[House Hearing, 108 Congress]
[From the U.S. Government Publishing Office]



 
        HOMELAND SECURITY: IMPROVING PUBLIC HEALTH SURVEILLANCE

=======================================================================

                                HEARING

                               before the

                   SUBCOMMITTEE ON NATIONAL SECURITY,
                   EMERGING THREATS AND INTERNATIONAL
                               RELATIONS

                                 of the

                              COMMITTEE ON
                           GOVERNMENT REFORM

                        HOUSE OF REPRESENTATIVES

                      ONE HUNDRED EIGHTH CONGRESS

                             FIRST SESSION

                               __________

                              MAY 5, 2003

                               __________

                           Serial No. 108-55

                               __________

       Printed for the use of the Committee on Government Reform


  Available via the World Wide Web: http://www.gpo.gov/congress/house
                      http://www.house.gov/reform







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                     COMMITTEE ON GOVERNMENT REFORM

                     TOM DAVIS, Virginia, Chairman
DAN BURTON, Indiana                  HENRY A. WAXMAN, California
CHRISTOPHER SHAYS, Connecticut       TOM LANTOS, California
ILEANA ROS-LEHTINEN, Florida         MAJOR R. OWENS, New York
JOHN M. McHUGH, New York             EDOLPHUS TOWNS, New York
JOHN L. MICA, Florida                PAUL E. KANJORSKI, Pennsylvania
MARK E. SOUDER, Indiana              CAROLYN B. MALONEY, New York
STEVEN C. LaTOURETTE, Ohio           ELIJAH E. CUMMINGS, Maryland
DOUG OSE, California                 DENNIS J. KUCINICH, Ohio
RON LEWIS, Kentucky                  DANNY K. DAVIS, Illinois
JO ANN DAVIS, Virginia               JOHN F. TIERNEY, Massachusetts
TODD RUSSELL PLATTS, Pennsylvania    WM. LACY CLAY, Missouri
CHRIS CANNON, Utah                   DIANE E. WATSON, California
ADAM H. PUTNAM, Florida              STEPHEN F. LYNCH, Massachusetts
EDWARD L. SCHROCK, Virginia          CHRIS VAN HOLLEN, Maryland
JOHN J. DUNCAN, Jr., Tennessee       LINDA T. SANCHEZ, California
JOHN SULLIVAN, Oklahoma              C.A. ``DUTCH'' RUPPERSBERGER, 
NATHAN DEAL, Georgia                     Maryland
CANDICE S. MILLER, Michigan          ELEANOR HOLMES NORTON, District of 
TIM MURPHY, Pennsylvania                 Columbia
MICHAEL R. TURNER, Ohio              JIM COOPER, Tennessee
JOHN R. CARTER, Texas                CHRIS BELL, Texas
WILLIAM J. JANKLOW, South Dakota                 ------
MARSHA BLACKBURN, Tennessee          BERNARD SANDERS, Vermont 
                                         (Independent)

                       Peter Sirh, Staff Director
                 Melissa Wojciak, Deputy Staff Director
                      Rob Borden, Parliamentarian
                       Teresa Austin, Chief Clerk
              Philip M. Schiliro, Minority Staff Director

 Subcommittee on National Security, Emerging Threats and International 
                               Relations

                CHRISTOPHER SHAYS, Connecticut, Chairman

MICHAEL R. TURNER, Ohio
DAN BURTON, Indiana                  DENNIS J. KUCINICH, Ohio
STEVEN C. LaTOURETTE, Ohio           TOM LANTOS, California
RON LEWIS, Kentucky                  BERNARD SANDERS, Vermont
TODD RUSSELL PLATTS, Pennsylvania    STEPHEN F. LYNCH, Massachusetts
ADAM H. PUTNAM, Florida              CAROLYN B. MALONEY, New York
EDWARD L. SCHROCK, Virginia          LINDA T. SANCHEZ, California
JOHN J. DUNCAN, Jr., Tennessee       C.A. ``DUTCH'' RUPPERSBERGER, 
TIM MURPHY, Pennsylvania                 Maryland
WILLIAM J. JANKLOW, South Dakota     CHRIS BELL, Texas
                                     JOHN F. TIERNEY, Massachusetts

                               Ex Officio

TOM DAVIS, Virginia                  HENRY A. WAXMAN, California
            Lawrence J. Halloran, Staff Director and Counsel
              Kristine McElroy, Professional Staff Member
                        Robert A. Briggs, Clerk
                    David Rapallo, Minority Counsel




                            C O N T E N T S

                              ----------                              
                                                                   Page
Hearing held on May 5, 2003......................................     1
Statement of:
    Fleming, David, M.D., Deputy Director for Public Health 
      Science, Centers for Disease Control and Prevention, U.S. 
      Department of Health and Human Services; and David 
      Tornberg, M.D., M.P.H., Deputy Assistant Secretary, Health 
      Affairs, U.S. Department of Defense........................     4
    Kelley, Patrick W., M.D., Dr. PH, Colonel, Medical Corps, 
      Director, Department of Defense, Global Emerging Infections 
      Surveillance and Response System...........................   134
    Selecky, Mary C., secretary, Washington State Department of 
      Health, president, the Association of State and Territorial 
      Health Officials; Seth L. Foldy, commissioner, medical 
      director, city of Milwaukee, health commissioner, chair, 
      National Association of County and City Health Officials, 
      Information Technology Committee; Karen Ignagni, president 
      and CEO, American Association of Health Plans; and Julie 
      Hall, medical officer, World Health Organization...........    62
Letters, statements, etc., submitted for the record by:
    Bell, Hon. Chris, a Representative in Congress from the State 
      of Texas, prepared statement of Dr. Hearne.................   122
    Fleming, David, M.D., Deputy Director for Public Health 
      Science, Centers for Disease Control and Prevention, U.S. 
      Department of Health and Human Services:
        Article from Emerging Infectious Diseases................    56
        Information concerning estimate for fiscal year 2004.....    40
        Information concerning moneys spent on the National 
          Electronic Disease Surveillance System.................    42
        Prepared statement of....................................     7
    Foldy, Seth L., commissioner, medical director, city of 
      Milwaukee, health commissioner, chair, National Association 
      of County and City Health Officials, Information Technology 
      Committee, prepared statement of...........................    77
    Hall, Julie, medical officer, World Health Organization, 
      prepared statement of......................................    88
    Ignagni, Karen, president and CEO, American Association of 
      Health Plans, prepared statement of........................   108
    Selecky, Mary C., secretary, Washington State Department of 
      Health, president, the Association of State and Territorial 
      Health Officials, prepared statement of....................    66
    Tornberg, David, M.D., M.P.H., Deputy Assistant Secretary, 
      Health Affairs, U.S. Department of Defense, prepared 
      statement of...............................................    25


