it is a
temporary action--we are treating the grandparents and adult
siblings the same way we would moms and dads, meaning if they
are seeking to sponsor the family member and there are no hits
or red flags on the public records check or the sex offender
registry checks, we do not do the FBI fingerprint checks which
does take additional time.
Mrs. Watson Coleman. So during----
Mr. Hayes. And I will just add, I visited over 50 of our
shelters, and that was one of the recommendations that came
from the field that I brought back and discussed with the team
and we implemented.
Mrs. Watson Coleman. So during that period of time, where
you were you able to facilitate those releases more quickly----
Mr. Hayes. Yes, ma'am.
Mrs. Watson Coleman [continuing]. Did they suspend looking
at everyone that lived in the household, determining what their
status was?
Mr. Hayes. We still do the public records check, but
again----
Mrs. Watson Coleman. What does that mean?
Mr. Hayes. It like, you know, looks at both the Federal,
the State, law enforcement-type background to see if there is
any hits or red flags or anything to give us any kind of
concern.
I will point out that at the end of the day it is about the
integrity of the sponsor.
Mrs. Watson Coleman. Yeah, I agree.
Mr. Hayes. They can only tell who is in the house and who
can move the next week. So that is where I want my team to
focus, on the sponsor.
Mrs. Watson Coleman. So, you know, I know you are not the
cause of these policies. You are the recipient of these
policies. So this memorandum of agreement, or understanding,
really doesn't need to exist. And do you have the authority or
does your department have the authority to withdraw from that
agreement? And if so, why haven't you?
Mr. Hayes. I do not have the authority myself. I am not
going to speak for the Department of Health and Human Services.
Mrs. Watson Coleman. But you are the frontline person. Do
you agree that we can function without that, if we had the
safeguards in place that were used to facilitate the release of
those children?
Mr. Hayes. I would just say, I think the actions I have
taken since becoming acting director and director speak to my
overall belief of the majority of the MOA. I just will flag
though that, you know, there is referral information,
information learned by DHS after the child comes into our care.
It kind of memorializes the--also the abuse reporting to DHS
when we learn about it. So there are some things left in the
MOA.
Mrs. Watson Coleman. Thank you.
Mr. Hayes. But in regard to your processing the children--
--
Mrs. Watson Coleman. And, Ms. Maxwell, do you agree that
this MOA could be suspended?
Ms. Maxwell. We recommend that ORR do what it is continuing
to do which is to assess all of their current policies to make
sure there are no unintended consequences for releasing
children. So we would recommend a continued reassessment.
Mrs. Watson Coleman. Thank you. I yield back. Thank you.
Ms. DeLauro. Congresswoman Lee.
Ms. Lee. Thank you very much, Madam Chairman. Thank you and
our ranking member for this hearing. And it is a very troubling
hearing for me personally, and as I am an elected official.
First of all, I have to remind you--and in making this
statement, I want to be very clear that we recognize that this
is the 400th year since the first enslaved Africans were
brought to America. One of the basic elements of the United
States policy was to take children from their families. That
was family separation. This has had generational impact. We are
still addressing it and dealing with the trauma today.
This is yet another stain, another stain on our country.
And I am not personalizing it toward any of you, because I know
what you are feeling and what you are seeing. But I want to put
this in context so we understand what is taking place. This
policy did not just start.
I am very concerned that a lot of the recommendations that
the American Psychiatric Association--and I want to read some
of their testimony to this committee--and also the National--or
American Society of Pediatrics. I am not sure if that is the
correct name of their group, but I want to explain a couple of
recommendations they made.
First of all, they said that we needed an independent
medical and mental health monitoring team, totally independent
from the government. Secondly, the psychiatric association--let
me just read you a couple of paragraphs from their statement.
``We know that children are more susceptible to trauma
because their brain is still developing. When a person is
exposed to a traumatic event, the brain naturally enters a
heightened state of stress, and fear-related hormones are
released. And although stress is a common element of life, when
a child is exposed to chronic trauma or extreme stress their
underdeveloped brain will remain in this elevated state.
``Ultimately, consistent exposure to this heightened stress
or trauma can change the emotional, behavioral, and cognitive
functioning of the child in order to promote survival.
``Psychiatrists are most qualified to help children and
family recover from the trauma inflicted upon immigrants and
refugees by displacement from and within their home countries
and can provide direct psychotherapeutic and psychosocial
intervention. Each staff and their leadership teams should
really address the appropriate care suffering and identify this
as posttraumatic symptoms and other migration-related symptoms
of distress.''
And then they go onto explain--one more thing I would like
to read from their testimony: ``Detention of innocent children
should never occur in a civilized society, especially if there
are less restrictive options because the risk of harm to
children simply cannot be justified.''
Now, I want to find out from you what in the world happens
to these children after this damage has been done by the
policies that this government has put in place in terms of
trauma-informed mental healthcare?
I recognize the mental healthcare has--I am a psychiatric
social by profession. There are a variety of treatment
modalities. But these children require specific trauma-related
treatment, and it is not one, two, three, four, five, six,
seven sessions. This is years of treatment they are going to
need.
So how are you going to do this? And what type of
resources--have you met with and talked with the professionals
on the outside who could probably give you a lot of help in
what you are doing?
Mr. Hayes. Thank you, Congresswoman.
I would just, you know, point out that I--and, again--thank
you again for the, you know, for the supplemental funding that
you all provided. I know a part of that was not less than $100
million to increase both legal services, post-release services,
and child advocates, and that is something that we are working
on with our grantees.
We have recently sent out a request for proposal to expand
those post-release services available to the children,
especially those that need long-term mental healthcare and
behavioral health issues as they leave ORR care.
Ms. Lee. Are you specifically saying trauma-related care
related to PTSD?
Mr. Hayes. I don't know how specific we are getting. It is
a broad array of post-release services. It could be medical
care, legal services, educational, school----
Ms. Lee. I understand that, but I am focusing on the mental
healthcare right now, in terms of the appropriate types of
mental health treatment modalities that you are going to use to
make sure that these kids don't end up, when they are adults,
not very happy with our own country.
Mr. Hayes. Right. Do you want to speak to that, sir?
Mr. White. Ma'am, that is a focus of the efforts. And as
you know, among the challenges are the delivery of
appropriately intensive psychotherapeutic services during the
duration of time the children are in care. So the answer to
your question is absolutely.
One of the key focuses for the current efforts to further
strengthen our ability to deliver appropriate trauma-informed
services to children in our care is to work with experts,
including NCTSN, to identify what are the best evidence-based
methods to respond to the very high--both the high ACEs scores,
the history of toxic stress, and the traumatic exposures that
children have during the window of time that we have and with
the resource picture we have. So the answer to your question,
Congresswoman, absolutely.
Ms. DeLauro. Congresswoman Clark.
Ms. Lee. Time is up, okay.
Ms. Clark. Thank you, Madam Chairwoman.
Thank you, all. We appreciate you coming back, and for our
new arrivals, your testimony here today.
It is hard to know where to start. Commander, as you said
in response to some previous questions, the only real way to
address this level of trauma in children is prevention. And we
know that many of these children are coming to this country
already experiencing great trauma, where they lived at home, in
transit. But we have added to this.
And I want to reiterate what my colleague, Congresswoman
Lee said. We know that you are trying to do jobs in a tough and
changing situation. But I think you have to understand how it
looks from our vantage point, that children are being used in
this immigration policy, and the harm that we are inflicting on
them and on these families may be irreparable, and that we have
a role in that as the U.S. Government.
And what troubles me deeply about Homestead is that this is
a private contract with Caliburn International, where Secretary
John Kelly sits on the board. And they wrote in their filings
for the SEC as they announce plans to go public, ``Border
enforcement and immigration policy is driving significant
growth for our company,'' significant growth. At what cost to
the human experience and to this stain on our country in the
way we are treating these immigrant children?
And to hear that we continue to pay--and I understand very
clearly that we need to understand that these--that migrant
patterns are patterns, and they go up and down and we want to
be ready. But there are other programs out there that exist
like the case management, that I understand is, you know--
homeland security program not under your purview. But it works.
And it has great compliance with families getting to court, to
making sure their asylum cases are heard, have a fair decision.
And what does it cost? It costs $36 a day.
These are the type of programs that I would think that when
we are experiencing a decline in population, why aren't we
looking at those type of programs that get kids out of
detention and with their families and have compliance? Why
aren't we looking at increasing our nonprofits that can save
money instead of continuing to operate Homestead empty at
almost double the rate of what we pay some other agencies to
take care of children. These are big questions, but if you
could give me some direction, Mr. Hayes, I would appreciate it.
Mr. Hayes. Yes, ma'am, Congresswoman.
So I think I just would point out that, again, the
Homestead site and the operator was chosen back in late 2015,
long before General John Kelly joined any of the companies that
you mentioned. Yes, we did renew that contract with them.
I would just say that--again, I want to reiterate my
statements earlier--I am absolutely committed to, as is
Assistant Secretary Johnson and Secretary Azar, to having as
many State-licensed permanent network beds as possible to
receive these children. And we are working to that end.
But the challenge that we have, Congresswoman, is that at
the end of the day, the final say in those facilities being
licensed and receiving children does not lie with the Federal
Government. It requires a partnership with the States and the
local communities.
And we are, again, starting to see some resistance to that,
and that is very unfortunate. I would respectfully request this
committee to help out and help us--as, you know, one of the
stakeholders in this process of caring for these children--help
us achieve that goal of expanding the type of shelters that we
have in Ms. Frankel's district that she and I went through. It
is about 140 beds for teenage girls, and it is a wonderful
facility. That is what we want, and we are working towards
that.
But to Commander White's point, when we see huge influxes
of children coming across the border, and the need to be able
to secure them, you know, we have to be able to, you know, have
those beds available. And if we are having challenges----
Ms. Clark. Mr. Hayes, are you working at all to redefine
what we mean by family members? When I was at Homestead, we
heard many stories of children coming across the border with
grandparents----
Mr. Hayes. Ah, yes.
Ms. Clark [continuing]. Who did not qualify and made these
children unaccompanied minors. If we are trying to reduce
trauma to children, if we are trying to keep children out of
detention beds, not be separated, are you working actively to
say why don't we include aunts and uncles and grandparents in a
definition of family that is rational?
Mr. Hayes. So that is not my decision. That authority lies
with Congress. And I know that the senior staff that I speak to
would absolutely support some modifications to the Trafficking
Victims Protection Reauthorization and the Homeland Security
Act that drives that.
Mr. White. The definition of children who cross the border
with a loving grandparent, with abuelita, with an older brother
who is over 18, to define those children as unaccompanied is a
Black Letter law issue.
Congress absolutely has the power to make that change, if
you wish. But neither DHS nor HHS has any legal authority to
consider a child who crossed, even with a loving grandparent,
even with a loving older sister, as anyone other than
unaccompanied. That is not our call.
Mr. Hayes. Right.
Ms. Clark. It is not your call, but would you support that
change?
Mr. White. I would support that change.
Ms. Clark. Would you, Mr. Hayes?
Mr. Hayes. I would as well, and I have heard it from a
number of my staff. And I just want to point--I believe that is
what is at the heart of my fourth operational directive in late
June, where we are at this time, when it comes to the
background check process of the sponsor discharge package, we
are treating grandparents and adult siblings the same way we
would moms and dads, because as a father of five, I completely
agree. I want these kids with family members as they wait for
their court proceedings to go forward. Anything I can do that
make that faster while still holding up an acceptable level of
safety, I will do that in conjunction with collaboration of my
team.
Ms. Clark. Thank you.
Mr. Hayes. Yes, ma'am.
Ms. DeLauro. You can be sure that we will address that
issue and that there will be legislation as quickly as
possible. And I am hopeful that my colleagues on both sides of
the aisle would be in agreement since you are all in support of
it.
The other piece is, I might add, that Assistant Secretary
Johnson at our hearing, who with all due respect, Mr. Hayes,
is, I think, your boss, if you will----
Mr. Hayes. Yes, ma'am, she is.
Ms. DeLauro [continuing]. That she said that we should
rescind the memorandum of agreement. So I am hoping that we
can, or that the assistant secretary will be listened to by the
administration of doing that. That is why you put good, solid,
bright people like the people who are here this morning, who
understand these issues, and make recommendations about what we
should do.
I am going to get to my questions but I have got to say,
the issue is discharge, discharge, discharge. Focus is always
on holding the influx facility and the numbers are going down.
Yes, they can go up. However--however, with a change in one
directive, in 2018, in December, we went from--and you pointed
out that I was inaccurate--I said overnight 15,000 kids. We let
4,000 out. You told me, Mr. Hayes, it was 8,000.
So if we can move kids that fast, we do not have to have
them sleeping on the floor at a DHS facility, which no one
wants them to do that. But we were able to move, we moved
quickly, and we are now down to, as I understand it, some 5,800
kids. We did not have to have a backlog. We did not. That was
created.
And you have got the $2.9 billion, and now, you are less
engaged in dealing with $750 a night for a facility, which was
the reason why we had to build the capacity, build the
capacity, build the capacity. And what we need to do now--and I
want to see that plan in October of how we move kids out as
fast as we can to a safe--a safe placement as expeditiously as
possible. That is your goal. I don't speak for DHS. I don't
know what their goals are. But that is HHS, which is under the
jurisdiction of this committee.
Mr. Hayes, you talked about the webinar series, okay. And I
am proud and excited, and the ranking member understands this,
the National Child Traumatic Stress Network--I will be self-
serving for the moment--I was the first Member of Congress to
put funding into that system, because I understood what it did,
as my understanding of it through the Yale Child Study program
in New Haven, Connecticut. And we helped to craft that and
provide money for it. So we have done that. I am glad you are
there.
You have talked about--I want to hear about the direct
services. You talked--other than the webinar series. What have
you done to increase access of child trauma experts to children
in HHS facilities, while children are in ORR care, and in the
post-release situations? As I said, you have got $2.9 billion.
Numbers are down. We don't have to pay the $750 a night. How
are we rearranging those dollars to assist in this process?
Mrs. Watson Coleman. We are still paying $600 a night.
Ms. DeLauro. We are paying $600 a night. Yeah. So $750 to
$600. $150 a night, that is real money. I believe that.
Mr. Hayes. It is, yes, ma'am.
Ms. DeLauro. Yeah. Talk to me about direct services.
Mr. Hayes. I just want to point out for the record, too,
none of our grantees makes the decision on any child going to
their shelter. That decision is made by Federal staff on the
intakes team at ORR. So, I just want to make sure that people
understand that whether it be Homestead or whether it be, you
know, a BCFS facility in the Rio Grande Valley, that is not a
decision that any of the grantees make. Federal staff provide
oversight and make the decisions on where the children go.
In regards to the children that are in our care, Madam
Chair, I just would again point to, you know, to the OIG's
report and to the counsel----
Ms. DeLauro. What direct services besides a webinar are you
going to? Please, because, you know, they are going to kill me
if I am going overtime.
Mr. Hayes. I understand. Given the very short time that
these children are in our care, the focus of the clinical work
of our team is to focus on both providing a safe and secure
environment in stabilizing the child. Again, that is right out
of the OIG report, and the report that you showed, you know,
the length of care significantly dropping.
And I do know that I always want to be the type of director
that listens to the counsel of our medical team. And I have
heard it firsthand out in the field, and also here in DC, that,
you know, there is a hesitation to really get into some of the
deeper trauma given the fact they don't know how long they are
going to be in our care.
Ms. DeLauro. But, you know, you need to deal with direct
services. Are you going to take any of this money from the $2.9
billion and provide it there? Because you say you are going to
add your own funds to what is going on at the NCTSI.
Mr. Hayes. We will continue to seek ways to properly invest
that money in the care of the children, yes, ma'am.
Ms. DeLauro. Okay. I will come back to additional
questions. Congressman Cole.
Mr. Cole. Thank you very much.
A point I want to make and then a couple of questions to
ask, the point is--and you were, I think, there, Director
Hayes, when we were down along the border--there is a lot of
manipulation of these unaccompanied minors by people coming
into the country.
We were told that, literally, only 1 percent of adult males
in 2015 that were coming across that border had an
unaccompanied child with them, and it is 50 percent now. So
there is clearly, you know--some of these kids are being used
by adults that think it enhances their chances of being--of
getting in the country and being able to stay. I don't know how
you deal with that, but it is something we ought to recognize
that they are having to confront down there.
It was very interesting to see. And, again, the money
Congress voted gave them the capability. We are doing DNA tests
on selected individuals just to see if the people were related.
About one out three of the people they tested were not related
in the manner described.
So this is--you know, these children have been used,
literally, in these kinds of cases by people trying to get into
the country illegally and by cartels, and that is just a fact.
And you are confronted and we asked you to deal with it and you
don't do the apprehensions. You just--you know, you are dealing
with the kids that we turn over to you.
Question I have, and there is a tension here--and I know we
are all trying to get to the right point, but a tension between
getting them placed as quickly as possible, and giving them the
best care that we can give them after a very traumatic
experience, because you don't have them there, as the commander
pointed out, very long, and as you have pointed out.
So could you describe a little bit how you handle that
dilemma and what, you know--in what ways, if any, does the care
follow the child or--you might not even have had time to
actually assess the full needs of the child in the amount of
time that you have them there. So this is a real problem area,
I think.
Mr. Hayes. Thank you, Congressman. To your point, I know of
a recent example where a child was in our care for 3 or 4 days
before she was discharged to her mother. It was not a
separation. And so, if there is circumstances surrounding what
happened back in home country, the journey, and then coming
into our care, I mean, she was only with our shelter for maybe
3\1/2\ days before where I think is a more appropriate
environment, she moved with her mom.
So, that is a question, that I would not seek to answer. I
am not a mental health clinician. But, again, I receive counsel
from a large number of them, and their focus, again, not
knowing exactly how long the children are going to be in our
care, they focus on stabilizing the child and making sure that
the child feels secure, because I think, to a point earlier,
they do view initially, at least all of us, as kind of the same
bucket in regards to the U.S. Government.
But we see that as they spend more time in an HHS shelter,
and it is like not in detention and they are surrounded by
medical professionals and clinicians and youth care workers and
other kids, you know, their comfort level and their confidence
in our team, you know, does absolutely increase, and we learn
more about the child and his or her journey and their history.
And as that stuff is told to them then that is incorporated
into the clinical work that our team does.
But, again, to the OIG report's point, you know, it is
tough when you really don't know how long you are going to have
that child and the licensed mental health professionals tell us
that there is a hesitation to want to try to get into that too
deep, if they might be gone within a week or two.
Mr. Cole. Commander, if I could, I would like your thoughts
on this. You know, in terms of--again, we obviously want to
place them as quickly as we can in an appropriate environment.
How do we make sure--and again, these kids have been
traumatized before they get here in many cases, either by
conditions at home or the journey, you know.
What are your thoughts on how we make sure that while we
are placing them rapidly, you know, we can both diagnose the
problem and see if there is something that we can do about it?
I mean, they move out of HHS's care pretty rapidly, and that
has got to be a challenge in this area.
Mr. White. Yes, sir. There are three things we have to do,
and I want to be really clear, both as a person who has managed
this program and as a clinician, they are hard. They are hard,
but they are necessary.
The first thing we have to do is we have to build every one
of our programs from a trauma-informed lens, so that not just
the minute that the child is sitting with his or her clinician,
but every moment that they are in the program we are doing what
we can to mitigate the traumatic experiences they have
sustained, as well as the distress of the time that they spend
in congregate care.
The second thing that we have to do, is we have to provide
both individual and group modality psychotherapeutic
interventions to every child. These are not a random cross-
section of children.
The life experiences of children, particularly for the more
than 90 percent of the children in the ORR program who come
from the Northern Triangle of Central America, these are
children literally coming from the worst places on Earth to be
a child, where the vast majority of these children have
observed homicides, have experienced personal traumatic loss,
have been victimized themselves through physical assaults and
sexual assaults. That is not uncommon in this program. That is
the norm. So the second is we need to have those methods in
place, recognizing all of the incredible challenges to doing
that.
And the third is that we need to continue to work as we do,
with sponsors, to identify the resources that they can access
individually in the communities where they live to provide
continuing care for the children. I want to be really clear,
all of these things are incredibly hard. And that is why the
guidance from OIG matters. We are not failing at an easy thing.
We are continuing to struggle at an incredibly difficult thing,
and I am very proud of what my colleagues in ORR do every day
on this problem.
Mr. Cole. Thank you very much.
Thank you, Madam Chair.
Ms. DeLauro. Thank you.
I would just say just to follow up quickly on something
that Congressman Cole said, which is--and I think you have made
reference to it, Commander, is the post-release services. And
we know, I think we all know that there is a serious, serious
backlog, and that there are children on this wait list,
thousands of kids flagged to receive services waiting weeks or
months before they receive the kinds of services.
So I am going to yield to Congresswoman Roybal-Allard, but
if we come back again, I really would like to pursue post-
release services and that backlog.
Congresswoman Roybal-Allard.
Ms. Roybal-Allard. Before I ask my question, I am a little
concerned, as was Mrs. Watson, that an impression may have been
left that somehow parents are just sending their kids here,
picking and choosing and sending their kids here. And, you
know, we have heard from the immigrants that we have spoken to
as to the various reasons, which we have all heard, rape,
gangs, and so forth.
I was on the trip to the Northern Triangle with Speaker
Pelosi, and the reason we went there was to hear from our own
government agencies, the NGOs, USAID, the Coast Guard, CBP, the
agencies that are there on the ground, as to what their
thinking was, and the reasons why so many young people and
parents were coming to the United States.
And they validated everything that we had been told by the
immigrants themselves as to why they were coming. In fact, in
some cases, what we learned was even more horrific. For
example, USAID was saying, and some of the other agencies were
saying that they were now focusing on the 8- to 12-year-old
kids, and using the money, or the foreign aid that we are
sending there to focus on the 8- to 12-year-old kids, because
that is where the gangs were focused, on recruiting the 8- to
12-. And if these kids didn't join, they would then threaten
them with killing their parents or a sibling. And to be part of
that gang, the 8- to 12-year-olds had to kill five people. That
was the price. That is why parents are sending their children
here.
Also, when I went to Texas with Congresswoman Escobar, we
crossed over to where there was one of the shelters on the
Mexican side, and there were about 80 or more immigrants there
from different countries. The Congresswoman asked them why they
were there. We heard similar things, including the fact that
they could no longer grow crops in their country, and they were
hungry. They couldn't feed their families and were coming to
the United States.
She then asked them, if you could provide for your family,
and if you could feel safe in your country, how many of you
would still want to come to the United States? Not one person
raised their hand. They said, No, we love our country, we want
to be in our country. We are here because we had no choice. So
I just want to make it clear that parents are just not deciding
for the heck of it to send their kids to the United States.
Ms. Maxwell, according to your report, even mental health
clinicians with prior experience in this field felt unprepared
to handle the level of trauma that these children had
experienced. If the trained mental health providers felt
unprepared, I would assume that ORR caretaking staff must be
completely overwhelmed when faced with the needs of these
children. And I understand that your investigators spoke with
the mental health and physical health clinicians during the
investigation, but did your investigators speak directly with
the caretaking staff about their training on how to meet the
mental health needs of these fairly traumatized children who
were under their care?
Ms. Maxwell. Thank you for that question. We have a broad
body of work that we are undertaking, and we asked a whole host
of questions. We did talk to the youth care workers. That is
for a future study that is coming out later this fall. In this
particular study, we focused only on the mental health
clinicians.
Ms. Roybal-Allard. So do you know when that study will be
coming out?
Ms. Maxwell. As soon as we can get it through our very
rigorous quality control process, we will have it in your
hands.
Ms. Roybal-Allard. Do I have time for one more? According
to the Flores settlement agreement, each child in our custody
should have a comprehensive and individualized plan for care.
Did your investigators check to see if there were care plans in
place for these sexually traumatized children?
Ms. Maxwell. Not in this particular study. We have an
ongoing series of audits that looks at eight grantees over six
different States. In those particular audits, we did look at
whether or not grantees were compliant with rules and
regulations, and one of the regulations we looked at was
whether they had care plans. In some cases, we did find
documentation missing in children's files.
Ms. Roybal-Allard. Okay. So a lot of the issues that we are
bringing up then will be in subsequent studies. Am I----
Ms. Maxwell. The audits that I am talking about, a number
of them are already public. I will be happy to share them with
you so you can see specifically what is happening at various
grantees. The study I was referring to looks at the safety in
the facilities, and that will be coming out later this fall.
Ms. Roybal-Allard. Okay, thank you. I see my time is up.
Ms. DeLauro. Congressman Harris.
Mr. Harris. Thank you very much, Madam Chair.
Let me just clear it up for the Congress ladies who had a
question about it. I just reiterated, I think, Mr. Hayes, that
you said the vast majority of children you are taking care of
now are UACs, not people separated by legal policy. Is that
correct?
Mr. Hayes. That is correct.
Mr. Harris. Okay. So to say that the Trump administration
is somehow responsible because of the pitiful conditions in the
Northern Triangle that make a parent choose to separate
themselves from their child is not this Trump administration,
neither is it the Obama administration or any of our policies.
It is a problem in those home countries.
The Northern Triangle, let's talk a little about the
Northern Triangle. Let's get back to Baltimore, or Detroit, and
New Orleans, all of which have a murder rate that is higher
than Guatemala. Baltimore's is on level with Honduras. El
Salvador does take the cake, all right, they are higher.
So, again, I would just offer that we have a public health
issue in this country with taking care of the mental health of
children who are exposed, and the failure, the failure to
control the murder rates in large American cities that
certainly the Trump administration doesn't control.
All right. Let's talk a little about the fingerprinting.
Under your policy, do you fingerprint fewer people or more
categories of people than the Obama administration
fingerprinted when they released? My understanding, for
instance, is you don't fingerprint grandparents----
Mr. Hayes. Right.
Mr. Harris [continuing]. Who have taken care of children,
when the Obama administration did fingerprint grandparents.
Mr. Hayes. At this moment, we are fingerprinting less,
because we are not doing grandparents and adult siblings.
Mr. Harris. Less. Well, that is interesting, because I
certainly didn't hear that as a compliment from anyone saying,
Oh, by the way, congratulations, you are actually doing less
fingerprinting; therefore, resulting in less fear of family
unification than under the last administration. So I thank you
for doing that, okay? No question about it.
Now, let me just get to the crux of how separation occurs,
because if you are a parent with your child, you are a single
mother with your child and you go to a port of entry, and go
through the legal process of filing for asylum, you don't end
up in ORR. The child doesn't end up in ORR custody unless there
is some question about the ability of the--the qualifications
of that parent to be an adequate parent, they are not a
criminal, et cetera. Is that right?
You are only taking care of children whose parents broke
the law, right? Because you don't break the law. If you request
asylum in a port of entry, you don't break the law and there is
no question of separation unless, of course, you are a criminal
yourself, the parent is a criminal. Is that correct?
The children in your custody, in fact, are not children
whose parents have followed the asylum law of the United States
by entering through a port of entry?
Mr. Hayes. I think I just would want to qualify,
Congressman, that the majority of children in the care of HHS
did not come across the border with a mom or a dad.
Mr. Harris. Yes. Oh, I fully get that. But now, I am
talking about whether this administration is responsible for
the parent breaking the law and not following--because my point
is, if the parent followed the law--and we know the vast
majority request asylum. I mean, that is not your bailiwick,
but the vast majority of people crossing the border now request
asylum.
If they request asylum at a port of entry, following our
asylum law, there is no question of automatic separation, and
there never was. Is that right? And, again, maybe I should be
asking DHS.
Mr. White. Unfortunately, Congressman, among the separated
children in the Ms. L. class, including the named plaintiff,
there are children whose parents presented at a U.S. port of
entry. Nonetheless, I think the take-home is that the vast
majority of children in the care of ORR are truly
unaccompanied, not separated children.
Mr. Harris. That is correct. And, in fact, their parents
broke the law. So one solution, prophylactic solution, I guess
would be, to enforce border law. Maybe if we actually enforced
the law, we would not allow people to enter illegally with
their children, which has resulted in separation. I am not
going to judge, but is that more or less correct? I mean, we
really are--and I am going to have to look at those cases. My
understanding of the law is if you enter--you are legally
present in the United States, if you entered a port of entry,
requesting asylum, so doing everything you need to do at a port
of entry. But I will check on that.
Again, if we just enforce border law, we wouldn't need to
have separations. We probably don't need to have it anyway, but
we certainly wouldn't need it if all we did was enforce border
law. I suggest maybe we just do one of the simple things and
maybe just agree with the President that the border ought to be
enforced. We shouldn't have an open border.
I yield back.
Ms. DeLauro. Congresswoman Lee.
Ms. Lee. Let me ask a question just to clarify who has the
authority--well, in terms of the MOA and its rescission, who
has the authority to sign for the rescission and who signed it
initially?
Mr. Hayes. I do know that the former Director of ORR signed
it, as well as the acting director--I am sorry, the Acting
Assistant Secretary of Children and Families. I am honestly not
sure at DHS who signed it, ma'am. I have read it, but I can't
remember specifically, so I would not want----
Ms. Lee. And who can rescind it? Who has the authority to
rescind it?
Mr. Hayes. I would assume the agencies that all signed it.
Definitely above my pay grade, but----
Ms. Lee. Well, okay, would it be the Secretary of HHS,
maybe?
Mr. Hayes. No. It was at the Assistant Secretary level. I
can, without a doubt, say that the former director of ORR and
the former Acting Assistant Secretary of Children and Families
inside HHS were two of the signatories. I cannot remember who
signed it from DHS.
Ms. Lee. Does anyone know? Ms. Maxwell, does anyone know
who has the authority to rescind this?
Ms. Maxwell. No, I do not know that.
Ms. Lee. Can you get back to us in writing who has the
authority to rescind the MOA?
Mr. Hayes. I will be happy to work with our Assistant
Secretary of Financial Resources and a team at HHS and get that
answer back.
Ms. Lee. Okay, thank you. Let me ask you another question
with regard to the children and the treatment. First of all,
policies that have been created by this administration have
very serious future potential problems if not dealt with
properly as it relates to the appropriate type of mental health
services.
I want to read to you, again, the National--this is from
the National Child Traumatic Stress Network, which gives us a
glimpse of what could happen if, in fact, these children aren't
treated properly.
They said: ``Complexly traumatized children are more likely
to engage in high-risk behaviors, such as self-harm, unsafe
sexual practices, and excessive risk-taking, such as operating
a vehicle at high speeds. They may also engage in illegal
activity, such as alcohol and substance abuse, assaulting
others, stealing, running away and/or prostitution, thereby
making it more likely that they will enter the juvenile justice
system.''
Now, this characterization really does outline the high
stakes associated with proactively mitigating the impacts of
childhood trauma. So I think--and I am wondering, Commander
White, have you all thought this through all the way out?
Because I foresee some very difficult issues that these
children are going to face as a result of the trauma that they
have experienced, and not treating them properly, just in terms
of some of these issues, but also in terms of other public
safety, national security issues.
I mean, how do you think someone is going to feel at 18
years old that they were taken from their parents, and then
they were treated in a way that wasn't healthy, and that did
not help restore their mental health as a result of PTSD?
Mr. White. So, Congresswoman, all of the outcomes that you
describe are well-supported by the evidence and the science for
children who have sustained prolonged and complex traumatic
experiences. This has long been part of the planning within ORR
for the care of unaccompanied children.
As I said before, separated children pose a unique problem,
one that I think the program is not designed to respond to. But
the one caveat that I would say in the list of outcomes you
have said is that the best evidence that we have would suggest
that the children in our program are at lower risk of
committing serious crimes than children in the domestic child
welfare environment. And given that sometimes they have been
characterized publicly as a high crime risk, I want to clarify
that record.
Ms. Lee. And I am not saying they are now. I am talking
about long term, if you don't treat traumatized children with
the appropriate psychotherapy long long-term care.
Mr. White. We agree, ma'am. And this is part of the
longstanding and evolving process of planning for the mental
health needs of the very specific population of unaccompanied
children who enter the country without parents, often fleeing
poverty and violence, which is the population we serve. Yes,
ma'am.
Ms. Lee. With children separated from their parents, you
have that added element of anger.
Mr. White. Yes, ma'am.
Ms. Lee. So how do you address anger management and how do
they work through that anger in the type of treatment that you
are proposing?
Mr. White. So fundamentally, as I said before, I do not
believe the UAC program is designed or capable of meeting the
behavioral health needs of separated children. The only way to
prevent that harm is to prevent separation.
Ms. Lee. Yeah, but you have got children now you have got
to address.
Mr. White. Correct.
Ms. Lee. So we have got to figure this out. And I believe
that some outside mental health organizations, such as the
American Psychiatric Association, such as the National Child
Trauma Stress Network, such as the pediatricians. I think you
need some help with this.
Mr. White. Many of those partnerships are underway. I just
want to speak to the reality that separation cannot be managed
with a tertiary intervention strategy, only by preventing
separation.
Ms. Lee. I understand that. I started my comment earlier by
African Americans, the policy of separation of children 400
years ago, the generational impact.
Mr. White. Yes, ma'am. The historical verdict on family
separation is in.
Ms. Lee. It is in. And so, hopefully, you will have learned
from this and, hopefully--I don't want to hear saying, We can't
do anything, or that this is a population of children that we
just don't have an approach or a solution to, because if not,
you are going to have thousands of children with this long-term
trauma that is going to be transmitted to their children
through DNA changes.
Mr. White. Yes, ma'am. If that is how I came across, that
was not my intention. The reality is most of the separated
children were discharged under an expedited court ordered
reunification process. But the fundamental reality is while we
continue to work on best efforts to respond to their needs, we
cannot plan for future separations. Instead, it is the job of
everyone, including Congress, to prevent them.
Ms. DeLauro. Congresswoman Clark.
Ms. Clark. Thank you, Madam Chairwoman.
First, I just want to share our witnesses that our Congress
ladies do understand the complex social and economic factors in
the Northern Triangle that impact immigration into this
country, and we also understand that threats to withdraw aid
from those countries do not help, that policies like remain in
Mexico do not help, and make your jobs, trying to meet the
needs of these children and families and deal with the trauma
they have suffered and their long-term mental health, even more
difficult.
Director Hayes, back when you were here on July 1st, we
talked about providing this subcommittee with additional
information on sexual assaults. I wondered if you could give me
an updated timeline for the release of the prevention of sexual
abuse reports, and if you have any preview for the subcommittee
on some of those findings, on how they may impact change in ORR
policies.
Mr. Hayes. So I believe those reports have been posted. If
they have not, they will in the very near future. And I will
definitely go back and check with the team and work through the
Assistant Secretary for Financial Resources and her team to
communicate that back to you.
What was the second question, ma'am?
Ms. Clark. If you could give us a preview of any of those
reports and any proposed change in policies you might be
proposing in response.
Mr. Hayes. Well, I would just say that, you know, we have
late--end of last year, we did hire the Prevention of Sexual
Abuse Coordinator, and that is a team that we are building and
seek to further build at ORR. And we will continue to remain
engaged according with applicable laws and ORR policies and
procedures. Yes, ma'am.
Ms. Clark. Ms. Maxwell, the OIG also recently released a
report on ORR's facilities' adherence to background checks. I
wonder if you could tell me are there any gaps that facilities
faced in conducting those appropriate background checks?
Ms. Maxwell. Thank you. That is correct. We did release
that report in conjunction with this report and found that,
generally speaking, facilities were adhering to the required
background check screenings necessary to protect children.
We did find some gaps, though, as you mentioned, and in
particular, one of the areas we found over half the facilities
were allowing clinicians to work with children prior to the
results of the background check being submitted to the
facility. We did alert ORR immediately about that fact, and ORR
has taken action, putting out information and reminding
facilities that clinicians should not be allowed to work with
children until the background check results are in.
We also had some concerns about waivers for the CAM checks,
and, again, that issue has been addressed by ORR. So we have
other recommendations out there, but we continue to work with
the administration to make sure that all the background checks
are in place.
Ms. Clark. Great.
Do you have anything to add, Director Hayes, into how you
are addressing these issues in background checks?
Mr. Hayes. No. I just would add, Chairwoman DeLauro,
Congresswoman Clark, I think it was on the tour that you all
both were on, but in regards to some potential changes to TVPRA
and has, one of your colleagues also talked about aunts and
uncles maybe being in that category as well. So when you all
have that discussion, I would just encourage you to consider
that as well as maybe being potentially close family in a lot
of these situations in families.
Ms. Clark. Thank you. I yield back.
Ms. DeLauro. Thank you.
Let me now yield to the ranking member, Congressman Cole,
for any further comments or questions.
Mr. Cole. Thank you very much. I will try and be brief,
Madam Chair, but I want to end where I began. I want to thank
you for the hearing, and your focus on this issue. And we have
a lot of pretty serious debates about immigration, what is
appropriate and what is not appropriate, but I think we all
agree that any child that comes into the custody of the
government of the United States needs to be taken care of and
well-treated. And I think we have come short in some cases, but
I think you have pushed us in the right direction, and you
ought to be proud of that. I am proud of you for doing it.
Second, again, I want to thank you, Madam Inspector General
Maxwell. I know you are an assistant, but we are going to
elevate you today, because I just think you have done a great
job here. I think this is a great service, and it is exactly
what we ask inspectors generals to do, to go and provide us
with the information we need to make appropriate decisions.
I want to thank you too, Director Hayes, again, and
Commander. I had the opportunity to visit the border with you.
I think things have gotten measurably better during your
tenure. I don't have any doubt about your dedication to try and
take the information that Ms. Maxwell has given you and respond
appropriately, within the limits of your resources. And,
fortunately, Congress expanded those resources in July,
something we need to think about going forward.
We were overtaken by this crisis in 2014. You know, we are
reliving this, and I am not sure that we prepared very well in
between for this happening to us again. And, again, I don't
have any magic solutions for what is going on in the Northern
Triangle countries, but I suspect this won't be the last surge
that we see.
So being a little bit better prepared and recognizing this
may come again, and institutionalizing some of these things I
think is important as we go forward. I know you are dealing
with the challenge you have now, but at a future time, I would
welcome your thoughts--and I know you guys are thinking about
this--as to what we need to do to make sure that if we have a
situation like this, we are a little bit better prepared to
deal with it than I think we were this particular time.
So, with that, again, I think this is a little case study
in how Congress ought to work. It is real oversight. It is good
information from the executive branch to act on. It is a
response by the executive branch, and a listing of what you
need, and its expiration, this whole discussion about what we
need to do going forward. I think that is a valuable exercise.
Again, I don't have the answers to all that, but I think
this moved us in the right direction in this hearing, and
certainly the manner in which each of you have discharged your
responsibilities to the country, quite frankly. And I thank all
three of you for doing that.
Madam Chair, good hearing. I think we made good progress.
Mr. Hayes. Thank you for the kind words, sir.
Ms. DeLauro. Thank you very, very much, Congressman Cole.
Let me just do a couple of housekeeping things, if I might.
This is with regard to two letters to HHS. It was a letter sent
by the ACLU regarding the influx facilities. That was flagged
for the administration, so we can get you further information
on that. Also, if you could respond to a letter that was sent
by public health officials regarding the flu vaccinations. The
vice chair and I flagged this letter for HHS as well. So we are
awaiting the response on those letters, so if we could get
that, that would be terrific.
Mr. Hayes. Madam Chair, do you have some dates on those, by
chance?
Ms. DeLauro. We will get those to you, no question. And we
will be wanting just to submit some questions for the record.
You do not have to address these. It is because TVPRA has
mandated post-release services, that I understand that there
are hundreds of children who qualify, and they are on a wait
list. If we can just know how long the children are waiting
before they are connected with post-release service, and have
the wait times increased. Again, we will get you the questions.
You don't have to--and what are the efforts that ORR is taking
to expand the post-release services capacity, and the use of
the $2.9 billion in the supplemental and how we go forward for
2020.
And I will get a couple of other questions, which I know
that have to do essentially with post-release services.
Let me just comment on a service that Congresswoman Roybal-
Allard mentioned to me, that there is something of a traveling
nurse program, where there is a pool of nurses who you can
apparently tap into and that are available. They get back in
less than a day, et cetera, et cetera. And we can find out more
about that and link that up with you, in terms of services,
because I continue to be interested in the kinds of direct
services that you are able to provide. And just as a point, it
is less than $600 a day for nurses.
So let me come to a conclusion here today. I really so
sincerely thank you for the time and the thoughtfulness of your
testimony and the thoughtfulness of the work that you do every
day. I think one of the things that we have established is that
the administration's policies, in fact, have traumatized
thousands of children. I am not going to dwell on that. I dwell
on it a lot, but I think we do need to move forward. But I
think we have established that some of these policies have put
children at grave risk. And so the fact is, is that how do we
try to deal with it?
And, Commander, you spoke about prevention, just as you
talked about, and how do we prevent this from happening? You
also did something very special, I think, Commander. So often,
we all hear that these children are programmed to tell us a
story about what happened to them, and they are just given a
line, and whether it is a coyote or someone else who got them
here, or how they got here, you know, and that they are
parroting something that someone told them to say in order to
gain access to the United States.
One of the things that you talked about were the horrific
circumstances that some of these children have faced.
Congresswoman Roybal-Allard pointed out the directives that
some were given. So it is not made up. There is a reality here,
which I believe we have to face, and have to address, and deal
with, in a humanitarian way, and, again, that we added to that
trauma for these children. We have to take responsibility for
that.
And I, too, some would say, you know, my colleagues will
tell you on both sides of the aisle, I suppose I am an equal
opportunity antagonist to whomever is in the White House,
because we have to do what is right. Improvements have been
made, and take credit for the directives, but, as we know from
the testimony, that there are current policies that we need to
address.
And specifically, I know I am a broken record, but the
memorandum of agreement has got to go. Let's find out who has
that authority. I know what the Assistant Secretary said; she
would rescind it. Let's do that. Let's do it and make the
changes. Accountability is where we need to go, and we talked
about that. And Chairman Cole spoke about that as well as where
do we go subsequently here to follow up, to make sure of what
is happening here.
We have to carry out the recommendations. Concurrence with
the recommendations is not enough, and I say that to you, both
of you. I say that to the IG. And you are following up, and
that is our responsibility as well. It is not here today, gone
tomorrow. We cannot forget about it. We cannot forget about it.
You have tough jobs, very difficult jobs, but you have a lot of
good people who want to do the right thing. And we need to work
together. And I will commit to you, as we have in the past,
that with regard to services, if they are going to be carried
out, we will have to provide the resources for that, because
this was wrong.
I also would talk about the discharge. I am singularly
focused on the discharge, and I believe we can do it. We have
been able to do it. We have demonstrated that we can do it. So
that we do not need influx facilities, which are not State-
licensed, but that we have a way that will help to try to make
sure that we have State-licensed facilities that can deal with
the issue rather than case managers, people taking care of kids
who are not checked out, have not been vetted the way they
should. Let's follow both the letter and the spirit of the law,
where we want to try to address these issues.
You know, and it is the State of Texas, I will just say,
defines child abuse as inflicting or failing to responsibly
prevent others from inflicting mental or emotional injury,
impairing a child's growth, development, or psychological
functioning. And I am not saying this to you, because you are
trying to take us down a good road, but people have to be
accountable. Those who employed a policy that would take us in
this direction have to be brought to task in some way. Let's
not follow a path of child abuse. No one here wants to do that.
That is not what you came to do, in terms of your public
service. It is not who you are.
So let's use the power of the agency to make the decisions
about what happens to those children who are in our care, and
let's make sure we take good care of them while they are here
and make sure they have good care when they are discharged, and
to discharge them as quickly as we possibly can, and as safely
as we possibly can.
I want to, again, say thank you for your time, for your
commitment. And that concludes today's hearing. Thank you.
[Answers to submitted questions follow:]
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
Wednesday, September 25, 2019.
INVESTMENTS IN MEDICAL RESEARCH AT FIVE INSTITUTES AND CENTERS OF THE
NATIONAL INSTITUTES OF HEALTH
WITNESSES
FRANCIS COLLINS, M.D., PH.D., DIRECTOR, NATIONAL INSTITUTES OF HEALTH
BRUCE TROMBERG, PH.D., DIRECTOR, NATIONAL INSTITUTES OF BIOMEDICAL
IMAGING AND BIOENGINEERING
HELENE LANGEVIN, M.D., DIRECTOR, NATIONAL CENTER FOR COMPLEMENTARY AND
INTEGRATIVE HEALTH
PATRICIA FLATLEY BRENNAN, R.N., PH.D., DIRECTOR, NATIONAL LIBRARY OF
MEDICINE
ELISEO PEREZ-STABLE, M.D., DIRECTOR, NATIONAL INSTITUTE ON MINORITY
HEALTH AND HEALTH DISPARITIES
CHRISTOPHER AUSTIN, M.D., DIRECTOR, NATIONAL CENTER FOR ADVANCING
TRANSLATIONAL SCIENCES
Ms. DeLauro. The subcommittee will come to order. Thank you
all very, very much, and again, we apologize for being late.
The days take on a life of their own.
So, but I wanted to say good morning. Good morning, Dr.
Collins. Welcome back to Labor, HHS, to the Appropriations
Subcommittee. Let me just say a thank you on behalf of the
subcommittee for hosting members of the subcommittee for the
site visit at the NIH campus last week.
We had a real wonderful opportunity to learn more about
NIH's work. We met with the researchers who were working to
cure sickle cell disease, to develop treatments for major
depression, shrink and treat cancer tumors in children. We
heard from participants whose lives have been changed by
clinical trials. So it was a moving--an informative, but a very
moving experience as well.
Let me welcome our witnesses, including the five Institute
and Center Directors who join us today. And in addition, and
always a great addition, Dr. Francis Collins, who has joined us
many times, Director of the National Institutes of Health;
today joined by Dr. Bruce Tromberg, Director of the National
Institute of Biomedical Imaging and Bioengineering; Dr. Helene
Langevin, Director of the National Center for Complementary and
Integrative Health; Dr. Eliseo Perez-Stable, Director of the
National Institute on Minority Health and Disparities; Dr.
Patricia Flatley Brennan, R.N. and Ph.D., Director, National
Library of Medicine; and Dr. Christopher Austin, Director of
the National Center for Advancing Translational Sciences.
Your work, all of the 27 Institutes and Centers, leads to
treatments and cures for diseases and conditions that affect
people around the globe. It is transformative and some of the
greatest good that we can do in Government.
And each year, this subcommittee holds a budget hearing to
hear from the NIH Director, as well as Directors of five or six
of the Institutes or the Centers. But today's hearing is an
opportunity for the subcommittee members to hear more and to
hear from Directors of an additional five Institutes and
Centers, which was very, very important to all of us.
When I joined the subcommittee about 25 years ago, we used
to invite every Director to testify. It has been a long time
since we have heard from many of them. So, in fact, I am going
to be plain-spoken about this, and my ranking member,
Congressman Cole, knows about this. I wanted to include the
National Institute of Nursing, I wanted to include the Fogarty
International Center, and the National Eye Institute as well
this morning. Unfortunately, the administration denied our
request on the grounds that we did not provide 2-week notice.
I am disappointed, but nevertheless, we will find another
opportunity to hear from other Directors.
Again, I think we ought to be inviting every Director at
least every 2 or 3 years to be able to listen to what you are
doing and how we can assist in that process. It is critical for
the subcommittee to get a picture, a full picture of the NIH's
portfolio as well as the research landscape.
So you have heard me say before, with each scientific
discovery, each medical breakthrough, the NIH advances human
knowledge. It improves our quality of life, and above all, it
saves lives. I am so proud that the Congress increased the NIH
funding by $9,000,000,000, or 30 percent, over the past 4
years.
And I will note that the subcommittee did this on a
bipartisan basis. So, in fact, for 2020, the House-passed
appropriations included increased funding consistent with
significant annual increases over the last 4 years. The House
bill increases funding for each of the Institutes by at least 5
percent.
Our funding bill is a statement of our values and a
reflection of our commitment to investing in basic biomedical
research at the NIH. It is not overstating the case to say that
the NIH has prolonged or improved the life of every American.
Because of NIH research, we have decreased childhood cancer
mortality 50 percent in 35 years. We have a vaccine to prevent
cervical cancer. We have a drug that prevents HIV transmission
with 99 percent effectiveness.
In fact, a recent study in the Proceedings of the National
Academy of Sciences in February found that NIH-funded research
contributed directly or indirectly to every single one of the
210 drugs approved by the FDA between 2010 and 2016. That is
your impact, and it is amazing.
So to our guests, we say thank you for everything that you
do. We look forward to our conversation today.
And now let me turn this over to my colleague from
Oklahoma, the ranking member of this subcommittee, Mr. Cole,
for any remarks.
Mr. Cole. Thank you very much, Madam Chairman.
I have a couple housekeeping things first, if I may? I want
to just say it is wonderful to have our friend, Ms. Herrera
Beutler back here. We have not had her for a while. She has had
the most excused absence of all time, but it is great to have
her back.
Ms. Herrera Beutler. Thank you.
Mr. Cole. And just to our witnesses, I have already told
the chair this. At some point, I have to get up to go to a
Republican leadership meeting. I will be coming back. It has
nothing to do with your testimony. I have just been called
away.
And I want to congratulate our chair for scheduling a
perfectly timed hearing because we need something up here that
brings us together, and this, you guys actually do that. So it
is wonderful to see and, as always, the chair of the full
committee.
Today, we have got our second budget hearing on the
National Institutes of Health. And again, I want to thank the
chair for having this hearing and inviting some of the
Institutes and Centers we do not get to hear from as often as
we should, and I associate myself with the remarks she made
about that.
I look forward to learning more about the research being
done and learning about the promising cures in the future.
However, I would also be remiss if I did not recognize Dr.
Francis Collins. I want to congratulate Dr. Collins on reaching
an amazing accomplishment of leading the NIH for 10 years as
Director. And he has heard me say it before, but he is clearly
the best politician in Washington, D.C., if he can get
appointed by both Barack Obama and President Trump. I mean,
that is a pretty amazing span of appreciation for the manner in
which he has led the NIH and a great deal of national
confidence, obviously, in his ability and the wonderful team
that he has assembled there and has been there for many, many
years.
Obviously, Dr. Collins is an advocate for ground-breaking
research done at the NIH and supported by NIH funding. And
again, I have said it here, but the 4 years of sustained
funding increases, which was, as the chair said, very
bipartisan, owes a great deal to, frankly, our confidence in
Dr. Collins as the leader of this Institute as well. And he has
made the case up here for a lot of years as to why this was an
important investment, and this committee, in a bipartisan
fashion, has listened to that.
I want to highlight some of the work being done, frankly,
at local universities in my district through the support of the
NIH. Somehow they always seem to miss that when they announce
some new cure. It never says funded by the NIH or awarded. So
we need to work on that. Maybe require it when they get grants.
But working with colleagues at Oklahoma State University
and the University of Oklahoma Health Science Center,
researchers at the Oklahoma Medical Research Foundation are
using a novel three-dimensional model made up of human tissue
to study the now respiratory--and I will get this wrong. But is
it syncytial virus? Well, I won't try it twice. Thank you. A
virus that affects the lungs.
This virus is the leading cause of pneumonia worldwide. It
can take a particularly heavy toll on children, infecting more
than half in their first year of life and nearly 100 percent by
age 2.
The virus is highly contagious, and for those with weakened
immune systems from conditions like asthma, it can be dangerous
and even deadly. These researchers hope to reveal what
predisposes infants to severe infection and to create a
launching pad for therapies down the line.
This lung in a petri dish model could prove to be valuable
for studying other lung infections like flu, allergies, and
asthma.
Another area of focus for the Oklahoma Medical Research
Foundation is lupus. Lupus affects up to 1.5 million Americans,
but it exacts a particularly heavy toll on African Americans,
Hispanics, and Native Americans. Lupus is a chronic autoimmune
disease that causes inflammation throughout your body.
An autoimmune disease is a condition in which your body's
own immune system is responsible for the inflammation and
breakdown of its own cells. The inflammation seen in lupus can
affect various organs and tissues in the body, including one's
joints, skin, blood, and internal organs. The disease can be
severe and potentially life-threatening. It can cause permanent
organ damage. Currently, there is no known cure for lupus.
Lupus remains a top 10 cause of death in African-American
and Hispanic women between the ages of 15 and 45, and to
understand more about it, scientists are conducting large-scale
genetic analysis of thousands of lupus patients and thousands
of healthy volunteers. They will focus on 25 genes that have
been previously linked to the disease. Their goal is to
identify the genetic culprits that disproportionately burden
African Americans with lupus.
The study builds on the ground-breaking work that the
Oklahoma Medical Research Foundation has already done in the
lupus space, including discovery by one of its own researchers,
Dr. Judith James, that anti-malarial medications can actually
relieve and delay the symptoms of lupus. Because of Dr. James'
discovery, these medications are now part of the standard
treatment of care for many lupus patients.
There are countless stories like these of ground-breaking
research taking part across the United States as a direct
result of NIH funding. NIH fosters such ingenuity. A simple
idea from one lone researcher can open an entirely new field of
medicine and biomedical research. All Americans benefit from
this research. Future generations will benefit from the untold
promises from the research being done today.
Despite some of the controversy that can surround this
bill, support for research at NIH has been broad, bipartisan,
and been supported by leadership in the House and Senate alike.
I do not want to take up any additional time recognizing
all the Institute Directors before us today because, quite
frankly, I would rather hear from them about their exciting
research. But I do want to thank each of you and your
colleagues and those Institute and Center leaders who are not
with us for their passion, dedication, and hard work.
I believe the work of the NIH has and will change the
course of disease detection and treatment for generations to
come. I hope Congress continues to be a supportive partner in
these efforts.
Thank you, Madam Chair, for holding this hearing. I yield
back my time.
Ms. DeLauro. Thank you very much, Congressman Cole.
I would just say I am not going to go into what they do,
but I am so proud that Yale School of Medicine has one of the
Clinical and Translational Science Awards. We are a hub, and
there is amazing work that gets done there as well. So we thank
you for that.
And with that, let me yield to the chairman of the
Appropriations Committee, my colleague Congresswoman Nita
Lowey.
The Chairwoman. And I thank my chair of this extraordinary
committee for this hearing, which is so very, very important.
And I thank--I am sorry you are leaving, but I thank my
good friend Mr. Cole for holding this hearing. There is no
question that whether it is Chairman Cole or not Chairman Cole,
there is bipartisan support for the outstanding work you are
doing, and I really thank my good friend Chairwoman DeLauro for
holding this hearing.
And I welcome our esteemed panelists, Dr. Tromberg, Dr.
Perez-Stable, Dr. Langevin, Dr. Austin, Dr. Brennan, and of
course, Dr. Collins. I have been greeting you with a big smile
for many, many years, and I really appreciate all that you and
your team are doing.
Earlier in the year, however, the Trump administration
submitted a budget that would cut the NIH by almost
$5,000,000,000. It is crystal clear that President Trump
doesn't really understand the nature of this committee and how
bipartisan it is and has no regard for the National Institutes
of Health and the cutting-edge work you do to save lives,
advance cures, improve the health of Americans.
Despite the President's heartless and misinformed efforts
to gut the NIH, we have responded resoundingly. Unlike the
President, my colleagues and I prioritize the health of all
Americans. We are on track to invest billions more than the
President would for our world-class National Institutes of
Health.
Our House-passed fiscal year 2020 Labor, Health and Human
Services, Education, and Related Agencies bill would provide
$2,000,000,000 more for the NIH, including a critical across-
the-board increase for all the NIH Institutes and Centers. This
would allow the NIH to better respond to scientific
breakthroughs that result from astonishing foundational
research done at the Institutes, such as those with us today.
We have the distinct pleasure to hear from several
Institute Directors who are leading innovation in their
respective fields. And there is so much innovation going on,
Dr. Collins, I don't know if you just threw the numbers of the
Institutes in a hat to try and pick which ones are here today,
but I really look forward to hearing your remarks.
Not only will we hear about the encouraging advances
achieved to date, but also the exciting innovations that are
just over the horizon. We are talking about lifesaving
achievements that, with our continued commitment and
investment, could soon be on our doorstep, thanks to the NIH's
extraordinary work.
So rest assured, the administration's attempt to slash your
budgets will not stand. We remain committed to ensuring that
you have the tools and the resources you need to deliver for
the American people.
So I really do want to thank you, and I look forward to our
discussion. Thank you all for everything you do just to improve
lives.
Thank you.
Ms. DeLauro. Thank you.
We now will proceed to opening statements from the NIH
panel. We have six witnesses today. So what we have done is to
ask you to please offer 3 minutes of opening remarks. I am
sorry to curtail the 5 minutes, but we want to get it all in,
and then the opportunity to be able to ask our questions.
And Dr. Collins, again, welcome. Thank you for being here
today. And you know the drill. The full testimony will be
entered into the hearing record.
You are now recognized for 3 minutes. Dr. Collins.
Dr. Collins. Thank you.
Good morning, Chairwoman DeLauro, Ranking Minority Member
Cole, distinguished subcommittee members. Yes, I am Francis
Collins, Director now for slightly over 10 years of the
National Institutes of Health.
On behalf of NIH, I want to thank the committee for your
work on the fiscal year 2020 Labor, HHS funding bill that
passed the House in June. We are really grateful for your
ongoing and bipartisan support, and we were very pleased to
host a visit by some of you last week.
Today, I am joined by the leaders of 5 of the NIH's 27
Institutes and Centers. Let me start by introducing Dr.
Christopher Austin, who is Director of the National Center for
Advancing Translational Sciences, NCATS. Like you, I am always
impatient for basic research discoveries to be translated into
new ways of combatting disease. To date, we have identified the
molecular causes for more than 6,500 diseases, yet treatments
exist for only about 500.
So addressing that gap requires translational research. One
of my first initiatives upon becoming NIH Director was to ask
Congress to create NCATS to speed this process, and you did,
and here is the Director.
Next up is Patricia Flatley Brennan, who is next to me on
my left, your right, Director of the National Library of
Medicine, NLM. Like everything at NIH, NLM's activities are
focused on innovation that advances biomedical research. One
way it does this is through PubMed Central, a database that
provides access to more than 5 million articles from biomedical
journals.
Another is through ClinicalTrials.gov, the online catalogue
of public and private clinical trials, which, by the way, is a
great resource to share with any of your constituents looking
to take part in medical research. That is where you can find
those trials.
Now meet Helene Langevin, Director of the National Center
for Complementary and Integrative Health, NCCIH, which this
very week celebrated their 20th anniversary. In fact, it was
you, this subcommittee, that established this Center back in
1999, citing the need for more scientific evidence on
complementary health practices. That need remains great today.
Next let me introduce Dr. Eliseo Perez-Stable, Director of
the National Institute on Minority Health and Health
Disparities, NIMHD. I think it is important for you to meet him
for many reasons, including at your April hearing, many of you
asked about health disparities and the critical issue of
maternal mortality.
Also part of today's distinguished lineup, at the end on my
right, your left, Bruce Tromberg, Director of the National
Institute of Biomedical Imaging and Bioengineering, NIBIB. His
Institute engages engineers and other new types of
investigators to push the innovation envelope to create
smaller, faster, and less expensive medical technologies.
So, again, I thank you for this opportunity. I hope what
you hear today helps explain why I am so excited to lead all of
NIH's Institutes and Centers. Working together to encourage
this next generation of researchers, I can assure you we will
speed the path from discovery to health.
My colleagues and I will be happy to entertain your
questions.
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Ms. DeLauro. Thank you very, very much, Dr. Collins, and
for being so succinct.
Dr. Collins. It is unusual for me, I know. [Laughter.]
Ms. DeLauro. Please now let me just recognize Dr. Tromberg.
Thank you again. Your full testimony will be entered into the
hearing record. You are recognized for 3 minutes.
Dr. Tromberg. Thank you.
Madam Chairwoman and members of the subcommittee, it is an
honor to participate in your hearing and represent the
thousands of talented engineers and physical scientists across
the country who are developing innovative new technologies to
improve human health. I have only been Director of the NIBIB
for about 9 months, but I have spent 30 years pioneering new
optics and photonics technologies and training students as a
professor of biomedical engineering and surgery at the
University of California.
NIBIB's mission is to transform through engineering the
understanding of disease and its prevention, detection,
diagnosis, and treatment. We support cutting-edge research that
can be applied to a broad range of biomedical healthcare
problems by building strong partnerships with industry,
academia, Federal agencies, and every NIH Institute and Center.
Our programs lead to better, faster, and less costly ways to
advance technologies from blackboard to benchtop to bedside.
NIBIB supports about 1,000 grants each year in four major
technical areas--computation and artificial intelligence,
engineered biology, sensing and imaging, and advanced
therapeutics. One of our most innovative and practical sensing
platforms has been developed to address the widespread problem
of food allergies.
We all know that eating out can be an anxious, even life-
threatening challenge for millions of Americans. Recognizing
this widespread public health problem, researchers have
developed a rapid, quantitative point-of-care technology. It is
small enough to fit on a keychain and can test for common
allergens such as gluten, milk, or nuts at your table in less
than 10 minutes.
Small personal sensor technologies are also helping drive
the development of new personalized imaging platforms. To help
address the challenging problem of breast cancer detection
painlessly and without x-rays or contrast agents, researchers
are using invisible laser light pulses that are one-billionth
of a second in duration to create ultrasonic vibrations deep
inside breast tissue. As these sound waves are detected by
sensors on the skin surface, 3-D images of breast tissue
structure and function are formed that can be used for tumor
detection, diagnosis, and guiding therapies.
In the same way that advanced imaging technologies have
practically eliminated the once common practice of exploratory
surgery, new technologies are revolutionizing brain surgery so
it can be done without scalpels. The approach uses special
ultrasound transducers placed around the head that are
controlled to target structures deep inside the brain.
Treatments are under development for movement disorders such as
essential tremor, as well as delivering therapeutic drugs to
tumors without collateral damage.
This is a brief snapshot of how spectacular advances in
biomedical technologies are dramatically changing our world. It
is exciting to be part of this rapidly growing
interdisciplinary community of innovators. We are committed to
working together with our colleagues in every NIH Institute and
Center to better engineer the future of health for all
Americans.
Thank you for your time, and I look forward to the
opportunity to answer questions.
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Ms. DeLauro. Thank you very much.
I want to get hold of this mechanism. I am lactose
intolerant. It is really unbelievable going to a restaurant and
trying to figure out what is in what. So we will speak.
[Laughter.]
Ms. DeLauro. Dr. Langevin, welcome. Thank you for being
here today, and again, your full testimony will be entered into
the hearing record. You are recognized for 3 minutes.
Dr. Langevin. Madam Chairwoman, Ranking Committee Member
Cole, and distinguished members of the committee, I am pleased
to talk with you today about the exciting work supported by the
National Center for Complementary and Integrative Health, or
NCCIH.
My clinical training is in internal medicine, but I also
have had a longstanding interest in complementary treatments
and practices like acupuncture and yoga that originated outside
of conventional medicine but are increasingly integrated into
mainstream healthcare. The most common reason Americans turn to
complementary and integrative practices is chronic pain, and
NCCIH devotes 40 percent of its portfolio to research related
to pain and pain treatment.
This research is now part of the HEAL Initiative, which
stands for Helping to End Addiction Long-term, an aggressive
trans-agency effort to speed scientific solutions to the
national opioid crisis, which is fueled by the highly addictive
opioids that are used to manage pain.
There is an urgent need for improved pain management,
including nonpharmacological methods and treatments. NCCIH
supports research on behavioral strategies for managing chronic
pain, improving adherence to the medical treatment of opioid
use disorders, and reducing the craving to take opioids.
Another important area of focus at NCCIH is natural
products. Nearly one in five adults in the U.S. use botanicals
and other dietary supplements such as fish oil and probiotics.
Adverse events related to dietary supplements are common,
especially when used in combination with drugs, and are
estimated to contribute to 23,000 emergency room visits each
year. NCCIH reports rigorous research on the biological
mechanisms, benefits, and potential harms of natural products
to improve the knowledge available to healthcare providers and
patients.
Integrative health means integration, but not just of
complementary and conventional treatments. It also means
integration of health as a whole. Our current biomedical
research model is superb in advancing the specialized treatment
of organ-specific diseases with increasing precision.
There is also a need for a better understanding of health
as a process involving the whole person. We know that a
combination of poor diet, sedentary lifestyle, and chronic
stress leads to major chronic conditions, including
cardiovascular disease, diabetes, degenerative joint disease,
chronic pain, and depression that tend to occur together in the
same people.
Behavioral methods, such as simple relaxation techniques,
especially when taught early in life, can equip patients with
tools to help themselves with stress, pain, and sleep for the
rest of their lives. And a good night's sleep does wonders to
stay motivated to eat better and exercise.
Advancing research on whole person health is imperative if
we want to improve the overall health of our society.
Thank you, and I look forward to your questions.
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Ms. DeLauro. Thank you very, very much. I am sure we are
all trying to figure out how to get more sleep here.
[Laughter.]
Ms. Lee. And less stress.
Ms. DeLauro. And less stress. Thank you, Barbara.
Dr. Brennan, welcome, and thank you for being here as well.
Your, again, written testimony, full written testimony is
entered into the hearing record, and you are recognized for 3
minutes.
Dr. Brennan. Thank you, Madam Chairwoman DeLauro, Ranking
Member Cole, and members of the subcommittee.
I am Patty Brennan. I am a nurse and an industrial
engineer. I have spent my career developing information
technology solutions to bring health information into the
everyday lives of people suffering from chronic disease and
illness. Now I direct the National Library of Medicine, the
world's largest biomedical library and one of the 27 Institutes
and Centers at the National Institutes of Health.
Every day, millions of scientists, health professionals,
and the public use the NLM's electronic resources to translate
research into new results, to develop new products, to inform
clinical decision-making, to devise new treatments, and to
improve public health. Let me show you what this actually could
look like, though.
Imagine you are a parent of a child newly diagnosed with
neuroblastoma, a rare childhood cancer. You have never heard of
the disease before, and you want to understand it better. So
what do you do?
Like millions of people every day, you turn to the NLM's
MedlinePlus, which has consumer-oriented information on more
than 1,000 diseases and conditions. There are 57 short articles
related specifically to the diagnosis and treatment of
neuroblastoma.
If there are no effective treatments approved for use, you
and your physician might search the NLM's ClinicalTrials.gov
database to find an appropriate study. One hundred forty-five
thousand people use the Clinicaltrials.gov database every day.
It contains information about more than 300,000 clinical
studies ongoing and completed. Today, you would find almost 100
studies related to neuroblastoma that are actively recruiting
participants across the United States.
Physicians and researchers studying neuroblastoma can use
NLM's PubMed resource to keep up with the latest findings, over
30 million citations, over 40,000 of which address
neuroblastoma. If they want to read a full-text article, they
can go to PubMed Central and find 5.5 million full-text
articles. More than 2.5 million people every day do this.
Researchers trying to discover treatments for neuroblastoma
can request use of data from NLM's database of Genotypes and
Phenotypes, where more than a dozen studies do relate
specifically to this disease.
And finally, you and your family can use the NLM's Genetic
Home Reference to get additional information about the disease
and its heritable components. Not only do we maintain enormous
databases of genes and journals, but we also have a vibrant
intramural and extramural program that develops modern data
science approaches, such as machine learning.
For example, one of our NLM-funded researchers at Stanford
has an on the moment consulting service, the Green Button, that
allows physicians to learn immediately about the experience of
thousands of patients and find out if there are any patient
like theirs, and how did that person respond.
In addition to our electronic resources, we have a human
network of 7,000 public and academic health science libraries
around the country, placing the NLM in every possible county in
the U.S. This helps build awareness of our resources and often
reaches into communities underserved.
Thank you for the opportunity to showcase the wonderful
work at the National Library of Medicine. I look forward to
your questions.
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Ms. DeLauro. Thank you very, very much. Dr. Perez-Stable,
your full written testimony will be entered into the record,
and you are recognized for 3 minutes.
Dr. Perez-Stable. Thank you, and good morning.
I would like to thank Chairwoman DeLauro, Ranking Member
Cole, and esteemed members of the subcommittee. It is really an
honor to be here today.
My name is Dr. Eliseo Perez-Stable. I am the Director of
the National Institute on Minority Health and Health
Disparities. I arrived at NIMHD 4 years ago after 32 years at
the University of California at San Francisco, where I was a
practicing general internist, educator, and clinician
scientist.
I became a researcher because of my passion for
understanding the factors that affect minority health and to
address health equity. As a practicing primary care physician,
I learned to appreciate the power of therapeutic relationships.
I witnessed health disparities in our minority communities at
every level of healthcare and noted the lack of diversity among
my peers. I came to NIMHD because of the opportunity to help
shape the field of minority health and health disparities
research at a national level.
NIMHD is moving beyond simply identifying the health
disparities that exist to understanding mechanisms and
developing the interventions to reduce these disparities. We
take into account behavior and biology; the individual and
structural social determinants of health; the built environment
where we live, learn, work, and play; how people interact in
our communities; and healthcare.
Through developments such as geographic information
systems, we can now understand the personal factors and social
interactions that contribute to disparities in defined
neighborhoods. For example, we know that life expectancy of
individuals may vary by 20 years from one neighborhood to
another within the same city, but full explanations are still
lacking.
Place matters in health. Or as many have said, your zip
code is more important than your genetic code in determining
your health.
Asthma is the most common chronic disease of children in
America and disproportionately affects African Americans and
Puerto Ricans. Ongoing research in asthma has shown that
children from different ethnic and racial backgrounds do not
respond to medication treatment for asthma in the same way.
There are genes that protect and genes that increase risk for
asthma among these populations, with environmental and
geographic factors that influence exacerbations of disease.
Lastly, we know diverse groups are more effective and
innovative in science and other fields. NIMHD's Center programs
are designed to build institutional research capacity, create
opportunity for diverse early-stage investigators to succeed,
and cultivate strong community engagement as part of the
research process.
We believe this is a sustainable intervention that will
help address the lack of diversity in the scientific biomedical
workforce. Through this scientific research agenda, I am
optimistic that NIMHD's funded scientists will lead to
discoveries that will promote health equity.
My patients from all backgrounds trusted that I would
strive to recommend the best possible clinical care for them,
regardless of the diagnosis. Ultimately, NIMHD envisions an
America in which all populations will have an equal opportunity
to live long, healthy, and productive lives.
Thank you, and I look forward to your questions.
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Ms. DeLauro. Thank you very much.
Dr. Austin, your full written testimony will be entered
into the record, and you are recognized for 3 minutes. Many
thanks for being here.
Dr. Austin. Thank you, and good morning, Chairwoman
DeLauro, Ranking Member Cole, and distinguished subcommittee
members. My name is Christopher Austin. I am a clinical
neurologist and a basic science geneticist by training, and I
have spent my career trying to bridge that gap, which we now
call translation in both the academic and the pharmaceutical
industries.