        HOMELAND SECURITY: IMPROVING PUBLIC HEALTH SURVEILLANCE

                              ----------                              


                          MONDAY, MAY 5, 2003

                  House of Representatives,
Subcommittee on National Security, Emerging Threats 
                       and International Relations,
                            Committee on Government Reform,
                                                    Washington, DC.
    The subcommittee met, pursuant to notice, at 2:01 p.m., in 
room 2154, Rayburn House Office Building, Hon. Christopher 
Shays (chairman of the subcommittee) presiding.
    Present: Representatives Shays, Murphy, Janklow, and Bell.
    Staff present: Lawrence Halloran, staff director and 
counsel; Kristine McElroy, professional staff member; Robert A. 
Briggs, clerk; David Rapallo, minority counsel; and Jean Gosa, 
minority assistant clerk.
    Mr. Shays. A quorum being present, the Subcommittee on 
National Security, Emerging Threats and International Relations 
hearing entitled, ``Homeland Security: Improving Public Health 
Surveillance,'' is called to order.
    As we convene here today, the world is conducting an 
involuntary, live-fire exercise of public health capacity 
against bioterrorism. Severe acute respiratory syndrome [SARS], 
emerged from the microbial hothouse of the Far East through the 
same vulnerabilities and vectors terrorists would exploit to 
spread weaponized, genetically altered disease.
    The global response to SARS underscores the vital 
significance of sensitive disease surveillance in protecting 
public health from natural and unnatural outbreaks. It also 
discloses serious gaps and persistent weaknesses in 
international and U.S. health monitoring.
    The lessons of the West Nile virus and mail-borne anthrax 
have not gone unheeded. Substantial enhancements have been made 
to the accuracy, speed, and breadth of health surveillance 
systems at home and abroad. The limited impact of SARS here can 
be attributed in part to increased preparedness to detect, 
control, and treat outbreaks of known and unknown diseases.
    But the public health surveillance system at work today 
against SARS is still a gaudy patchwork of jurisdictionally 
narrow, wildly variant, and technologically backward data 
collection and communications capabilities. Records critical to 
early identification of anomalous symptom clusters and disease 
diagnoses are not routinely collected. Formats for recording 
and reporting the same data differ widely between cities, 
counties, and States. Many key records are still generated on 
paper, faxed to State or Federal health authorities, and 
entered manually one or more times into potentially 
incompatible data bases.
    In a world made smaller by the speed of international 
travel and the rapid mutation of organisms in our crowded 
midst, the interval between local outbreak and global epidemic 
is shrinking. Virulent, drug-resistant organisms easily 
traverse the geographic and political boundaries that still 
define and inhibit public health systems.
    Efforts to build a more modern ``system of systems,'' 
envision routine collection and rapid dissemination of real-
time data from public and private health systems and 
laboratories. Early warning capabilities would be enhanced 
through the fusion of innovative syndromic surveillance--
automated screening of emergency room traffic, pharmacy sales, 
news wires, and other public data streams--for potentially 
significant signs of an outbreak.
    Pieces of this planned health monitoring system can be 
assembled at different times and places, but no fully national 
system yet integrates the observations and communications 
needed to protect public health from rapidly emerging 
biological hazards. Successfully operating the elaborate, 
elegantly sensitive surveillance network of the future will 
require unprecedented levels of human skill, fiscal resources, 
medical information, and intergovernmental cooperation.
    At this moment, sophisticated radars scan the skies and the 
seas to detect the approach of forces hostile to the peace and 
sovereignty of this Nation. A similarly unified, sensitive 
system of disease sensors is needed to detect the advance of 
biological threats to our health and prosperity.
    Testimony today will describe civilian and military 
programs under way in the United States and abroad to overcome 
the natural and man-made barriers to health monitoring. We 
deeply appreciate the dedication and expertise all our 
witnesses bring to this important discussion, and we welcome 
their participation in our oversight.
    At this time, we will call on Mr. Bell, who is the acting 
ranking member today.
    Mr. Bell. Thank you, Mr. Chairman.
    I would like to thank you and those who are providing 
testimony before the committee here today.
    Today's hearing is critically important to this Nation's 
security and the safety of its health in general. We are all 
aware of the need to detect the outbreak of disease and respond 
immediately and effectively. This could be no clearer than in 
my congressional district, which is home to the world's largest 
medical center in the world in Houston, TX.
    Public health surveillance has been described as ``the 
cornerstone of public health decisionmaking and practice.'' The 
events of September 11, 2001, and the subsequent anthrax 
attacks raise the profile of this issue significantly, so much 
so, President Bush proposed the creation of ``a national public 
health surveillance system to monitor public and private data 
bases.'' He argued that the anthrax attacks of October 2001 
prove that quick recognition of biological terrorism is crucial 
to saving lives; and he proclaimed an urgent need to integrate 
the Federal interagency emergency response plans into a single, 
comprehensive, governmentwide plan.
    But what concerns me most is that there has been no 
evidence of any attempt to follow through on this proposal. 
Additionally, the administration's fiscal year 2004 budget 
slashes funding in core Centers for Disease Control functions.
    I would hope that our witnesses can clear up the 
discrepancies between the administration's rhetoric and its 
proposed funding levels, and I look forward to your testimony.
    Thank you, Mr. Chairman.
    Mr. Shays. Thank you, Mr. Bell.
    At this time, the Chair would recognize Mr. Janklow.
    Mr. Janklow. Thank you very much, Mr. Chairman. I am going 
to be extremely brief.
    If you go back to the period of time just a couple of short 
years ago when those anthrax letters were mailed around the 
country, they had the anthrax outbreak, the situation down in 
the Carolinas, the reality of the situation is, from and after 
that point in time, phenomenal things have been accomplished.
    But as you indicated, Mr. Chairman, in your opening 
remarks, we still have a patchwork in this country that we have 
a responsibility to overcome very, very quickly. We have cities 
that have public health laboratories and counties with public 
health laboratories. We have prisons with public health 
laboratories. We have States that have public health 
laboratories; we have private health laboratories.
    The Federal Government has Indian health service 
laboratories, they have public health service laboratories, 
they have military laboratories. We have a whole host of 
different laboratories, reporting centers in this country, and 
still a large amount of it is based upon paperwork. And it is 
incredibly important, it is really incredibly important that in 
today's day and age, when it is not that difficult to put 
together reporting systems based upon electronic means--and not 
facsimile, but far more modern electronic means--that this be 
done in the most expeditious manner.
    The Centers for Disease Control frankly have accomplished 
phenomenal efforts in terms of working with local communities, 
working with States and communities over the last couple of 
years. But notwithstanding all the accomplishments that have 
been made, Mr. Chairman, the fact of the matter is, we are not 
where we have to be, we are not where we want to be, and we are 
not where we should be. And so anything that can be done to 
speed that process up can only be of a beneficial nature to the 
people of America.
    Thank you very much, Mr. Chairman, for giving me this 
opportunity.
    Mr. Shays. I thank the gentleman for this statement.
    Mr. Murphy.
    Mr. Murphy. I will wait and ask questions.
    Mr. Shays. Wonderful to have you all here. You all are such 
wonderful, active members of this committee.
    Before recognizing our witnesses, let me just get some 
housekeeping in place here, and ask unanimous consent that all 
members of the subcommittee be permitted to place an opening 
statement in the record, and the record remain open for 3 days 
for that purpose. And without objection, so ordered.
    I ask further unanimous consent that all witnesses be 
permitted to include their written statements in the record. 
And without objection, so ordered.
    At this time, we will recognize our first panel. We have 
two panels. Our first panel is Dr. David W. Fleming, Deputy 
Director for Public Health Science, Centers for Disease Control 
and Prevention; and Dr. David Tornberg, Deputy Assistant 
Secretary of Defense for Clinical and Program Policy, 
Department of Defense.
    Gentlemen, as you know, we swear in our witnesses, all our 
witnesses. If you would stand, raise your right hands, and then 
we will take your testimony.
    [Witnesses sworn.]
    Mr. Shays. Note for the record that both our witnesses have 
responded in the affirmative.
    I should have asked, is there anyone else that might help 
you respond that might have to say something publicly? If so, 
we will swear them in.
    We will start with you, Dr. Fleming, and then we will go to 
you Dr. Tornberg.
    Let me just tell you what we do. We do a 5-minute, and then 
we roll it over for the next 5 minutes. Stop sometime between 
the first 5 minutes and the second 5 minutes. Please don't go 
over the second 5-minute.
    I've never figured out what would happen if you did.
    Dr. Fleming. I don't want to be the first. Thank you.
    Mr. Shays. I'm using a little poetic license. It's happened 
once or twice.
    OK.

 STATEMENTS OF DAVID FLEMING, M.D., DEPUTY DIRECTOR FOR PUBLIC 
  HEALTH SCIENCE, CENTERS FOR DISEASE CONTROL AND PREVENTION, 
    U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES; AND DAVID 
  TORNBERG, M.D., M.P.H., DEPUTY ASSISTANT SECRETARY, HEALTH 
              AFFAIRS, U.S. DEPARTMENT OF DEFENSE

    Dr. Fleming. Mr. Chairman, members of the subcommittee, I'm 
Dr. David Fleming. I'm the Deputy Director of CDC for Public 
Health Science. Good afternoon. On behalf of CDC, thank you for 
inviting us here today. We very much appreciate your leadership 
and attention to the issue of public health surveillance.
    You know, this weekend when I was preparing my testimony, 
my 10-year-old asked me what I was doing. And when I told her I 
was working on a talk about public health surveillance, she 
said, Wow, I didn't know anybody was interested in that. And, 
you know, she had a point. Public health surveillance isn't an 
issue that most people know they should care about; and for 
that reason, we doubly appreciate your interest in this issue. 
And in some ways it's funny.
    Mr. Shays. Given her great insight, would you give her full 
name for the record.
    Dr. Fleming. Sure. Absolutely. Her name is Whitney Lynn 
Fleming.
    Mr. Shays. Well, she gets it.
    Dr. Fleming. Thank you.
    And it's funny, because I think all of us would be fairly 
concerned if we walked into our personal doctor's office and he 
or she suddenly started treating us without taking a history or 
without doing a physical or without doing any diagnostic 
testing.
    For public health, our patient isn't a person, it's the 
community. And just as clinicians need to know about blood 
pressure and about blood chemistries to diagnose the patients, 
public health practitioners must have the eyes and the ears and 
the tools to get the information that's needed to diagnose 
what's going on in their communities.
    Although the range of information that's needed to monitor 
community health is broad, today we are focusing on one piece, 
the piece that's needed to respond to a biologic threat in a 
community, to detect an epidemic or a bioterrorist event. And 
the problem here is that in the early phases of an outbreak, 
affected people don't turn to public health because no one 
realizes there is an epidemic. Rather, one by one, affected 
people seek health care for their symptoms. And to overcome 
this problem requires a system that, first, recognizes and 
diagnoses cases as they occur; second, transfers information 
about those cases to the public health system, where, third, 
it's analyzed, investigated, and acted on.
    Now, in this country this critical function is performed by 
our reportable disease surveillance system. Every physician, 
every laboratory in this country is required to report specific 
diseases and conditions to their public health authorities. 
And, you know, remarkably this system generally works. 
Thousands of disease reports are initiated each day and 
investigated each day, resulting in the detection of routine 
and exotic epidemics.
    This is the system that identified the anthrax attacks, and 
odds are it's the system that will identify the next 
bioterrorist attack on this country. Is it perfect? No. It is 
the best in the world. But not all reports are complete, not 
all are timely, and not all are appropriately acted on. It is, 
however, the core of our detection capacity, and it is the one 
to work on to make us more prepared.
    And there is good news here. The bioterrorism resources 
recently appropriated for building public health capacity have 
strengthened the system through a wide range of activities, 
such as increased provider training, improved laboratory 
diagnostic capacity throughout the country, better linkages 
between the clinical system and the public health system, and 
improved public health department 24/7 ability to receive and 
investigate reports. And these investments are paying off. Our 
remarkable success in detecting and responding to West Nile 
last summer and SARS right now are good examples.
    In addition to these general improvements, let me just 
mention three specific enhancements that we are working on, and 
all of them capitalize on the fact that we are at a critical 
moment of opportunity regarding the use of information 
technology.
    First, our current system emphasizes that providers 
recognize an event so that they can report it. In today's 
electronic age, there is a new potential that some of you have 
already alluded to, to use preexisting electronic data bases 
like nurse call lines or pharmacy records to check for 
clustering of events that might indicate an unrecognized 
problem. This type of monitoring is sometimes called syndromic 
surveillance, and it can supplement our existing disease 
reporting system. It holds promise for potentially detecting 
some kinds of events sooner and for providing a richer set of 
information to monitor and respond to any recognized problem.
    Second, we are working to improve the transfer of 
information from providers to public health. Though our 
National Electronic Disease Surveillance System [NEDSS], 
program, CDC is moving to move reporting from a paper system to 
an electronic system by establishing secure connectivity, by 
agreeing on those critical data standards, and by developing 
public health expertise that is necessary to make this system 
work.
    And, third, we are working on our ability to integrate 
real-time information from a wide range of sources. You know, 
our detection methods have to be sensitive, but the price for 
that is the potential for false alarms. Creating the capacity 
to rapidly look across a range of inputs to see if one is 
confirmed by the others is an increasingly critical capacity. 
And the scope and speed with which a bioterror event could 
evolve also puts a premium on our ability to monitor the 
emergence of an epidemic and the response capacities that are 
needed to fight it.
    I know the committee is also interested in surveillance at 
the international level. Let me just quickly say that the 
detection and tracking of SARS is an example of the 
international system working right, particularly given the 
resources that are available in most of the affected countries, 
and particularly given the fact that the very basics that we 
are beginning to take for granted here, like laboratory 
diagnostic capacity and personnel trained in case investigation 
and response are the rate-limiting need in most of the 
developing world.
    So, in conclusion, public health surveillance is as 
critical to public health as clinical information and 
diagnostic testing is to the practicing physician. The basic 
elements of our system to detect a bioterrorist event are 
operational and increasingly robust as a result of the recent 
investments that we have made. More can be done, however. In 
particular, enhancements with a strong information technology 
component, accessing existing electronic data bases, 
facilitating electronic reporting, and improving our ability to 
rapidly analyze a wide range of information sources, once only 
dreams, are now possible. The challenge now is to make them a 
reality.
    Thank you very much. And I would be happy to answer 
questions.
    Mr. Shays. Thank you, Dr. Fleming.
    [The prepared statement of Dr. Fleming follows:]
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    Mr. Shays. Dr. Tornberg.
    Dr. Tornberg. Good afternoon, Mr. Chairman, distinguished 
committee members. I am grateful for this opportunity to 
discuss the activities of the Department of Defense military 
health system, and to focus today on those activities engaged 
in medical surveillance.
    The military health system, with over 8.7 million 
beneficiaries, has a global mission that's continually involved 
in health surveillance. Our medical treatment facilities are 
daily collaborating, planning, training, and participating in 
homeland defense operations with our civilian community 
partners. Our military bases coordinate in the development of 
mutually supportive surveillance, defense, and consequence 
management plans. These efforts will be part of the Joint 
Services installation pilot project demonstrations.
    Integral to this project is ESSENCE II, the electronic 
surveillance system for early notification of community-based 
epidemics. This program is a cooperative venture between the 
Defense Advanced Research Projects Agency [DARPA], and the 
Johns Hopkins University applied physics laboratory.
    ESSENCE II is an outgrowth of ESSENCE I, which was 
developed for DOD-GEIS. ESSENCE II monitors the National 
Capital Area and performs syndromic surveillance based on 
school absenteeism, pharmacy prescription, over-the-counter 
transactions, emergency room and hospital clinic visits, and 
other disparate data sources to detect natural disease 
outbreaks or possibly covert biological weapons attack. A rapid 
display of clusters of suspicious symptoms or findings provides 
decisionmakers with outbreak information not currently 
available. This program shows great promise for providing early 
detection and response to numerous public health challenges.
    Medical surveillance of our new recruits and our Active 
Duty population presents us with the unique opportunity to 
detect the emergence of infectious illness. This knowledge can 
impact public health strategies by national authorities. In the 
past 2 years, virus isolates from military sources have twice 
driven the composition of the influenza vaccine used throughout 
the Nation in both the military and civilian communities.
    Development of vaccines to counter the relentless spread of 
old and newer biologic threats is a major contribution by 
Department of Defense laboratories. Current studies include 
working on improving vaccines for anthrax, Venezuelan equine 
encephalitis, plague, botulism, and toxins such as 
staphylococcal enterotoxins, and ricin.
    Medical oversight and surveillance of our military members 
from the moment they are recruited until the day they die 
provides unprecedented opportunity to monitor the potential 
impact of occupational, environmental, and geographical 
exposures. The defense medical surveillance system, a 
longitudinal surveillance data base, allows the Department to 
capture and then track significant events and exposures 
throughout a members' accession, training, deployment, and 
retirement. Improved occupational environmental surveillance 
programs protect forward-deployed service members' health by 
providing improved monitoring. The Theater Army Medical 
Laboratory, the Navy's Forward Deployable Preventive Medicine 
Unit, and the Army's Center for Health Promotion and Preventive 
Medicine provide rapid analysis and risk assessment 
information.
    To facilitate rapid biologic identification, DOD has 
supported development of the Ruggedized Advanced Pathogen 
Identification Device [RAPID], as we call it. This device is a 
miniaturized polymerase chain reaction [PCR], technology. It's 
a bioagent detection system that can frequently identify the 
cause of the outbreak or bioterror attack within 2 hours. This 
process could possibly take 4 days using standard laboratory 
techniques to identify agents.
    DOD has implemented weekly tracking of field clinic visits 
for various diseases and nonbattle injuries during deployments, 
and has increased such daily monitoring for current operations 
in all field clinic reports through command channels at least 
daily on the current situation, so notification of an outbreak 
or development of an unusual pattern is relatively immediate. 
The value to the Nation of these systems extends beyond DOD to 
industrial agents whose work forces parallel those in the 
military by providing valuable insight and methods to prevent 
or mitigate long-term disability.
    The Department of Defense partners with a number of civil, 
military, and international partners. The Armed Forces Medical 
Intelligence Center, an arm of the Defense Intelligence Agency, 
performs classified and unclassified global medical 
intelligence to arm theater commanders with the latest 
environmental, biological, and medical threat assessments. 
Their unclassified assessment is available to citizens and 
agencies.
    Enhanced Federal agency sharing and knowledge exchange is 
achieved by assigning military epidemiologists to the Centers 
for Disease Control. Public health service experts are also 
assigned from CDC to DOD. This sharing of our joint resources 
and expertise enhances the national response to both local and 
global threats.
    In like manner, we have detailed a military medical 
specialist to the World Health Organization. In the recent 
severe acute respiratory syndrome outbreak [SARS], the 
Department detailed a military expert in epidemiology to CDC 
from DOD-GEIS--and GEIS, as we know, is the Global Emerging 
Infection Surveillance response system--to provide our unique 
perspective. Additionally, DOD-GEIS experts were detailed from 
our laboratories in Indonesia to Vietnam in the outbreak's 
earliest days. Our experts contributed essential knowledge in 
the acquisition of specimen collection and biologic 
identification, and provided skill in transporting specimens. 
The existing infrastructure of the GEIS global laboratory 
influenza-based surveillance program was rapidly expanded to 
facilitate the transport of these specimens.
    A daily executive summary is issued by DOD-GEIS to 
communicate not only news with respect to general SARS issues, 
but also specific DOD information on possible cases, policy 
guidance, referenced laboratory resources, and surveillance 
data from ESSENCE and other DOD sources. DOD and service-
specific clinical disease control and air evacuation guidance 
has been disseminated to our forces. To date, we have had no 
active confirmed cases of SARS.
    GEIS's mission is directed by Presidential Directive 7, and 
includes support of global surveillance training and research 
and response to emerging infectious disease. Recognized by the 
Institutes of Medicine in 2001 as a critical, unique resource 
of the United States in the context of global affairs, and as 
the only U.S. entity that is devoted to infectious disease 
globally that has broad-based capacity in the overseas setting, 
DOD-GEIS stands as our commitment to surveillance for emerging 
infectious diseases in direct support of our national security 
efforts.
    Emerging infections, as has been discussed, are a threat to 
global security and have the ability to harm U.S. interests 
through reversing economic growth, fomenting social unrest, and 
complicating our response to refugee situations.
    Biological terrorism and warfare are additional concerns. 
The recent emergence of SARS and the inextricable progress of 
the HIV/AIDS epidemic in Africa have provided ample evidence of 
the economic and societal damage that infectious disease can 
cause.
    During our continuing operations in Afghanistan and Iraq, 
the military health system has applied the lessons of 12 years' 
experience since the first Persian Gulf operations. Through a 
force-held protection strategy, the Department promotes and 
sustains the health of our service members prior to deployment, 
protects personnel from disease and preventable injury during 
deployment, and provides comprehensive followup treatment for 
deployment-related conditions. A deployment health surveillance 
program with pre and post-deployment health assessments 
validates each individual's medical readiness to deploy, and 
addresses health concerns upon his return.