And I am now proud to be Director of the National Center
for Advancing Translational Sciences, or NCATS. NCATS was
established almost 8 years ago now to address a central
biomedical issue of our time, which is how to dramatically
accelerate translation, which is the process of turning
observations made in the laboratory, the clinic, or in the
community into interventions that improve the health of
individuals in the public.
NCATS is focused on the science of translation,
understanding of which will allow us to overcome common
roadblocks to success and increase efficiency of the
translational research process for all. In short, NCATS mission
is, to paraphrase Matt Damon's character in the movie ``The
Martian,'' is to ``science the heck'' out of translation.
A few examples to illustrate our approach and successes so
far. First, to look for commonalities. Rather than focus on
what is different among diseases, NCATS focuses on what is
common to diseases and common to the translational process,
allowing us to transition from a one disease at a time to a
many diseases at a time therapeutic approach.
For example, our Platform Gene Therapy Program is
developing standard gene therapy vehicles, or vectors, for
unrestricted use in potentially hundreds or even thousands of
different diseases.
Second, NCATS Cures Acceleration Network, or CAN, CAN
supports initiatives that advance the development of high-need
cures. The CAN Tissue Chip Program is addressing the frequent
cause of translational failure due to animal models not
accurately predicting safety or effectiveness of new drugs in
people. Tissue chips are made of human cells and can better
model human organs, diseases, and response to candidate drugs.
As an example, tissue chips of the human kidney, and I
happen to have a kidney with me here today, have been developed
to study polycystic kidney disease, a condition not well
replicated in animal models.
And finally, collaboration is a team sport. This is one of
NCATS' operational mantras, and we find that the more diverse
our teams are, the bigger the problems are we are able to
solve. So every project NCATS does is a collaboration with
another Institute or Center or an outside partner.
For example, the CTSA Trial Innovation Network, or TIN,
includes a Recruitment Innovation Center that has developed
innovative approaches to collaborating with diverse patient
communities in the planning and implementation of clinical
studies. These community engagement studios have recently
helped researchers better design studies to determine the
health effects of exercise in children with sickle cell disease
and cystic fibrosis.
Involvement of patients and communities in the research we
hope will benefit them is another central NCATS strategy for
increasing translational efficiency.
So when I became NCATS' first permanent Director 7 years
ago this week, it was unclear whether our ambitious mission to
close the translational gap could actually be achieved. Our
accomplishments since then make me more optimistic than I have
ever been that we can, indeed, both understand translation as a
science and use that knowledge to dramatically increase the
efficiency of the process of developing treatments and cures
and, in so doing, help bring the promise of science to patients
in need.
I thank the committee for its support and confidence in our
mission and would be happy to answer any questions.
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Ms. DeLauro. Thank you all very, very much.
I have a question that goes to the panel. Much of the
success of biomedical research in the U.S. is attributed to
NIH's strong support of basic research ideas and proposals,
individual scientists at the NIH, across the country, and many
of the ideas led to major discoveries came from the bottom up
and not from the top down.
At the same time, as the Director of the Institutes and
experts in your fields, you have a unique vantage point to
target resource to specific areas of research that might be
especially promising or compelling or that may have been
neglected or short-changed.
The question is how do you strike that balance in
allocating resources between investigator-initiated research
and targeted initiatives? So whoever would like to start. We
don't have to go in order, but whoever would like to start to
answer the questions.
I am going to ask each of you that question. How do you
strike that balance?
Dr. Tromberg. So thanks for your question. It is actually a
very easy one for us in some sense. We are constantly
communicating, interacting with our community. We have many
methods of convening the community together with conferences
and workshops, and we are quite responsive to state-of-the-art
and needs from the community.
As a result of many of those discussions and conferences
and working together with our colleagues, we are able to create
targeted opportunities that will respond to those needs. So
there is a kind of a push and a pull that is very dynamic. It
is ongoing. It is very fluid, and we have a number of
mechanisms for both accelerating targeted mechanisms, as well
as encouraging the individual investigator applications.
Ms. DeLauro. Go ahead, Doctor. Yes, Dr. Brennan.
Dr. Brennan. At the NLM, we sometimes release notices of
areas of interest. So right now, we have vast databases, and we
know that some of these databases may have sparse, incomplete
datasets that may be biased in some way.
So we have released a notice to the community saying we
want to understand mathematical approaches to making sure the
databases are better. We let the community decide how to
respond.
Ms. DeLauro. I will be quick about it. You both talked
about community. Identify the community.
Dr. Brennan. Oh, good, that is--thank you very much.
Ms. DeLauro. And you, too, Doctor Tromberg----
Dr. Brennan. In our case, it is the data science and
medical informatics community. And beyond them, the clinical
care community.
Ms. DeLauro. OK. Dr. Tromberg, just quickly.
Dr. Tromberg. In our case, it is the biomedical engineering
and bioimaging community, which are often distributed in
radiological science departments, radiology, and bioengineering
in the country.
Ms. DeLauro. Thank you.
Dr. Perez-Stable. So when I arrived at NIMHD, most of the
portfolio was already targeted. So I shifted some of those
funds to create a new pool of investigator-initiated
applications. And we are about 50-50 now, and I think--we will
have to see how it goes over the next several years.
So we have Center program, we have loan repayment, we have
endowment program, we have targeted programs. Now the--our
community, which are the minority health/ health disparity
scientists spread across academic health centers, schools of
public health, some organizations, non-academic affiliated
organizations, are responding to ideas that we have put out,
but also on their own ideas.
Ms. DeLauro. Mm-hmm.
Dr. Austin. And I would note and answer it this way. I
think the way we think about this, that distribution depends on
the kind of science that you are trying to do. In basic
science, the investigator-initiated model works really well
because the individual person is the unit of productivity.
I mentioned that translation is a team sport. It doesn't
matter how smart you are or how devoted you are, you can't do
it by yourself. You need a community of about 20 different
disciplines in order to do that.
So the way we tend to think about our programs, the way we
structure all of them is that we have programs, like the CTSA
program, which support individual programs, and those programs
that those individual projects happen within this ecosystem
which allows them to succeed. However, I must say one of the
things that NCATS is really working on is to have an
investigator-initiated pool, which we currently do not have,
and I think is really, really necessary for the translational
science community academically to flourish.
Ms. DeLauro. Thank you. Dr. Langevin, yes?
Dr. Langevin. Well, at NCCIH, we study treatments and
practices that are already occurring in the patient community.
This is a grassroots kind of phenomenon that is going on. So it
is a natural thing for us to want to extend our research into
what we call the real world. Now how are these treatments
actually being implemented? How is it possible to bring
something like, for example, acupuncture into a hospital and
have it be basically integrated with the rest of the care that
is going on?
So we have a sort of a translational arc that goes all the
way into implementation, and those types of grants are large-
scale projects that we perform in collaboration between NCCIH
and the outside investigators.
On the other hand, we have some investigator-initiated
basic research to understand the mechanisms. How do these
things work? How does something like acupuncture work? And so
we do basic research all the way down to animal models, and
mostly we rely on the creativity of the community to go there.
Dr. Collins. Just one sentence, if I might? This is a very
important question, Madam Chairwoman, and something that we
obviously think about a lot at NIH. I would point you to the
NIH Strategic Plan, which we put together about 3 years ago and
which is now getting ready for a refresh because it is supposed
to be done every 5 years. And it has a whole section on sort of
how do we balance investigator-initiated efforts, sort of the
bottom-up part of what we do, with identifying areas that need
a push, the top-down part, and how do we get that balance
right?
And as you heard, it is different for every Institute, and
it should be.
Ms. DeLauro. Congressman Cole.
Mr. Cole. Thank you very much, Madam Chair.
I am going to direct my first two questions to Dr. Collins
because I want to, frankly, get these on the record. As the
chair accurately pointed out, we have had 4 years of bipartisan
sustained growth here. I know that is her plan. Certainly, it
is in the bill that she has prepared for fiscal year 2020.
So, Dr. Collins, if you could quickly tell us what sort of
difference has that made in the last 4 or 5 years? I don't mean
the specific things, but just in terms of the environment for
biomedical research. And then what are the advantages if the
Congress chooses to continue on that course?
Dr. Collins. Well, I really appreciate the question, and it
has been such a shot in the arm to our whole community--and
here, I am talking about the research community across many
different disciplines and different institutions--to have had
this upward trajectory that you, the appropriators, have
managed to sustain now for 4 years, going on 5. And that has
changed the whole morale of the community in very substantial
ways.
I have got to tell you, when I would go and visit a
university in 2014, it was sometimes difficult to meet with the
trainees because they were anxious about whether there was a
future for them and whether they got into the wrong field. I
don't hear that anymore. I hear a lot of excitement and a lot
of energy.
Over these last 4 years, my gosh, the things that have
happened, a lot of them in the area of technology. You
mentioned what you saw when you went and visited in Oklahoma,
where they are making basically in a petri dish something that
they can study in infectious disease, RSV. That is happening in
lots of different laboratories with the ability to do this kind
of regenerative medicine research.
The single-cell biology revolution, which, 5 years ago, we
really didn't know how to study biology in a single cell. Now
we do, and that has just completely transformed our
understanding of human biology but also given us insights into
treatments.
In terms of the therapeutics, the revolution in gene
editing has been accelerated by the opportunity to take risks
here with something called CRISPR. And I don't know how many of
you got to see the 60 Minutes piece about 6 months ago. An
individual at our Clinical Center who appears now to be cured
of sickle cell disease because of the opportunity to take gene
therapy to a whole other level that we didn't think we would be
able to do this soon.
All of that takes a lot of money and resources. It means
taking risks where you don't know if it is going to work or
not. And you have given us that kind of confidence that we can
make those investments with this particular pathway.
The one I would say is most important, though, is actually
investing in the next generation of researchers. I was really
worried about that 5 or 6 years ago. Again, it was very hard
for a new faculty member to be sure that they were going to be
able to get NIH support, and that is kind of the requirement if
you are going to be able to run a research lab at an
institution around this country in an academic environment. We
funded about 600 of those first-time investigators in 2013.
Last year, we set a very high mark, and I challenged all the
Institutes to hit it, of 1,100. We funded 1,287.
This year, as of this morning, we also set an 1,100 goal.
We have exactly 1,287 again. And we are not done with the year
yet. So we are going to break through that. That will be a new
record. But we could not do that if it were not for the
improved circumstances that you have made possible.
And going forward, again, all of those same things apply,
the ability to ramp the technology up, to support programs like
All of Us that is enrolling a million Americans in the largest-
ever long-term prospective study of health and illness, which
is going to be critical.
The big data and artificial intelligence opportunities,
which I see maybe as one of the most exciting and significant
developments and where we have a working group that is going to
give me a whole lot of recommendations in December about how we
should be doing more in that space. All of that becomes more
possible with what we see as potentially a good outcome for
fiscal year 2020.
So I can't thank you enough.
Mr. Cole. Well, you just did. But I think you highlighted
the importance of us continuing on the path that we have
embarked on.
I have a quick question in the time I have got left that I
think you are going to want to answer, too, and that is the
National Academies of Science and Engineering and Medicine
released a report last month highlighting the challenges your
agencies face to maintain the Bethesda campus. The campus
contains more than 12 million square feet of facilities, nearly
100 buildings.
Due to insufficient funding for buildings and facilities
and other infrastructure needs, essential maintenance for many
facilities and the campus overall has been deferred for many
years. So I want to thank you for bringing this to our
attention and doing such a thorough review.
I think this is actually something that we ought to,
Chairman, interject into our discussions when the Senate
follows your lead and actually gets a bill done because I think
this is something we need to really focus on, and I would like
you just to comment on the adequacy of your infrastructure.
Dr. Collins. Well, I really appreciate that question. It is
a critical issue. As the National Academy report documented, we
are about $1,300,000,000 behind where we need to be in order to
support the infrastructure of the NIH campus, and that is
mostly the Clinical Center, the largest research hospital in
the world.
They recommended an investment of $700,000,000 over a 5-
year period just to catch up with all the deferred maintenance,
which has led to all kinds of problems that we have recently
experienced in terms of major leaks and so on. But they also
said we need another $600,000,000 for really new investments
into badly needed facilities.
The most critical one is a new surgery and radiology wing
for the Clinical Center, which currently is in a pretty
dilapidated state. We have even had situations where leaks
happen in the ceiling in the operating room in the middle of a
procedure. Obviously, we can't keep that going.
So I appreciate very much your invitation to talk a bit
more deeply about that to see if we can bring this back up to
being the finest place that it possibly could be.
Mr. Cole. Thank you, Madam Chair.
Ms. DeLauro. Sure. Thank you. Congresswoman Lowey.
The Chairwoman. Thank you again for being here. Some of us
have been working on these issues for a long, long time, and if
it were up to us, we would keep raising that number, as Mr.
Cole knows.
Dr. Tromberg, I am particularly concerned about a lack of
early detection tools for certain cancers, in particular kidney
and pancreatic cancer. I understand your Institute is
supporting research related to point-of-care technologies,
which may be used for more efficient diagnosis of some cancers.
If you could explain some of those technologies, what advances
in detection are on the horizon, I would be most appreciative.
In one of my visits to one of the New York hospitals, we
were talking about just this issue, and I said, well, why can't
you--Mr. Murtha, a former, may he rest in peace, Member of
Congress, used to tell all of us we should get a scan every
year so we know what is happening everywhere.
Is that the reason? Is it cost that we are not doing more
of this? Or could you respond to me with a technical response?
Dr. Tromberg. Thank you, Congressman Lowey. There are so
many things that are happening that are super exciting. So I
will try to condense this as best as I can.
In general, there is really a revolution going on in micro
and nano devices, such as some of these that I have brought
with me, an optofluidics device that can analyze body fluids
for cancer components. So you have heard of liquid biopsies. We
are able to detect DNA from cancers. We are able to detect
proteins, tumor-associated antibodies.
We know they exist, but we need the technologies to be able
to measure them quickly at the bedside with very, very
sensitive hardware and computational approaches. These are some
of the things that are going on, liquid biopsies.
We are also developing imaging technologies at the point of
care. So what does that mean? Can we have a personalized
ultrasound, for example, at the point of care like this one
that we have helped develop? Or do we have optical sensors that
can measure tumor metabolism right at the bedside and see how
patients are responding to chemotherapy, and here is one of
those that is under development.
There are also sensors that can be implanted in you and
follow whether or not you may have cancer and then deliver
lifesaving vaccines or therapies like this microneedle patch.
So this is a platform technology of disposable microneedles
that once they go inside you painlessly, and they can be
delivered to your home. They go inside you. You can't see the
needles. And they deliver what their payload is, and then the
needles disappear. And then you can get another one in the
mail, and you can do it again and again and again.
And they can be built with very smart chemistry inside them
to be able to sense things and then deliver the therapy. So
closing that feedback loop.
So there is an explosion of technologies. Big imaging
technologies as well are improving dramatically, and there will
be a time where we are able to go into scanners and have full-
body imaging and be able to see early-stage disease. This is
coming. This is actually happening through your investment and
support.
The Chairwoman. I have a little more time. How widespread
are these technologies being used now? Are they just at the
NIH, Dana Farber, MSK in New York? How widespread are these
technologies?
Dr. Tromberg. So we have--thank you for that question. We
have mechanisms to try and dramatically expand this. So we have
30 advanced biomedical technology centers that we, at the
NIBIB, support all around the country. Many are developing
these technologies.
We have five point-of-care technology research centers that
are networked and coordinated. So this is where the discovery
and the validation is occurring. They are also all deeply
engaged in the dissemination and the movement of the
technologies, as I mentioned before, from the blackboard to the
benchtop to the bedside, ultimately for commercialization.
So we work very closely with the FDA in order to ensure
that once these things are validated, they actually get out to
impact the most number of people.
The Chairwoman. This is quite extraordinary, 53 seconds. We
have been talking before about the translational science
spectrum includes turning observations found from basic,
preclinical, clinical, clinical implementation, and public
health research into tangible intervention.
I just wonder--maybe I should go back to Dr. Collins
because we used--or whoever else wants to answer quickly, or
with the permission of the chair, you can all answer. Because I
can remember very clearly years ago, no names, having these
discussions with a former person who had your position who was
totally focused on basic research.
So do we have another couple of seconds if someone else
wants to answer this?
Ms. DeLauro. Very few.
Dr. Collins. I think probably the NCATS Director would have
an appropriate response to this.
Dr. Austin. Well, I certainly appreciate the question. You
know, from our vantage point, basic research is, of course,
absolutely critical. That is the seed corn that we translate.
But it is necessary, but not sufficient to get treatments and
cures to people.
And the focus that we have is on how slow that process
currently is. You probably know it takes around 15 years to go
from a fundamental discovery to a treatment that is approved,
and another 15 years to get it to all the people who can
benefit. And the success rate is less than 1 percent.
And that is one of the reasons why this thing takes so
long, this effort takes so long and costs so much. And what is
interesting about that process is that we just don't understand
it. We don't understand the fundamental science of that
translational process. It has never been studied as a science
before, interestingly. And that is what NCATS is doing.
So we are firm believers that like every other science,
whether it is engineering or genetics or data science, once we
understand the fundamental principles of the translational
process, it will turn this from a trial-and-error
phenomenological failure-prone process into a predictive
science. And that will bring the promise of all of this basic
research to people.
The Chairwoman. Thank you, Madam Chair.
I just want to say one more word because having been on
this committee a long time, I think the hardest thing to do
with regard to that issue is how you identify and prioritize.
Dr. Austin. Yes. [Laughter.]
The Chairwoman. When you get past the basic research, then
where do you go? But I will save this. I won't take any more
time.
Ms. DeLauro. Congresswoman Herrera Beutler, welcome back.
Ms. Herrera Beutler. Thank you, Madam Chair and full
committee chair. It is a pleasure to be here.
You know, of course, we could all sit here and talk to you
all for a long, long time. I was bummed to miss last week. I
was flying back from the district. Otherwise, I would have been
up.
But I notice that there are different folks here than
generally when you come, which I love. So you are getting us a
full circle. There is a couple of pieces I wanted to try and
hit.
The first one, you know, how you identify and then turn it
into I think what she would say--identify where to spend the
money and then how it gets down into that. You know, we have
had some conversations around Down syndrome research and making
sure that the funds follow the congressional intent. The other
piece on that, you know, I was asked to cosponsor, which I will
be, a childhood cancer bill with regard to research.
And what the bill does is it would ensure that Federal
funds for pediatric research match the same percentage of the
number of American citizens under the age of 18 as part of the
general population.
One of the things we have seen in our hearing from
different areas, I hear it from disease groups, is that the
piece that goes into children's--treating children's diseases
or research on childhood cancer, for example, tends to lag
behind, obviously, the adult population, even if it is a higher
incidence in a younger population.
I am wondering how--and this might be a translational
piece--how we make sure--our job hasn't been to dictate, okay,
this is where you are going to do all the research, and this is
how you are going to fund it. We are not the scientists. You
are. So we have given that responsibility to you.
However, when we have constituents who come back to us and
say, well, we don't see that the money that we are helping, you
know, is actually trickling down proportionally. Help us either
answer that question or make those changes, and I will throw
that to you, Dr. Collins, to give to whoever.
Dr. Collins. It is a great question, and I will start out,
maybe figure out a way to draw at least one other person in on
this.
Certainly, we are completely in accord of the importance
for focusing on childhood cancer research, given how incredibly
painful and tragic these diagnoses can be, and where we still
have many of these childhood cancers that we have not been able
to find cures for. Let us point out that, happily, for many of
them like leukemias, we have done extremely well. But we need
to do that for all.
We currently spend $514,000,000 a year on childhood cancer
research, but that just counts the part that you can say this
is research that we know is directly relevant to that. Many of
the advances that have happened in children's cancer have come
from unexpected directions, and a lot of it from very basic
science, just understanding what makes cells divide when they
are not supposed to because that is really what cancer is.
So if you really tried to add up all of the things that are
probably relevant, it would be a larger number. But I
understand the concern of advocates who feel like there is
still more that needs to be done.
I was pleased that this committee put an additional
$50,000,000 in your mark for fiscal year 2020, and we certainly
will find lots of ways to take advantage of that.
It would be the case, I think, though, that the advances
right now that are happening in terms of genomics have opened
up new potential. The Pediatric MATCH trial, which now makes it
possible for children with otherwise not treatable solid tumors
to get into a very creative clinical trial mechanism, is making
it possible for lots of these new ideas about therapies to be
tried out in a very efficient way and access being offered to
those who need it.
Maybe I will ask Dr. Austin to just say a word because I
know NCATS is working on DIPG, which is one of the most
frustrating and horrifying----
Ms. Herrera Beutler. That is a great example.
Dr. Collins [continuing]. And tragic circumstances, diffuse
intrinsic pontine glioma.
Ms. Herrera Beutler. And I want to hear about this briefly,
but then I also want to ask a question over here.
Dr. Collins. Okay. So, Dr. Austin, quickly.
Ms. Herrera Beutler. Thank you.
Dr. Austin. Just briefly, DIPG stands for diffuse intrinsic
pontine glioma. It was an absolutely horrific childhood cancer
with a very, very short life expectancy in months, and we have
teamed up with a number of academic investigators to develop
and deploy a new way of identifying combination treatments that
will be--that will treat these children.
And as we know, very rarely does one drug treat these
children, and it has been a trial-and-error process to figure
out how to do those. And those children don't live long enough.
And so we have developed a novel technology at NCATS that we
are developing with academics and with the NCI that allows us
to take those cells from the children and screen across tens of
thousands of different combinations very, very efficiently and
then deploy those very rapidly in the clinic.
Ms. Herrera Beutler. I have a constituent who is taking
part in that and am excited to see the progress.
Really briefly, so what you are talking about with all
these different devices, and you totally lit up--clearly, you
are--it is almost like the Silicon Valley space because like
why not? Let us do it. Let us make this work. Which I
appreciate very much because I feel like we often are way
slower than that.
Speaking of slow, is the FDA--so with all these promising
technologies and to her question about, okay, how do we get
these out? How do we get this working? What is the biggest
slowdown that we could help with? Because, obviously, we have
been working on the money piece--and within like 2 seconds.
Dr. Tromberg. Yes, thank you. This is a great question, and
I, as a technology developer, and all of the community that I
represent, we think about this a lot. So we have sat down with
the FDA many times and have tried to identify bottlenecks, and
some of these are quite famous. We all know about ``valleys of
death.''
One of the ones that we have worked with the FDA to try to
understand is how do they develop standard reference methods to
evaluate the 25,000 or 30,000 new applications for devices that
come in? Every one that comes in has a validation method, and
so that gives them 20,000 different validation methods.
So we are working with them to identify and validate
validation methods. So this can potentially increase the
throughput. We are also working to develop and fund prototypes.
Because you can have a device, it may look cool. This is a
pretty good prototype. But in the end, we want it to look like
this.
So we have to get to the prototypes faster, and then we
have to have these validation methods that are more uniform and
applicable to all classes of devices.
Ms. Herrera Beutler. Thank you. Thank you, Madam Chair.
Ms. DeLauro. Thank you. We also have to make sure that we
don't cut corners in terms of devices so that we put people at
risk. That really has happened over and over and over again. We
need to take a very, very hard look.
It is great to get something to market quickly, and I will
make reference to e-cigarettes and so forth, without any
premarket review. And there we go, in terms of difficulty and
deaths. We are not talking here a park or a road. We are
talking about people who potentially can die. So we have to be
careful in cutting those corners.
Let me--Congresswoman Lee.
Ms. Lee. Thank you very much.
Thank you, Dr. Collins, for being here. Thank your team. It
is always good to see you and to know that you are continuing
with this life-affirming and lifesaving work.
A couple of questions I would like to ask. Well, I have
three that I am going to try to get in.
First of all, let me just mention this request that we had
made in terms of the participation of black men in the medical
profession. We inserted into the report language in 2019 to
coordinate with NIH to review the proceedings of a joint
workshop on this topic because, of course, African-American men
in medical schools are very underrepresented. And so I just
wanted to get a status on that because we hadn't received the
report back.
Then my second question has to do with Dr. Langevin. I want
to thank you for being here. I have witnessed the benefits of
complementary and integrated health as it relates to pain
management, also as it relates to preventing--as an alternative
to surgery.
My late mother, who I mentioned in this committee, had COPD
in her latter life, and thank you for the action plan, and we
are following that. But when I was a child, my mother went to a
chiropractor. I mean, this is in the like late '50s and '60s.
And it worked.
Secondly, when she was in her mid-eighties, she needed a
knee replacement surgery in her left knee. She--in her right
knee. She got the surgery, and it was fine. But when she turned
89, she needed her left knee, and the doctor said because she
had COPD, high risk, blood pressure--high blood pressure, he
didn't recommend it.
One day, she was out, and she was in a lot pain, getting
her walker repaired, and a woman--and she was complaining about
her knee--gave her some lotion. And she tried it, and she never
was in pain anymore. And I would call her and just say, ``How
is your knee?'' And she said, ``It is drunk.''
This was cannabis lotion. So I have witnessed at least my
mother and other senior citizens, the health benefits of
cannabis. So I don't know if NIH is authorized to conduct
research on cannabis, but I know good and well, based on
personal experience, that it works for some people.
And then, finally, let me just ask you about the HIV/AIDS
strategy and the funding, and hopefully, we will really see our
goals of ending HIV and AIDS by 2030. And so I want to thank
you all for your continuing work and just want to know how this
is going to work now that we are going to increase the funding
for domestic AIDS, for our domestic PEPFAR and, hopefully, will
end it soon.
Thank you.
Dr. Collins. Thank you. Dr. Perez-Stable would like to
start with the first question.
Dr. Perez-Stable. Well, the situation of diversity in the
scientific biomedical workforce, as well as the clinical
medical profession, is a dire one. And I agree with you that we
face an urgent crisis to diversify our professions. Black men
in particular are notable here, but it is across all
underrepresented minority--race, ethnic, minority groups.
We have empirical evidence that more clinicians of these
groups take care of more poor people, more people that look
like them, people who don't speak English. And this has been
consistently shown in three different studies over the last 30
years.
Whether the scientific workforce also benefits from this
diversity, we don't know. But Dr. Hannah Valentine and others
at NIH are working on this.
Ms. Lee. Sure. But the National Academy of Sciences and
Engineering, they had a report that came out and had a joint
workshop, and we put into the bill we wanted you all, NIH, to
work with the Academy and report back in 180 days what we were
going to do in terms of increasing the representation based on
the recommendations of the 2017 workshop.
So I would like to make sure we get that report as soon as
possible because this is a dire situation.
Dr. Collins. Yes, I agree. It really is a very serious
concern. We are working with HRSA on that, as you can imagine,
since this is a critical part of their agenda as well, which is
training of the medical professional. And we will get back to
you.
Ms. Lee. Thank you. And Dr. Langevin.
Dr. Langevin. Well, thank you for the question about
cannabis. Certainly, it is available now. People are using, for
example, CBD in the form of oils and lotions, and the public is
using this.
And so we are essentially now playing catch-up with what is
already happening. We need to understand the potential
beneficial effects of some of these compounds derived from
cannabis and particularly for pain. There is a lot of potential
there. NCCIH has just funded seven grants for looking at the
basic mechanisms of cannabinoids and minor terpenes, what we
call the different components of cannabinoids, that could be
useful for pain.
And we really want to understand how it works, but also we
are very interested in looking at potential interactions of
cannabis with drugs. Because when people take these
cannabinoids--or CBD--with medications, there can be some
problems.
Ms. Lee. Sure, yes.
Dr. Langevin. So we need to understand that as well.
Ms. Lee. And it is important, but since so many States have
passed medical marijuana laws now, we need to catch up with
NIH, and I want to find out legally can we do that? Or how can
we help you catch up with where the States are in terms of
their----
Dr. Langevin. Yes. Well, the issues of regulation is a
broader matter I am going to defer to Dr. Collins on that.
Dr. Collins. Yes, we do have a problem in that because
marijuana is Schedule I. It is difficult to set up research
programs, and we have certainly been talking about the need for
some kind of an alternative pathway so that we could do
research on potential valuable uses of marijuana without going
through such an incredible bureaucratic rigamarole that it
scares away most investigators from even doing the work.
And we could use some help from Congress in coming up with
a better strategy about that part.
Ms. Lee. Thank you, Madam Chair. I would like to work with
you on that for our next bill.
Thank you again very much. Thank you for being here.
Ms. DeLauro. Congressman Harris.
Mr. Harris. Thank you very much.
And you will be pleased to know we have a bill filed that
it does exactly that. It has been bouncing around for a couple
of years. Hopefully, it has some legs that will make research
into the potential beneficial use of medical marijuana much
easier before it further expands with, I think, a lot of false
hopes.
Dr. Langevin, you are absolutely right. There are
definitely interactions. In fact, published just last week in
the anesthesia literature was a study that looked at people who
used medical marijuana, whether or not they had more or less
pain after joint surgery, and found out that they had more pain
after joint surgery.
Clearly, this is not a drug that acts only on its own. It
clearly interacts with other systems in the body, including the
analgesic systems in ways that we don't fully understand.
But I am going to ask a question on a very different topic,
but it is a very timely question because next month, the Harris
Funeral Homes v. EEOC case will be heard a couple blocks down,
the Supreme Court, which, of course, involves sexual
orientation and gender identity. And as you know, Selina Soule
and Alanna Smith, two female runners in Connecticut, have filed
a complaint with EEOC about gender identity issues with sports.
Now my daughter is an all-American Division I athlete. I
have talked to her about this issue, and she just can't
understand how you could possibly have men competing against
women in a women's sport.
But let us talk about medical research now because a lot of
times before this committee, you have said, yes, it is very
important. We study men, and we study women. When we look at
something, we should be studying men, and we should be studying
women.
So I have a very simple question. If you have a transgender
woman who would like to participate in a study, are they going
to be assigned to the men or the women? And Dr. Collins, I
guess first question is to you because sex is genetically
determined 99 percent of the time. That is what I learned in
medical school.
Now maybe I am wrong. Gender may be different. But in fact,
when you are doing this research, is it sex or gender that is
important? Where are the differences? And how would you do
that?
And in fact, if you say, well, we are just not going to
assign that person, isn't that discrimination against them? And
depending upon what the outcome of this case is, where does
this stand at the NIH?
Dr. Collins. Very important issue and, obviously, a very
timely one. And we noted with interest and concern a few years
ago, the Institute of Medicine's report on health of
individuals who are LGBT, and it is clearly an indication that
this is a circumstance that is associated with bad health
outcomes, particularly in terms of mental health issues,
depression and suicide.
So we took that very seriously and actually have set up at
NIH a Sexual/Gender Minority Office to try to be sure that we
are paying attention to what the research needs might be to try
to better understand that as a health disparity.
Mr. Harris. Excuse me. Can you just define what a sexual
minority is? I am not sure I understand. I understand a gender
minority. Can you define a sexual minority.
Dr. Collins. I am not sure I want to try.
Mr. Harris. You are a scientist. Look, this is science, and
we hear all about science deniers and all. What is a sexual
minority?
Dr. Collins. I think at the present time, without trying to
be too precise about it, most people would say those who are
not in a traditional heterosexual role would be considered a
sexual minority, and that would be LGBT and others in that
category.
Mr. Harris. So as a scientist, you believe that sex is not
binary and 99 percent, it is not based on genetics?
Dr. Collins. I believe that sex assigned at birth is very
heavily, probably 99 percent or so, influenced by genetics. Let
us not forget, though, there are individuals who are born with
ambiguous genitalia where sex is not obvious.
Mr. Harris. I was very specific. I said 99 plus percent. I
didn't say 100 percent. I am being very--this is serious
because our colleagues in the third branch are going to have to
rule, I think, on what some people feel is a scientific
question, the definition of sex.
Now they may also rule on the definition of gender, I am
not sure. But the law, Title VII, which is what is under review
by the Court, uses the word ``sex.'' And as a scientist, I want
to ask you what is the definition of sex?
Dr. Collins. Again, as I said, I think at birth, sex is
highly, 99 percent associated with the genetic measure of
whether there was an X--whether there is an XX or an XY
chromosomal constitution.
But let us be clear. Biologically is one thing that one's
actual personal identity can be in a different space. I think
that is a very complicated issue that I am probably not saying
anything particularly novel or illuminating about in this
conversation, but one that needs to be respected for those
individuals who find themselves in a circumstance where they
are not comfortable with their genetic sex----
Mr. Harris. So how will NIH, which study will the--arm will
the NIH put a transgender woman into? The male arm or the
female arm?
Dr. Collins. Well, it might be that that study was actually
looking at transgender women and trying to understand----
Mr. Harris. Dr. Collins, if it is looking at the metabolic
studies on female collegiate runners, is a transgender woman
going to be assigned to the female or the male branch? And if
they are assigned to the female branch, isn't there a risk that
it makes the study less valuable and applicable to female
runners?
Dr. Collins. I don't have an easy answer to your question.
Mr. Harris. Thank you very much.
Dr. Collins. I think most of my studies would ask for sex
assigned at birth.
Mr. Harris. Thank you very much.
Ms. DeLauro. Congresswoman Roybal-Allard.
Ms. Roybal-Allard. First of all, Dr. Collins, let me just
say thank you for a truly informative and very hopeful tour
last week of NIH----
Dr. Collins. So glad you all were with us.
Ms. Roybal-Allard [continuing]. And I just want to say that
I also share my concerns about the infrastructure that we
talked about and look forward to working with you on that.
Dr. Perez-Stable, as you mentioned, research has not always
been inclusive of certain population groups like racial and
ethnic minorities, and this has resulted in treatment and
healthcare practices that do not work with the same
effectiveness for everyone. The All of Us research initiative
has the potential to radically change what we know about
minority health and how we approach the elimination of health
disparities.
What was NIMHD's role in the development of the All of Us
initiative, and how are you currently working to recruit and
retain diverse and inclusive minority populations in this
research program?
Dr. Perez-Stable. Thank you, Congresswoman, for that
question.
So I arrived at NIH just as All of Us was being conceived.
So the Precision Medicine Initiative was all the buzz when I
got here 4 years ago, and I have been supportive and
enthusiastic supporter of the cohort study and, in fact, have
been one of the Directors who have worked with Eric Dishman on
his ``kitchen cabinet'' of IC Directors.
So we are very enthusiastic about it. First, on the fact
that it will be a tremendously rich research resource for
future investigators. It already is the largest cohort study of
Latino participants and African-American participants in the
country, although it is not yet fully developed, over 200,000
fully enrolled. And so we are very, very supportive of it.
I would add that the inclusion of diverse participants in
NIH clinical studies has actually improved a lot. So we are
about 30 percent now and that one of the problem areas have
been in genetic studies, and we are working systematically to
address that.
Ms. Roybal-Allard. It seems to me that there are multiple
opportunities for NIMHD to consult and to collaborate with
other Institutes to help to define a better focus on health
equity and to ensure appropriate minority representation in
clinical trials. What unique portfolio has NIMHD defined for
itself in the 10 years since it was elevated to an Institute?
And can you give us some examples of research studies that are
being led by NIMHD?
Dr. Perez-Stable. So thank you again.
Our involvement with other Institutes is full. I have met
with all of them. We have common areas with every single
Institute and Center on the NIH campus. We have, for the last 4
years, been working on redefining the categories of minority
health/health disparities, how these apply, going through a
detailed scientific visioning with NIH scientists, as well as
extramural scientists, and have a strategic plan for all of NIH
that we have led for minority health/health disparities that is
almost completed.