    Improved deployment health protection measures are designed 
to counter an increasingly broad range of threats. Such 
measures include the fielding of new biological and chemical 
warfare agents, detection alarm systems, and the operational 
testing of integrated electronic medical surveillance and 
emergency response networks. Current vaccines and antimalarial 
drugs and research on the next generation of vaccines and 
pharmaceuticals are but some of the many efforts we are engaged 
in.
    DOD has coordinated with the VA to address deployment, 
health-related concerns of both service members and veterans in 
developing a post-deployment health guideline. This practice 
guideline and the use of it through electronic information 
sharing through the Federal Health Information Exchange 
provides significant improvement in the care of our veterans' 
health.
    The military health system participates in the National 
Science Foundation's multiagency project to prioritize national 
research agenda for information systems to detect and respond 
to natural outbreaks or intentional release of biologic agents 
that target not only humans but plant and animal resources. 
Economic and health strains and vulnerabilities are being 
mapped, while requirements for information systems to track, 
alert, and notify disturbances are being developed. A national 
strategy involving combining Federal and civil agencies to 
combat bioterror will strengthen the national response.
    In conclusion, I am proud to say that the Department of 
Defense military health system is a solid partner in support of 
the national public health security through daily medical 
surveillance and support of the continuing war on terror. I 
believe that you will find that the military health 
surveillance has many complementary and overarching systems 
that cooperate with both other Federal agencies and the 
civilian medical community. These activities are enhanced 
through outstanding programs such as DOD-GEIS and the ESSENCE I 
and II programs.
    Thank you, Mr. Chairman, and distinguished committee 
members.
    [The prepared statement of Dr. Tornberg follows:]
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    Mr. Shays. I am stunned by the timing of your speech. You 
had 5 seconds left. Thank you. It was a thoughtful statement. 
Both of your statements were very helpful.
    I am going to recognize Mr. Janklow, and then we will go to 
Mr. Bell and Mr. Murphy. We are going to do 10-minute segments.
    Mr. Janklow. Thank you very much, Mr. Chairman.
    Dr. Tornberg, the system that you described, DOD-GEIS, is 
that suitable for civilian use in America?
    Dr. Tornberg. It is, sir. It's a developing system. The 
ESSENCE II is in fact a system that is involved with the 
civilian community. ESSENCE II is a lab data base analysis and 
recognition that we are conducting in conjunction with Johns 
Hopkins. It is based on the National Capital Area and the 21 
jurisdictions surrounding it.
    Mr. Janklow. Dr. Fleming, as I look at your testimony, you 
cite 30 States that have asked for funding under the NEDSS 
strategy. Is the NEDSS strategy, is that an end result or is it 
just part of a process?
    Dr. Fleming. N.E.D.S.S., or NEDSS as the jargon, is a 
program that's designed to transfer at the State and local and 
national level from a paper reporting system to an electronic 
reporting system.
    Mr. Janklow. Can you tell me why 20 States have not yet 
requested funding for that?
    Dr. Fleming. In fact, there may be a misunderstanding or a 
misinterpretation. All States are getting funding for NEDSS. 
Some States, approximately 20, have bought into the concept, 
but are using the standards that have been developed to develop 
their own software and process for making this happen. Thirty 
States have said, no, we don't think we have that technical 
capacity, and we want to jointly invest in the system that CDC 
is developing that will allow this to happen.
    Mr. Janklow. Sir, help me with this. And I understand, you 
know, interest in open architecture and competitive 
marketplaces. But why in the world would we be encouraging what 
looks like maybe one system, based upon 30, that CDC is 
developing--30 States, in reporting--major reporting 
jurisdictions, and then 20 more separate ones that all have to 
be tied together?
    Frankly, sir, what sense does that make?
    Dr. Fleming. The fundamental principle that NEDSS is 
operating on is to say that, independent of whether systems are 
homegrown or developed outside, that they have to conform to an 
agreed-upon set of strict standards that assures 
interoperability.
    Mr. Janklow. That makes my point, sir. I mean, that's the 
very point that I'm making.
    If you have strict standards and criteria that people have 
to meet, why aren't the other 20 part of the first 30 and all 
in the same system? Is there a reason, other than good feelings 
or, you know, good relationships that this is being done?
    Is this a sovereignty issue or is it a competency issue or 
what, sir?
    Dr. Fleming. I think it's actually a good public health 
practice issue.
    At the end of the day, these systems will be 
indistinguishable and transparent from each other as far as 
enabling the needed transfer of information. But the reality 
is--is that in different jurisdictions there are different 
needs and issues such that it does make sense for a particular 
jurisdiction adhering to a set of standards to say, we want to 
be able to customize this to meet not only the national needs 
but our local needs as well.
    Mr. Janklow. Doctor, if I could, and I'm referencing page 6 
of your written testimony: You give examples of different 
States, the Michigan example, the Missouri example, the 
Pennsylvania example, and then Virginia, Maryland, and 
Washington, citing that they are buying into the Pennsylvania 
example.
    Where you have an example like, let's just take Michigan. 
Michigan is implementing a secure Web-based disease 
surveillance system to improve the timeliness and accuracy of 
disease reporting. Why would that be any different than what 
Missouri is doing?
    And I know the answer is going to be Missouri is doing it, 
too. But why do they all have to be done in different ways? 
Because what we are going to end up with is, some jurisdictions 
are going to be more comprehensive and more thorough than 
others. And when we're dealing with national information that's 
coming from all over America, different jurisdictions are going 
to be reporting or not reporting certain data based on what it 
is they decide to do.
    Dr. Fleming. Let me draw a distinction. First, I understand 
the point that you're making. And rest assured that CDC, as 
well as State and local governments, are working very hard to 
prevent what you are talking about from happening.
    Mr. Janklow. But it doesn't indicate here it's happening. 
And I'm not trying to interrupt you, sir, but the testimony 
here indicates that may not be happening.
    But go ahead, please.
    Dr. Fleming. And there are really two different systems 
that we are talking about. In my oral testimony I talked about 
the reportable disease system that is standardized across the 
country and which NEDSS is seeking to make electronic with 
strict standards.
    In addition, with the availability of electronic medical 
records and other electronic data bases out there, there is now 
a new potential as you heard about, for example, in essence to, 
independent of that system, develop syndromic surveillance that 
accesses these data bases.
    We are right now at a stage where pilots and demonstrations 
and experiments are needed in that syndromic surveillance part 
of how we detect diseases. We do not yet know for sure how 
effective that system will be or what the best way to do it is. 
In that context, we are allowing innovation at the State and 
local level, under the guidance of CDC, to assess different 
ways of conducting not this reportable disease surveillance 
that NEDSS is standardizing, but rather this new enhanced, 
complementary approach of syndromic surveillance.
    Mr. Janklow. Doctor, given the history, I will call it in 
the nonwarfare sense, whether it's botulism, whether it's 
measles, whether it's other types of clusters--I remember an 
incident involving the Schwan's trucks several years ago with 
respect to the ice cream that was nationwide in scope. CDC and 
the systems in America have done a tremendous job of getting on 
top of that, meningitis, very, very quickly.
    What's the difference between the system in place for that 
and the systems you are describing now, sir?
    Dr. Fleming. OK. And it's two different approaches that are 
complementary, that are both designed to try to detect one of 
these events as soon as they are happening. The system that's a 
standard system that detects the salmonella outbreak is one 
where people with salmonella go to see their physician, a 
diagnosis is made, those cases are reported to the health 
department, and as a result of cases coming in from multiple 
physicians, there's a recognition that there is an outbreak of 
salmonella that is happening, and the appropriate investigation 
is occurring.
    Now, there are some conditions. Let's take anthrax as an 
example, where before someone gets to the point where it would 
be possible to diagnose the disease anthrax, they have several 
days of milder symptoms that are influenza-like, if you will, 
with fever and other illnesses. One potential way of jump-
starting our recognition of an anthrax attack would be not to 
wait for people to come in at the stage where you could 
diagnose anthrax, but by monitoring reasons that people are 
coming into emergency rooms or in pharmacy records, seeing that 
there is a sudden upswing in the nonspecific seeking of 
attention for an influenza-like syndrome.
    Mr. Janklow. But isn't that done now?
    Dr. Fleming. Actually, that's what we are talking about 
trying to implement with respect to this jargon, ``syndromic 
surveillance.'' Which is to say, is it possible to implement 
systems that could pick up earlier in the course of an epidemic 
some of these nonspecific illnesses that aren't yet diagnosed, 
and by seeing an uptick, put the public health and the clinical 
health system on alert? We are right now in the phase, though, 
of figuring out how best to do that.
    Mr. Janklow. One thing that the Department of Defense 
excels at is educating their people. They have a worldwide 
system that's in place.
    Recognizing that the traditional method that we follow in 
this country is to bring a lot of people together for a 
conference, would it not make sense to start using to a far 
greater extent, for example, satellite television, recognizing 
that in a lot of instances it will be video one-way and audio 
two-way, but that you could really reach an awful lot of people 
and, frankly, a lot of general public?
    I think where you are dealing with, especially the new 
world we live in of terror, the more the general public knows, 
the more equipped we are as a nation, one. And, two, the better 
it is in terms of reporting things to their physicians and 
their medical providers. I mean, it isn't like grandmas and 
mothers can't look at the symptoms. By the time you get to be a 
grandma, you know them pretty well. The school of hard knocks 
has taught you an awful lot.
    Is there any approach being looked at to more effectively 
use--like direct broadband, direct broadcast satellites, as 
opposed to specialty satellites like SS and direct TV?
    Dr. Fleming. You are absolutely right that with the new 
technologies we have available to us, we need to be creative 
and make sure we are staying ahead of the curve of how best to 
communicate----
    Mr. Janklow. Are you doing any of that?
    Dr. Fleming [continuing]. With people. And so there are a 
number of avenues that CDC, along with State and local health 
departments, are doing. One you mentioned is that many people 
now have access to the Internet, and one of the most effective 
ways to educate people is by putting information on Web sites, 
including interactive Web sites. CDC's Web sites gets millions 
of hits each month. And you can watch it uptick when West Nile 
comes, or with SARS, when SARS came. So people are using the 
Internet.
    Second, we need to take advantage of distanced-based 
learning techniques, as you have alluded to, via satellite 
transmissions, Webcasting, via even old-fashioned, if you will, 
videocassettes that allow people to learn at the time that they 
are able to do it, rather than going to the expense of bringing 
people all into the same place. There are many of these kinds 
of technologies that are now available to us, and we need to be 
smart and use them, and we are trying.
    Mr. Janklow. Thank you.
    Mr. Shays. I thank the gentleman.
    Mr. Bell.
    Mr. Bell. Thank you, Mr. Chairman.
    Dr. Fleming, we've obviously all heard about the anthrax 
scare in 2001. We read constantly about the threat of 
bioterrorism, and we pick up a newspaper or turn on the 
television just about every day to hear another story or see 
another story about SARS and the spread thereof.
    I think, given all of that, everybody recognizes the need, 
the very pressing need, for a national surveillance system. And 
many, certainly, on this side of the aisle are quite curious to 
see the cut to CDC in the President's budget to offset a $550 
billion tax cut, or what would appear to be a cut in order to 
offset the $550 billion tax cut--and I'm very curious as to why 
these cuts to CDC--what impact the cuts would have on the 
efforts to establish a national surveillance program.
    Dr. Fleming. Thank you, Congressman. I think there has been 
a bit of confusion about the nature of the reductions you are 
talking about. In fact, in the President's 2004 budget compared 
to the President's 2003 budget, there was actually a proposed 
increase of $125 million in chronic disease, $50 million for 
HIV prevention, $10 million for a public health information 
network, initial development, $5 million for health statistics, 
$17 million for pay raises.
    What happened though is that the President's 2003 request 
was modified by Congress and increased. So if you look at the 
President's 2004 request compared to what it was that Congress 
authorized in 2003, there is this difference.
    From our perspective, it does make sense for the President 
to operate off the budget that he proposed in 2003. And in that 
budget there are not any programmatic reductions. Obviously, 
when the budget comes to you all, you are going to need to sort 
this out as far as what you authorized in 2003 compared to what 
you authorized in 2004.
    Mr. Bell. What about moneys spent on the National 
Electronic Disease Surveillance System?
    Dr. Fleming. The dollars that were requested by the 
President in 2003 for that system match the dollars that were 
requested by the President in 2004 for that.
    Mr. Bell. That's been going down every year since 2002, has 
it not?
    Dr. Fleming. I could get back to you on the record with the 
specifics. My understanding is that the amount has been 
constant, with the exception of an earmark that was deleted. 
But let me get back to you on the record.
    [The information referred to follows:]