It needs just to go through the final clearance processes.
So I have presented to the Institute Directors and have worked
with them on.
Now we, NIMHD participates in several important NIH-wide
programs. We co-fund the Jackson Heart Study and the Hispanic
Community Health Study out of the National Heart, Lung, and
Blood Institute. We work closely with National Institute on
Drug Abuse on the ABCD, the adolescent cohort study. And just
we agreed to continue supporting that.
We have been part of the Centers for AIDS Research that
primarily are funded through the National Institute of Allergy
and Infectious Diseases.
We also, when we put out a call for our own research
community, we asked other Institutes are they interested, and
we had a terrific participation for a very timely post-
Hurricane Maria research in Puerto Rico that had to be from
Puerto Rico. And we had six different Institutes agree to set
aside money if they got applications that were in their area.
And sure enough, National Institute of Mental Health, National
Institute on Drug Abuse, and National Cancer Institute, and
National Institute on Aging all had applications that they
funded, along with the 9 or 10 that we funded ourselves.
Ms. Roybal-Allard. And just one final question. I
understand that there have been some challenges with the NIMHD
research endowment program, and I am not going to elaborate on
what those are. But has that been reinvigorated, and how does
the endowment program contribute to the mission of your
Institute?
Dr. Perez-Stable. So, briefly, the endowment program is
money that the NIH provides to an institution that to be
eligible has to have less than the 25th percentile of the
average endowment for academic institutions. That they need
they have to bank for at least 20 years after the end of the
grant.
So the amount varies. Right now, it is at $2,000,000 per
year. They can get it for 10 years. So you can do the math,
$20,000,000. They use the interest to develop programs that
promote their research capacity in minority health/ health
disparities. Most of the institutions are working on issues
around training and other sort of infrastructure that relate to
research, not administrative work.
We have gone through--our advisory council went through a
review in the first year I was here, and there are no
restrictions on applications. Right now, our budgetary
allotment was full, but in fiscal 2020, we will have another
Funding Opportunity Announcement, and there will be no issues
with eligibility.
It has been linked to having a Center of Excellence funded
either from HRSA or from NIMHD. And we believe that is a
limitation that will actually limit the number of institutions
much more than anything else that we have.
Ms. Roybal-Allard. OK, thank you.
Ms. DeLauro. Mr. Moolenaar.
Mr. Moolenaar. Thank you, Madam Chair.
Dr. Collins, welcome back, and great to see everybody here
today, and thanks for participating.
I had a couple areas I wanted to ask about. I know in May,
there was a symposium that NIH participated with the USDA,
looking at a collaboration on research opportunities that may
lead to translational benefits in other fields looking at
animal research and how--and specifically on farm animals. And
I am just curious as to kind of where you see that going and
maybe what benefits might come out of that?
So that is one area I wanted to talk about, and then the
other area I wanted to ask you to address is antimicrobial
resistance and kind of what our strategy is for combatting
superbugs, if you will?
Dr. Collins. Thanks. Those are both great questions, and I
will start. If others want to jump in, they should signal me.
Basically, you are quite right. There are great
opportunities for looking at health issues by comparing what
happens between animals and people. We are all rather similar
when you start looking closely at various metabolic pathways
and illnesses that can happen.
Certainly, we at NIH have tried throughout many decades to
try to build on that, and certainly, there are many instances
where illnesses that we want to understand in humans, a model
appears in a farm animal, and we can learn something from that,
both in terms of what the actual mechanism is and what possible
treatments might work.
So, for instance, right now, we are having great concern
about EEE, this Eastern Equine Encephalitis, which has had a
particularly bad outbreak in a few States and has killed some
young people and some middle-aged people. And that is, of
course, really a disease of horses, and the more that we can
understand that.
Interestingly, there is a vaccine in horses, but there
isn't yet one in people. So go figure. There is an interesting
story behind that somewhere.
So I totally agree. And USDA has been a wonderful partner
in this. They have a great interest in research, although an
awful lot of their dollars go into other service activities
that they are required to do.
Certainly, this also applies not just to farm animals, but
also to other animals. Certainly, I am thinking the very first
effective gene therapy for a human disease was for an eye
disease called Leber's congenital amaurosis. The reason we knew
it was going to work because there was a dog model, a
spontaneous example that happened in a particular dog.
Some of you might have met that dog 10 years ago because it
took quite a tour through the Capitol after having the therapy
work in the dog, and a couple of years later, it worked in the
kids. So we get it as far as this interaction.
Antimicrobial resistance continues to be a vexing and
deeply troubling problem because of the way in which so many
instances are happening of organisms that are resistant to all
known antibiotics, which are causing outbreaks particularly in
hospitals. We have done a lot to try to be sure we track those
down quickly in hospitals by providing the kind of diagnostics
necessary to understand the transmission.
Basically, there are two problems here. One is the overuse
of antibiotics that has caused these resistant organisms to
appear, and the other is the market failure where essentially
the development of new antibiotics has not been appealing in
the private sector.
NIH's role, and this has been in part supported by this
Congress by providing resources, is to try to be sure we are
doing everything we can to develop that next generation of
antibiotics to take it further down the pathway toward an
actual approved drug than we normally would have to, to try to
de-risk these projects so that an industry partner will decide
it is worth taking it up, even though they know there are not
going to be a lot of profits there.
I think that is making progress, but I think we are still
well behind where you would want to be to say that this is a
problem we have solved. We have not.
Mr. Moolenaar. Is there--okay, go ahead.
Dr. Brennan. If I may? You may be surprised that the
National Library of Medicine is playing a role in some of this
integration of antimicrobial approaches. One of our
researchers, Eugene Koonin, is an evolutionary biologist who
uses computational methods to understand how these germs
actually change over time to determine if there is a point of
intervention that may happen earlier in the cycle.
Thank you.
Dr. Austin. I just wanted to add one thing about the
animals. We have a collaboration among 12 of the Nation's
veterinary schools with the same number of CTSA hubs who are
working on diseases in common between humans and animals to see
what we can learn by studying those together.
And as a matter of fact, next week--actually, this
Thursday--at the CTSA annual meeting, we are having a speaker,
a representative from the USDA come and talk to the entire
group in order to figure out how we can expand this approach.
Mr. Moolenaar. Thank you very much.
Dr. Tromberg. Can I also add that point-of-care types of
platform technologies have traditionally moved in from humans
into animal care as well, and this is a great opportunity for
further growth, both from the bedside diagnostics, for example,
of bacterial infections, doing that rapidly onsite by owners in
their--wherever they need to do this, as well as interventional
approaches like the microneedle vaccine that I was just showing
you.
Ms. DeLauro. Thank you.
I would just say to my colleague the issue of animals, we
need to take a hard look most recently at the rule that was
approved by the USDA in dealing with lessening the inspection
force in our--on swine slaughter and also with line of speed,
there is taken off the cap. So right now, the inspector has
about 4 seconds to look at any animal that is going by and so
forth.
So if you just don't cap the speed, it is going to be very
little ability to deal with that. The second part of it is with
the FDA and the regulation of the use of antibiotics in
livestock, a serious issue, John. And you are thoughtful about
this. Take a look at it because, in fact, we are allowing--we
don't allow it for growth promotion anymore, antibiotics.
We have to have--if there is a sick animal, we need to have
a veterinary provider prescription. But we have left a gaping
loophole, which says that it is the--we can use antibiotics for
prevention, and that has opened up unbelievable because of the
way we are dealing today with a herd of 5,000 swine. It used to
be 150 and 120. They are prone to illness or disease. We take
care of that, but we are also using antibiotics for prevention.
That means that you buy a pork chop. You get it. You get
ill. We are then not able to treat you, or we treat you and it
is resistant because it is the same thing.
Longer than I wanted to go, but you need to check with what
is going on at the Department of Agriculture and with the FDA
on what is a very, very serious issue. Sorry, guys. I just--we
did something about about it in the ag bill here. We said you
couldn't use--we put a limitation on doing this, but the Senate
hasn't approved it. So we will see where we go.
Congressman Pocan.
Mr. Pocan. Great. Thank you, Madam Chair.
And thank you all for being here. And sorry I missed the
testimony. I had two meetings back-to-back, but I did hear and
I was very happy to hear that funding for first-time
investigator researchers is up considerably, and this year, we
are going to have another record. So I am very happy to hear
that, and people back home will be very happy to hear that.
Back in March, Dr. Collins, I had asked a question about
there is a study that the--or an update from the National
Academy of Sciences that had a report from 2011 to 2016, every
single drug approved by the FDA had NIH support. I think I
asked at that time, was there an update?
I am going to ask my question again because I really,
really would love to have an update on that. Is there an update
on that study yet that you can share?
Dr. Collins. That is a very important study published in
the Proceedings of the National Academy of Sciences. The senior
author was Fred Ledley, and they studied all the 210 drugs that
were approved by FDA between 2010 and 2016 and concluded that
100 percent of them had had significant input from NIH-funded
research in order to get to that point of having an FDA-
approved therapy.
This was not funded by us. That study was funded by the
National Biomedical Research Foundation, which is a private
foundation. I suspect they might be interested in renewing the
effort, and we can reach out to them and see if they would like
to--it is almost better, I think, if this is something that is
funded not by us because it will seem less self-serving.
I suspect that the answer will be very much the same. I
mean, the way in which our ecosystem works where the kind of
NIH-funded basic science and translational research gets handed
off to industry for them to actually turn into an FDA-approved
product has been the envy of the world, and it is very
successful. And I think it probably hasn't changed in those
last 3 years.
But I will reach out to that foundation and see if they
would like to update that study.
Mr. Pocan. I would really appreciate the nudging because
especially now this is an issue that people talk about back
home, we are talking about in Congress. It would be very
valuable. So thank you.
Another question. In July, the administration made changes
to the NIH requirements regarding proposed human fetal tissue
research, and one of the changes was to implement an ethics
advisory board. I think it said something about no fewer than
one-third, no more than one-half shall be scientists with
substantial accomplishments in biomedical or behavioral
research.
I have researchers like back in UW-Madison, who conduct
this critical research, and they would like some clarity on the
guidelines for the selection process for the advisory board
scientists. Specifically, will there be an effort to appoint
scientists to the board who have substantial experience or
substantial accomplishments in research involving fetal tissue?
Dr. Collins. You are quite right that the new guidelines
require the establishment of this ethics advisory board, and
its constitution is basically laid out in legislation from
1993. So this is not a new formula, and it does say between
one-third and not quite one-half of the membership should be
scientists without particularly specifying exactly what
disciplinary expertise they have.
The appointments are to be made by the Secretary of Health
and Human Services, Secretary Azar, and this is the moment, I
think, where ideas are being put forward about what would be an
appropriate roster for that, for us at NIH. We are obviously
very interested in seeing this get up and going so that
additional applications for human fetal tissue research can go
through this additional level of review.
That is going to take some time, and so it will mean over
the course of the next several months that we won't be
approving such applications. But if the board gets set up and
can be constituted in such a way that they can review these in
a timely manner, then that is what we expect will happen
perhaps in the next year.
Mr. Pocan. Any idea on their timeline or----
Dr. Collins. I couldn't really guess at it at the moment.
Mr. Pocan. All right. And then, finally, a question on
autism, specifically on autism as it relates to people who are
transitioning from essentially youth to adult ages. There was a
report, I know, that came out from Interagency Autism
Coordinating Committee that said about 2 percent, or actually,
less than 2 percent of the combined Federal and private autism
research funds are going to that specific population of people
who are transitioning to adulthood.
I was just wondering if there are any opportunities for
additional investment in research regarding adults with autism,
and any additional investment in understanding the issues
regarding the lifespan of people with autism?
Dr. Collins. Certainly a very appropriate question, and I
think most people, when they hear the word ``autism,'' they are
not necessarily thinking about this group of individuals who
are entering adulthood, many of whom actually would tell you
that they don't really appreciate being considered in the same
boat as a child with autism who needs a lot of interventions.
Many of these are highly functioning individuals.
We are certainly looking at that. The NIH, particularly the
National Institute of Mental Health, has a very vigorous
portfolio in autism, and through the IACC that you mentioned,
this kind of opportunity for thinking about the priorities in
that portfolio is what comes up. And Dr. Josh Gordon, who is
the head of that, is no doubt considering that.
Dr. Brennan.
Dr. Brennan. Yes, Mr. Pocan, I would like to also comment.
The National Library of Medicine is actively working in two
areas related to this.
One is we have a researcher at the University of Cincinnati
and Children's Hospital who is working on creating the proper
integrated medical record for children aging out of supervised
care into individualized care. And although it doesn't
specifically address the issues of autism, what we are learning
from that is how a young adult, and the emerging adult, moves
into self-management of health information.
The second piece is we are working with using innovative
technologies to bring into adulthood some of the tools that may
be necessary that are less stigmatizing in terms of the illness
part of autism, but interpreting social cues and understanding.
So using visual technologies to help a person who is trying to
function in their adult life get the cues that they need to be
able to continue to work there.
Mr. Pocan. Thank you very much.
Ms. DeLauro. Congresswoman Frankel.
Ms. Frankel. Thank you all for being here, and I enjoyed my
visit the other day.
I want to follow up first with Dr. Tromberg, and I might be
asking you something you already said. But sometimes, you know,
when you hear something for the first time, it doesn't really
penetrate.
So on the imaging, is there anything new on the mammograms
that is going to lead to women not having to have those regular
mammograms all the time? Or the----
Dr. Tromberg. Yes, thank you. Thank you for your question.
That is a very, very active area of research in our
community. There are number of things going on.
First, just in terms of mammography, there is a lot of work
to improve mammography itself and develop new computation-based
techniques to help us read mammograms better. There are other
technologies using x-rays called digital breast tomosynthesis
that give you more of a three-dimensional view and give you a
better appreciation for detection and diagnosis.
Then there are alternatives to mammography, like the one
that I mentioned using lasers, very short pulses. They can
create sound waves deep inside breast tissue so you don't have
compression and contrast agents and so forth.
There is enormous amount of activity in the MRI community,
and using artificial intelligence, we can actually do MRIs
faster and more inexpensively so you can reap the benefits of
an MRI but possibly do it with smaller and more compact
devices.
So this is a very, very active area of engagement in our
technology development community and definitely one of our
target goals.
Ms. Frankel. So where are you in terms of something really
being out there to the public so you don't have the compression
mammograms?
Dr. Tromberg. All of these technologies that I just
mentioned are actually in various streams of both clinical
studies, entirely computational studies. So another really
amazing advance is that we don't even have to build some of
these technologies. We can model them and then do simulated
clinical trials--and the FDA has just recently published a
paper doing that exact thing, comparing digital mammograms with
digital breast tomosynthesis and just said, ``Hey, which one is
going to work better?''--before we go out and do expensive
clinical trials.
The MRI studies are ongoing in our centers all around the
country. That photoacoustic tomography with the ultrafast
laser, that technology is currently being developed and
commercialized. So lot of really interesting, wonderful
alternative approaches, and they can potentially provide
information at all stages of care.
Ms. Frankel. So those MRIs, is that going into those
claustrophobic tubes?
Dr. Tromberg. So there are a number of really beautiful
advances in MRI in both the magnet technology that are making
the magnets more portable, the computation to do image
reconstruction. And also, if you notice, there is that big
tube, but you also have a coil that picks up the signals after
the radio frequency is launched into the body, and then you
have coils that pick up the signals from inside the body.
Those coils are being made for individuals now. So breast
coils, hand coils that are flexible so that we can look at
movements, other types of body coils. So make MRI actually even
more compatible and flexible with each of these applications.
Ms. Frankel. OK, I don't know whether that you said you
still have to go into the tube or not? [Laughter.]
Dr. Tromberg. Well, I think if we are going to have MRI, we
are going to have some kind of a tube. So one of the big
advances, though, in brain MRI, just to pivot a little bit, is
a small cap that you can wear on your head. And that is
portable, you can still move around, and it is just looking at
brain.
So as those technologies develop and get out there, they
can be translated to other applications such as breast or
fascia imaging, as I have talked with Dr. Langevin about many,
many times. So wonderful opportunities. As these technologies
are developed, they can move into other areas of importance.
Ms. Frankel. What about detecting ovarian cancer?
Dr. Tromberg. This is certainly one of the most difficult
things to do. There is a lot of work going on in trying to do
what we call liquid biopsies. There has been a number of really
exciting advances in being able to both detect and diagnose
ovarian cancer during surgery using technologies that take, if
you think of medical research, you often think about
microscopes.
Imagine you could take the most powerful microscope and
turn that into a small, hand-held endoscope and get the same or
even more specific and better information. Then you could stick
that inside the body and you could help guide ovarian cancer
surgery. We know that surgery is still the best therapy for
cancer. You can get lots of cells out very, very quickly.
What if you could identify every one of those cells by
looking at the same microstructure of the cell that a
pathologist uses after you take the tissue out. They go away.
They examine it for weeks and then come give you an answer.
What if you could get that information at the bedside
intraoperatively during surgery and then get rid of all the
cancer?
So that is one advance that is going on in ovarian cancer.
Ms. Frankel. Madam Chair, if I could just have one more
question, which is have you had anybody--have you had any
directives from the Trump administration to either discontinue
or change research on reproductive health?
Dr. Collins. We are all looking at each other like no.
Ms. Frankel. I don't want to give anyone any ideas, but OK.
Dr. Collins. Of course, there is, as we talked about a
minute ago, this limitation on doing research on human fetal
tissue. If you want to include that in reproductive health,
that would be an answer to your question. I wasn't sure if you
were thinking about that.
Ms. Frankel. OK, thank you. Yield back.
Ms. DeLauro. Congresswoman Watson Coleman.
Mrs. Watson Coleman. Thank you. And I apologize for not
being able to hear all of your testimony. I was in another
hearing, but what I have heard and the answers to the questions
have been very intriguing.
I want to ask a question about the disparity in health with
maternal mortality and infant mortality, and I wanted to know
what is actually happening in researching those particular
issues.
Dr. Perez-Stable. Thank you.
Mrs. Watson Coleman. And what resources are applied there,
too?
Dr. Perez-Stable. A critical question of great interest
across the agency. First, NIMHD is really establishing
collaboration with other Institutes and Centers about this
topic, I think being led by the National Institute on Child
Health, and we are very much there, as well as with other
Offices of Minority Health across the Department.
So we have to think of maternal mortality as a continuum.
It is the worst outcome of what we call maternal morbidity. So
having sickness or illness as a woman goes through the process
of conceiving, having a pregnancy, and delivery. And we look at
disparities, the African-American women, the American Indian
women have disproportionally high burden of disparity in the
maternal morbidity/mortality space.
We have to look at the continuum of what happens at
conception, during prenatal care, visiting the hospital and the
clinicians that take care of the delivery, and then, very
importantly, postpartum what happens. And at each of these
places in this continuum, there is opportunity for intervening
to decrease these disparities.
African-American women, for example, have greater burden of
cardiovascular disease and diabetes when they conceive.
African-American women may have a greater risk for developing a
thrombosis and deep venous thrombosis, which may lead to clots
into the lung.
Mrs. Watson Coleman. So that is really kind of what I am
getting at. What are we doing in terms of researching the whys
of all of that?
Dr. Perez-Stable. A lot of it depends on the well, the whys
is, you know, is it genetic? Is it behavior? Is it preexisting
illness?
Mrs. Watson Coleman. Environmental?
Dr. Perez-Stable. But a lot of it has to do with the access
to the quality of care and the settings where they are getting
their care.
Mrs. Watson Coleman. So are we doing intensive research on
these disparities on the why, what to do about it, and things
of that nature? I want to know--you stated the problem, I
agree. I wanted to know what are we doing about those things?
Are we initiating research studies? Are we doing whatever one
does in this space?
Dr. Perez-Stable. The process has come very much to our
attention. We actually have funded a research grant in New York
City that examined this level of continuity of problems,
looking at how much was related to the mother's health leading
to bad outcomes, how much was related to the care she was
getting, and to the setting she was going to.
Mrs. Watson Coleman. Are you able to isolate the amount of
resources that have been identified for looking at these
issues? So if I asked for a report on the dollars that are
spent in this area, could I get that, Dr. Collins?
Dr. Collins. Yes, I am quite sure we could figure out--I am
not sure whether it is one of the things that we track in what
we call RCDC, where we automatically keep track of dollars. But
we can try to see what we can do.
I will tell you this is an area--and thank you, members of
this subcommittee, for particularly drawing our attention to
this--that all of NIH is now focused on with much greater
attention, considering that the trends are all going in the
wrong direction.
Mrs. Watson Coleman. Yes.
Dr. Collins. And so there is now a trans-NIH group of high-
level research leaders, including Dr. Perez-Stable's Institute
and many others, to try to see what are we collectively maybe
not doing that we should be in this space. Not just to identify
what are the factors, but also to identify possible
interventions that could be tested in a research environment.
Mrs. Watson Coleman. So, thank you. These, I guess, first-
time investigators, you did 1,287 of them, is that--last year?
Dr. Collins. That is exactly right. That was last year, and
this year, as of this morning, we are also at 1,287, expecting
we are going to break through that ceiling.
Mrs. Watson Coleman. So could you break down for us the
racial and ethnic breakdown of those who are these
investigators who are getting these opportunities for us?
Dr. Collins. I don't have the numbers in front of----
Mrs. Watson Coleman. I know you may not have them now,
but----
Dr. Collins. I would be glad to provide them.
Mrs. Watson Coleman [continuing]. I am asking if you could
prepare----
Dr. Collins. I will tell you that there are not as many as
we wish there were, but we are working intensively on that. We
have an entire set of programs to increase the diversity of our
workforce.
Mrs. Watson Coleman. Thank you. Through the chair, if that
is possible, not only would I like to know the numbers of the
representation, I would like to know whatever efforts are being
used.
I have one last question. I have a number of them. This one
here I just have to ask. I was told by a doctor that at the age
of 75, you no longer get a colonoscopy. Why is that?
Dr. Collins. The United States Preventive Services Task
Force, USPSTF, is the organization that looks at all the
evidence for all kinds of preventive actions to decide whether,
in fact, they are justified in terms of benefits and risks. So
they have looked at all the studies--and this has recently been
reevaluated--to assess what is the benefit of colonoscopy?
And their conclusion is by the time one is 75, if at that
point you have not had any identified colon abnormalities, you
are not likely to have them in the future. You are kind of----
Mrs. Watson Coleman. OK.
Dr. Collins. You are like out of the risk zone and into the
clear.
Mrs. Watson Coleman. I just wanted to make sure somebody
wasn't thinking, well, you are 75 so----
Dr. Collins. So you are not worth it. [Laughter.]
Dr. Collins. No, that was not the reason for their
conclusion. No, I think it is a much happier outcome.
Mrs. Watson Coleman. I would like to just--I asked the
question before, one about autism and what is happening,
particularly as it relates to minorities and research. And
other one was sarcoidosis. And I just wanted to ask you for
updates on those.
And with that, I yield back, madam.
Ms. DeLauro. If we can get those updates, we will be happy
to----
Dr. Collins. For the record, happy to do that.
Ms. DeLauro. Yes, please, in response to Congresswoman
Watson Coleman.
Dr. Langevin, let me address a couple of things here. You
talked about NCCIH and the natural products, dietary
supplements. These products today are unregulated, as you know.
So consumers have to seek out information on the safety and the
effectiveness on their own.
This is of particular interest to me, and I will say it
here so that it is in the record. I believe that we ought to
regulate dietary supplements. Some of the claims are truly
outrageous.
But how do you disseminate your research findings to the
general public? How do you work with the FDA and other Federal
agencies to disseminate the research findings, and what is the
outcome? Have we used your research, both positive or in a
negative way to say this should stay, this should go?
Thank you.
Dr. Langevin. Thank you. These are all very important
questions.
In terms of dissemination, first of all, highly important.
We don't want people to be getting the information randomly
from the Internet. So NCCIH is very active in maintaining an
information list on their website. It is called HerbList. It is
actually an app that you can use from your phone. And if you
want to look up a specific type of nutritional supplement or
natural product of some kind, you can just go and look it up,
and you will get the information right there. And that is
constantly updated.
The other thing you mentioned is finding out are these
products effective? Do they actually work?
Ms. DeLauro. Safe.
Dr. Langevin. And are they safe? Exactly. NCCIH conducted a
number of clinical trials--or actually, earlier on, when it was
still called NCCAM--on substances like, for example, gingko and
echinacea, things like that that people were taking, and to
find out do they actually work? And most of these trials ended
up showing no significant benefit compared to placebo.
What we think, though, it is not a matter that we should
just abandon this research. I think what we need to do is
actually go back to the lab and take these plants or whatever
they are and really go into their basic active ingredients.
Look at the chemistry, see whether we can find out in vitro,
and then find out are they actually having effects? For
example, anti-inflammatory effects would be an important piece.
If we find these effects in vitro, then we can go into an
animal model. Find out if they actually work and then test that
in the clinical trial. But it is almost like we don't want to
just go and pick something off of the shelf at the health food
store and do a clinical trial on that. That wouldn't make any
sense.
Ms. DeLauro. With that, and I would love to have offline to
proceed with this, but this, the whole area of dietary
supplements has been left, and I was pleased to read your
testimony and what you are doing. But there needs to be serious
collaboration with what can go back and look at, look at the
properties, see what that relevant to other areas. But there
has to be, you know, some defining answer to what is on the
shelf, which people are just picking up and using without any
knowledge of whether or not this is dealing--is going to
address whatever their need is in this regard.
Dr. Collins.
Dr. Collins. There is an Office of Dietary Supplements also
at NIH, works closely with NCCIH. One of their goals is to make
sure that all the information we do have is available in
labels. Eighty thousand labels now available on dietary
supplements that contain the information we have.
Unfortunately, most of it is pretty incomplete because a
lot of it is not based upon any rigorous kind of scientific
study. There was a Federal task force last year that pointed
out the lack of data on the extent of use and the safety and
utility. And I did see FDA earlier this year, back in February,
signaling that they thought it might be time to look more
closely at dietary supplements. So what you are saying might
actually be getting some traction.
Ms. DeLauro. Well, I hope so, but we are going to proceed
to make sure it does.
Let me just--because Ranking Member Cole is not going to be
able to get back, so I think it is just Congresswoman Roybal-
Allard and myself. So I am going to ask a couple more questions
and then leave you with time for your questions. Okay?
Let me with regard to the pain research that you are doing,
I just want--we are spending, and we should, enormous amounts
of resources to deal with the issues of opioids. So your work
is critical here, and one of the things that I very much wanted
to do was to look at a cross-cutting way of--honestly, today,
if you write a grant that says you are going to deal with
opioids, you are bound to get the money to be able to do it
because that is--it is really a crying need.
But with the kind of research that you are doing, that
needs to be overlaid, in my view, on where we are directing our
funding. I don't know how far along you are with what you are
doing to provide us with some real sound advice about directing
dollars to what is appropriate, what will work, rather than
just saying, okay, my God, we have got to do something, and
here is the money for opioids.
That seems to me, you know, we should not be throwing good
money after bad. I don't know what is working or not working.
It may all be working. But I think you have a really big piece
of the puzzle here to help us to do that.
Dr. Langevin. I would agree. And as I mentioned before, we
are conducting a large effort right now in what we call
pragmatic trials. So, basically, we take therapies that have
been shown to be effective in a controlled setting, say, in a
randomized trial compared to a placebo, and then we say, OK, if
we put that into a healthcare setting. For example, in the
military, we are having a big effort right now in collaboration
with the Department of Defense and the Veterans Administration
to test behavioral interventions in service members and if
veterans to see can this be implemented in that healthcare
system, and does it help with pain?
So that is an area where it is very pragmatic. You want to
know just the way that these therapies are being delivered in
the healthcare setting, do they actually work? Do they actually
help patients?
And at the other end of the spectrum, we are investing a
lot of effort, especially in our intramural program, in basic
pain mechanisms to understand what are the effects, for
example, of emotions on pain? We know that the same painful
stimulus is very different depending on the mood that you are
in. So we need to understand that better.
And some therapies actually interact with that. How
opiates, for example, have an effect on the brain is very
different depending on if the person is depressed or not. So it
is very interesting, and we need to understand that better to
understand pain research better.
Dr. Collins. Chairwoman, if I may, because this is such an
important issue, all of the NIH Institutes have been asked to
come up with the most creative possible ideas that we could use
to approach this epidemic of opioid overdose and death, as well
as the need for nonaddictive pain treatments for the current
people who suffer every day from chronic pain.
We broke this down into six different themes that you see
as bullets around there, including worrying about neonates that
are born addicted to opioids because their mothers have had
that issue. That doesn't look like a particularly impressive
diagram, but underneath that are more than 40 different Funding
Opportunity Announcements that have been issued in the course
of the last year and a half, thanks to you because of the
provision to NIH of $500,000,000 a year for this particular
initiative, which we call HEAL, Helping End Addiction Long-
term.
And we got an outpouring of response from the community.
And unfortunately, what you said, not everybody who wrote an
opioid grant did get funded. Some of them are still pretty mad
at me because, actually, the success rate was more like 20
percent, just like our usual, because there was so much
opportunity there.
And it is everything from basic science of understanding
how pain works to the HEALing Communities Study, which is
moving into four States to try to see what happens if you bring
together all of the stakeholders and see if you could actually
end the epidemic of opioid overdose deaths.
There will be more announcements about this later this
week. So it is a timely question for you to pose. I want to
assure you this has been all hands on deck for everybody around
this table and all the people you don't see who are also
working on it.
Ms. DeLauro. Thank you so much. Congresswoman Roybal-
Allard.
Ms. Roybal-Allard. Well, thank you, Madam Chair, for
covering my first question. I appreciate that.
First of all, Dr. Collins, since the administration did not
allow the NINR to come before our subcommittee, I do want to
raise an issue which I am sure you are very aware of. And while
I am very pleased that someone so experienced has been put into
position of Acting Director to lead the NINR until you can find
a permanent Director, I am sure you are aware that there is a
lot of concern regarding the fact that there is not a nurse in
that position.
And so what I am hoping is that you will quickly find an
outstanding Ph.D. prepared nurse to lead that Institute, and I
just wanted to make that point.
Dr. Brennan, expanding the scientific workforce for
biomedical and behavioral research and increasing its racial,
cultural, and disciplinary diversity is one of NLM's strategic
goals and is essential to ensuring that discoveries that lead
to healthcare innovations and cures. The question I have is
that as the first nurse Director of the world's largest
biomedical library, what efforts are you leading at the NLM to
build a diverse, educated workforce for data-driven research?
And how are you ensuring that this workforce will include
not only physicians and Ph.D. scientists, but also clinical
practitioners across multi disciplines, such as pharmacists,
nurses, physical therapists, and psychologists?
Dr. Brennan. Thank you very much for the opportunity to
address that.
First, I would also like to say that I am co-chairing the
search for the new Director of NINR.
Ms. Roybal-Allard. Good.
Dr. Brennan. And we are very, very excited about the
opportunities. Dr. Perez-Stable is my co-chair with this. So we
are off and running.
Secondly, to address the workforce issues, we have started
at home first. So we have initiated an internal training
program for all the 1,700 women and men who work at the
National Library of Medicine to do individual assessments of
what are the data science skills that we need across the board
from librarians to computational scientists, to computer
scientists, and to the clinicians who work with us.
Second, we are helping to lead--across--the NIH the
designation and development of workforce competencies that
address not only scientists, but also those that acquire and
use scientific information, particularly making sure that
clinicians have the ability to read and understand and to learn
from data science-driven resources.
But finally, we are also funding an initiative that we call
personal health libraries that actually directs to laypeople,
to patients, to help understand what does it mean to have data-
driven discovery?
We recognize that building the evidence for practice from
data-driven discoveries is going to require that clinicians
need to learn differently about how they interpret evidence.
And so projects that use artificial intelligence to make
interpretations of clinical images or make recommendations
about how one might expect a care process to occur require that
we bring clinicians along to understand how to interpret this
information.
So we are looking at model curriculum. We are looking at
enhancing the library science workforce around the country in
our academic medical centers and health science centers so that
across the health science curricula, physicians, pharmacists,
behavioral scientists, nurses have access to these data
concepts and data-driven discovery.
And finally, we have to recognize that we need not only the
Ph.D. prepared workforce and the clinically prepared workforce,
but we need community college trained individuals. We need
baccalaureate individuals who are able to assist in data
preparation, data cleaning. We are developing models of data
security to make sure that we can actually safely learn from
the data we are acquiring.
Thank you.
Ms. Roybal-Allard. Dr. Austin, one of my legislative
priorities in Congress has been newborn screening. And since
its first passage in 2008, the bipartisan Newborn Screening
Saves Lives Act has supported Federal programs that expand
State newborn screening programs, ensures laboratory quality,
and supports the Secretary's Advisory Committee on Heritable
Disorders in Newborns and Children.
And the law also authorized the NICHD Hunter Kelly Newborn
Screening Research Program to identify additional conditions
for newborn screening and to develop and test innovative
treatments. I understand that NCATS was created from several
existing NIH initiatives, which included two rare disease
research programs. Your mission of accelerating new treatment
development is a priority that is shared by all parents of
children born with the types of rare diseases that newborn
screening can detect.
Given that NCATS and the Hunter Kelly Research Program have
similar missions, I am interested in knowing how NCATS and
Hunter Kelly work together to investigate new treatments of
rare diseases that can be detected at birth and what new
therapeutics are you currently investigating for diseases that
could become eligible for inclusion in the recommended uniform
screening panel?
Dr. Austin. Mm-hmm. Wow, what a great question. I will try
to be brief, although that will be difficult, given the
question you asked.
The opportunity here is absolutely huge. And the way to
think about this is moving, as I think I mentioned before, from
the idea of studying one disease at a time to studying many
diseases at a time, eventually perhaps all 7,000 at a time. And
newborn screening has novel technologies, which will allow us
to make that transition.
What I am talking about here is genome sequencing. About 80
percent of rare diseases are genetic, and most of them can be
detected on--if we use more widespread whole genome or exome
sequencing before the children leave the hospital. We are
already doing this via some work we are supporting at Rady
Children's Hospital, doing genome sequencing in the NICU for
particularly sick infants.
But the larger application here is to short-circuit
entirely what is called the diagnostic odyssey that is this
terrible wandering in the wilderness that parents do with
children with rare diseases, where they will go through 5, 10,
15, 20 years of going from provider to provider to provider
until one provider says, ``I know what you have. I once saw one
of those in medical school once.'' But they are so rare that
they have to go to multiple providers to identify.
And most of these we could identify at birth with newborn
screening across the whole genome. And so one asks, well, why
aren't we doing this? So this is not so much a technical
problem. There are people who are doing, supported by us and by
NICHD and by the genome institute, developing and deploying
these technologies, combining rapid genome sequencing, which
can get done in as little as 24 hours from the time the
consultation is done to when the data get back to the caring
physicians and using AI to interpret the data.
So the limitation here is, as we have talked about before,
is in what is called implementation science. So once the--you
have proof-of-principle, and it has been--the technology has
been developed and has been demonstrated as being used, how do
you disseminate it to the whole community?
And this is a complex problem that, of course, includes not
just research, but it includes reimbursement, et cetera. But
the important lesson here is that the only reason that the
odyssey exists is that Odysseus leaves home in the first place,
remember? Then he has to take 10 years to get back.
If we sequenced these children before they left, we would
never have that odyssey. And realize that during that 10 years,
the quality and quantity of life of those children is
declining, declining, declining. And by the time they are
finally diagnosed, they are often beyond our ability to reach,
or they have died.