    FY 2002 Actual--$27.8 million
    FY 2003 Enacted--$28.6 million
    FY 2004 Request--$27.6 million

    Mr. Bell. Well, let's discuss in a more positive light what 
progress has been made in bringing the 100 district 
surveillance systems together under a more comprehensive 
program.
    Dr. Fleming. There has been remarkable progress made. Let 
me say that more can and needs to be done, but within the last 
year many States have begun actually operationalizing a system 
where clinical laboratories in their jurisdictions are now 
automatically and electronically forwarding disease reports so 
those reports are coming in a more complete and timely fashion. 
And States like Hawaii have performed brilliant analyses of 
this that show that they are now better able to detect 
outbreaks more rapidly and more efficiently than they were 
before.
    In addition, there has been absolute commitment at CDC and 
agreement with our State and local partners that we need to 
establish a uniform set of standards for developing our 
information technology systems, and especially those systems 
that are relevant to biosurveillance.
    And so, over the last year, for the first time there is a 
comprehensive list of standards that all of the public health 
partners have bought into that said, as we move forward, these 
are the standards that we agree we're going to abide by to 
assure that a clinical laboratory that reports to multiple 
jurisdictions only has to do it one way because there will be 
one set of standards and to assure that, as information passes 
from one jurisdiction to another, that passage will be 
transparent, because it will be sent and received in a standard 
format.
    In addition, there has been good initial work done on what 
we are calling the public health information network, which is 
the underlying information architecture that we need to do all 
of our business, not just surveillance, but also alerting of 
providers through routine e-mail communications and training 
and informing the public. So, we build one system with multiple 
functionalities rather than multiple independent systems. We 
have gone a long way.
    Mr. Bell. OK. But we don't have one system right now as we 
sit here today; is that fair?
    Dr. Fleming. That is correct. We are moving toward that 
single system. But we need to recognize that we were starting 
from a baseline of many disparate systems, and we need to keep 
the trains running as we move forward.
    Mr. Bell. Sure. And I agree with that and I understand 
that. But what challenges still exist in order to get to that 
one system? Because I assume from your comments that is the 
ultimate goal.
    Dr. Fleming. There are several challenges. I won't deny 
that resources is certainly part of it. Information technology 
and these systems are expensive. And in this era where there 
are finite resources available, tough decisions are going to 
have to be made.
    Second, though, we need to look critically at the human 
capacity, because in fact you can have the best computers and 
the best information system in the world, but unless there is 
somebody sitting behind that computer that is knowledgeable and 
competent and trained and knows how to act on that information, 
you haven't bought anything. And I think at CDC we are most 
concerned perhaps about whether or not there is this pipeline 
of trained public health professionals out there to use this 
new technology.
    And, in fact, there may not be. So, a major area that we 
are looking at in conjunction with our State and local health 
departments is, what does need to be done with respect to 
schools of public health and other educational institutions, 
preparing public health professionals to assure that the work 
force that we are generating is one that is competent and knows 
how to take maximum advantage of the system that we are 
building?
    Mr. Bell. Dr. Fleming, given the fact that, as you state, 
resources are one of the challenges we face, is it fair to say, 
when the amount of money is decreasing that is being spent on 
the surveillance system, we are not going to get there anywhere 
fast toward the one system?
    Dr. Fleming. Moving toward the one system certainly is 
going to be both resource and people-dependent.
    Mr. Bell. What kind of money are we talking about?
    Dr. Fleming. Right now, we are engaging with OMB according 
to the Klinger-Cohen Act to develop the business case for 
exactly what it is with respect to this overall vision that we 
are going to need in the next few years. When that process is 
complete, we will have a specific target amount that will be 
needed, and we will get back to you with that. We are working 
through exactly that issue right now.
    Mr. Bell. So we don't even know how much it would cost at 
this point in time?
    Dr. Fleming. We need to complete our discussions with OMB 
and under the rules of the Klinger-Cohen Act.
    Mr. Bell. Is there any kind of estimate available at this--
has anyone made any sort of estimate how much one system might 
cost?
    Dr. Fleming. Let me get back to you on record for that.
    Mr. Bell. I'm sorry?
    Dr. Fleming. I will get back to you on the record.
    [The information referred to follows:]
    [GRAPHIC] [TIFF OMITTED] 89547.026
    