And this was something when I was in training 35 years ago,
we had--we knew this happened, but there was nothing we could
do. This has utterly changed in the last 35 years. And so we
feel a real urgency to diagnose all children who have a rare
disease within a year of coming to medical attention, and many
of those can be diagnosed via newborn screening.
Not all, but still, systems exist to identify them much
more efficiently. This is a systems implementation science
problem.
Ms. Roybal-Allard. Is there any--I am sorry----
Ms. DeLauro. No, no. Go ahead.
Ms. Roybal-Allard. I may have missed it, but is there any
collaboration at all in working with the Hunter Kelly----
Dr. Austin. Oh, boy. Oh, yes. We are joined at the hip with
them. As a matter of fact, we hired a person who used to be at
NICHD to help us run this.
We are also doing this on an international level because
this is a--this is an international problem. Up until last
January, I was chair of an organization called the
International Rare Disease Research Consortium, and while I was
chair, I am proud to say that we developed 3 new strategic
goals for the next 10 years, one of which is to decrease the
diagnostic odyssey from 10 to 15 years to 1 year, as well as
develop in the next 10 years, 1,000 new therapies for rare
diseases.
And we think that is--those therapies are only possible
when you have a diagnosis. And those diagnoses also allow you
to group diseases to do the therapeutic part of what we call
many diseases at a time, which is to say, well, gosh, if we can
target with a drug a commonality to 20 different diseases, then
we have just cured 20 diseases at once, not 1. Or platform
technologies like the gene therapy technologies that would be
applicable to many, many diseases at a time.
And so this has diagnostic aspects and therapeutic aspects,
has information aspects as well, rebuilding databases to be
able to make them AI friendly, which we are doing as well.
Ms. Roybal-Allard. Thank you. I think we need to do
something to help address some of those challenges that they
face.
Ms. DeLauro. Actually, I am going to submit a number of
question for the record, and you all have been wonderful. Just
do you find that your work--I have just a couple of things, and
I want to end up with one question for everything.
I guess, Dr. Brennan, the ClinicalTrials.gov, in other
words, just to build on a question that Congresswoman Roybal-
Allard asked, that Congresswoman Lee is talking about, is
dealing with how can we bring more diversity into the clinical
studies? Can you do that through your efforts?
How do we improve on ClinicalTrials.gov through--you know,
to bring more people, including the underrepresented groups
into it?
Dr. Brennan. Thank you very much for the opportunity to
talk about one of our treasured resources.
ClinicalTrials.gov actually has two key purposes at NIH.
One is to demonstrate stewardship of clinical trials, but the
other is to let the public know about trials that are
available. We have worked with the support of NIH leadership to
launch an improvement of the interface for ClinicalTrials.gov
so it is easier for people to find studies. We have developed
better search strings so that a person who puts in a word that
might be misspelled or might need to--might not be exactly the
precise way that this trial is described can actually find it.
But in addition to this, we are also working with
community-based groups. And in this case, the community might
be breastcancer.org or special purpose communities who are able
to extract from our ClinicalTrials.gov registry an entire suite
of studies specific to either the neighborhoods they are
working in or the populations they are working with and expose
those studies through the lens of the specialty organization.
Ms. DeLauro. Thank you.
I am going to follow up with staff. This is a parochial
issue on the Connecticut Medical Society and their journal
being removed from Medline, but we will follow up with you on
that.
Dr. Brennan. Thank you. We would be happy to talk about
that.
Ms. DeLauro. Now I do want to do this, and I want each of
you briefly to--I know it is about resources, you know? If
resources were available, though, what is the innovative
research that you would like to pursue?
Dr. Austin, you just mentioned a piece of this which is
really quite extraordinary in a direction that we can go in.
But let me just ask you, you know, where would you like to go?
What would you like to pursue?
Dr. Tromberg. You were looking at me. Does that mean I
should start? [Laughter.]
Ms. DeLauro. Well, look, you know, you don't have to. This
is not--it is anybody who wants to go first can go first. Let
us go. You go first. [Laughter.]
Dr. Tromberg. Okay. Well, one of the areas that I am really
excited and passionate about is, is kind of the idea that
current medicine, as it is practiced, takes snapshots, kind of
static snapshots. A little bit of blood chemistry here. Maybe
another year or two after that, an image here. Maybe another
year or two or five after that, blood pressure.
You know, even that is not measured very frequently. It is
difficult to measure at home. And some of you may know, every
time you breathe in and out, your blood pressure changes. We
call this dynamics, and the dynamics could be the most
important thing about managing your blood pressure.
And then you go to the doctor's office, and your blood
pressure is elevated, and they give you medication. Then you go
home, and then you come back later, and they say, well, it is
not working. And then you go home, and then you come back
later.
So there is this iterative optimization. Current medicine
is practiced at large time intervals. So a big challenge for
our community is to come up with better, faster, more accurate,
continuous wearable and implantable sensors that are measuring
many, many complex things because we know biology is not
simple. And we also know it is quite dynamic.
If we can capture the dynamics--every time you eat, your
body chemistry goes crazy. How about if we could measure all
those things and figure out how to better manage your diabetes
and metabolic disease and prevent obesity?
What if we could wear this continuous, flexible patch that
is an ultrasound device that measures blood pressure on a
continuous basis? And we can look at what happens when you go
to a hearing to your blood pressure. We could follow that with
everyone. [Laughter.]
Dr. Tromberg. And how well it is regulated by the
medication that you are receiving from your physician. So I
think this is the big challenge for us.
What it would do is it would extend health span. So it
would prevent disease better. It would give people the power to
control what they do and how it impacts their future health. So
that is our big challenge.
Ms. DeLauro. Thank you. Thank you very much. That is a
very, very interesting personal example.
My husband's doctor told him he should measure his blood
pressure. So he brought this machine home. I said what are you
doing, you know? I mean, and he doesn't use it, et cetera. Has
no--you know, it has become just a nonfunctional piece of
equipment that we now have. [Laughter.]
Dr. Tromberg. Has he tried it with his arm up and down and
his feet up and--yes.
Ms. DeLauro. In any case, that is really very, very
interesting, and I was very serious about the allergy issue. It
really is quite extraordinary in terms of quality of life, and
I am very seriously having to look at everything that you are
eating and know what you are eating and what kind of an effect
that will have.
Dr. Langevin, thank you. Thank you. Where would you go?
Dr. Langevin. Our innovative and kind of big idea right now
is very much along the same lines that Dr. Tromberg was talking
about in terms of the health span. We are very interested in
health and the sort of dynamics of it.
We often think about, oh, we want to prevent disease. But
one of the things we don't think about so much is how do you
restore health? How do you get people back to health after they
have been sick?
If you have a chronic condition, for example, that has
relapses, how do you return? How do you recover? So there is
all these wonderful words that start with R. You know,
recovery, resilience, resistance, resolution, repair,
regeneration. These are all mechanisms that we understand, we
are starting to understand them now in animal models and basic
biochemistry.
But how do we translate that back to the human level, and
how does that relate to also what is going on psychologically?
We talk about resilience, psychological resilience. But what
about physical resilience, and how are the two related?
So we really want to move into that space and understand
especially to utilize behavioral, physical, nutritional
interventions to try to promote that and to encourage
endogenous, built-in mechanisms of health that we all have
inside us. But how do you boost them? How do you, you know,
promote them?
Ms. DeLauro. Thank you. Dr. Brennan.
Dr. Brennan. The National Library of Medicine is frequently
behind the scenes in every discovery that happens. One of the
things we do is we make information more useful. And now with
the emergence of artificial intelligence and machine learning
strategies, we have the potential to take many different kinds
of data types from genomic data to images, from videos of
family interaction to pictures of food, and apply advanced
analytics so we can more rapidly interpret what is occurring to
give better and more transparent and more ethically driven
recommendations about whether the food you eat is going to
actually cause this metabolic storm that is being predicted.
Our work is in advancing the analytics that make
information more useful to society.
Ms. DeLauro. Great. Thank you.
Dr. Perez-Stable. Thank you. At NIMHD, I will mention two
areas. One is know why some disadvantaged communities actually
do better than predicted. So what are the protective factors
that lead to this resilience? And I think one of our methods
will be to leverage these data tools that are now available to
link both individual factors from like the All of Us study and
big data structures that exist.
And I have to mention a second one, which is related to the
dire condition of the American Indian and Alaska Native
population in the U.S. and looking for a special way to
strengthen their own capacity to build a research capacity,
engaging their communities on tribal lands, including the urban
American Indians.
Ms. DeLauro. How much interaction do you have with the
Indian Health Service?
Dr. Perez-Stable. Well, funny you should say. Tomorrow, I
am meeting with the Acting Director about a specific program,
but we also have a Tribal Health Research Office. Dr. David
Wilson is the Director of that, and we are in close interaction
with him.
And just last Friday, I was at the Zuni Pueblo Reservation
in New Mexico.
Ms. DeLauro. I know because both of those communities seem
to have some very, very serious problems that we have not, you
know, really focused our time and attention.
Before you answer the question, Dr. Austin, I wanted to ask
does--how do you avoid duplicating your work with
pharmaceutical companies. Is there----
Dr. Austin. It is really there are two ways to answer that
question. One is that the projects that we work on are the 95
percent of diseases and targets that can't be worked on on a
return on investment environment either because the targets are
too risky or not well understood enough, or the disease
prevalence is too low.
So, actually, the catchment area, if you will, of the kinds
of diseases that pharma can work on is actually relatively
small. I learned that when I worked there before I came to the
NIH.
The other is that we work on the science of drug
development or the science of translation, which includes the
science of drug development, but regulatory science also fits
into what we call translational science. And that is a more
fundamental, basic science really of how this whole process
works.
That is not worked on at all by pharma and really can't be
because they can't use internal drug development resources to
answer fundamental science questions. So we work with them
quite closely on what are the problems that they run into that
kill projects, effectively, and problems that they run into.
We work with--just like we work with the FDA and other
organizations on those questions. They make up about a third of
our advisory board, actually, because of the Cures Acceleration
Network. So we work--and we do lots of collaborations with them
as well.
Ms. DeLauro. I do want us to get to a point--and I want you
to answer the last question. I do want us to get to a point
where there is the recognition of the amount of taxpayer dollar
research is being done that then is picked up by the
pharmaceutical industry.
Dr. Austin. Oh, and they are very well aware of that.
Ms. DeLauro. And well, they are aware of it, but the cost
of their treatment often is prohibitive to the recovery or the
cure or the treatment of an individual, and where the basic
research is being done at, you know, at your Institute, at the
NIH, et cetera, and that needs to be figured into where we go
in terms of the availability. It is great to discover it, which
you do, but it is better if people can take advantage of that,
of that product.
Please, where would you want to go?
Dr. Austin. I would just leave you with one very
provocative term, which you may not have heard before, but we
are actually quite serious about, which is ``just in time''
gene therapy.
So wouldn't it be great if one could go from a molecular
diagnosis to a kind of gene therapy which is customized to
whatever the mutation is that you have in a very short period
of time? And we are at the point, believe it or not, where with
some kinds of gene therapy, particularly oligonucleotide-based
gene therapy, which is the same sort of technology that has
been used in Spinraza, if you know what that is. It is an oligo
therapy for spinal muscular atrophy made by Biogen.
But the idea is that one uses essentially a molecular band-
aid to put on the mutated gene to prevent it from expressing
itself, and there are thousands of other diseases which are
characterized by this kind of fundamental genetic lesion. And
working with some researchers at Children's Hospital in Boston
who have used this kind of technology in other diseases, it
became evident to us is that if we could work with the FDA to
figure out what are the general toxicology, manufacturing
principles that the FDA needs in order to approve an IND for an
individual patient then--and make all that information publicly
available, then that recipe is right there.
And when a treating physician wants to treat a novel--a new
person, they can go to that recipe book and pick that
information up because it is in the public domain and
potentially treat that child very quickly.
The other thing that I would just as far as the things that
just keep me up at night because the opportunities are so huge
are new uses of treatments which are already out there, and we
have put a lot of effort into this area since NCATS was formed.
But the fundamental idea here is that through projects like the
Genome Project, we have discovered that there are not actually
7,000 individual diseases, and there aren't individual genes
which function on individual cell types. They are all the same
genes. They just get reproduced and reused in different ways in
different diseases.
And so as a result, many of the drugs that target one could
be used to target many others. But we haven't done a very good
job exploiting that. We tend to say, okay, one gene--or one
drug, one disease, and end it at that.
So one example that you may have heard of, because the
original discovery was done at Yale, was this ketamine example,
where ketamine has been around since the '50s.
Ms. DeLauro. I saw it. Saw it. Saw it used with a patient--
--
Dr. Austin. Yes.
Ms. DeLauro [continuing]. When I was at the NIH last year.
Dr. Austin. And some, some investigator, John Krystal at
Yale and then Carlos Zarate and others at NIH, discovered that
this was useful for suicidality and depression. The problem is
it is dissociative, it is an anesthetic, it is hallucinatory,
and it is an addictive. And you can only give it IV or
intranasally. So it is just not a very practical treatment.
And so, working with NIMH and the National Institute on
Aging, we asked, well, gosh, if it isn't actually ketamine
doing it, is there an active molecule in the body that is
actually doing the anti-depressive activity that wouldn't have
all the other stuff--wouldn't be addictive, wouldn't be
dissociative, wouldn't be sedating, all of that stuff. And so
doing some very fancy chemistry, we figured out what that
molecule is.
It is actually a byproduct that your body makes when a
person take ketamine. It also happens to be orally available.
And so working again with our colleagues--this was a big team
effort and continues to be, we are working through the drug
development process now to do all the manufacturing and safety
and toxicology and all that to get into people.
And what is so exciting is that this has a completely
different mechanism of action than ketamine was thought to
have. So it has illuminated novel concepts in mental health and
potentially will give us treatments not only for depression,
but potentially there is evidence for anxiety, obsessive-
compulsive disorder, pain, and PTSD.
And so we will be doing trials in all of those at the
Clinical Center probably starting next year.
Ms. DeLauro. Dr. Collins, do you just want to just wrap up
from your point of view? And then I will----
Dr. Collins. Do I get one also about what is like really an
idea that hasn't been----
[Laughter.]
Ms. DeLauro. Yes, you do. Yes, you do.
Dr. Collins [continuing]. Hasn't been brought up yet.
Ms. DeLauro. Sure.
Dr. Collins. And that is the brain. We haven't had a chance
in this conversation, because we had so many things to talk
about, to highlight the remarkable journey we are in the middle
of, trying to figure out by developing new technologies--and
there is a lot of them that are pretty exciting--how those 86
billion neurons between your ears do what they do.
And how to use that information then to understand how to
prevent and treat schizophrenia, Alzheimer's disease,
Parkinson's, autism, depression, epilepsy, on down that long
list. We are now 5 years into the BRAIN Initiative, which you
all have supported with appropriation, and we will release in
the very near future an entirely new plan for the next 5 years,
which is enough to knock your socks off in terms of what the
capabilities now are for beginning to take apart how these
circuits in the brain actually do what they do.
When history looks back at this era in biomedical research,
they will probably point to a lot of things. They will
definitely point to this as crossing into new territory where
we really began to understand the most complicated structure in
the known universe, the human brain.
Ms. DeLauro. Extraordinary, and I mean that just broadly
speaking in terms of the information this morning. That is why
I was so anxious, you know? It is very special to hear from
each and every Director, Centers to find out what you are doing
so that we can be responsible in the role that we play in
fostering what you do.
You know, all of our kids have the expression, the
testimony this morning, it is awesome. It is really that is all
of our--you know, you can go to any--but more than that, we
have the ability, which we try to do, to provide the resources
in order for you to carry out what you do. They are not
unlimited, as you know, but we try our best to continue the
effort.
I would ask you to pursue, as you do, the science of what
you do. None of us here are scientists. We are not. We are not
doctors. And we have got to take our lead from you. We cannot
just pick and choose where we think dollars should go, but we
need to--and we do have the faith and trust in you to follow
the science and have the money and the resources help you to
follow that science for the discovery.
An area that you--and I ask you as well, Dr. Austin, when
you talk about gene therapy and genetics, we cannot allow
people's personal theology or beliefs to direct where our
scientific discovery and those dollars go. You are a bulwark
against that.
It is oftentimes uncomfortable to enter that arena because
that is not what your training and your professional ability
direct you. But you have such standing, domestically and
internationally, to guide us through with the safeguards. You
understand better than anyone what those safeguards need to be
and what the ethics need to be.
But we cannot at the Federal level be in the business of
shutting down biomedical research. It is not what we came here
to do. You know, always, as I say, you know--and we will,
again, cooperate with you. Your testimony this morning, the
work that you do helps us to do our job better. I can only hope
that what we do helps you to do your job better.
Thank you for being here this morning. The hearing is
adjourned.
[Material submitted for inclusion in the record follows:]
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
Wednesday, October 16, 2019.
E-CIGARETTES: AN EMERGING THREAT TO PUBLIC HEALTH
WITNESSES
ANNE SCHUCHAT, M.D., PRINCIPAL DEPUTY DIRECTOR, CENTERS FOR DISEASE
CONTROL AND PREVENTION
RENEE D. COLEMAN-MITCHELL, MPH, COMMISSIONER, CONNECTICUT DEPARTMENT OF
PUBLIC HEALTH
SALLY SATEL, M.D., RESIDENT SCHOLAR, AMERICAN ENTERPRISE INSTITUTE
BONNIE HALPERN-FELSHER, PH.D., PROFESSOR OF PEDIATRICS, EXECUTIVE
DIRECTOR OF THE STANFORD TOBACCO PREVENTION TOOLKIT
MEREDITH BERKMAN, CO-FOUNDER AND PARENT, PARENTS AGAINST VAPING E-
CIGARETTES (PAVe)
Ms. DeLauro. The subcommittee will come to order.
Before I begin, I would like to welcome our guests. In the
first panel this morning, we have Dr. Anne Schuchat, Principal
Deputy Director for the Centers for Disease Control and
Prevention. She is the staff lead for the investigation aspect.
Then in our second panel, we will have the following
witnesses. Renee Coleman-Mitchell, commissioner of the
Connecticut Department of Public Health. It was wonderful to
speak with the commissioner at an event that we did several
weeks ago about vaping. We were hosted at Yale New Haven
Hospital, and I just want to say thank you, thank you, thank
you for your dedication to this issue.
We also have Dr. Sally Satel, resident scholar, the
American Enterprise Institute; Dr. Bonnie Halpern-Felsher,
professor of pediatrics and the executive director of Tobacco
Prevention Toolkit at Stanford University; and Meredith
Berkman, co-founder of Parents Against Vaping E-cigarettes,
PAVe, P-A-V-e.
I will introduce them again before their testimony, but we
are so delighted that you could all join with us this morning.
I know that our full committee chair is going to be here
shortly, and I mentioned Congresswoman Lowey because this issue
on e-cigarettes and vaping has been a signature issue for her.
She has focused on it over and over again over the years.
This is an important hearing. We are here for several
reasons, to hear from the CDC on their investigations into e-
cigarettes related to lung illness and death. We are here to
talk about the ongoing Federal response to the public health
crisis of e-cigarettes. We know that the increased numbers of
young people vaping have really created a public crisis.
We are here to identify the public policy remedies we need
to be advancing to address this public health crisis, and we
are here to highlight the important investments we need to be
making through the Labor, HHS appropriations. These investments
include tobacco prevention and awareness activities and our
national public health data infrastructure.
There are multiple areas of focus because this is a
multipronged crisis. One track is the rising incidence of lung
injuries and deaths from vaping and e-cigarettes. The other is
the youth epidemic, which is hooking the next generation on
nicotine products.
These are the symptoms, but at the heart of this issue is a
fundamental question about the use of e-cigarettes and vaping.
Are the products safe? Are they unsafe? Do we know? Do we have
the scientific data? And how do we regulate these products?
Of course, the CDC falls under this committee's
jurisdiction. The FDA does not, although I do also sit on the
Agricultural Appropriations Committee, which has jurisdiction
over the Food and Drug Administration.
But the work of these two agencies is critical and linked.
Yet while the CDC has routinely warned of the health risks of
youth vaping, starting back in 2013--and I would mention to
CDC, it was 2013 they published a report highlighting the
doubling in youth cigarette use during 2011-2012.
Again, in 2016, they collaborated with the Surgeon General
to release the Surgeon General's report, entitled ``E-cigarette
Use Among Youth and Young Adults.'' Then again, in 2018, they
again worked with the Office of the Surgeon General, writing
and launching of an e-cigarette advisory to bring awareness to
relevant audiences--teachers, parents, clinicians, et cetera.
So the CDC has played a very constructive role in making
information known about e-cigarettes.
The result----
[Pause.]
Ms. DeLauro. I am going to interrupt myself for a second
just to say that the chair of the Appropriations Committee, and
I mentioned this a few minutes ago, Congressman Lowey, that
this has been a signature issue of yours, you know, for a very,
very long time, and one that is near and dear to your heart.
The Chairwoman. Thank you.
Ms. DeLauro. I also might add you will always and ever be
the chair of the Appropriations Committee. So there, my friend,
anyway.
The Chairwoman. Actually, I am not standing because I want
to speak out of turn. I am just trying to adjust this chair.
[Laughter.]
Ms. DeLauro. We have got to get rid of the chairs. The
chairs are too big. The chairs are too big.
The Chairwoman. Thank you for your kind words, as long as I
am standing.
Ms. DeLauro. Right. I was saying the CDC has, I think,
routinely warned of the health risks. I will just also say that
the FDA has appeared to have ignored these warnings. It has
taken no meaningful action to regulate e-cigarette products,
though the Congress gave it the authority to do so in 2009 by
talking about premarket review of these products.
The result of which is that we now have a public health
crisis. The Centers for Disease Control and Prevention has
confirmed vaping-related lung illnesses have risen to over
1,000 cases and now 26 deaths, with the numbers climbing each
week. The FDA is investigating the link between e-cigarettes
and seizures, and the U.S. Surgeon General has warned that e-
cigarettes pose risks for brain development, the human
respiratory system, and lifelong nicotine addiction.
In Connecticut, we had our first fatality, and one fatality
is over the line. People should not be dying. The other part of
this crisis is the youth vaping epidemic. It was on a cover of
Time magazine, and the headline read--and I quote--``The New
American Addiction: How Juul Hooked Kids and Ignited a Public
Health Crisis.''
According to preliminary results from CDC's 2019 National
Youth Tobacco Survey, 1 out of 4 high school students have used
e-cigarettes within the last 30 days. This youth vaping
epidemic has nearly tripled since 2017. In my home State,
vaping is now the most common form of youth smoking among
Connecticut high school students. The commissioner of the
Connecticut Department of Public Health will reference this,
but there is clear data demonstrating that as use of
combustible cigarettes among teens is dropping, e-cigarettes
are rising.
Now I spoke to my 14-year-old granddaughter. I think we are
all speaking to our grandchildren at ages 13 and age 14. She is
the first year in high school in Washington, D.C. And I said,
``Rigs, tell me, are people vaping?''
And she said, ``Bubby, it is everywhere. Everyone is
vaping.'' She even sent me some articles in their school
newspaper of--I have got to get her hooked on wanting to be--
you know, get involved in politics and so forth and so on.
[Laughter.]
Ms. DeLauro. But she sent me the articles showing me what
her school is doing to notify parents of the dangers of Juul,
of vaping, and of e-cigarettes.
I recently spoke at an event with Dr. Pnina Weiss, medical
director for Pediatric Pulmonary Function Laboratory at Yale
New Haven Children's Hospital. She ran through the chemicals
that are present in these devices.
Ethylene glycol, which is used in antifreeze; propylene
glycol, which is used as toner for laser printers; vitamin E
oil, which is under investigation and implicated in the
outbreak of lung illnesses; fine particles and carcinogens;
fruit flavorings to attract youth; and nicotine, which is the
addictive chemical in cigarettes that hurts children's brain
development. One Juul pod has as much nicotine as one pack of
cigarettes.
You know, we have such little information about the
chemical additives. One of them that was brought to my
attention was a chemical called diacetyl. I dealt with diacetyl
many, many years ago because it was in manufacturing. It causes
something called ``popcorn lung,'' which is a very serious lung
disease that we found.
So this is a cocktail. All of these pieces is a cocktail,
and it is a recipe for disaster.
Further compounding the risk to youth is the fact that
there is no approved nicotine replacement therapy for children
under the age of 18, that we do not know what will happen to
kids who turn teen vaping into a lifelong addiction.
There is a lack of scientific data. A lack of FDA approvals
is an important factor in this discussion that I want to touch
on briefly. Despite the anecdotal claims that some businesses
have made, there is no data demonstrating the long-term safety
of vaping. There is no evidence that e-cigarettes are
successful as a cessation tool, which experts have confirmed.
And there is no e-cigarette that has been FDA approved as a
smoking cessation device.
Let me just--this was in 2018, the National Academies of
Sciences, Engineering, and Medicine report, they concluded--and
I quote. ``Overall, there is limited evidence that e-cigarettes
may be effective aids to promote smoking cessation.''
So we don't have the scientific data to move forward.
Anecdotes, company claims must not be stymying the bipartisan
push to protect our communities, especially when the science is
so clearly on our side.
Today, the Energy and Commerce Committee is holding a
hearing on a comprehensive legislative package that, among
other things, would ban kid-friendly flavors. The Judiciary
Committee is marking up my bill, the Preventing Online Sales of
E-cigarettes to Children Act. This bipartisan bill, which I
first introduced in 2015, will close an existing loophole in
Federal law by mandating age verification of online sales and
deliveries of e-cigarette and vapor products.
Despite announcing a proposal, which the administration
did--to their credit--to ban flavored e-cigarettes that was
well over a month ago, we have not seen anything yet. And we
are now seeing industry pressure the administration into
exempting mint and menthol flavored e-cigarettes from its
flavor ban, when these are among the most popular flavors among
youth.
Such action is necessary because, clearly, industry self-
regulation is not working. Past time for the FDA to uphold its
mission as a regulatory agency, use their authority to protect
people from these harmful products.
Again, I mention that this goes back to 2009. The Congress,
the Congress said, we gave the FDA the authority to regulate
all tobacco products, including e-cigarettes. The bipartisan
Family Smoking Prevention and Tobacco Control Act, or TCA, gave
FDA the authority to regulate new tobacco products before they
enter the market, and that includes e-cigarettes. FDA has not.
Instead, it has allowed dangerous products to come onto the
market. It has exempted e-cigarettes from premarket review.
And again, what that review would have said is, is this
product safe? It would have collected scientific data to test
whether or not it was safe. The FDA uses something called
``enforcement discretion'' and allowed the devices to be sold.
I might add, I just want to say that in the past two
administrations--this delay just has not been caused now. This
delay occurred under the prior administration as well, and the
delay continues. This is now 10 years of this product, and we
now know that the industry is continuing to push to see if
there an opportunity for a future delay on what we talked about
in terms of applications in May 2020. So there is this delay
process, which we have to break through.
Here in our committee, the Labor, HHS Subcommittee, we have
been advancing funds that could be a crucial part of the
response. In the House-passed fiscal year 2020 Labor, HHS
appropriations bill, we include a $40,000,000 increase for
CDC's tobacco prevention and cessation efforts. Its Office on
Smoking and Health is committed to a world free from tobacco-
related death and disease.
This crisis has demonstrated the need for the $100,000,000
that we provide in fiscal year 2020 in the bill for a new
initiative to begin addressing the gaps in our Nation's public
health data infrastructure. I might add, and I say this to you
and to my colleagues, the Senate bill--the Senate bill has not
put an additional dime into these programs.
So I think this epidemic has spotlighted the gaps in our
public health data infrastructure. I believe what we have done
in this committee is the right thing in terms of increased
funds, and we have to persuade our Senate colleagues to do the
same.
When it emerged, the CDC had to create entirely new
databases and systems. The process was neither speedy nor
seamless. The first iteration crashed and burned in less than a
week, system errors and bugs.
The second iteration required States to enter data by hand
in a cumbersome, fragmented, and not automated file submission
process. Yet further evidence that our public health data
systems are too antiquated. They are in need of grave--a grave
need of upgrades. Our systems still rely on obsolete
technologies like faxes and compact disks.
To me, this is evidence as to why we need $100,000,000 in
the House-passed bill. But as I said, this is a crisis
demanding more immediate action than our funding for fiscal
year 2020.
I know many of our witnesses today have recommendations for
what the Congress can do and should do. Please share with us
your suggestions. We need your help, and we must act, and we
need to act now.
Let me just turn this now over to my good friend from
Oklahoma, the ranking member of the subcommittee, Congressman
Tom Cole, for any remarks he may want to make.
Mr. Cole. Thank you, Madam Chair.
Before I begin my official remarks, it would be remiss of
me, because I have not seen our chairman since her announcement
that she is going to retire at the end of this Congress, to
tell her how much we are going to miss her, how much we admire
her and the manner in which she has led this committee as
chairman and the manner in which she served it when she was
ranking member, and all the years of service in all the
capacities. You have been a Member's Member and an
appropriator's appropriator. And just you are going to be sadly
missed.
Now I was also going to throw my support to my chairman to
be the distinguished ranking member of the full committee the
next Congress. And so I am happy to head the Republican effort
to get that done.
But again, both of you have served with such great
distinction, and it has always been a pleasure. You were always
at this committee when I was privileged to be the chairman. You
are always here now. We know how interested you are in these
subject matters, and I certainly associate myself with the
ranking--excuse me, with the chairman's remark--or the chair's
remark that we know you are passionate and knowledgeable about
this subject, and we appreciate your input and your guidance.
But more than that, we just appreciate you as a friend and
as a leader in Congress for many, many years and wish you well
in whatever you choose to do next.
The Chairwoman. I speak out of turn by just saying thank
you. Thank you. And I really do think what I will miss most is
all the friendships because we have had the opportunity to work
across the aisle and, of course, all my friends on this side.
So I want to thank you.
But I will be here about 15 more months. So we can do a lot
of good work. Thank you for your kind words.
Mr. Cole. I know. I know. We look forward to working with
you in those 15 months.
The Chairwoman. Thank you.
Mr. Cole. You bet. Thank you, Madam Chair.
Madam Chair, I want to again thank our chair for holding
this important hearing. We have all been alarmed by the
frequency of lung illnesses related to the use of electronic
cigarette products. We are the third committee to hold a
hearing in the last few weeks on this topic, and I am glad to
see such a concerning issue getting serious, rigorous oversight
and attention.
Over the last few months, the Centers for Disease Control
and Prevention began an investigation into lung illnesses and
deaths associated with e-cigarette use. Of particular concern
is the relationship of those getting sick and the use of THC,
the psychoactive compound found in marijuana.
Recent investigations in Wisconsin uncovered 10,000 THC
vaping cartridges in a residential home. We know obtaining
cartridges from friends or on the black market is dangerous. An
overwhelming majority of the lung illnesses incidences are
linked to THC-containing products, although certainly not all
of them.
As we have seen States pass laws permitting greater access
to marijuana, the market for devices using THC has exploded.
This market growth has spawned a new black market for the
production of THC-laced vape cartridges.
A report released from Wisconsin and Illinois found that
nearly all THC-containing products reported were packaged,
prefilled cartridges that were primarily acquired from informal
sources, such as friends, family members, illicit dealers, or
off the street. We should be cautious about associating THC-
related misuse to appropriate use of nicotine-only products.
The same report found that over 80 percent of the nicotine-
containing products were obtained from commercial sources. An
overreaction banning the sale or purchase of nicotine-based
products could very well endanger more people. Studies have
shown nicotine-based products do provide an alternative to
traditional combustible cigarettes, an alternative that is
safer and often assists smokers to abandon the use of
cigarettes.
The reduction in the use of combustible tobacco is one of
the largest public health achievements in the last decade. E-
cigarettes have been part of this reduction, and they can
continue to serve as a healthier alternative for adults who are
current smokers. The CDC acknowledges that e-cigarettes have
the potential to benefit adult smokers when these products are
used as a substitute for regular cigarettes.
The science around the benefits and associated risks of e-
cigarettes is still new and in many cases not available. More
research on the impact of these devices have for adult users is
needed and currently underway at the National Institutes of
Health.
If we remove nicotine-based e-cigarettes from store
shelves, there is a strong likelihood adult smokers will
continue using combustible tobacco, and that is something to be
avoided.
While I believe the products should remain an option for
adults, we can all agree that children should not be using
these products under any circumstances. All necessary
precautions should be taken to ensure e-cigarettes and
associated products stay out of the hands of children.
Moreover, companies selling these products should not be
targeting children in marketing or advertising. These are
principles on which we all agree.
And to its credit, the Trump administration has taken an
aggressive approach to keep these products out of the hands of
children. Under Food and Drug Administrator Gottlieb, the FDA
issued more than 8,600 warning letters and imposed more than
1,000 civil monetary penalties or fines to retailers related to
the sale of electronic nicotine devices to minors.
The FDA has also issued warning letters to companies
related to marketing efforts that could target children. The
Surgeon General has launched a prevention initiative aimed at
educating young people on the dangers of e-cigarettes and
information on how to stop the use of these products for those
who may already be active users.
President Trump also announced last month that his
administration would be looking at potential future regulatory
action regarding the use of flavored products in e-cigarettes
and the impact that such a decision could have on teenage
usage.
I want to commend the work of the Centers for Disease
Control and Prevention. The leadership by the CDC is critical
to understanding the emerging public health issue.
Publicly, I want to thank Dr. Schuchat for her efforts and
testifying here today. Doctor, you have come to the Hill
several times in the last few weeks for several committees, and
I am sure you will be inviting back more in the future. We
appreciate your service.
In the span of a few weeks, the CDC has set up a response
team to track, respond, and inform all interested parties on
this troubling public health issue. CDC is sending assistance
to States, supporting lab tests to learn more about the
illnesses, and providing guidance to public health departments
and clinicians nationwide. Their work here demonstrates why
investments in our public health infrastructure can prove
critical.
A complicated issue that involves coordination amongst
enforcement, research, testing, clinical diagnostics, and an
ongoing public awareness campaign demands a public health
infrastructure that can mobilize and respond rapidly, and that
is exactly what CDC has done in this case.
I also want to thank our second panel of witnesses for
coming here today as well. We look forward to learning from you
and appreciate your time.
Thank you, Madam Chair, for holding this really and
genuinely important hearing, and I yield back the balance of my
time.
Ms. DeLauro. I thank the gentleman.
And now it gives me great pleasure--and she said it well.
You know, it is 15 months. We can do a lot of great work in 15
months, and she will continue to do that as chair of the
Appropriations Committee. I would like to yield time to
Congresswoman Nita Lowey.
The Chairwoman. Well, thank you so much, Madam Chair and my
friend ranking member, and members on both sides of the aisle.
We have been working together on critical issues for a long
time.
And I love this committee. My heart is with this--my heart
is with all the committee, but my special love here. And I look
forward to hearing your testimony.
I just want to say I remember very clearly,--and I think my
friend the chair had a similar experience. My granddaughter was
visiting me a few years ago in Washington, and we were just
chatting around the table with another friend. She brought
another friend with her.
I didn't have the foggiest notion that this even existed,
that it was as widespread. And when she said that 60 percent of
the kids in her high school class, 60 percent were addicted, I
said ``What?'' And that is when I and many of us began really
aggressively going after this.
In fact, I walked into a local store, and I said, ``I am
going to do everything I can, sir, to put you out of business.