    Mr. Bell. I would appreciate it.
    It is not your impression--and, Dr. Tornberg, you can 
comment on this as well--that the administration has stepped 
away from its earlier desire to see this national surveillance 
system? Do any of you all get that impression?
    Dr. Fleming. Dr. Tornberg can comment. I certainly do not. 
If anything, the administration, and especially the Vice 
President's office, has been very supportive of the notion of 
doing what needs to be done to make sure that we have a 
surveillance system that's competent and, particularly, a 
surveillance system that can detect not only naturally 
occurring events but bioterrorist events as well.
    Mr. Bell. Dr. Tornberg.
    Dr. Tornberg. I would agree. I think that there is a full 
commitment to providing a national surveillance system. I have 
not detected any variance from that point.
    Mr. Bell. Has everybody made it clear that more money is 
going to have to be committed to the project if we are going to 
be able to realize one system?
    Dr. Fleming. We made it clear that resources are needed to 
make systems work and that we need to balance the expectations 
for what those systems are against the resources that are 
available.
    Mr. Bell. Thank you very much.
    Mr. Shays. I thank the gentleman.
    Before recognizing Mr. Murphy, what I'm wrestling with is 
one country, 50 States, thousands of local governments, and the 
comment is made, it's a question of resource and people. It's 
not a question of legislation that would allow you to mandate 
one system throughout?
    Dr. Fleming. Mr. Chairman, I don't think so.
    Mr. Shays. OK. We will come back to it.
    OK, you've got it, Mr. Murphy.
    Mr. Murphy. Thank you, Mr. Chairman. Actually, you were 
reading my mind. My mind is working along the same lines.
    In Pittsburgh, we have a system called the Real-time 
Outbreak and Disease Surveillance System [RODS] system, which 
has been operating pretty well. And in southwestern 
Pennsylvania--and, also, Utah used some of this during the last 
Olympics where they do monitor those very things you were 
talking about, over-the-counter supplies and pharmacies, etc. 
And that's one sort of system, and you are looking at others.
    I just want to make sure I understand this. Are you at this 
point testing different systems that are being used to 
determine which one is the best system? Have you determined 
that yet as different universities are involved in these 
functions?
    Dr. Fleming. The RODS system that you are referring to 
would fall into that category of syndromic surveillance 
systems, where in fact right now a number of different 
systems--ESSENCE would be an example; ESSENCE I and II would be 
examples--are being tried in different jurisdictions. I 
personally think that the outcome of this is not going to be 
that one of those systems is going to be proven best, but 
alternatively we will see the aspects of each that provide the 
most functionality. And by combining the best of all of them, 
we will create that, if you will, one system that serves our 
needs.
    But we are really right now in a phase of piloting and 
demonstrating and, to a certain extent, experimenting, because 
this is new ground for the public health community.
    Mr. Murphy. So you are working with different places like 
the University of Pittsburgh and others to monitor the kinds of 
parts that are in place, so you can pull out of each one what's 
the best?
    Dr. Fleming. Exactly right. And in addition, I mean, a key 
to these--the underlying notion here is that these systems can 
detect problems more effectively and more rapidly in some 
instances than our existing reportable disease system, and can 
be a complement to it.
    That's a concept that has not been totally proven yet, and 
before investing a whole lot of resources in a nationwide 
system, we do need to see the evidence that these systems are 
able to do what they, in theory, might be able to.
    Mr. Murphy. Let's walk through what happens next. Say you 
come up with a national system that's been working in the 
cities and rural areas, etc. The thing about bioterrorism, it 
moves slow enough that you can detect and then implement 
strategies to quarantine, to have public education, to 
immunize, whatever. But, of course, the drawback is that it 
also moves slow enough that it can be spread throughout the 
Nation in a matter of a few days before anybody has a sense 
that they need to take some steps.
    When that happens--and we have had some other hearings 
here, for example, with NORTHCOM, some wonderful hearings and 
discussing some of the aspects taking place.
    But let's go--let's say there is some disease that begins 
to be picked up in multiple cities around the country, it's 
spreading by whatever mechanism, through contact, it's around. 
Can you walk us through what happens once you get this data, in 
particular, the plans in place to notify physicians and 
hospitals, coordinate efforts, get products to communities, 
notify the Defense Department, even to the level of local 
emergency responders, EMS people, etc?
    Can you walk us through what happens once you identify that 
there appears to be something out there?
    Dr. Fleming. It's a complicated question. Let me try to 
answer it in a couple of ways.
    First and most basically, the health department needs to be 
the nerve center for making this happen. What we are talking 
about is gathering the information through the surveillance 
systems to allow competency in making the decisions that need 
to occur. Then, the different arm needs to come in action. The 
health department, as you have said, works with providers and 
works with appropriate policymakers to make the right things 
happen.
    A fair amount of the dollars that have gone out over the 
last year for enhancing bioterrorism preparedness have been put 
in place through plans and exercises, exactly the kind of thing 
that you're talking about. So even as we speak, health 
departments around the country are, in fact, making plans, 
drilling, making sure that they have the ability to connect 
with the providers that they need to connect with, testing 
that, making sure that they're connected with the policymakers 
and others.
    Mr. Murphy. Is this part--there'll continue to be drills 
around the Nation? There's funding available for that aspect 
that communities can also apply and work with health--because 
you also have State health departments in some--I know in 
Pennsylvania many counties don't have a health department. They 
have to rely on the State. It's a slow system. And so it will 
require some drills and exercise to take care of that. Is that 
a part of the States as well?
    Dr. Fleming. Absolutely correct. And let me point out that 
one of the ways that we are really focusing on using these 
resources is to invest them in the same systems that are used 
every day to detect naturally occurring outbreaks and to mount 
the responses that are necessary to combat those. So in 
addition to exercises and drills, in fact, we are, because of 
Mother Nature, constantly being drilled in this country and 
around the world through the natural everyday public health 
emergencies that our health departments are facing.
    Mr. Murphy. Was this 5 or 10 minutes that I have?
    Mr. Shays. Ten minutes.
    Mr. Murphy. Ten minutes? Oh good. Let me continue to pursue 
this.
    With this kind of data out there, the question becomes one 
of Big Brother and how do you protect confidentiality of 
records. And let me add to this, a lot of hospitals are 
concerned now about HIPAA regulations and problems with 
confidentiality. So now they can't get the information that 
they need to track what's happening with patients.
    Let me continue to build this. As we're working on such 
things as other aspects of pharmaceutical care for the elderly, 
without some openness of sharing some records, you run the 
continued risk of the problems that there are with prescription 
and nonprescription drugs. Some estimates have been out there 
about 10 percent--I'm sure you're aware that about 10 percent 
of emergency room admissions they say are related to some 
pharmaceutical problems; perhaps the person took the double 
doses they weren't supposed to. Perhaps a physician did not 
know what else was being prescribed. They didn't know that the 
patient was taking over-the-counter products. Someone forgot 
their medication for 2 days, they took it all at once. The list 
goes on. And in aspects where pharmacists have data available 
or where the pharmacy benefits manager may have information 
available of what else that person is on, it helps them prevent 
a lot of those accidents.
    Now, we're looking, too, here at collecting data on 
symptoms. If it is just looking at sales, numbers for what's 
happened with antihistamines and pharmacists, that's one thing, 
but ultimately you have to get down to the level of who has 
this? That's been part of the elegance of tracking SARS around 
the world, that you were able to track it down to a hotel in 
Hong Kong, ninth floor, who was there, and tracking them around 
the world. Clearly you're going to need some sort of records 
like this, too, but it has to be looming over people's minds 
of--on the one hand they want to know if there are symptoms in 
a town, they want action to be taken to identify that, but also 
protect confidentiality. How do you walk that line?
    Dr. Fleming. OK. An excellent question. Let me say first 
that I think most people in public health would not see it as 
public health versus privacy, but rather only by protecting 
privacy can we expect this information to be made available, 
and so we're on the same side of this.
    There's a couple of strategies that are used. First there 
are some kinds of surveillance where you don't need identifying 
information, and so the first question that we always ask in 
any of these surveillance systems is can we get what we need 
without having identifying information there, and if so, let's 
not get it.
    But as you pointed out, there are some places where, in 
fact, identifying information is needed so you can track back 
to the individual or the individual's provider to get more 
information to assure that the right things are happening to 
that person and to take the appropriate actions in the 
community.
    This is an issue that public health has been dealing with, 
you know, for 100 years. And, in fact, on a day-to-day basis, 
personal identifying information is routinely relayed from the 
medical community to the public health system, and that 
information is guarded very carefully both from a legal 
standpoint and from a security standpoint so that there have 
been few, if any, breaches in the history of public health 
where an individual's confidentiality has been compromised, and 
that's by maintaining attention to the sanctity of privacy and, 
when information that is identified is obtained, making sure 
that it's used wisely. That's the answer.
    One last thing about HIPAA is that there is a lot of 
confusion out there, obviously, and we're working in the health 
care sector, but HIPAA, in fact, does give an exemption to 
public health, so--providing information from the clinical 
sector to the public health sector for public health purposes 
and says in that situation it is OK to transfer identifying 
information.
    Mr. Murphy. Well, I certainly hope as all this is gathered 
a great deal of training information is available to 
physicians, hospitals, emergency responders, police, etc., 
because a lot of them still don't know what to do.
    And let me ask one final quick question. Who is ultimately 
in charge when a disease outbreak is determined? Who is the top 
of the chain of command?
    Dr. Fleming. Well, the President, obviously.
    Mr. Murphy. I mean, is it where the thing occurs first? 
Oftentimes first responders, whoever's first on the scene in 
that community, is now in charge either nationwide, or it 
begins in some State----
    Dr. Fleming. I'm sorry. I misunderstood your question. 
Health is a State's right, and so it will be the State health 
department at which there is legal jurisdiction for the health 
events going on in the State. If an event crosses State 
boundaries, then it becomes also from a legal perspective a 
Federal jurisdiction issue.