Have a good day.'' [Laughter.]
The Chairwoman. True story. Wish I could be more successful
in that. But I do want to thank our chair, Ranking Member Cole,
thank you so much for holding this hearing today. And I want to
thank--there is so much going on--for all my colleagues on the
subcommittee for being here, and we are all pleased to welcome
our distinguished witnesses.
To say that we are concerned is the biggest understatement
because since that time, I have had roundtables in my district.
I have talked to dozens, perhaps more, hundreds of kids. And
when you hear now there are 26 deaths confirmed, including in
my home State of New York, it is really shocking.
The dramatic use of these products among youth, which is an
epidemic, is alarming. When you look at the numbers, one in
four kids are using e-cigarettes, and now a new generation of
Americans is hooked on nicotine.
So, as a Member of Congress with a long history of support
for anti-tobacco efforts and advocacy for tough regulations on
e-cigarettes, but as a mother and a grandmother, it really is
so heartbreaking, in addition to being outrageous, that we are
at the nexus of two public health crises, vaping-related
illnesses and deaths and an epidemic among youth that really
was largely avoidable.
I do remember my meeting with Dr. Gottlieb in the office
with my wonderful staff, who is now on maternity leave, brought
me all kinds of samples that you could buy in the mail. And
frankly, I shouldn't have been so innocent, but I said, what,
tutti-frutti, all these different flavors that clearly were
encouraging kids and that they could just buy in the mail was
so shocking to me at the time.
So in my role as chairwoman of the House Appropriations
Committee, I have consistently opposed tobacco industry efforts
to weaken FDA's enforcement of the Family Smoking Prevention
and Tobacco Control Act. I supported this committee's increase
for the CDC's Office on Smoking and Health in fiscal year 2019,
and I support a further increase in fiscal year 2020. This is
particularly important now, given the current outbreak in
illnesses and deaths related to e-cigarettes and other vaping
products.
So I want to urge again the CDC to continue its vital
laboratory research and investigatory efforts to get to the
bottom of the ongoing outbreak, to update the public on the
serious health risks associated with these products. In fact, I
have to--I won't go into too much detail, but I was part of one
of my roundtables, where I was really arguing with some of the
young people there who thought, hmm, nothing wrong with it.
Boy, they didn't realize now that they are addicts. But at the
time, they thought nothing wrong with it.
And I just want to say that I know how important it is that
CDC receive adequate funding to do the work. The advocacy
community must remain vigilant in helping to communicate to the
public the risks of these products, and we have to do
everything that we can through legislation, outspoken--
outsourcing the message wherever we can get it. But I really do
thank the chair and the ranking member for having this hearing
today. I think it is so very important because somehow,
although we have known about this for a couple of years, the
numbers keep increasing and increasing. In our public schools,
private schools, wherever you go, the numbers of users keep
increasing.
So thank you, thank you, thank you.
Ms. DeLauro. Thank you.
Now let me recognize Dr. Anne Schuchat, Principal Deputy
Director for the Centers for Disease Control and Prevention.
I want to just say thank you for being here today and for
the many, many times that you have come before us. And you have
been at the forefront of a number of these public health
crises, whether it is Ebola or other infectious diseases, and
we are so grateful for your expertise and competence, but for
your dedication and for your commitment to these issues.
Thank you so much. Your full written testimony will be
entered into the hearing record. You are now recognized for 5
minutes.
Dr. Schuchat. Thank you so much, Chairwoman DeLauro,
Ranking Member Cole, and members of the committee. I also want
to congratulate Chairwoman Lowey on her retirement and thank
you for your many, many years of service to the Nation.
The Chairwoman. I will be here 15 more months. [Laughter.]
Dr. Schuchat. Absolutely, and I am happy to come back, OK.
I would like to tell you today what we know and what we
don't know and what we are doing about the lack of knowledge
and also a bit about what we are doing about the youth epidemic
of e-cigarette use. I want to make four key points.
First, since we first learned of these cases of lung
injury, CDC has been working 24/7, hand-in-hand with State and
local public health as well as the FDA, to try to get to the
bottom of it.
Secondly, our ability to do this kind of investigation
critically relies on the infrastructure of public health,
including the data systems that need modernization and a
trained and data savvy workforce.
Thirdly, CDC has made important recommendations for the
public. Based on the investigation so far, we have recommended
that people do not use vaping products that contain THC.
Regardless of this investigation, e-cigarettes or vaping
products should never be used by youth, young adults, or
pregnant women; people should not acquire these products off
the street, and they shouldn't further modify them. Adults who
use e-cigarettes or vaping products because they have quit
smoking cigarettes should not return to smoking cigarettes.
Fourthly, we need to address the broad epidemic of e-
cigarette use among youth. What we know so far about this
epidemic is that it is striking young people. More than half of
the cases are under 25 years, about 70 percent are male, and
new cases are being reported every day. I expect this week's
numbers to grow considerably.
What we don't know, unfortunately, is the cause. We know
that the most recent reports suggest that most patients report
using THC-containing products or both THC-containing products
and nicotine-containing products. However, because nicotine-
containing products have been reported to be used either alone
or in conjunction with THC-containing products, we cannot
exclude the possibility that nicotine-containing products play
a role.
No single product, brand, substance, or additive has been
identified in all cases so far. It may be that there is one
cause or that there are many problematic substances causing
lung injury, and there may be complex root causes for the
increases that we are seeing right now.
CDC is working vigorously with States to respond. We have
dispatched our disease detectives to assist some of the State
and local public health departments. We have activated our
Emergency Operations Center. Our incident manager is
coordinating our response.
Last Friday, we issued updated clinical guidance based on
inputs from clinical experts who have been caring for these
patients and the accumulated information from cases around the
country. We are doing frequent calls with the public health
community, clinical organizations, and the media to keep people
informed.
We are working very closely with the FDA on traceback of
products that people have used, and our laboratory is assisting
with the clinical pathology testing and working with FDA's lab
on testing of products and aerosols produced by the products.
But this outbreak has a number of challenges. The
investigation includes trying to gather information about
exposures to potentially illicit products, so some respondents
may not be totally forthcoming. State laws vary regarding THC
and cannabis use, and that can also complicate the data
collection.
E-cigarettes or vaping products are part of a marketplace
that is very wide and extremely diverse. A multitude of product
varieties and different substances can be used with the
devices. And there is the issue of counterfeiting or black
market products.
Public health data collection for the response, as you have
said, is relying on antiquated and fragmented systems that need
modernization. The disease, unfortunately, is moving faster
than our data systems, and that is a barrier to getting to
quick answers.
Briefly, I want to mention the epidemic of youth use of e-
cigarettes. We know that youth are much more likely than adults
to use e-cigarettes and that flavors are a key part of that
appeal. We have been messaging our concerns about youth use of
e-cigarettes since 2013, when we got the initial data about the
alarming increase from 2011 to 2012. The problem is much worse
now, and we continue to consider this a great concern.
In closing, CDC is dedicated to working around the clock,
together with State and locals and with the FDA, to get to the
bottom of this and to keeping you updated.
I look forward to your questions.
Ms. DeLauro. Thank you very much.
Dr. Schuchat, August 1, CDC was notified by Wisconsin about
a cluster of pulmonary illness among young adults that began in
July. September 16, CDC activated the Emergency Operations
Center. It is now exactly a month later in the outbreak
investigation, but this suspected chemical exposure is ongoing.
During your career at CDC, you have been engaged in the
numerous responses including H1N1, pandemic influenza, SARS,
Ebola, and anthrax. How is this outbreak similar or different
than others conducted by the CDC?
And if I can just mention a follow-up at this moment, what
impact do you expect flu season to have on the current outbreak
investigation? It is my understanding that lung injury from
vaping can result in symptoms that might be misdiagnosed as the
flu.
Dr. Schuchat. Thank you.
I have been involved in a number of complex multi-State and
also international outbreaks. This is extremely complicated and
difficult. It is affecting young people. It is fatal or
potentially fatal, with half of the cases requiring care in an
intensive care unit.
It is affecting every State, and it is not caused by an
infectious pathogen, which is our usual story. But like most of
the other outbreaks, it is relying on the public health
infrastructure of the Nation--State, local, and Federal--and
CDC's tried and true approaches with our Emergency Operations
Center and Incident Management System are helping. But as I
have mentioned, the antiquated data systems are kind of
handcuffing us at some point.
The issue with influenza is very important. We are right
now moving into the winter season when influenza illness may be
increasing, as will other respiratory viruses that are common
in the winter. Last Friday, in our updated clinical guidance,
we urged recommendations for evaluating individuals with
respiratory symptoms to consider both lung injury associated
with vaping or e-cigarettes, as well as influenza, and to treat
for both, if appropriate.
Of course, a person who has lung injury or lung damage from
e-cigarette or vaping product use may be vulnerable to worse
complications of influenza. We don't want to withhold treatment
of one at the expense of the other. It is going to be a very
challenging winter.
Ms. DeLauro. Last year, there was an outbreak of E. coli
that sickened 62 people in the U.S. When CDC determined that
the source of the outbreak was romaine lettuce, CDC delivered
the clear message, ``Do not eat romaine lettuce.''
However, despite CDC's overall warning to the public that
no one should use tobacco products, CDC's message for weeks
around an outbreak that has sickened nearly 1,300 people,
killed 26, has to been to ``consider refraining from using e-
cigarettes or vaping products that contain nicotine.''
Let me just ask you why hasn't CDC's warning been more
urgent? Why are we not saying don't use e-cigarettes at all
until we figure out what is going on?
Dr. Schuchat. Thank you.
We strive for clear, actionable communication. For this
investigation, we are trying to update our recommendations
frequently based on the best evidence available. And we have
updated that information as more and more data has come to
light about the THC-containing prefilled cartridges.
Regardless of this investigation, we want to be very clear
that e-cigarettes should never be used by youth, young adults,
people who are pregnant, or by adults who aren't currently
using tobacco products. No tobacco product is safe, and we
really want to make sure that is clear. But for the outbreak
investigation, we are following the evidence and trying to make
our messages as clear as possible, but still evidence-based.
Ms. DeLauro. Let me just say the current outbreak really
highlights the role of CDC and the FDA working together in
terms of the public health. CDC--well, FDA is a regulatory
agency. What role does CDC have in providing information to FDA
as it makes regulations?
Dr. Schuchat. We work very closely with the FDA to share
the evidence that we have. In fact, we actually collaborate on
the National Youth Tobacco Survey, the results that showed that
shocking increase in the e-cigarette use in high school
students and middle school students. So we feel that our--as an
evidence-based, data-driven agency, we want to get the best
information possible available as quickly as possible to the
regulators, but we don't make the regulation ourselves.
Ms. DeLauro. But just I have got 3 seconds here, in terms
of do you have any sense of timing when you will make a
forthright statement the way you did on ``Do not eat romaine
lettuce'' to the public? I mean, what is the timing on that?
I understand the areas that you have carved out about
youth, young adults, pregnant women. But where are we going on
this?
Dr. Schuchat. We follow the evidence, and we update it as
there is more evidence. For this investigation, we have updated
to say do not use e-cigarette or vaping products containing
THC. Do not buy any products off the street or from informal
sources.
But for the e-cigarette use in general, we have focused on
the populations where the evidence is very clear in terms of
the developing brain up through age 25. That is why we focus on
young adults as well as youth and on pregnant women.
In terms of adults who are trying to quit smoking, there is
mixed evidence now, and none of the products are approved as
cessation devices. But that is an area where we haven't said
don't do that yet, and that is basically following the evidence
as it emerges.
Ms. DeLauro. Let me be clear. The THC, while it is a
factor, it is not the only factor. Nicotine is a factor. So
that the notion that if you remove this THC, then everything is
hunky-dory, it is all right to move forward, that is not what
you have said. You said that it plays a very--nicotine plays a
very, very strong role in what the problems are.
Dr. Schuchat. Well, in terms of the youth use of e-
cigarettes, it is a huge role. In terms of the epidemic of lung
injury, we don't know yet.
Ms. DeLauro. Thank you. Mr. Cole.
Mr. Cole. Thank you very much, Madam Chair.
And thank you very much for your testimony. It is very
helpful. The speed at which this has evolved reminds me
sometime of the opioid crisis or things like that where we have
seen products have consequences we didn't really initially
understand when they were released into the marketplace, and
particularly the youth addiction.
You mentioned in your testimony some of the various factors
that make this so difficult to analyze compared to an
infectious disease. I would like you to elaborate on that a
little bit, particularly in two areas.
One, in terms of the difficulty of investigating when you
have illicit use in many of these cases of THC. And second,
what, if anything, does the difference--and you have touched on
this a little bit in your testimony--the difference in
marijuana laws at the State level, which we have had an
explosion of legalization, obviously, in the last few years.
How does that play into both your investigation and the
potential spread of the delirious consequences of vaping here?
Dr. Schuchat. Some of the complications of the
investigation involve the substances that are being used. The
e-cigarette or vaping products have a variety of components.
They are not necessarily labeled fully, and there probably are
counterfeit and black market influences such that even if there
were labels, they wouldn't be telling you everything that is
inside.
In terms of the interviews with patients who are very, very
ill, they may be too sick to tell you. They may have had many
different products that they used. I think some of the
interviews suggest like 40 different products that people
report having used. There may be little product left to test,
and it may not be the product. It might be the device that the
product is being used with or the aerosol that the product
produces. So the laboratories are busily testing a variety of
things.
There may be more than one outbreak. This outbreak that has
nationally got our attention may be a lot of local sources of
problematic substances.
In terms of the State laws, obviously, we are working very
closely with the States. We are working very closely with the
FDA and the DEA on the traceback investigations and the
particular substances.
In terms of interviewees being forthcoming, of course,
there are some issues about if they will be forthcoming about
an illicit product. But I think it is also worth remembering
that a lot of kids don't want to tell their parents that they
are using any kind of tobacco product. That, of course, it is
illegal in most States, depending on the age. So there is a
challenge for the clinicians and the State investigators to
gain trust and get real histories from people.
So this is complicated, fast-moving, and challenging, but
it is critical. And it is exactly why CDC exists, to stop this
kind of outbreak before we have more deaths.
Mr. Cole. Obviously, you know, vaping is done
internationally, not just here. What are--your contacts in
other countries with other healthcare organizations, are they
experiencing the same sorts of things that we are? Are they
somehow different? Is there a better regulatory scheme that you
have seen out there than we have?
Dr. Schuchat. The international contacts that we have do
not reveal a large problem in other countries. There are
individual reports being investigated, but nothing right now
like what we have seen.
The regulatory environment is different. The smoking
environment is different. Both the legal and illegal markets
are very profit-oriented. And the environment for smoking
cessation is quite different country to country.
So sometimes an outbreak, a food-borne outbreak might be
international. This one doesn't yet seem to have international
scope.
Again, you mentioned the opioid epidemic. We are
experiencing a very different opioid epidemic than Europe, but
we had a backdrop of a huge amount of prescription opioid use.
I do think it is possible that the epidemic of nicotine-
containing e-cigarettes has created a generation that is almost
addicted to vaping, whatever the product is.
And now we have devices that are so small that can be used
discreetly inside the classroom with no odor and making it very
hard to stop that behavior, whatever is in the cartridge.
Mr. Cole. Well, again, I know we have put a lot on your
plate here, and I, frankly, appreciate the quality and the
speed with which you are working. But I would hope that you
look at this internationally as well, just to see if there are
lessons to be learned from other countries and to see if there
are some unique factors, obviously, in the problem we have in
this country that truly are a product of either the manner in
which we regulate or the diversity of regulatory schemes that
we have across multiple State lines.
Dr. Schuchat. Thank you. Actually just last week formed an
international team as part of our incident management and are
connected with the WHO and with European and Canadian
colleagues.
Mr. Cole. Thank you. Thank you, Madam Chair.
Ms. DeLauro. Congresswoman Lowey.
The Chairwoman. Thank you. And I want to follow up on the
wise comments of my good friend Mr. Cole.
Thank you. I was just complimenting you. [Laughter.]
Mr. Cole. I know. You are being really nice in your last 15
months.
The Chairwoman. Oh, you are always my good friend. But I
think that is a very important point that I want to follow up
on.
E-cigarettes have been marketed as an alternative or off-
ramp for existing adult smokers seeking to stop using
combustible cigarettes. Several of us, as you have heard, are
concerned that this is a false narrative that only encourages
tobacco use and that both adults and young people will, for
lack of a better word, graduate to combustible cigarettes if
they use e-cigarettes.
So, number one, I would be interested in your thoughts on
this. And I know CDC has been working on the stop smoking for a
long time, but what more can CDC do and what help is needed
from Congress to help current e-cigarette users and smokers
just quit? I will leave it at that.
Dr. Schuchat. CDC acknowledges that e-cigarettes are used
by some adult smokers to help them quit, and there is emerging
data about whether there is strong enough evidence there for
that to be recommended, although none of them have gotten
approval from FDA as a cessation device. But we are very, very
troubled by the marketing to youth and the flavors and the
stealth approach to get teens hooked on nicotine-containing e-
cigarettes with very high levels of nicotine and sort of a life
of addiction, and we share the concern about whether they will
move on to combustibles and the dangers that nicotine has on
the developing brain in general.
In terms of the support from the committee and from
Congress, we really were very appreciative of the proposed
increase in the tobacco line. Our State and local colleagues
tell us that they are stretched very thin in terms of
addressing the epidemic of adolescent tobacco use while
continuing the other approaches that are so critical as part of
a comprehensive tobacco control project. And we are also very
appreciative of the proposed increase for the data systems,
which we think is just vital.
What we know right now about how to help young people quit
tobacco or e-cigarette use is not as much as what we know about
adults. But we think that in addition to the individual
counseling and cessation efforts, the environmental or
population-based activities are very important. Tobacco-free
indoor areas, restrictions on where the products can be sold
and so forth, all can reinforce youth not being able to go back
to nicotine use if they stop.
So I think that there is a lot of work to be done, and
unfortunately, while there is a strong evidence base of how to
reduce tobacco use, we have a growing problem of a new
generation that we need to apply those tools to. So we do know
what works, but we have to apply it on a larger scale than we
did.
The Chairwoman. Well, I thank you so much. And just
closing, I wonder what kind of research is being done on just
that? If more information is coming out about THC, and kids are
getting a little worried because they see their friends
coughing, coughing, coughing, getting sick, is there any
movement to using e-cigs without the THC because you don't want
them to be addicted to nicotine with or without?
I just wonder if it is too early or what is happening out
there?
Dr. Schuchat. What I would say is that it is hard for us to
keep up with the behavior changes. We know from the National
Youth Tobacco Survey that among e-cigarette users of nicotine-
containing e-cigarettes, use of THC is very common. About a
third of them also use THC in their devices.
But our annual survey barely is keeping up with the market
changes and the product introductions. We do sales monitoring
to keep up with that. But I think we have to really pick up our
pace to understand what the practices are in order to
intervene.
So there is just a lot to do right now. And again, it is
kind of shocking how large the numbers are of teens now that
are reporting current use, and much of that current use is
frequent use.
The Chairwoman. Well, I have 2 seconds left, or minutes,
whatever this is. So I just want to thank you, and this is what
is beginning to worry me. So if they say, OK, I don't have any
of that stuff in there, but they are getting hooked on
nicotine.
Dr. Schuchat. Yes.
The Chairwoman. Just when we were making product----
Dr. Schuchat. Progress, yes.
The Chairwoman. ``Progress'' is the word I was looking for.
So I thank you for your work, and we have to, obviously, invest
more and just stop it, no smoking. Thank you. Don't get started
is more the word.
Ms. DeLauro. Congressman Moolenaar.
Mr. Moolenaar. Thank you, Madam Chair.
Dr. Schuchat, nice to see you again, and thank you for
being here and for your testimony.
You had mentioned the challenge of the data collection and
reporting systems being antiquated and fragmented. Could you
speak to that a little bit and also what you feel Congress
should be doing to help address that in terms of investment in
CDC's data collection and reporting systems? Also kind of where
you see data standardizations and interoperability being a
hindrance to some of these investigations.
Dr. Schuchat. Yes, thank you.
The public health data system has a lot of challenges right
now. If you look at what has happened in healthcare information
technology, we have really seen a dramatic improvement in
electronic medical records across the country and in better use
of technology to improve health. The public health system
hasn't benefited from that. The systems that we rely on are
different in many States. Many States are still using paper and
pen or faxes.
When we have a multi-State challenge like this, there are
different approaches in each State, and we try to get
consistency, and we are not connected with the healthcare
system records. So when you are trying to review a complex
medical chart about a difficult lung injury, people are faxing,
you know, hundreds of pages of medical records to the health
department for that review. We are just not using technology
effectively.
CDC has been working on a strategy and a plan for how to
catch up, and we are working with the public and private sector
on that strategy, but we really think that the public needs the
public health system to be in better shape than it is, and it
is definitely slowing down our response.
We think that interoperability and data standards are
critical. So is innovation, and so is recognizing that we are
not trying to build one, big monolithic system that can crash.
We want to be investing in a smarter way that will be adaptive
over time, but that will get us information earlier and with a
workforce that can actually use data to predict problems rather
than react on it late.
Mr. Moolenaar. Do you have a timeline on when you think
that plan would be completed, and I am sure with your support,
you know, I think it would be fascinating for this committee to
hear that once it is ready.
Dr. Schuchat. And we would be happy to share with you where
we are with it and then more details about where we want to go.
Mr. Moolenaar. Thank you.
Ms. DeLauro. To my colleague, if you yield for a second,
that is one of the reasons why we have put in the $100,000,000
because we found--and this turned up. In most health crises, we
leave our States at--really at risk because we don't have a
very substantial public health infrastructure nationwide.
Again, which is one of the reasons why we buttressed that up in
our bill.
Mr. Moolenaar. Thank you.
I wondered if you could also talk a little bit about--
because, you know, I have been reading different articles, and
I am still trying to get a picture for what is actually
happening here. I am assuming the lung injury is pretty similar
in each case, or are there different types of lung injuries and
infections, or how would you characterize what we are seeing?
Dr. Schuchat. Yes, we are still gathering the data. The
clinical symptoms are fairly similar. The people develop
shortness of breath, cough, sometimes chest pain, sometimes
fever, and about three-fourths of them have gastrointestinal
symptoms around the same time--nausea, vomiting, stomach pains.
Many progress to life-threatening difficulty breathing,
where half of them are admitted to intensive care units, and
about 20 percent need to be on a mechanical ventilator. The x-
rays look like what we call bilateral, both sides of the lungs,
diffuse infiltrate. That is very nonspecific.
The extra testing that is done doesn't show an infection,
which would be common. The imaging, the x-ray or chest CT,
shows many different patterns that are diffuse. But what we are
trying to do right now is look at pathology, look at the
clinical specimens, and there are a couple different patterns
that are being seen.
I think it is too soon for us to know whether this is one
substance causing a chemical reaction or multiple different
kinds of substances in individual cases. And so that is why I
say it may be multiple outbreaks on this as common backdrop of
the vaping or e-cigarette product use.
Mr. Moolenaar. And I recognize the challenge when you have
illicit drugs being used, and you aren't sure what someone is
putting into the mix. In cases where these are being sold
legally, you had mentioned sometimes there is not full labeling
or, you know, that is there is a mystery there. Can you speak
to that?
Dr. Schuchat. Yes. I think that, State by State regulation
of THC, or marijuana, will vary how the products are required
to be tested and labeled. The e-cigarette products aren't right
now approved by FDA. So there are really no requirements of
what they have to say. So it is kind of hard to know what is in
them or what is produced by them, at least that is my
understanding.
And what we do know is that the aerosol that a nicotine-
containing e-cigarette can have will produce a lot of different
compounds. Not as many as combustible cigarettes, but there can
be organic volatile compounds, heavy metals like lead. You
know, there is a device that is involved heated to high
temperatures, what they call ultrafine particles, which has
lung specialists worried because that is kind of like silica
and silicosis.
Then what we see with--especially young people using e-
cigarettes--is they are using them all day. It is not like the
old days where you had to go, you know, before school or after
school they were smoking cigarettes. They are using them in
class, in the bathrooms, all through the day. And so they are
getting enormous amounts of that aerosol exposure. And then,
similarly, we hear that the THC use is often quite frequent.
So I think that the damage that the variety of substances
might have on the lungs could be diverse, and then what we are
really worried about with the outbreak is adulterants or
cutting agents or solvents being used to increase the profit.
Adding oil or other chemicals to the THC-containing cartridges
that will make more of a product for the dealer, but really it
is uncharted territory what that does when it is heated to high
temperatures and is inhaled.
Mr. Moolenaar. OK. And then, finally, we had the NIH
Director Collins and a team from NIH talking about the current
scheduling of marijuana and the effect that that has on the
research. Do you find--do you feel that it would be helpful to
you to have additional research on THC in this area, and is the
scheduling of that interfering with some of that research?
Dr. Schuchat. Well, we don't have specific funding for the
THC work right now. So that might be more of a barrier for us
than the scheduling. But, I share Dr. Collins' view that a lot
more research is needed and that there are many questions that
it would be helpful to understand.
So the scheduling may have less impact on us because
essentially in our National Youth Tobacco Survey, we have a
couple questions, and in our Behavioral Risk Factor Survey, we
have a couple questions. But we are not investing in research
right now on marijuana or THC.
Mr. Moolenaar. OK. Thank you very much.
And thank you, Madam Chair.
Ms. DeLauro. Congresswoman Roybal-Allard.
Ms. Roybal-Allard. Dr. Schuchat, thank you for being here
today and for everything that the CDC is doing to identify and
address the causes of lung illness and death associated with
vaping.
I think up to this point it has been well established that
we are in a crisis situation, and so I would like to focus my
questions on the resources that CDC is going to need in order
to adequately address this crisis. So, first of all, I would
like to have you maybe elaborate on the strategies that CDC is
employing to address youth vaping behaviors, and what resources
do you need to be successful in this?
Dr. Schuchat. Yes, thank you.
We carry out much of our work through funding of the State
and local tobacco control efforts through the public health
departments, and they are stretched thin right now. They say
about half, 50 percent or so of their resources are going
towards youth issues, and that is inadequate in terms of the
growing problem in youth and that we haven't finished the job
in adults yet.
The approaches that are taken are a comprehensive program,
which involves a variety of strategies. Mass media, which can
include school-based efforts as long as they are not industry-
sponsored school-based efforts. But also things like our TIPS
campaign or what the Truth Initiative is doing or FDA is doing
targeted at youth.
A second area is around price controls, which is certainly
done by the States, not by us. A third area is smoke-free
policies, and that that really can play a role in terms of
reducing secondhand smoke or secondhand aerosol exposures, but
also reinforcing quitting once people have quit and help people
not start.
So those are the types of approaches, and I think a key
thing that CDC wants to do is monitor the data. Each State is
tracking the youth tobacco use as well as adult use through
other means, and having that data accessible quickly and being
able to adapt it to the newer threat.
So those are the kinds of things we do with the resources.
But of course, in this response, we are also doing a rapid-fire
incident management, multi-State investigation, which involves
epidemiology and laboratory and communication and policy, the
international team I mentioned, as well as data systems work.
So I think we are working on a lot of fronts right now, but
with an increase in resources for tobacco, we would very much
want the States to be able to focus on expanding their youth
activities.
Ms. Roybal-Allard. It was mentioned earlier, after years of
relatively flat funding, the House fiscal year 2020 Labor, HHS
bill included a $40,000,000 increase for CDC's Office of
Smoking and Health. Unfortunately, the Senate bill level funds
OSH at $210,000,000. If the Senate level were to be approved,
what activities would CDC not be able to undertake to stem this
youth epidemic?
Dr. Schuchat. Yes, essentially, the States would be having
to decide between children and adults, and that is not really a
great option. We know that of adult smokers, 70 percent or more
want to quit, and their access to cessation products and
quitlines is really important. And that is a key thing that the
States do.
And we know that new young people taking up e-cigarette use
is possibly leading to a life of addiction and harming the
developing brain and increasing their risk for addiction to
other substances. So it is really a terrible choice.
But I think you can see in the numbers between the acute
investigation and the rising youth use of e-cigarettes that
there is a growing problem, and diminished resources would not
help.
Ms. Roybal-Allard. OK. Can you tell how much of the current
OSH budget is dedicating to addressing the e-cigarette
epidemic, and is that funding being drawn from resources that
would have otherwise been used to reduce the use of cigarettes
and other tobacco products?
Dr. Schuchat. The States tell us about half is going
towards youth, that is pretty much e-cigarette targeted right
now, and yes, that is drawing from--the resources available for
adults in terms of the quitlines and cessation access and so
forth.
So it is, and having the mass media campaigns can be quite
expensive and having ones sort of targeted towards where youth
get their information is a different approach. So there is
quite a lot to do right now.
Ms. Roybal-Allard. So my understanding is a large part of
the burden is falling onto the States themselves to do this?
Dr. Schuchat. That is right. We----
Ms. Roybal-Allard. They are not adequate--they don't have
the adequate amount of resources?
Dr. Schuchat. That is right, yes. That is right. Most of
our resources go to the States directly or indirectly. And they
are stretched thin now. Some of their tobacco settlement
resources are gone, are going to the general fund, not towards
their tobacco control program.
So with this increase, we thought we were making progress.
Adult smoking was down, and even e-cigarette use was down, and
then the last couple years, it is starting to skyrocket. So the
resources are stretched thin, and we need to really redouble
our efforts to get the trends to go back down.
Ms. Roybal-Allard. Thank you.
Ms. DeLauro. Congresswoman Herrera Beutler.
Ms. Herrera Beutler. Thank you, Madam Chair.
Okay. So I think our goal is to do the hearing, at least
the way I see it, is we want ideas that are going to help us
end not just the current outbreak, but address the underlying
situation, right? And we are just gathering information.
I wanted to really quickly read a couple things that are
now updated on the CDC website for our constituents to read.
``Most patients report a history of using THC-containing
products.'' There is another line, ``The latest findings
suggest products containing THC play a role in the outbreak.''
Next line, ``While this investigation is ongoing, CDC
recommends that you consider refraining from using e-cigarettes
or vaping products, particularly those containing THC.''
Another line, ``Anyone who uses e-cigarettes or vaping products
should not buy these products from informal sources or off the
street,'' right?
And then I guess my next thought is, you know, let us be
very clear, ``No teen use of marijuana is legal anywhere,''
right? There is no regulated market for marijuana use for
teenagers recreationally. And THC is still federally illegal
everywhere. So we all know that. And it is illegal in 39
States.
You know, no THC vapor is legal for 8th, 9th, 10th, 11th,
12th grade use. Yet CDC, your Youth Behavioral Risk Survey or
surveillance system tells us almost 20 percent of youth have
used marijuana in the last 30 days. And then according to
Federal data, the percentage of those kids vaping marijuana
instead of smoking it or ingesting it is also going up.
So this is the pool of kids I am most worried about, and
yes, I am worried about adults who want to get off of smoking,
absolutely. But when you are looking at investment and how do
we put our money in, you know, stopping that expense on the
backend, in lives and in dollars, we need to get at them now,
especially as this is exploding.
You know, this has taken the lives of at least 26 people.
Where do we--I was so concerned to hear that there is not
research with regard to THC or marijuana use, especially the
impacts of it, at CDC. What do we need to do to help you get
that research?
Dr. Schuchat. Yes, thank you.
I do think there is general agreement that youth should not
be using THC or nicotine, and the scope of the problem is
getting worse. The marijuana rates are probably kind of flat,
but the exposure to these vaping devices that allow for very
discreet use may be changing the dynamic a little bit.
CDC works really closely with both NIH and FDA on the
tobacco issues and also on the substance issues, and so the
research portfolio that NIH has, we may be very support of.
Exactly what research we are doing or would do with resources
would need to be complementary. It would be less of the basic
science kinds of lung pathology that they would be doing or
addiction research that they do in NIDA and probably more of
the behavioral change, marketing strategies that would help the
State health departments get their challenges met. The State
health departments really want more help with marijuana as well
as with nicotine.
Ms. Herrera Beutler. And is that something then--so
addressing the behavioral or the way to communicate with young
people, I am just going to break it down.
Dr. Schuchat. Right.
Ms. Herrera Beutler. That is where--that would be more in
your wheelhouse, yet you guys don't have necessarily any
proposals for that? You are not requesting that? Or is that
something----
Dr. Schuchat. We don't have a marijuana funding line
through your appropriations. We have broader lines that we use
to support the core work that we do, but we are not funded to
do research on marijuana.
Ms. Herrera Beutler. And so we would have to specify that?
Dr. Schuchat. I think so, yes. But we could probably get
you more informed information after the hearing, then, about
the particulars.
Ms. Herrera Beutler. I would like to have it, just because
everybody keeps saying it is a problem, it is growing. And yet
no one can answer this question, and you are the CDC. That
baffles me.
And my State has legalized it, a number of States have, for
recreational use. And yet I don't even hear, hey, you guys
aren't funding what we are asking you to do here. You're
saying, well, we haven't necessarily really even put it in our
ask.
And I don't blame you. I'm just saying that tells me we
need to get this--we need--I am ready to help step up and get
you what you need. But we--you guys are the--you are the
doctors and the researchers, right? We need your help.
Dr. Schuchat. Yes, and we do hear from the States across
the country that more understanding of the trends that are
going on and the risks and benefits and the best approaches to
the regulatory requirements that they have would be helpful. So
we get a lot of requests from State health departments and
their organizations.
Ms. Herrera Beutler. Well, now I have a request of you. I
would love to have someone in your office come maybe meet with
us on how we could help facilitate that.
Dr. Schuchat. OK, thank you.
Ms. Herrera Beutler. Thank you.
Ms. DeLauro. Congresswoman Clark.
Ms. Clark. Thank you, Madam Chairwoman.
Thank you, Dr. Schuchat, for being with us today.
I had a question for you on the National Youth Tobacco
Survey that showed a decline in e-cigarettes and then an
increase in 2017-2018. Do we know some of the reasons behind
that increase?
Dr. Schuchat. Yes, the timing of the increase tracks pretty
well with what we call the ``fourth-generation e-cigarette
device,'' and Juul is the sort of poster child for that. And
those devices use nicotine salts, which are not as harsh as
plain, old nicotine, and so the taste is more acceptable to
young people first trying it.
They had higher concentrations of available nicotine, and
the device is quite small and can be put in your pocket or used
discreetly so that kids could use them in school. Parents
wouldn't know what they were. They look like USBs or
highlighters and so forth.
And so the huge uptake from 2017 to 2018, and then again in
the preliminary results for 2019, really tracks with the market
share of Juul just skyrocketing during that period.
Ms. Clark. And do we have good data on the use of e-
cigarettes and giving up smoking? Do we have data on the
efficacy of that?
Dr. Schuchat. No. There is emerging data, but there have
just been three randomized control trials in terms of a
cessation approach, and the data from those trials is mixed.
The evidence basis, as Chair DeLauro mentioned, from the
National Academy of Medicine reviews that it is sort of mixed
evidence at this point and not yet recommended as a cessation
approach. And none of the e-cigarettes have FDA approval to be
used for cessation.
There are seven different FDA-approved cessation tools that
have gone through full review. So there is mixed data there in
the U.S. We are a data-driven, evidence-based organization, and
we love to see data. But at this point, that data hasn't been
pulled together.
Ms. Clark. You know, it is alarming to hear you talk about
these ultrafine particles, that even though it may be less
toxins than in combustible cigarettes. But how long--if you can
answer such a general question, how long does it take for us to
see those kind of what we saw with asbestos showing up in lung
disease from usage like this? Or do we have any idea?
Dr. Schuchat. Yes, there is so much research that is
needed. I think that, actually, CDC's National Institute for
Occupational Safety and Health has done a lot of work on lung
diseases, including silicosis and asbestosis and so forth and,
in fact, the popcorn lung that we were hearing about before
with the same chemical that is in some of these flavors.
We are used to studying these things occupationally because
of the high doses that people used to get as workers when they
weren't using respiratory protection, but we don't really have
the same kind of science yet on young people doing 24/7 vaping
of high doses of fine particles into the depths of their lungs.
And I think this outbreak of lung injury is showing us that
some damage can happen really fast, depending on what the
substance is. In terms of the nicotine e-cigarette devices and
the harms they may have over time, I don't think we have that
data yet.
Ms. Clark. And one of my concerns, using a small focus
group of my teenage sons and their friends, is that there is a
growing--well, you know, if you are not using THC, this is
still perfectly fine. So we need to get those education pieces
out, and you have talked a lot about the infrastructure. And I
know you have a report coming, but can you give us some
specific supports that we could give you around educating the
public, where sort of we are breaking down in the public health
infrastructure on this?
Dr. Schuchat. Yes. I think the teens definitely have that
impression that there is no problem. It is not a cigarette.
They don't recognize there is nicotine. They don't often have
any idea that it is harmful.
Ms. Clark. And the salts have higher levels of nicotine?
Dr. Schuchat. Yes, the salts can make a higher level
available. One pod of Juul is like a full pack, it is like 20
cigarettes. And people, may go through a pod a day or every
other day, and as I said, they can be using them in class.
Whenever the teacher turns her back or his back, they are using
these products. And slip it in your pocket, and you have no
idea it is going on. The level of use may be quite high. So I
think there is a lot of work to do.
Now the FDA has a campaign called ``The Real Cost,'' which
is really aimed at youth, and the Truth Initiative has a youth-
targeted campaign. But I think there is a lot more we need to
do. We know that some of the companies have gotten youth
influencers and very, very sophisticated youth-targeted
advertising to get people hooked, and we have to counter that.
Ms. Clark. Thank you.
Ms. DeLauro. Congresswoman Lee.
Ms. Lee. Thank you, Madam Chairman. Thank you for this very
important hearing. I apologize for being late. So if I ask--
these questions are redundant, just say so, and I will move on.
But this is such an important issue that so many
communities have been grappling with, and so I just wanted to
ask just a couple of really just basic, cut through the smoke
questions. In terms of just e-cigarettes, are they safe to be
used right now?
Dr. Schuchat. We don't think there is any safe tobacco
product. So e-cigarettes containing nicotine should never be
used by youth, young adults, or pregnant women, or by adults
who aren't previously tobacco users. The developing brain
through age 25 can be harmed by nicotine, and the individuals
using nicotine at young ages may have a higher risk of
progressing to combustibles and also to addiction to other
substances.
So there are populations where nicotine-containing e-
cigarettes are just absolute noes. But in general, we don't
think there is any safe tobacco product.
Ms. Lee. Well, if they are not safe, then why is there not
a complete ban until we figure out what is causing these
negative health outcomes?
Dr. Schuchat. Well, the CDC doesn't have the regulatory
role and----
Ms. Lee. But you can recommend.
Dr. Schuchat. Right. That is where what we have said is
that there are groups that should never be using e-cigarettes,
and those are, you know, youth, young adults up to age 25,
pregnant women.
There is a lot of debate out there about adults who want to
use e-cigarettes as a ``safer'' alternative to cigarettes. We
are worried that a whole generation is starting e-cigarette use
that was never going to go on to using cigarettes, and we don't
want, an off-ramp for adults to be an on-ramp for kids.
Ms. Lee. Sure.
Dr. Schuchat. And if there is, sufficient data for them to
be used for cessation, that could go through the process for
approval.
Ms. Lee. Yes, I understand that, and I am happy that you
all are raising the alarm. But I don't see any policy
recommendation coming to us saying the Congress should ban the
use of e-cigarettes for the following reasons.
Dr. Schuchat. Yes. So, again, we are not the regulatory
body, but----
Ms. Lee. The recommendations----
Dr. Schuchat. Yes, right. But the----
Ms. Lee [continuing]. Based on the data that you have right
now?
Dr. Schuchat. Right. And so, based on the data, the
administration has proposed to enforce the regulatory
authorities they have in terms of non-tobacco flavored e-
cigarettes. None of the products are considered legal or
authorized yet, but that hasn't been enforced, and they are
proposing to enforce that with----
Ms. Lee. But this has been going on for a long time.
Dr. Schuchat. Absolutely, yes.
Ms. Lee. So it is time for you all to speak out and say
something, that they should be banned for the list of reasons
you just enunciated.
Dr. Schuchat. Yes, and we have been saying, you know, young
adults, teens, pregnant women should not use e-cigarettes and
adults who haven't----
Ms. Lee. I understand that, but I am just saying I believe
that this does not take you out of your lane if you make a
recommendation, a public health recommendation that we should
establish a policy to ban them.
Dr. Schuchat. Right. Yes, and so I would just keep saying
that no tobacco product is safe. And the more we can get people
not to use these, the better.
Ms. Lee. But it is not working.
Dr. Schuchat. Yes, I agree with you.
Ms. Lee. Thank you very much. I yield the balance of my
time.
Ms. DeLauro. Let me just say one point. The FDA at the
moment has the authority. They have refused, both in the last
administration and this administration, not to exercise that
authority for a premarket review, which would make a
determination as to the safety of the product.
CDC--we had the conversation before--recommendations, I
concur with my colleague Congresswoman Lee, needs to be maybe
heightened, strengthened, et cetera, to provide a
recommendation that tells them that until we have the data, the
information is let us get the product off the market.
Dr. Harris.
Mr. Harris. Thank you very much, and I apologize I missed
your testimony before. But we have another committee I was in.
And thank you, Doctor, for being here. I have a couple of
questions that really revolve first around the lung injury
issue, and one thing that came to mind is that my understanding
is that in the UK, as you know, they believe that access to
vaping actually helps in decreasing the use of combustible
tobacco products. And it has been around a while there. Have
they seen the same issue in the UK?
I mean, they have a nationalized health system. They should
have centralized data collection. In their system, it actually
should be much easier to detect this early. What is the UK
experience?
Dr. Schuchat. Our conversations with the UK do not reveal
the lung injury outbreak presentations. However, their products
are different than ours. My understanding is that the e-
cigarettes in the UK are limited to a 20-milligram level, and
ours are at a much higher level currently with the latest
generation of nicotine salts.
Mr. Harris. And what about the use of THC-containing
compounds in the UK?
Dr. Schuchat. That, I am not familiar with, but we could
try to get you that later.
Mr. Harris. But my understanding is that on Friday, the
indication was that there is the belief that this is linked to
the use of THC-containing substances?
Dr. Schuchat. The----
Mr. Harris. Not the level of nicotine. It is not whether it
is----
Dr. Schuchat. Right. The latest lung injury outbreak data
in the U.S. suggests that the vast majority have used THC. A
lot of them also have used nicotine-containing, and about 13
percent of cases in the U.S. report only having used nicotine-
containing devices.
Mr. Harris. Right. In fact, in your testimony, I think you
said that one-third of youth who use, who vape actually use
THC-containing substances?
Dr. Schuchat. One-third of youth who use nicotine-
containing e-cigarettes also use THC in their devices.
Mr. Harris. So, and how--what percent of youth are using
nicotine devices?
Dr. Schuchat. The latest, the preliminary data for this
year is that it is more than a quarter----
Mr. Harris. More than a quarter----
Dr. Schuchat [continuing]. Of current use. Current use.
Mr. Harris. And of those, so a third of those actually are
using marijuana derivatives in their--I mean, that is how
widespread the use of these marijuana derivatives are among our
youth?
Dr. Schuchat. Based on the data that we have.
Mr. Harris. Wow. So when we are told that it is OK to make,
you know, recreational marijuana legal because, don't worry, it
is not going to--we are not going to let children use it. The
indication is, just like with e-cigarettes, children are using
it?
Dr. Schuchat. We don't have a great track record of keeping
things away from children.
Mr. Harris. Away from children. And in fact, it appears
that it is actually killing our children, in some cases, right?
Because some people die of the lung injury. They are rare, but
they do.
Dr. Schuchat. Yes. We have had more than two dozen deaths
so far, and we continue to hear about new deaths.
Mr. Harris. Right. So, look, I agree. Because one of your--
one of your conclusions, actually, we probably ought to study
the use of marijuana a little bit more before we go willy-nilly
and make it available recreationally throughout the country,
and I would say do you think this is one instance where, in
fact, the unbridled and, according to Federal law, illegal use
of marijuana for recreational purposes--because I am assuming
that people who vape, the youth who vape are not doing it for
medical reasons.
Is that what you are finding, or are you looking into that?
Because there is a big discussion about medical versus
recreational. Well, these 8 percent or 9 percent, are they
using it because they have, you know, the usual indications
that people claim for medical marijuana, or are they just using
it recreationally? What is your feeling, doc?
Dr. Schuchat. Yes. We don't have data. There is a lot of
anecdote. But one thing I would say is that there is a lot of
debate out there about whether legal status makes things better
or worse in the States because some of our concerns right now
are about the counterfeit and black market, whether the
substances that are in products that are completely unregulated
by the States are riskier than the products that are regulated
by the States.
I don't think we have good data either way, but that is a
discussion that is happening.
Mr. Harris. So are States regulating the THC-containing
vaping compounds?
Dr. Schuchat. Where it is legal, they inspect the
dispensaries. It is every State has to set up their own plan on
how they are going to do the regulation.
Mr. Harris. So is the feeling that the States have gone
ahead, basically approving these THC-containing substances
through regulation when they were basically unhealthy? They
basically didn't have the scientific information about whether
this was safe, but they were approving these compounds?
Is that right? I mean, they were legally sold. Is that what
you are saying? They were legally sold. They ended up hurting
our children, and these are when the States claim that don't
worry, it is all safe. You know, we will regulate it. We don't
have the knowledge to know what is safe and what isn't, do we?
Dr. Schuchat. Yes, let me clarify. For the lung injury
outbreak, while the vast majority report using THC-containing
prefilled cartridges, they report getting them from informal
sources or off the street, not necessarily from licensed
dispensaries.
Mr. Harris. Even in States that have legal----
Dr. Schuchat. Yes, so far, that is what we found.
Mr. Harris. Thank you. Thank you----
Dr. Schuchat. But we are still gathering data.
Mr. Harris. Thank you, Doctor.
Ms. DeLauro. Just a point, and I would share it with my
colleagues. This is about UK, and I think we need more
information there, about this estimate that 95 percent--that e-
cigarettes are 95 percent safer than cigarettes first gained
prominence, that was in 2015.
But there are the claim has very serious limitations. It is
an educated guess among the small group of contributors, not
based on thorough evidence or scientific risk analysis. I think
the whole issue of what is out there and risk analysis and the
whole issue of scientific data is critical to this debate.
Mr. Pocan.
Mr. Pocan. Thank you, Madam Chair.
And thank you very much for being here, and I, like Ms.
Lee, apologize for not being here for the testimony. I have
three hearings at the exact same time, and the one I went to
earlier was about our congressional schedules. [Laughter.]
Mr. Pocan. So we are trying to fix that--and modernization.
So kind of ironic, but I thought I would mention that.
To the very last point you said, I think you have made a
very strong case for why we want to have legal regulation of
marijuana. We already have it in many States. The problem is,
in fact, in my hometown of Kenosha, Wisconsin, was one of the
national cases, the two kids--and by kids, they were early
20s--who were retrofitting these devices for marijuana.
And that is the problem. It is people, because we don't
have proper regulation in Wisconsin because we are going to
apparently be one of the last States to do any kind of
legalizing and having regulation around marijuana, that is what
is killing people.
And so I think a strong case is made by our colleague from
Maryland about why we should actually have legal marijuana
everywhere because that way, we can have the proper regulation
on it. But specifically, I missed the one part. I know you said
since the moment you heard about what was going on, CDC, you
have been working on this 24 hours a day.
When did you start working on this? Just I don't know that.
Dr. Schuchat. Yes, we were first alerted about a small
cluster in Wisconsin on August 1st.
Mr. Pocan. Okay.
Dr. Schuchat. And we learned soon thereafter about what
sounded like similar cases in Illinois. Those two States
started to collaborate and issued an alert for other States.
And by mid-August, we had engaged in a multi-State
investigation and dispatched people to Wisconsin and to
Illinois to assist them in their investigation and instituted a
coordinated response.
We have ratcheted it up and now have had more than 200 CDC
staff involved in the response so far, but every State health
department is working vigorously on this.
Mr. Pocan. And thank you. And I think, you know, that was
right on the State line, that particular case we are talking
about. So I think it had a little overlap in both of those
areas.
You know, this is one, I was trying to find an article I
read earlier today. But you know, the FDA for 10 years punted,
did nothing in this area. And the chairwoman of this committee,
actually, Mrs. Lowey was one of the first people every time we
had this issue up talked about what she was hearing from her
grandchildren. And you know, hearing about her great-
grandchildren, but the stories about what was going on and
really put it more in our awareness.
And one of the issues that I have been surprised, and I
don't know if this is something you can take on since the FDA
apparently is not, but people are getting around the law and
advertising these products. I have had constituents actually
send me an ad, and honestly, it was geared towards a high
school crowd. It was not geared towards people who are watching
Downton Abbey.
It was, you know, people worrying about ``downtown abbey''
maybe, right? It is a little different sort of audience. And
they are really circumventing, I think, what both policymakers
and agencies always tried to stop in this area. Are you going
to be able to look at that issue at all? I know there is a bill
introduced around this, but I think this is one of the
problems.
Dr. Schuchat. Yes. We don't take the enforcement actions
around advertising to youth, but we do study what is out there.
And I think you are absolutely right that there have been a lot
of clear youth-targeted strategies to get people hooked on e-
cigarettes, whether it is social influencers or digital
campaigns that don't have the name of a company on them.
Looking back, that is what you can find. And they are
clearly not for that middle-aged smoker who is trying to quit,
but really for a teen or a tween who doesn't even know what is
in the e-cigarettes.
Mr. Pocan. And we know that, clearly, from the flavors as
well and things like that. So also in this article, it was
interesting, and they said there are some specific things that
are actually worse than cigarette smoking to a body because of
how it comes in. Can you address--have you looked at some of
that? Because this article talked specifically about the intake
through vaping that actually is more likely to cause disease
and addiction.
Dr. Schuchat. Yes. The latest generation of e-cigarette
devices use nicotine salts, and those are less harsh. So they
are more palatable for folks who have not used tobacco before,
and they can make very high levels of nicotine accessible,
including to the brain, which is developing in a teenager. The
flavors that are used are very appealing to youth, and part of
the strategy, there are the ads, then the flavor, and then the
nicotine, which is the addictive piece.
The aerosol that is produced from these e-cigarettes can
include heavy metals like lead, volatile organic compounds that
can be really nasty. Cutting agents can be used that are
essentially toxins. And there are also, we were talking about
it briefly, ultrafine particles that when they deposit in the
lungs may--and you have high exposure over time, they may
eventually give us something like a chronic lung condition like
silicosis or asbestosis.
So those are the kinds of lung problems that we are facing,
and you are really not expecting a 13- or 15- or 17-year-old to
be doing things that are going to turn their lungs into that of
an 80-year-old.
Mr. Pocan. Yes, I think they even mentioned eyes, too,
something with arsenic, if I am right? Or there is some other
aspect.
Dr. Schuchat. We don't even know.
Mr. Pocan. Okay.
Dr. Schuchat. CDC has a smoking lab that is now studying
aerosols from some of these. And I think they haven't really
gone through the reviews that you would need to do, and the
animal studies are concerning.
So I think that is where, unfortunately, we have a
generation that is being experimented on right now.
Mr. Pocan. Thank you.
Ms. DeLauro. Thank you. We are going to now move to our
second panel. But I think for all of us, I just wanted to say,
Doctor----
Mrs. Watson Coleman. Madam Chairwoman? I am sorry----
Ms. DeLauro. Oh, I thought you had----
Mrs. Watson Coleman. I didn't.
Ms. DeLauro. Go for it.
Mrs. Watson Coleman. Thank you, Madam Chair, and thank you
very much.
I am so sorry I haven't been here. But I asked my staffer a
question, and it was do we know what the FDA is doing? Do you
know what the FDA is doing to look at the danger or the
perceived danger of these e-cigarettes with marijuana laced,
without marijuana laced, with sweetenings and without
sweetenings?
Dr. Schuchat. Well, I can comment on two things that the
FDA is doing. One thing is the aggressive collaboration as part
of this outbreak of lung injury where they and their
investigators in States are collecting products for testing,
testing a variety of things--the product, the device, the
components, which may or may not have been expected, sort of
looking for those cutting agents and so forth.
And that they have announced, as part of the
administration's announcement in September, that they intend to
be issuing guidance related to enforcement of the non-tobacco
flavored premarket approval process. So those are the two
areas. And CDC is collaborating on the testing of the aerosol.
Mrs. Watson Coleman. That was the other thing I was
wondering if they were going to be benefiting from the kind of
research that you all are doing and findings that you are
doing?
Dr. Schuchat. Yes. We are working very closely with them,
as well as with the National Cancer Institute. We have a tri-
agency group that is focused on sharing our results as well as
coordinating the research and the campaigns and so forth.
Mrs. Watson Coleman. And did I understand you say that they
will come out with some recommendations and findings with
regard to the non-?
Dr. Schuchat. The non-tobacco flavors. That is what they
announced, that flavors----
Mrs. Watson Coleman. The non-flavored?
Dr. Schuchat. Flavors other than tobacco. So they actually
have a tobacco-flavored e-cigarette, and they are not intending
to issue guidance related to that. But for all of the other
flavors, that is what they announced they were going to be
developing guidance for because they hadn't yet enforced that
guidance or enforced that regulatory authority that they
already have.
Mrs. Watson Coleman. But is it--but is it tobacco?
Dr. Schuchat. Yes, it is for the nicotine----
Mrs. Watson Coleman. Is that not a danger? Is that not a
possible danger as well?
Dr. Schuchat. Yes, it is. Well, I think the idea is they
are all potentially dangerous, but the non-tobacco flavors are
particularly attractive to young people. You know, candy,
popcorn, bubblegum.
Mrs. Watson Coleman. Yes, as we move forward and have the
cigarette industry be more aggressive in its cautionaries,
either on the pack or any advertisements or whatever, it just
seems to me that this is a new--this is an alternative that
we--that has been presented, and we need to be as aggressive in
making sure that people don't get addicted or exposed as much
as possible.
Thank you. Thank you. I yield back.
Ms. DeLauro. Thank you very, very much, and we would like
to--I want to just say thank you so much. The clarity, the
lucidity of your explanation, the scientific--you know, making
it as easy as possible for us to understand.
And obviously, our continued conversations about
recommendations, we will say that like the--I know you are in
the business of making recommendations. I think we all want to
see the recommendations as strong as possible that they
translate into real action by the FDA, which is the regulatory
agency.
I am just going to ask the second panel to come up and say
thank you to you so very, very much, Dr. Schuchat.
I would like to say to my colleague while we are changing
that the FDA currently has the authority. They did not take on
this authority to deal with the premarket review either in the
last administration or this administration. We would have then
been able to know the scientific difficulties or the positive
side of these products, and therefore--and also the FDA, to my
colleague who asked about advertising, they regulate the
advertising as well.
They are a regulatory agency, and quite frankly, in my
view, they have abdicated that responsibility.
Thank you, Doctor.
[Pause.]
Ms. DeLauro. Good morning, and thank you very, very much
for being here this morning. We will proceed to opening
statements from our panelists, including Renee Coleman-
Mitchell, who is the commissioner of the Connecticut Department
of Public Health. As I mentioned earlier, it was great to have
you join me at Yale New Haven Hospital in September to talk
about the public health crisis, and it is wonderful to have you
with us today.
If I also might add, we want to welcome not only you, but
we want to welcome your family who is here today--your son,
your daughter, your husband. Really, welcome. I know how proud
you are of this lady. She is terrific.
We have also with us Dr. Sally Satel, resident scholar at
the American Enterprise Institute; Dr. Bonnie Halpern-Felsher,
professor of pediatrics at Stanford University, executive
director of the Stanford Tobacco Prevention Toolkit; and
Meredith Berkman, co-founder of Parents Against Vaping E-
cigarettes.
Public health crisis. Again, thank you for being here. We
look forward to the discussion.
Commissioner, your full written testimony will be entered
into the hearing record. You are recognized for 5 minutes. Go
for it.
Ms. Coleman-Mitchell. Good morning, Chair DeLauro, Ranking
Member Cole, and members of the subcommittee.
Thank you for allowing me the opportunity to come before
you today with great concern for all our victims who have been
misled and misinformed about the human health risks of vaping.
As a State health official, I am deeply alarmed by the outbreak
of severe lung illnesses and deaths associated with vaping.
This is a public health emergency with serious consequences.
I know you join me in expressing our heartfelt sympathy to
the families who have lost loved ones. In Connecticut, so far
we have 31 cases and 1 death, but any death is too many.
As Dr. Schuchat indicated today, we still do not know what
is causing the lung disease outbreak among e-cigarette users,
but public health is working tirelessly in partnership with our
Federal, State, and local partners to investigate this illness
fully so that we can work better to protect the lives of
Americans.
What we do know, however, is vaping and e-cigarette
products are highly addictive and are unsafe. The younger the
age of initiation, the harder it is to stop using these
products. Connecticut managed to reduce the high school youth
combustible cigarette use rate to less than 4 percent by 2017
by implementing such best practices, which included enacting a
clean indoor air law, levying a high excise tax rate, and
providing youth education on smoking.
However, the increase in vaping that has overtaken our
trend. The Connecticut Youth Tobacco Survey shows that our
overall rate of e-cigarette use among all high school students
was 14.7 percent in 2017. For high school seniors, the rate is
24.4 percent, nearly 1 in 4.
This is one of the most frustrating facts when it comes to
vaping. After decades of work, we substantially decreased youth
tobacco use. We were headed in the right direction. But with
aggressive marketing campaigns touting interesting flavors and
pitching e-cigarettes as safe alternatives to smoking, youth
nicotine use is once again on the rise.
I want you to take a quick look at a graph that we have.
Are we able to pull it up? And if we are not, I am just going
to have to summarize it. All right.
The bottom line is that you have seen over time is
comparing Connecticut youth cigarette use versus e-cigarette
use among youth. And it was cigarette use gradually went from
25.6 percent in 2000 to 3.5 percent in 2017 versus e-cigarettes
at 2.4 percent in 2011, and now at 14.7 percent in 2017.
It shows you what we are up against here in the declining
number of young people in Connecticut reporting use of
combustible tobacco products. And just in the last couple of
years while the introduction of e-cigarettes and vaping,
nicotine use is up sharply among our young people. Here is the
graph.
And again, what I really just want to emphasize is that you
saw over time. This was between 2000 and 2018. It is a gradual
progression down in terms of overall youth cigarette use, but
look at the trajectory regarding e-vaping, the e-cigarettes and
vaping. From 2000 to 2017, look at that. That is alarming
because it is going straight sky high. Excuse that pun.
With the introduction of e-cigarettes and vaping, nicotine
use is up sharply among our young people. This has wiped out
all our gains we made in reducing tobacco use among young
people. We were using all available resources to address the
use of e-cigarettes, vaping products, and the lung disease
outbreak.
Specifically, on September of this year, I authorized the
amendment to the list of reportable diseases by adding
unexplained vaping-related injuries. As of October 1st of this
year, Connecticut passed T21 legislation, which raised the
minimum age from 18 to 21 years of age to purchase all tobacco,
e-cigs, and vaping products.
We continue to amend our Indoor Clean Air Act, which we now
can proudly say it is 24/7 in regards to prohibiting smoking in
indoors workplaces, but also our school grounds and all of our
daycare facilities. We have put a tax on vaping products. We
are encouraging our residents to use our quit line. We are also
getting the word out on media.
We are using, as a State health department, personnel from
our infectious disease section, our tobacco prevention section,
from our injury section, our toxicologists, and our State lab.
We are using their expertise to interview the cases looking at
the data involving our tobacco prevention program to enhance
our messaging and education programming. These resources are
being used for three things--investigating the cases, the
completion of the case reports, and for the transmission of
that data to CDC.
The greatest danger we face is that vaping-related lung
illnesses are not only an outbreak but may, in fact, become an
endemic or costly chronic disease. I am going to have to
summarize due to the time.
It comes down to this. The question I ask, do you want to
wait another 50 years to combat the vaping epidemic? We need to
act now. Otherwise, we run the risk of losing a whole
generation to severe costly illness or, even worse, what we
already have experienced, death.
Ms. DeLauro. Thank you. Dr. Satel.
Dr. Satel. Thank you, Chairwoman DeLauro, Ranking Member
Cole, and the subcommittee, for inviting me.
I am an addiction psychiatrist, a resident scholar at the
American Enterprise Institute, and a lecturer at Yale
University School of Medicine, where I did my residency and was
an assistant professor.
I want to talk about nicotine vaping by smokers as a public
health asset, but I will start by briefly addressing the recent
outbreak of pulmonary illness and mortality. Crucially, the
vast majority of patients, as Dr. Schuchat was telling us, with
respiratory failure appear to have used underground,
adulterated cannabis vape cartridges. Vitamin E acetate oil,
pesticides, and so on, these things cause extreme inflammatory
responses that can actually be life-threatening, and that is
why the FDA has been warning people to ``stop using THC vaping
products.''
But the FDA has issued no such warning on users of
commercial nicotine vaping products. I will refer to them as e-
cigarettes from now on. So while the current rash of lung
illnesses and fatalities is a very serious problem, it is not a
problem that will be solved through bans involving commercial.
Now it could be that counterfeit e-cigarettes are causing some
problems, but they won't be solved by bans involving commercial
e-cigarette products because those haven't been implemented as
a cause.
But moving on to smokers, to be unmistakably clear, the
only permissible consumers of e-cigarettes are smokers, period.
But kids don't know that, and one in four, as we have heard,
have reported vaping at least once within the last month. And a
minority actually vape considerably more than that.
If candy and fruit flavors no longer existed, the policy
rationale goes, kids would be deterred, and I suspect that is
true of a lot of them. The problem is, though, that those bans
will harm adult smokers, and they need flavors.
Those flavors are the reason they were able to switch from
cigarettes to a much less risky activity, and their preferred
flavors are fruit. And if they can't get those fruit-flavored
products, many will have two really bad options.
They can go to Walmart, where cigarettes will now be--e-
cigarettes will now be banned, but the shelves will be stocked
with cigarettes so that they may now resume smoking a much more
deadly alternative. Or they can head to the new black market in
flavored vapes, and we have already seen what black markets can
do.
In the end, it is difficult, if not impossible, to make
vaping less appealing to kids by banning flavors without
simultaneously making it more difficult for smokers to quit
cigarettes with this safer alternative. And I feel I need to
repeat ``safer'' because in all this anxiety, much of it
warranted, about teen vaping and certainly about the deaths, I
think we have lost this powerful truth, that e-cigarettes,
again, do not combust tobacco. That means no smoke, no
carcinogenic tar produced.
Are they safe? Nope. No one says they are safe. But they
are safer. They do emit toxins. E-cigarette aerosol does have
some toxins and some trace metals, but they emit far fewer in
number than found in cigarette smoke, and those that are
present exist at a much lower level.
The National Health Service in England, which actually has
relied considerably on data, and I am happy to provide that, is
so confident of the relative safety, it estimates that 95--
others have estimated perhaps even 90, even 80 percent, but
they have estimated at 95. And hospitals within the National
Health Service have vape shops within them. This is their anti-
smoking month called Stoptober, and they have promoted vaping.
In the U.S., vaping is the most popular and successful
product for quitting smoking. I have data on that, references
to that in my testimony, written testimony.
Do scientists need to follow vapers for many years out,
decades? Definitely. We need to know the possible long-term
effects of inhaling e-cigarette aerosol.
In closing, though, we cannot allow the vaping issue to
become a contest between the health of teens and the health of
smokers. We can and must protect teens, and we can and must
protect smokers. Not through flavor bans, which will lead many
to return to smoking, which is probably the deadliest consumer
product there is. It will also lead to a market for dangerous
counterfeits.
We must pursue a very aggressive series of barriers,
Tobacco 21 being the first. There are others in my testimony,
written testimony.
I will close by saying e-cigarettes are not a threat. They
are an invaluable option for improving smokers' health, adult
smokers' health, the ones who have already switched and the 36
million who are still smoking.
Thank you.
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Ms. DeLauro. Thank you. Dr. Halpern-Felsher.
Ms. Halpern-Felsher. Thank you, Chair DeLauro, Ranking
Member Cole, and other members of the subcommittee, for giving
me the opportunity to speak with you on this important and
urgent topic on youth e-cigarette use.
I am a developmental psychologist with additional training
in adolescent and young adult health, and my research,
prevention, and policy work for the past 25 years has focused
on factors involved in youth tobacco use.
As you know, we have seen an unprecedented number of youth
using and addicted to e-cigarettes, with this largely due to
Juul, which accounts for 70 to 80 percent of the e-cigarette
market share. But I would actually argue that these statistics
are underestimates. I go around the country speaking to
students, parents, and educators, all of whom tell me that 50
to 75 percent of the students in their schools are using e-
cigarettes.
Whether the numbers truly are 27 percent or 75 percent or
somewhere in between, we clearly have a vaping youth epidemic,
and I would call it a Juul epidemic. Importantly, there is
absolutely no difference in e-cigarette use among adolescents
based on sex, race/ethnicity, socioeconomic status, or
geographic region. Let me emphasize this. Regardless of income,
it is easy for youth to obtain e-cigarettes legally and
illegally through friends, on the Internet, and through other
means.
So why am I concerned about e-cigarettes? Well, first, let
us discuss nicotine. As you heard earlier, unlike cigarettes
and many e-cigarettes products, they use ammonia and sugars to
enhance the delivery and absorption of nicotine to the body.
But Juul has patented a salt-based nicotine, whereby benzoic
acid is added to change the pH level of the product to help
deliver more nicotine to the brain faster with less throat hit,
making it more appealing and more addictive to youth.
Moreover, while earlier versions of e-cigarettes had
between 0 and 36 milligrams of nicotine per milliliter, Juul
and other newer pod-based products have at least 59 milligrams
per milliliter of nicotine.
Now you may hear that that translates to about one pack of
cigarettes, but actually, in our lab, we have looked at it and
done some research and the math to show that it is actually
more like the nicotine found in one and a half to two packs of
cigarettes. It is, therefore, no wonder, given the amount and
the type of nicotine that we have, that we are seeing more and
more youth using and addicted to these products.
Second, aside from or really in addition to the current
concern over the vaping-related lung illnesses and deaths that
we have heard about today that may or may not be caused by
nicotine e-cigarettes, there is clear evidence that the
flavorants and other chemicals that are in nicotine e-
cigarettes cause lung, heart, and other health problems.
Third, schools are heavily impacted. Schools are spending
an enormous amount of time, money, and resources directly
related to the e-cigarette epidemic. Schools are not equipped
to handle the number of students caught using e-cigarettes, nor
can they provide addiction treatment services due to legal and/
or staffing constraints. And yet schools are frantically trying
to find ways to help prevent and reduce use of e-cigarettes in
their schools and their communities.
The demand for our toolkit, for example, increased
dramatically in the past 2 years. In 2018, we trained about 730
educators to use our prevention toolkit. In just the first 9
months of 2019, we have already trained over 1,500 educators,
and we have reached well over a million students in the past 2
years.
Fourth, there is a significant impact of e-cigarette use on
non-using students. Youth are frustrated by the constant
disruptions of students using e-cigarettes, the disciplinary
actions needed, and concerns over peers who use e-cigarettes
having diminished athletic and academic abilities.
Finally, as was said earlier, we have absolutely no data to
inform e-cigarette cessation for youth. There are no nicotine
replacement therapies or other medicines approved by the FDA
for anybody under 18.
So action is really needed now, including eliminating
flavored tobacco products, including mint and menthol; raising
taxes to ensure that e-cigarette devices and e-liquids have the
same price point as other tobacco products; enacting a nicotine
standard that applies to e-cigarettes and all tobacco products;
prohibiting the marketing of e-cigarettes as well as product
placement, celebrity sponsorships, and so on; prohibiting
coupons, other promotional materials; and regulating the
products. The FDA has the authority to do these now, including
pulling these products off the market.
So, finally, in conclusion, there is an urgent need for
education, prevention, and cessation programs in schools, for
parents, and for healthcare providers. It is important to note
that such strategies should not be conducted by the tobacco or
e-cigarette companies as there has been a history of these
companies providing ineffective and often inappropriate,
misleading, and harmful messages to youth.
I look forward to discussing this more. Thank you.
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Ms. DeLauro. Thank you.
Let me now recognize Ms. Berkman, and your full testimony
will be entered into the hearing record, and you are recognized
for 5 minutes.
Thank you for being here.
Ms. Berkman. Thank you. Thank you so much for having me,
Chairwoman DeLauro, Chairwoman Lowey, Ranking Member Cole, and
other distinguished members of this committee.
My name is Meredith Berkman, and I am a co-founder of
Parents Against Vaping E-cigarettes, PAVe, a national
grassroots advocacy group founded by three concerned moms as a
response to the youth vaping epidemic, and as we all know, this
is the most serious adolescent public health crisis our country
has faced in decades.
We have all heard the staggering latest Federal figures--5
million teens vaping, a 135 percent increase in over 2 years in
youth use, 1 out of every 4 high school students. It is the
eternal kid exaggeration, the proverbial ``Everybody is doing
it.'' But sadly, this time, it is more or less true.
FDA allowed flavored e-cigs like Juul, especially Juul, to
remain on the market, even until today, without undergoing full
regulatory review. These products we know contain enormous
amounts of nicotine that harm our kids' developing brains, and
they are a toxic cocktail of known toxins, degraded metals from
the devices themselves, and unknown toxins in the proprietary
flavors. So we really have no idea what millions of our kids
have been pulling so deeply into their precious developing
lungs all day long and all night long, 24/7. In some cases,
kids have been doing this for years.
The current outbreak of vaping-linked pulmonary illness is
terrifying. But really, it is not surprising.
Now I am not a doctor. I am not a public health expert, but
I am a volunteer parent advocate. And we know that these
symptoms have been going on for years because we hear about
them. And so the underlying crisis is the youth vaping epidemic
that has harmed so many kids across the country and ended the
lives of so many families, of entire families.
I want to very briefly share with you my story, the reason
that I am sitting here today. In April of 2018, one night my
son Caleb, then 16, came home and said, ``Mom, Dad''--Dad is
over my shoulder--``I want to talk to you.'' And if you are a
parent of teenagers, as I am with four of them, you know you
never hear that. And so when you do, you listen.
And my son began to tell us about what he referred to as a
very confusing e-cigarette presentation that he had heard at
school that day, given by a speaker who was brought in through
an outside anti-addiction group. When the teachers were out of
the room, the educator repeatedly told the ninth graders that
while Juul was intended for adults, it was ``totally safe'' and
that the FDA would be approving this product any moment. Both
things are untrue.
At the end of the talk, my son went up to the speaker,
who--to ask more questions. He took out his Juul, showed my son
and his friends how it worked, and referred to it as ``the
iPhone of vapes.'' It turns out he was a Juul rep and that the
school had no idea.