    Mr. Murphy. And so such actions as quarantining, other 
information then becomes through--Health and Human Services, 
HHS and CDC begin to take control and begin to tell States what 
they should do in communities and travel, etc?
    Dr. Fleming. The short answer is yes. The more accurate 
answer is that we really do have a good partnership in public 
health, and so CDC and State and local health departments 
routinely, every day, in the absence of who is in charge, make 
critically important decisions about what needs to be done.
    Mr. Murphy. Thank you.
    Thank you, Mr. Chairman.
    Mr. Shays. I thank the gentleman.
    In our two panels we have the national looking at the 
civilian and the military, and then we have basically State and 
local and international, and we're also looking at the private 
in our second panel.
    I was just curious, Dr. Tornberg, as you're hearing the 
questions being asked to Dr. Fleming, besides thinking what 
you're going to do this evening or tomorrow or on the weekend 
as it related to this hearing, what kinds of things go through 
your thoughts? I'm just trying to figure out how you interface 
with CDC.
    Dr. Tornberg. Well, we interact extensively with CDC and I 
have with Dr. Fleming on issues. The collaboration extends not 
only to CDC, but to a host of other Federal agencies and the 
World Health Organization. As I indicated in my earlier 
statement, we have representatives assigned to CDC, military 
epidemiologists. We are currently assigning an individual to 
represent--Dr. Winkenwerder--at the--to Dr. Gerberding's office 
as we speak.
    So the collaboration is very close, and there's an ongoing 
active discussion. Particularly with the SARS outbreak, there's 
been really intense collaboration between CDC and the World 
Health Organization and our assets, the assets of DOD-GEIS, in 
addressing this issue, and I think we have a really fine 
working relationship.
    Mr. Shays. Now, if there wasn't the terrorist threat, you'd 
still be in business, and why would that be true? In other 
words, if you never had to worry or--not just the terrorist 
threat, but a sanctioned military effort on the part of an 
adversary to use biological agents, if you didn't have that 
concern, whether it was sanctioned by a government or 
individual terrorist attack, one used against the military or 
one used against civilians, would you still be in business, and 
why?
    Dr. Tornberg. Yes, sir, we would be. In fact, our ongoing 
efforts and our fight to preserve the health and safety of our 
personnel demands that we be very active and proactive in this 
arena, as we have been from the earliest days of the Department 
of Defense. Our forces are expeditionary in nature and exposed 
to a host of----
    Mr. Shays. I get the gist of that. Thank you. That's clear 
to me.
    Let me ask you, Dr. Fleming, though, so you have Dr. 
Tornberg, who's focused on a national and international, tell 
me how your focus becomes international in terms of the fear--
in other words, we have representatives from our military all 
around the world. Is your focus international as well as 
national?
    Dr. Fleming. Absolutely. And it is for several reasons. The 
spector of infectious disease is perhaps the most obvious 
threat. A case of drug-resistant tuberculosis or SARS is simply 
a plane ride away in today's world. And one of the best ways to 
prevent the emergence of both known and unknown diseases in 
this country is to make sure that we have a strong global 
network and a U.S. presence, a CDC presence, overseas fighting 
those diseases in the countries that they're occurring, 
minimizing the chance that they will come here.
    Mr. Shays. How many laboratories would CDC have overseas?
    Dr. Fleming. CDC's primary expertise is in people and 
epidemiologists, so we have a handful of field stations, but in 
my opinion, the real international resource, the resource that 
CDC provides for the world, is in the trained epidemiologists, 
and we currently have approximately 60 CDC medical 
epidemiologist in various countries working with local 
ministries of health on critically important issues, be it 
polio eradication, or HIV prevention, or surveillance for 
infectious diseases.
    Mr. Shays. Dr. Tornberg, how many--is that classified 
information?
    Dr. Tornberg. No, sir, it's not. We have five overseas 
laboratories.
    Mr. Shays. And where are they located?
    Dr. Tornberg. We have a laboratory in Thailand, in Jakarta, 
Indonesia. We have one in Peru, Kenya and Cairo.
    Mr. Shays. OK. Now, getting to where Mr. Bell is, in 
Congress, we have to wrestle with a constituent who will say we 
need to do this, and they want a State law because they don't 
like what their--they want a Federal law because they don't 
like what their State is doing, and we get into this issue of, 
you know, do we overrule State law and have a uniform law. And 
I try explain that you sometimes can end up with a common 
denominator, and you might want a stronger law in one State 
versus another.
    But when you get into health care and you get into this 
issue of collecting data, I'm really unclear as to what 
restraints there are. I mean, is there an untold story here 
that Republicans don't want to get into this because there is 
the States rights issue, and Democrats may not want to get into 
this because of the personal privacy? I mean, is party 
ideology, conservative or liberal, getting into play here 
besides the issue of resources and people-dependent and money, 
because I'm thinking, good grief, we're not going to have a 
vaccine for every potential pathogen, every potential illness 
inflicted on us. So one of the ways that we are going to deal--
and we wouldn't want to necessarily even if we could, because 
there's always some side effects with that.
    So we want to--it seems to me our strategy is identify 
quickly, isolate it, contain it, and deal with that as we find 
it. And I'm unclear from you, Dr. Fleming, as to, you know, are 
we going here and there, or are we just trying to say, well, 
given this disparate kind of system we have, we'll make the 
best of it? Or should we say this is absurd, this is 
ridiculous, we want to have unified information, we want to 
have every local community send it up to the State on real 
time, we want it available to the Federal Government on real 
time, just like K-Mart might know what they have in their 
inventory and what they sold in the last 15 minutes? In my 
mind, that's kind of the way I'm thinking, but I'm not sensing 
that's the way the Federal Government's thinking.
    Dr. Fleming. First off, I think--just so that you'll know, 
I have about 20 years experience. Most of that is actually 
working at the State level. I have been at CDC for about 3 
years, and so I have a little bit of history here. And I think 
if you'd asked me this question 20 years ago, I would have said 
you're absolutely right, because I would think that the rate-
limiting step is the fact that people don't want to work with 
each other, and we can do it more quickly if we mandate it.
    That has changed dramatically, particularly in the last 
couple of years, such that there is now essentially uniform 
agreement that what the vision you just articulated is where we 
need to be heading. So the rate-limiting step isn't that people 
don't agree to that, the rate-limiting step is getting there 
through resources and planning and people, as we've talked 
about.
    Mr. Shays. And you said we don't need a law. You said CDC 
has the power to mandate a standard form, standard information. 
Do you have the capability under law to say we want it within 
an hour of your knowing, etc?
    Dr. Fleming. I'm sorry, I may have misunderstood your 
question. When I said we don't need a law, it is not because we 
have the authority to mandate it, but rather because it's my 
perception that it doesn't need to be mandated; that the system 
out there agrees with the vision and is trying to move toward 
it. We don't need the stick in this instance to get people 
where they need to be. They are there on their own. There is so 
much logic to it, and now there's now the information 
technology that enables it to happen, that with more and more 
people working at the State and local level, seeing the need 
for cross-jurisdiction communication and coordination, there is 
essentially uniform agreement out there that this is the way we 
need to go.
    Mr. Shays. If it's not a law requiring it, and someone 
doesn't provide it, then is there any liability?
    Dr. Fleming. Well, first off, in individual States, as you 
know, there are laws that mandate the provision of this 
information, and those are enforced generally through the 
licensure acts so that an agency or a laboratory that does not 
submit required information can be acted upon through their 
licensure. So there is a governmental stick, if you will. I'm 
just saying I don't see the need for a Federal stick.
    Mr. Shays. Let me go through just--you said our 
surveillance--on page 2 of the statement I had--it was 3 on 
another one, so I guess a different copy--but it said our 
surveillance systems generally use paper facsimile reporting by 
health care providers to health--if a case of illness is 
particularly unusual or severe, such as in the case of anthrax 
or rabies, the provider may call the local health department 
immediately. You had the word ``may,'' which I think is 
interesting. Then you say, as mentioned, health care provider 
recognition of the illness and awareness that certain health 
events require immediate notification of public health 
authorities is critical to our ability to detect problems and 
mount a public health response. Such reporting requirements are 
mandated at the State level. But aren't they mandated in 
different ways, different timeframes, etc?
    Dr. Fleming. There is currently some State-to-State 
variability around the specific conditions and the timing. I 
think my experience has been that the right things are 
happening, though, so regardless of whether you say a case of 
anthrax should be reported immediately in one State or within 
an hour in another State, if you look across States, the 
bottom-line message is the same, is that there is a common list 
of conditions for which immediate action is warranted, and then 
another category of diseases for which you can have a little 
bit more time to do the steps.
    I'm not trying to make it sound like it is a perfect world 
out there. What I am saying, though, is that tremendous 
progress has been made such that, at least in my opinion----
    Mr. Shays. You know, I agree with the tremendous progress, 
and I do think that if you can get things to happen voluntary--
and I'm going to just roll my 5 minutes over and start a second 
round of just 5 minutes, if I could. So I'm going to begin the 
second round of questioning.
    I guess this is what I'm wrestling with. I kind of have 
been listening to Representative Bell, and I'm thinking, as 
he's asking these questions, we are safer than we were before 
September 11, but we don't feel as safe because we had a false 
sense of safety before September 11.
    But we've had--you know, SARS is an interesting kind of 
process here that just kind of makes us alert to the fact that 
both of you are dealing with defense against the pathogens that 
may attack us. You know, for the nonscientist, me, the 
nondoctor, me, when I hear there are mutations of SARS, and you 
think, you know, this thing is like an interesting threat to 
say the least, I'm just wondering, what in the world it is 
going to look like in a year or two? Will Mr. Bell or Mr. 
Janklow or Mr. Murphy and I be able to say a year from now when 
there is an outbreak, one--excuse me--if there is an illness in 
one place and an illness in another place and an illness 
somewhere else, and they don't see the severity of it, but if 
you put it all together, we would see it clustered, will we 
know within an hour of that, or will we know 5 days later? And 
if one or two States don't have the same requirements, will it 
be incomplete information? Or are we going to have a good 
system in a year from now?
    That's kind of what I'm asking. And I'd like, Dr. Tornberg, 
even though this isn't your direct responsibility because it's 
CDC, I want you to tell me what you think is going to happen, 