It was the realization that Juul was blatantly going after
kids in their own schools, in their safe haven, that motivated
me and my friends to take action, and we learned more and more
about the predatory practices of Juul in particular, but others
as well. The use of flavors, always flavors. Young-looking
influencers. Targeted social media marketing done in places
where we adults, we parents, we teachers were not going. And
that is why we started our group.
Since then, we have gone national with our PAVe pods, an
intended pun on Juul's flavored pods, in more than a dozen
States and growing, including States like New York, California,
Illinois, Kansas, Maryland, New Jersey, and Massachusetts. But
we are getting bigger because we represent a movement, a
growing army of volunteer advocates. Motivated ``momvocates,''
I like to say, though also some dads, of course, fighting to
protect our kids from these tech-chic, stealth by design,
flavored vapes, the latest incarnation of big tobacco.
Some of these companies are so brazen, they are marketing
to kids on the Internet, on school websites like Quizlet. My
seventh grader saw a vape ad on an app game that she and her
friends like called Flippy Birds. But we cannot allow big
tobacco to use our kids as human guinea pigs. We know we are in
a race against time, as I am now, on multiple levels, and so I
very briefly want to say we need help.
We want to partner with the CDC. We want to partner with
you. There is a huge disconnect between what the public
understands and knows and what--the important work of the CDC,
in coordination with the FDA. There should be an interagency
task force, not just a CDC task force. There should be a
central reporting portal. There should be a central information
portal--VapingIllness.gov.
There must be a massive social media marketing campaign
that is the opposite of what Juul and its copycats did, right?
A media campaign that uses influencers, the Surgeon General,
and athletes and celebrities that tells kids and their parents
that this is the emergency. Yes, God forbid more people will
die, and more people will get sick, but we all must have known
this was coming.
And now it is here, and if we don't solve the problem now,
we will have, as everyone has said, an entire generation of
nicotine addicts or worse. We need your help. We need more
funding and more education, more prevention work.
Thank you so much.
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Ms. DeLauro. Thank you all very, very much for very
compelling testimony.
Before I ask a couple of questions, I just want you to know
that we are trying to move here. The Judiciary Committee just
passed, I mentioned earlier, a piece of legislation that I have
been pushing over the years is Preventing Online Sales of E-
cigarettes to Children Act, and they did it by voice vote. That
means that we have got bipartisan support for this--for this
effort.
So thank you for your advocacy in these areas.
Commissioner, let me ask you these questions. You have
talked about the rising rates in Connecticut, went through all
of that, and that e-cigarettes are now the most common form of
tobacco amongst high schoolers. How is it impacting public
health in Connecticut? How does it impact the schools?
And if you can then just mention the challenges that you
face while you are investigating the outbreak and how you
collaborate with CDC, Federal partners, and what additional
resources do you need?
Ms. Coleman-Mitchell. It is a loaded question, but I will
attempt to make sure I answer it to the best of my ability.
[Laughter.]
Ms. DeLauro. You can do it.
Ms. Coleman-Mitchell. I have to say that, as I shared in my
testimony, that it takes a number of resources from varying
sections within the department. I shared that our tobacco
program, you know, our infectious disease, our State lab, these
are individuals that are working on--tirelessly, right, on all
different types of public health matters. And then we pull them
together to say here we have now vaping-related lung diseases,
and it is just the resources are very scarce in regards to
staff resources and funding.
Right now, in Connecticut, our tobacco prevention program
has been level funded at about $874,000, and then we get an
additional pot, which comes up to be about $1,000,000. That is
a staff of about four people who really are spread quite thin
throughout the State to really focus on working with colleges
and universities and having the ``train the trainer'' aspect of
working with schools, high schoolers, in terms of training
them.
Also with the colleges, we are trying now to have
counseling done because it is so pervasive on college campuses.
And then we also have trainings and we have education, we have
campaigns, but it is just scarcity. You know, Connecticut is a
small State. But in essence, it really is not making the
messaging that we want and need across the entire State to
reach our young people. It is very limited.
Ms. DeLauro. What is the impact on schools?
Ms. Coleman-Mitchell. As it was eloquently shared, it is
tremendous. I mean, you have people that are starting as young
as 13 and 14. Let me just share a quick story.
On my way here, I was in the car with a guy who was my Uber
driver, and he asked me what I did, and I shared it. And I knew
when I got in the car, I smelled smoke. Clean car, but I
smelled it.
And he says, ``You know, I smoke.'' And I said, ``I know. I
smell it.'' And he says, ``But I am going to tell you
something. I tried to quit.'' And he is an adult, and he says,
``I started when I was 14.'' And I said, ``What was it?'' And
he said peer, peer pressure.
He went ice skating. Now this--and he said to me, ``This is
the dumbest thing that I thought of.'' And he said, ``I thought
that--we thought smoking would keep us warm for ice skating,''
and he said, ``But I loved it. And from that moment on, I
smoked and smoked and smoked.''
He is 70 years old. He tried to quit many times. He used
Juul. He put out $120, he said. He said it burned his lungs. It
hurt him to inhale. He threw all of that out, and he says, and
he is still smoking.
So what I am saying to you is that it is starting at a very
young age. It is starting with all of the peers. And one of the
best approaches that we can take, as public health has seen
over and over again, is that peer approach. When we put
together that Tobacco 21 legislation, effective October 1st, it
was beautiful. Not because all the legislators or that myself
as a commissioner, you have governors, and everybody was there.
It was beautifully said.
But when that young lady who was a high schooler stood up
and said that she had three of her friends that were
hospitalized and one remaining friends who was hooked up to
tubes in the hospital as she was standing there speaking to us,
what did I see sitting up front? Every single one of those
young people leaned forward and listened.
That is the impact that we have to have because people,
young people truly, honestly believe it is a safe practice. We
have to continue to educate, educate, educate. That is the
challenge.
Ms. DeLauro. I have time remaining, but let me yield to
Congressman Cole.
Mr. Cole. Well, first of all, I want to thank each of you
for your testimony. It is incredibly helpful, and I think there
is no question we clearly need to educate lots of folks about
the dangers involved here. And you being here is part of that
education process. So thank you.
I think your advocacy will probably make a difference,
already has, as my good friend the chair has put additional
resources behind these kinds of efforts. And that will be an
interesting discussion we have with our colleagues in the
Senate.
Ms. DeLauro. On the Senate side.
Mr. Cole. You know, because I think you are on the side of
the angels here, Madam Chair.
But, you know, I do have some concerns, and so let me start
with you, Dr. Satel. We have had efforts to ban, entire bans,
outright of e-cigarettes. And I think we would all say, gosh,
we are extremely worried about this youth epidemic, but how
have those bans worked? What have been the consequences of
them? It has been relatively recent, so you may not have any
data.
Dr. Satel. Are you referring to the ones that have just
been announced since September?
Mr. Cole. Yes, I mean, do you have an opinion about them,
whether or not that is a good approach?
Ms. DeLauro. Use your microphone.
Dr. Satel. Well, I do know that vape shops have reported an
incredible decrease in people who are patronizing them, and
that is the thing to worry about, of course, is if--you know,
in the case of e-cigarettes, in the case of harm reduction, and
this is, basically, we are talking about people who are
addicted to nicotine, just as if we were in a way talking about
people addicted to opiates.
We deal with people with opioid addiction. We have
methadone. We have needle exchange. These are risky behaviors,
but we try to mitigate the risk. And that is what an e-
cigarette device is for smokers. It is an attempt at risk
mitigation.
So the question is, and I have worked in methadone clinics
my professional life. The question with addiction is always
compared to what? And so if it is e-cigarettes as opposed to
smoking because a person has failed patches and gums and all
the conventional ways of quitting, then that is an infinite
benefit.
Again, are these devices safe? No one would say that. And
should they ever be used by nonsmoking teens? Never.
Mr. Cole. That is, I think, a very important point. Let me
ask you this. You mentioned in your testimony the experience of
the United Kingdom. Did they have the same explosion among
youth that we clearly have in this country?
Dr. Satel. They don't seem to, and it is an interesting
question. And the UK has had a long record of harm reduction.
In fact, they legalized heroin back in the '20s, and Michael
Russell was one of their most--kind of the godfather of smoking
harm reduction. He always said people smoke for the nicotine
because it is addictive, but they die from the tar.
And Public Health England, which is their equivalent of our
CDC, the Royal College of Physicians, they have all endorsed
vaping as an alternative for smokers who can't quit any other
way, and they have based it on research. And I certainly can
provide all that.
Mr. Cole. Yes. Well, I am curious what they are doing on
the marketing angle. I mean, you have all mentioned about
marketing and targeting, and that is clearly a big problem
here. And clearly, targeting toward an uneducated audience of
young people in very duplicitous and septic way.
Do they have a problem in that, or they have some set of--I
am looking, I guess, for a regulatory scheme that gets us a
better outcome than we have got here because there is no
question we have this explosion amongst young people that
really is concerning.
Dr. Satel. It is interesting to think of the comparative
approaches, and I don't know how they advertise to kids--or not
advertise to kids, of course, but how their advertising could
be mistaken to be attractive to, you know, teens. That, I don't
know.
But, but what is so important about their approach, again,
is that they--is that their--forgive me. I sort of forgot my
point for a moment. Well, maybe ask me another question, and it
will occur to me. It just slipped my mind.
Mr. Cole. I don't have much time. I will just end with
this.
Dr. Satel. OK.
Mr. Cole. That is what I am looking for is something we
could do that would stop the epidemic or start educating
people. At the same time, look, I have had constituents that
were lifelong smokers that have told me, please, this is how I
got off cigarettes. Don't put me back on it.
Now they are a smaller part of the audience, and sometimes
we are in the business of comparative goods and who is most at
risk and that sort of thing. So I am just trying to find if
there are ways. We clearly have addiction problems, all sorts,
in this country.
We are like 4-point--4 percent of the poor population use
half the illegal drugs. I mean, this is like something in our
DNA as a society at some level.
Dr. Satel. Yes. Well, we can't forget the purview of public
health is all vulnerable people, teens and adults. But I did
remember my point, which is that--and this is so key to the UK,
which is they have nationalized health. They don't have
individual insurance. And that is why they are so invested in
vaping because the cost savings to the government could be
huge. And that is a big difference between here and there.
Mr. Cole. Interesting. Thank you, Madam Chair. Appreciate
that. Appreciate this hearing very much.
Ms. DeLauro. Thank you. Congresswoman Roybal-Allard.
Ms. Roybal-Allard. Since the United Kingdom has been
mentioned, since the 2016 Royal College of Physicians report
endorsing e-cigarettes as 95 percent less harmful than the
combustible tobacco-containing kind, many in this country and
in Congress have used harm reduction as an argument to oppose
any Government regulation of e-cigarettes.
However, that same year, the American Medical Association,
the American Thoracic Society, the American Academy of
Pediatrics, and 10 other medical organizations sent a letter to
Congress that explains why they believe currently available
data does not support the use of e-cigarette products as a
smoking cessation strategy.
Dr. Halpern, can you provide some clarity to counteract
this harm reduction argument, and has any e-cigarette been
found by the FDA to be safe and effective in helping smokers
quit?
Ms. Halpern-Felsher. Thank you for asking that question. It
is a good one.
There has been a profound difference between what the UK
data say and what our U.S. data are saying, and part of it has
to do with science, has to do with the methods that are behind
this. A lot of it also has to do with and in response to some
of what we were hearing earlier, has to do with the marketing.
In the UK, we don't have--they don't have the marketing to
youth that we have seen here in the U.S. It doesn't exist.
Also, their e-cigarette products are different. They have a
nicotine standard, where they have no more than 20 milligrams
of nicotine in any given product. So they also just have
different products, and they don't see it.
They have started off all along saying that it is a device
for quitting, whereas in the U.S., that was not the original
message. The original message was more to be a youth product.
So that is one of the big differences there.
In terms of do we have any safe products? No. As of now, we
have no products, no e-cigarette products that have been
submitted for premarket authorization to the FDA, nor do we
have any products that have been submitted as a cessation tool.
Whereas in contrast, we do have products that are very
effective in helping adults quit smoking, like nicotine
replacement therapies, other medicines, cognitive behavioral
therapy, and so on. So those are definitely more and have been
approved, whereas e-cigarettes have not.
Ms. Roybal-Allard. I passed a bill known as the STOP Act
that was directed at educating parents about the dangers of
underage drinking. And this national media campaign has
actually helped to reduce underage drinking in this country.
Would you suggest or what are your ideas in terms of having a
similar national campaign to educate parents about the dangers
of vaping?
Ms. Halpern-Felsher. For me? I think it would be a very
good idea to have such. I go around the country, and Meredith
and I team up on some of this work, to give talks to parents
throughout the country. But I will also say that--but I will
also say that, yes, we do need to educate parents.
In our toolkit, some of our materials on there do educate
parents, where we have information about how it is hidden in
plain sight and how easy it is--or how hard it is to spot these
products and what parents need to be doing. But we also really
do need national campaigns and information and help that go
directly to schools, to healthcare providers, and to youth
themselves.
Parents, absolutely. But it is a bigger issue than just
parents right now. And youth also in schools 8 hours a day, we
need to really target schools as well and helping them.
Ms. Roybal-Allard. Ms. Berkman, your view?
Ms. Berkman. Yes, thank you.
I think there--again, I said this earlier. There is an
enormous disconnect between all of the important work. I mean,
we know that CDC is working 24/7, but we also see education as
a very important form of advocacy, and we are lucky enough to
share some--Bonnie shares some of her resources with us. We
give a lot of parent presentations, and it is shocking to me
that just the other day, we spoke at I think it is the largest
public high school in New York, and there were parents who were
shocked by the information we were giving.
You know, we are all so deeply in this. But I also think
there is an enormous disconnect between also public health
providers, and I will give you an example that terrifies me.
Over the weekend, I mean, we have parents who reach out to
us all the time, and sometimes I carry these emails where
people spend you can see, you know, 45 minutes pouring out
their hearts. You know, my child was en route to be recruited
as a star athlete in college, and now he can't even run a mile.
Or I had an easygoing kid who is having bouts of extreme
anger. Or I have a kid who was a great tennis player. Now he
has restrictive lung disease. Things that have been brewing for
some time.
But a woman reached out to us over the weekend in a panic,
and she just sent it to our regular info line. And she said,
``I am in the hospital now with my child. We were here before a
few weeks ago. She was in the pediatric ICU. She was sent home.
Now we are back again.''
''I am terrified,'' she wrote to us, ``that the doctors
here--'' And I won't say where she is from to protect her
privacy, but a small town out West. She said, ``The doctors
really don't know enough. How can you help me?''
And we immediately wrote back to her and saying, you know,
where are you? What hospital? And we didn't hear back from her
again.
And those kinds of stories are so common, and they are
haunting. That is a parent who found us online who may not have
thought to go to, you know, a CDC reporting portal or an FDA
reporting portal. But she looked up parents, and her feeling,
and we hear this a lot, is that the doctors in some places
still don't know. We find that shocking, but it is true.
I just want to make one other point, if I may? There has
been so much talk about this outbreak and THC. But if you look
a little more closely at the CDC's own numbers, when they say
that 76 percent of cases are people who were using THC, that is
not THC exclusively. Only 32 percent were using THC
exclusively. Of the 58 percent who said they were using
nicotine not exclusively, 13 percent.
But if you just focus on this as a THC crisis, it is an
enormous mistake. This is a crisis of an entire generation of
kids who are vaping, who have been having these symptoms for,
in some cases, years. And the numbers we have are so important,
but we need to get a--I don't know what it is called because I
am not a public health commissioner or expert--but a population
surveillance study that shows us what the symptoms are.
Because if we don't start recording--we talked a lot about
the data, the recording, the modernization. If you don't start
recording the symptoms of these 5 million kids, then we are
going to have an even bigger problem for even more years.
And again, I am not a public health expert, but we hear
from parents--hundreds and hundreds of parents--who are so
frightened, who see changes in their kids physically and
emotionally, and they are terrified, and there is a disconnect.
We need more education. We need more social media for kids and
parents and doctors and everyone.
Thank you.
Ms. DeLauro. Did you want to comment?
Ms. Coleman-Mitchell. Yes, I did. I just want to support
what was just being said. It is extremely important. At the
State health department, we have, again, many resources. The
interesting thing is that I had to go about making it a
reportable disease so that we could get a handle on what was
going on. And that was just the beginning.
We have surrounding neighboring States that we are working
with and trying to find out what is going on there. And then
that linkage to CDC, it is incumbent upon looking at how do we
get additional funding and resources to really tie into a true
data surveillance system that not just for this, because there
will be other public health concerns that come about. But this
is one clear example because of the loss of our young people
and the addiction that we see, that we really do need funding
to support a true surveillance system that is at a State--at a
local, a State, and a Federal level that is totally connected.
Absolutely.
Ms. DeLauro. Thank you. Dr. Halpern-Felsher.
Ms. Halpern-Felsher. Thank you. If I may, two more quick
follow-up points on this very important conversation.
First, when we are talking about funding for research. We
really need to understand the nicotine levels that are in these
products. You are hearing just today in the span of an hour
differences between a pack of nicotine--a pack of cigarettes'
worth of nicotine and two. And I have never seen public health
experts on the same side confused.
We need research to understand that why, similar to
Meredith, I get called constantly by healthcare providers,
saying how much nicotine replacement do I give? Not only is it
not approved by the FDA to give this for those under 18, we
know it is. We know that it is being used off label. My
adolescent medicine doc friends are using it all the time, but
how much?
Do you give one patch, which is 20 milligrams of nicotine?
Do you give one and a half? Do you give two to match that 41?
We don't know, and we really need the research to be able to
inform healthcare providers.
Second, we also need the research and the surveillance and
the information to inform schools once again. Because I get
principals all the time who say I am so tired of busting kids.
I don't even want to go into the bathroom anymore because then
I am spending the entire day filling out paperwork, and I
actually have other things I need to be doing. So we also need
information and research to really inform those constituents as
well.
Thank you.
Ms. DeLauro. Thank you. It was a really great conversation.
I don't know, Dr. Satel, if you would like to add anything
here?
Dr. Satel. I would. Just one point. E-cigarettes, again
commercial nicotine vaping, which is regulated by the FDA, but
none of the devices have been approved yet. Oh, yes, they have
all had to submit their----
Ms. DeLauro. They have not. No, no----
Dr. Satel. Okay. I am referring, though, to the PMTAs. No,
those are due in May of this year.
Ms. DeLauro. May 2020. They are due.
Dr. Satel. Yes. Well, the one just did submit last week.
But yes, it is true they are not approved.
Ms. DeLauro. They are not approved.
Dr. Satel. I agree with that. That is a fact. But they have
been around for at least 10 years, and I don't disagree for a
moment that if teens have tried them, I am sure some of them
have had respiratory or one would cough, you know, feel some
irritation the next day. Kids with asthma will have that
exacerbated, no question about that.
But it hasn't been until this summer that we have seen
these dramatic pulmonary complications. So that is also another
bit of evidence, in addition to the basic epidemiologic
tracking of, you know, what did these people use and what was
in their blood and what was in their urine? And have they taken
lung biopsies?
But the point is that this makes--this is more suggestive
evidence that what we're seeing is the illicit cannabis
products or illicit nicotine products. They are out there, and
those should be--those aren't permissible either.
Ms. DeLauro. It is obviously a great topic and various
points of view, and making the case. But it would also seem
that--and one of the points I will make is that we have no
scientific data. I said at the opening in my statement are
these products safe? Are they unsafe? How do we regulate them?
We have a regulatory agency that has abdicated its
responsibility to regulate a product that we now find after 10
years, or whatever it is, is creating a public health crisis.
So that, you know, we have the tool to address an issue that is
a public health crisis. We are not using the tools, and we are
being subjected, I will tell you, on the premarket review, we
are now looking at an industry that is pushing back.
And as a question I have for you, Dr. Halpern-Felsher, is
about mint and menthol because the industry is pushing back
when the HHS has said no mint, no menthol, no flavors, and they
want to exempt mint and menthol. This is a moneymaking
proposition for a tobacco industry. That is what is at the
center of this effort.
Let me ask you, Doctor. Flavors--mint, menthol--attractive
to kids who would not normally smoke tobacco products?
Ms. Halpern-Felsher. Absolutely, yes. No doubt about it. In
our own data, we are showing that at least 30 percent of youth
who are using e-cigarettes started and continue to use with
mint and/or menthol. And that is true not just with e-
cigarettes, but across all tobacco flavors, and our latest
publication shows that.
And we talk to youth, and they will say absolutely ``I love
mint. I love menthol. That is what I am using.''
Ms. DeLauro. Let me ask you this. Your response to those
who say these flavors are needed for adult smokers?
Ms. Halpern-Felsher. I would say there is no evidence, and
I would say that even if you like these flavors, I would--you
don't do that on the backs of youth. And not only that, as I
said before, we have other ways for adults to quit smoking
conventional cigarettes that are proven, that are approved by
the FDA, whereas e-cigarettes are not.
And if e-cigarette companies want to be approved and used
by the--approved as a cessation device, then it is not just a
premarket review, they need to go through CDER. So there is a
much higher standard if they are going to be arguing to be a
cessation device, and they have not gone through those proper
channels.
Ms. DeLauro. And that is what the FDA should be doing in
that regard there?
Ms. Halpern-Felsher. That is correct.
Ms. DeLauro. And the illegal--well, let us just talk about
it because there are challenges on the marketing of these
products. And there is a question across illegal marketing
created the perception that the devices are safe. Let me just
ask you, as a mom, do kids understand the risks involved?
Ms. Berkman. Even now, I think that they don't. What is
really scary is kids now want to--now that the kids are
frightened, they realize what addiction is. They are terrified.
And my son comes home and says, ``Mom, there is a boy at
school. He wants--he is scared, he is afraid he is going to
sick, but he doesn't know how to stop. How do I--what do I tell
him?'' And I think we don't have anything to tell him. They are
addicts, and they don't know it.
Ms. DeLauro. What is the marketing doing to kids?
Ms. Halpern-Felsher. So we have data on that as well and
published. We are well aware of the fact that the marketing is
influencing young people. We did a study looking at flavor ads,
not Juul, but across the board flavor ads, and we asked
adolescents are these ads targeting you, somebody older,
somebody younger, because the e-cigarette market says they are
targeting for adults.
Uniformly, the young people in our study said they are
targeting me, maybe somebody slightly older--what kid doesn't
want to be older--or slightly younger. Kids are not saying that
they are targeting adults.
We also did a study that we published looking at
adolescents' perceptions of what are really not allowed,
cessation ads like quitting and switching. And uniformly, youth
knew that those were cessation ads, and those are implying if
it is Okay for adults to use them to quit, they, therefore,
must be safe.
So young people are not only attracted to the ads, they are
being misled by the ads. And we have lots of papers that we
published and others, some of which I provided in my written
testimony, to show that adolescents are very much misperceiving
the e-cigarettes, the products themselves, the harms, and the
nicotine potential. Until recently, they were not aware and did
not understand those terms.
Ms. DeLauro. Just--I just--there was one point that was
made. Is it true that adults who are using the e-cigarettes are
also using cigarettes as well, that they are dual use? Is
that--am I wrong in that perception?
Dr. Satel. You are not wrong.
Ms. DeLauro. That is right. So they do both?
Dr. Satel. That is----
Ms. DeLauro. So it is not a question that if they have
this, that they will go to cigarettes----
Dr. Satel. Correct.
Ms. DeLauro [continuing]. They are dealing with cigarettes
at the moment. The UK data, well, we can get back to that. Let
me just, my colleague, let me just yield to my colleague from
Oklahoma.
Mr. Cole. Thank you, Madam Chair.
Actually, I am going to yield to my friend from Maryland,
if I may? I am going to have to leave shortly. I have got
another appointment. But before I do, I just want to thank each
of you. This has been an excellent, excellent hearing, and we
appreciate the information you have brought to us.
There is a lot of areas of agreement here, quite frankly.
Clearly, in terms of the youth epidemic. Clearly, in terms of
advertising concerns. Some areas of disagreement, but not the
kind that would keep us from making additional investments here
and, frankly, I think finding hopefully a better regulatory
scheme than we currently have because it doesn't seem to be
getting the job done in terms of young people.
But that said, I will just yield the remainder of my time
to my friend from Maryland.
Mr. Harris. Sure. Thank you very much.
Thank you, Madam Chair, and thank you. I am sorry I had to
step out.
But this is obviously an important topic. Clearly, no one
wants, you know, children to be exposed, develop habits that
they shouldn't be developing. I think we have broad agreement
on that. The question is how you go about doing that.
Because in the last panel, I think most of you were here, I
mean, the bottom line is it is very hard to stop this leakage
across age, and that is of a concern to me. Now I have a staff
member in the District was a chain smoker, you know, I guess
about 4 years ago started vaping, completely gave up
combustible cigarettes.
Now I am convinced because I know, I talked to him. You
know, he is the guy that had a chronic cough, things like that.
None of that. I mean, I am convinced that his life span will be
actually lengthened by this device. That being said, clearly,
you know, if a 16-year-old decides that they are going to do
this--and there is some evidence that more will decide to do
this than smoke combustible cigarettes, that that is something
we have to watch out for.
My concern is that throwing the baby out with the bath
water. The bottom line is how do we preserve access to people
for whom this is a very useful smoking cessation device. And
look, we all have friends, we all have relatives, we have
people who tried to stop smoking. They try the gum, and they
try the patches. They try everything. Didn't work. And for some
of them, e-cigarettes work. Vaping works.
So how do we do this, and how do we avoid--and Dr. Satel,
let me ask you. How do we avoid--one of my concerns is that if
we outlaw it, we are going to get black market stuff. And you
know, the testimony from the CDC was just that this is actually
the problem. The problem is if you don't make it available, if
someone says, look, this person works for me. He says, look, I
really want to stop smoking. He is going to go get a black
market product, and that might be even more dangerous.
So how do we--how do we balance that? How do we come to the
right conclusion?
Dr. Satel. Well, I think there is no question you will get
black market use. I mean, no question about that. The way to
balance it is to preserve the flavors because, actually, there
are data, are a number of studies that show how essential they
are to adults, and they are in my testimony. But so very
significant, that evidence that the flavors matter, that
pulmonary function tests improve over time and blood pressure.
Now extrapolating that out, you would imagine life
expectancy to be longer than if those people had continued to
smoke, but we will have to follow them. The way to do it is to
crack down much more--much more aggressively than we have been
doing.
I know the FDA is working hard on this. I know Juul has a
$30,000,000 campaign. But the enforcement on selling, the
enforcement on age verification and so on, even still the
packaging and all this, even though I know the FDA is working
on it, that just has to be tripled down on. There is no
question about that, very important.
Someone mentioned before, though, I must say that puzzled
as to why menthol and mint still occur. Well, the biggest
consumers of those Kools and Newports actually are the African-
American population, and I would worry again that they would go
back to their cigarettes because there is such a perversity in
this issue. Cigarettes are legal, and now e-cigarettes are in
danger.
You know, the device that can help people who fail those
other options, which do have a pretty poor track record of
working. And it is wonderful when they can. I would always
recommend something you don't have to inhale to get off
cigarettes, or cognitive behavioral therapy, they don't have to
have nicotine at all. But some people just can't. It is a last
resort for them.
And so these devices are so important, and flavors are so
important to their effectiveness. So we have to preserve that
for adults while beating every, you know, intervention we can
targeted at preventing teen use.
Mr. Harris. Sure. No, thank you. And I will just ask
generally, any of you can comment. You know, one of my concerns
is that the lung injury is now connected to the use of THC
because I think we sent a message to our children that,
actually, marijuana is safe. I mean, we call it a medicine. I
mean, aren't medicines safe?
How concerned are any of you that we are sending a message
to children that marijuana is safe, and one thing we end up
getting is this vaping problem that has resulted in very
serious lung injury to young people?
Ms. Berkman. Dr. Harris, may I?
Mr. Harris. Yes, ma'am.
Ms. Berkman. First of all, I think you were out of the room
earlier, you know, if you look at the CDC's own figures about
why everyone keeps saying that this is just about THC, it is
not correct. Because 76 percent of the people who have had
these issues were using THC not exclusively, and I haven't seen
the breakdown that says if all 76 percent were using THC and
nicotine. Because it is 32 percent are only using THC, but 76
percent say THC and nicotine and perhaps other things. I would
have to look at those numbers.
This is not just about THC, and I know this because if
these kids are using THC in vapes, and I think we know from the
research that many of them are, these kids, so many of them,
started with nicotine. They likely started with Juul, right?
That was the market disrupter.
Nicotine, it has long been known and long been proven by
scientists--now I am not a doctor, I am not a scientist, but I
have also reach research. Nicotine is a gateway drug. Nicotine
opens pathways for further addiction.
So unless these kids are being--these patients are being
asked what did you start with, we really will never know. This
is about the youth vaping epidemic. This terrible outbreak is
an outgrowth of the underlying epidemic that FDA failed to
fully regulate these products, that we as a society allowed a
company like Juul, worth $38,000,000,000 before maybe the last
couple of months since valuation was affected, to go into my
child's school, to go into other schools, to use influencers
and the flavors.
We should talk about harm introduction, rather than harm
reduction. We are talking about a generation of kids we all
know who would otherwise not have been initiated into tobacco
use in such enormous numbers.
Mr. Harris. No, I understand that. My only point is that I
am going to disagree with you. I think there is actually a
close link between THC use because if you look at the number of
people who have this disease who said they used THC versus the
number of people who vape and have not used THC, the
discrepancy explains that there is a clear association.
Just so everybody else understands, I mean, you are not
saying there is no association?
Ms. Berkman. I am not saying there is no association----
Mr. Harris. Thank you very much. Thank you.
Ms. Berkman [continuing]. But there is no answer about what
the problem is.
You're welcome. Thank you.
Mr. Harris. Madam Chair, thank you.
Ms. DeLauro. Thank you. Yes, go ahead.
Ms. Coleman-Mitchell. Actually, I wanted to follow up with
a comment, one that was said earlier that will also reflect in
responding to Congressman Harris.
The statement was made that we have just recently seen the
impact of e-cigarettes and vaping. I will beg to differ. I will
beg to differ to say that there have been situations where many
people are now reflecting, saying that I have had respiratory
distress, respiratory illness over a span of years. So it just
not has happened this year that we are now seeing the
skyrocketing.
The unfortunate thing is that people were thinking that it
could be the environment. It could be an environmental issue.
But the bottom line is that it still goes back to support of
having some type of surveillance system in place so that we can
comparatively collect data and look at what is happening.
I will secondly say that the black market exists. Let us
just be honest. It exists. It is going to exist. And there is
an underground that is pervasive to our young people that is so
attractive to them. It is intentionally attractive to them.
So we would be remiss--and I come from strictly a public
health perspective. We would be remiss if we did not do
something in regards to overall population health, in regards
to addressing nicotine and its effect and this addictive
behaviors that it has on people. But at the same time, we need
to do something, period, in regards to the impact that it is
having on our young people.
And why? Because they are getting hooked at a very early
gage, which makes it difficult for them to somehow cease, stop
using these particular products, and they go on, as it has been
said, to use other products.
And we are going to end up, as I said earlier--and you
weren't here to hear this--with a nation of a whole generation
that has perished or have severe chronic illness that will
impact our healthcare cost tremendously. But besides that, it
is going to impact quality of life. And I also said ultimately
death, which you have already seen.
Ms. DeLauro. Go ahead. And then we will wrap it up.
Ms. Halpern-Felsher. Thank you.
I totally agree with that. And I just want to say also that
when we are talking about research and we are talking about
funding and regulation, it is not just the e-liquid that is in
these. It is also the device. And we are also seeing is that
young people are taking the same devices that they became
addicted with with nicotine, opening them up, whether it is
Juul, which is a closed system, or the open system like the
mods, opening them up and putting all the other products into
it, such as marijuana.
So it is not just whether we are talking about nicotine e-
cigarettes. It is a combination of the nicotine, the marijuana,
and the vaping devices themselves that we need research on. And
like was said earlier, I get calls from physicians for the last
3, 4 years saying that they are seeing vaping-related
illnesses, pneumonia, asthma, that they can only trace back to
e-cigarettes even before the current epidemic.
Ms. DeLauro. Well, first of all, let me just say, as my
colleague Congressman Cole pointed out, this has been an
extraordinary hearing, starting with Dr. Schuchat at CDC and
what they are engaged and involved in. And with all of you and
the richness of the information about what has struck us, and
it has its roots years and years ago, but it is now here full
blown.
And I will go back to the principle that I started with on
this because it was the Congress that gave the authority to the
FDA to look at all tobacco products, including e-cigarettes.
The FDA--and I will continue to repeat--prior administration
and in this administration abdicated the responsibility of
looking at the safety of this product that now is on the
market, that is sweeping the country, that has created an
increase with young people that is of epidemic proportion, as
we hear.
And now we see that the result is of serious illness, lung
injury, and even death. And we have at the moment no data from
which to go with. You can talk about each of the pieces, the
increase in the vaping by youngsters. You could talk about the
illness. But unless we address the fundamental issue, we really
are not going to get to the bottom of this.
I would like to ask unanimous consent to enter into the
hearing record a letter from N-A-C-C-H-O, NACCHO. And hearing
none, no--so ordered.
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Ms. DeLauro. There are so many pieces here. You talked
about devices. Well, part of the devices, some of those devices
come from China. We haven't got a clue as to what they are,
whether they explode, whether they don't, what are the
repercussions of the devices themselves?
We have heard about the UK, and there is--there is really,
in essence, a discussion about that data there, but you all
have highlighted what is different here than what is different
there. But the data is subject to whether it is criticism or
whether it is real or not, et cetera.
So there is so many pieces that need to be investigated. We
have an outbreak. We have epidemic levels. CDC will continue to
investigate. I want them to be more clear in their
recommendation. They are clear. But they recommend, they do not
create the policy.
The FDA--and that is not in the jurisdiction here--but in
the jurisdiction of the Agriculture Subcommittee, and the
reason why I speak about that so because I sit on the
Agriculture Subcommittee, and I am the senior member of that
subcommittee. The FDA has got to uphold its mission.
We need to move faster. We need to take action. It is now a
month since the Secretary said we were going to move forward on
the flavors. Nothing has happened as of yet.
So, and you know, for decades the tobacco industry has lied
to us. There are those of us who are sitting here will remember
the hearing that Congressman Waxman had when each Member held
their hand up and said that nicotine was not addictive. We
don't put people in this committee under oath. Those folks were
under oath at that time, and we found out that they were
peddling false information.
And now we are looking at false information about e-
cigarettes. It is not allowable for the tobacco industry to
regulate itself. And if we so allow that, then we are not doing
our job.
If we focus only on--we do have to focus on THC, but if we
only focus there, we are missing the full scope of this effort.
We need to provide more resources, which is what this
subcommittee did, and we will go to battle with our colleagues
on the Senate side so that we can provide the kinds of
resources that are necessary for smoking and smoking cessation,
but in addition, to building a public health infrastructure
that can allow our very committed commissioners of public
health around the country to be able to do their job, and so
much of this responsibility is placed on the States.
So, again, I want to thank you. I want to thank my
colleague, the ranking member, thank you. I know you had things
to do as well, but thank you for being here.
Congressman Harris, thank you for hanging in it to the end.
But to all of you, let us keep on. Please make your voices
heard. Thank you very, very much.
And let me conclude this hearing. Thank you.
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