and then I want you, Dr. Fleming, to tell me what you think.
    Dr. Tornberg. I think we are moving clearly in the 
direction that you described. Will that be a year from now? 
Difficult to say. But the recognition time of a syndromic event 
is really somewhat based on the kinetics of the event itself 
and how rapidly it travels. But we clearly are moving in that 
direction and would hopefully have that capability and make 
this a much safer place.
    Mr. Shays. What would be wrong for me to say that we should 
be able to say, all right, we will have it ready in a year, or 
we will have it ready--what is the puzzlement that says that we 
won't? I mean, what--if everybody realizes we should have it, 
why are we talking this way?
    Dr. Tornberg. Well, what we are gaining in part of the 
growth phase--and we are in--with syndromic surveillance 
itself, and that's what we're talking about, we are in the 
toddler stage, if you will, in the development and the 
maturation of the process, and it's clearly a process that has 
to mature from a--data acquisition is part of the problem, but 
a bigger part of the problem is the analysis of the data we 
have, because there's, as we discussed, many disparate sources 
of information, and there can be data overload. The key in the 
challenge is to analyze that data to allow it to be--have a 
meaningful pattern, and subsequently to allow us to----
    Mr. Shays. You're telling me that it is going to be very 
difficult, and it is just not going to be adding numbers. I 
hear you.
    Dr. Tornberg. We can't identify aberrations if we don't 
know our baseline. That's critical for early detection. And we 
are very much right now in the phase of developing our 
baselines and noting exceptions from that.
    Mr. Shays. Well, basically I'm just trying to make--this is 
kind of like telling me we have a learning curve?
    Dr. Tornberg. Yes, sir.
    Mr. Shays. OK. And you're not able to tell me how long that 
learning curve is going to take.
    Dr. Tornberg. I would be hard pressed to give you a year 
timeframe on that, but certainly within several years.
    Mr. Shays. Dr. Fleming.
    Dr. Fleming. In some ways I don't think it is a yes/no 
answer either. We have already around the country a system that 
works and that does identify these events. It does need to be 
improved, but how long that takes depends on what level of 
improvement and what we are trying to get to. A year from now 
our system will be better than the system we currently have 
today, and if we at CDC are doing our job right, 2 years from 
now it'll be better than the system a year from now.
    Mr. Shays. OK. Let me just real quickly, in the 40 seconds 
I have left, have you explain to me what would be a good 
system, a really good system. In other words, is the analogy of 
a K-Mart being able to tell me what's in their inventory, 
what's sold in the last--real time, is that just totally 
unrealistic?
    Dr. Fleming. Absolutely not. Real time is an aspect of 
this. But the true measure of a system is how responsive it is 
not in detecting the event, but in responding to the event and 
putting the actions in place that need to be put there to keep 
people healthy. And so my definition of the perfect system, if 
you will, is a system that is rapid enough such that the 
preventive actions that need to be put in place will happen 
before individuals become sick or die.
    Mr. Shays. Thank you.
    Mr. Bell, do you have any questions you want to ask?
    Mr. Bell. Can we do another round?
    Mr. Shays. Yes, another 5 minutes, and then we're going 
to----
    Mr. Bell. Thank you, Mr. Chairman.
    I'm curious, Dr. Fleming, because in your original 
statement you said that there are reports, or your--I believe 
it was your strong-held belief that there are reports that are 
not completed or acted upon.
    Dr. Fleming. That's correct. The system we have is not yet 
perfect. It works, it's good, but it can be improved.
    Mr. Bell. But let's say someone in Texas sees a case of 
SARS and decides not to, for whatever reason.
    Probably wouldn't be true today, but several--a couple of 
months ago--and chooses not to report that. Then certainly it 
would be your strong desire that they would report it, but if 
they didn't, there's absolutely no law in place to punish that 
individual in any way, shape or form, correct?
    Dr. Fleming. Certainly within the State of Texas, providers 
are licensed and are required by law to report.
    Mr. Bell. To you.
    Dr. Fleming. No, to the State health department.
    Mr. Bell. OK. And so--good. That's helpful. Where is the 
breakdown coming in the reporting mechanism then?
    Dr. Fleming. There are several places. First off, I think 
not everybody that's sick sees a doctor, so there's illnesses 
out there that may never be diagnosed.
    Second, some of the diagnoses that happen are--happen in 
such a way that the provider forgets to report. It is just--you 
know, it's not a willful act, but it just doesn't happen. The 
NEDSS system that we're putting in place, which basically says 
when a provider, clinician or a laboratory, as part of their 
clinical records, indicate they have just diagnosed this case 
of salmonella or E. Coli or whatever it is, they don't have to 
report it to the health department at that point. The computer 
system automatically recognizes it as a condition that requires 
reporting and automatically instantaneously transports it to 
the health department. That's a big part of the fix of the 
system.
    The third part is to make sure that when that report is 
received, that there's somebody at the health department to 
look at it and to investigate it. The bioterrorism resources 
that have been made available go a ways in making that happen.
    Mr. Bell. As the chairman alluded to, what would be--I'm 
just curious. What do you all see as the downside to having 
some sort of law that would mandate reporting to have that in 
place?
    Dr. Fleming. Well, first, I do think that there are 
different diseases that are of greater or lesser importance in 
different parts of the country. And so, for example, some of 
the fungal diseases that are common in the Southwest need to be 
reported there, but because they're not prevalent in other 
parts of the country don't need to be reported there. There is 
need and room for local flexibility. In addition, within the 
confines of a system that's trying to accomplish these agreed-
upon goals, there is some flexibility about the best way to get 
things done. And in one--in all aspects of the government, the 
thing that will work best in one part or one jurisdiction isn't 
necessarily the thing that'll work as well in another. So we 
need to allow, in my opinion, for local flexibility around the 
process so that the agreed-upon outcomes that we're striving 
for can be achieved as best as possible.
    Mr. Bell. And one final question. It would appear, going 
back also to the--if we can get there in 1 year, it would 
appear that would be somewhat impossible. We don't know how 
much--as far as having one unified system, we don't know how 
much that would cost as we sit here today. You said you'll get 
back to us on that. If that price figure comes back, and it's 
obvious with the money that is presently allotted there's no 
way to get there, or do you all plan to advocate for more 
funding to go toward a national surveillance system?
    Dr. Fleming. We will make it clear within the 
administration and to you what can be done for what level of 
resources, recognizing that it's you all's decision where the 
tradeoffs need to come from.
    Let me just make one other comment, if I might. I would 
hate for you to leave thinking that we're talking about only 
one system; there's only one thing that needs to be done. 
Public health surveillance, including infectious disease 
surveillance, is a system of systems. We're talking about one 
today. But clearly the vital records system in this country for 
looking at births and deaths; the systems that we have in place 
for figuring out who's been vaccinated and who isn't, vaccine 
registries; the system that on a real-time basis surveys people 
out there to find out what they know about SARS, etc., are also 
critically important parts of our surveillance. And so we need 
to be thinking about ensuring that the system of systems is as 
robust as possible, not focusing on only one element.
    Mr. Bell. Thank you, Mr. Chairman.
    Mr. Shays. I thank the gentleman.
    Mr. Janklow.
    Mr. Janklow. Thank you, Mr. Chairman.
    Dr. Fleming, I've got several questions. I'm going to try 
to be really quick with them. One, does DOD have a good--in the 
words of the chairman--a truly good system?
    Dr. Fleming. The ESSENCE system has promise. I mean, I 
would say it's in evaluation, so I can't tell you yet.
    Mr. Janklow. How long has it been in evaluation?
    Dr. Tornberg. ESSENCE II has been in operation, I believe, 
for the last 2 years.
    Mr. Janklow. Dr. Fleming, in your testimony you talk about 
several years ago you initiated development of the NEDSS 
System. How long does it take to develop a system? Aren't we 
talking about two things? One, we're talking about software; 
and, two, we're talking about baseline or the data for the 
information you're going to gather on the software and how it 
is going to be utilized, correct?
    Dr. Fleming. That is correct.
    Mr. Janklow. In terms of developing the software, when--how 
long did it take to do that?
    Dr. Fleming. The software development process takes about a 
year to 18 months, but you also need to have the standards, 
agreement on what that software needs to do, and in addition--
--
    Mr. Janklow. Excuse me. I thought you had the standards, 
and you've already told people what they're going to be that 
they have to meet to come out of the system.
    Dr. Fleming. No. Right. But what I'm saying is those needed 
to have been developed, in essence, before software can be 
developed.
    Mr. Janklow. How long have they been out?
    Dr. Fleming. It's an iterative process. We started work on 
it several years ago, and they're still being refined.
    Mr. Janklow. Let me ask if I can, picking up on Mr. Bell's 
question from before, can you tell me what hasn't been done 
because you haven't had enough money? What hasn't been done? 
What's lagging?
    Dr. Fleming. There's two things. One is the capacity on the 
clinical laboratory side, to computerize and send their 
information. So even if a public health department is equipped 
to receive information, that information can't be received if 
it can't be sent on the clinical side.
    Mr. Janklow. Why do you think it can't be sent? What's 
holding that up?
    Dr. Fleming. There's a wide range of systems that are out 
there, and, in fact, some aspects of the health care system 
still aren't computerized.
    Mr. Janklow. Isn't that what we started out talking about 
today? Does that take a mandate to get that done? If we've 
still got some aspects of the health care system that aren't 
computerized, and if there are no mandates in place, how's it 
ever going to get there?
    Dr. Fleming. I was hearing the question about mandates 
relative to a mandate on the public health system from the 
Federal level relative to the State level. There's a separate 
question about the need for electronic medical records and the 
development of clinical standards to create those records. 
That's a bit beyond my domain of expertise, but it is an active 
part of this, active part of this process.
    Mr. Janklow. But, sir, aren't we--what--we're talking about 
a reporting basically, either a diagnosis or a symptom; isn't 
that correct?
    Dr. Fleming. It's actually a bit more complicated, when you 
think about the range of information that is being collected in 
the health care setting.
    Mr. Janklow. I understand. But when we're talking about 
looking at this from a national sense, aren't we really talking 
about, one, diagnoses that have been made, and, two, symptoms 
that would lead one to the conclusion someplace else as you 
gathered this from all over that there may be a problem that we 
need to look into?
    Dr. Fleming. I think you might hear from the clinical 
sector that they would want that system integrated into their 
overall way of doing business so that they did not have to go 
off just for this purpose to enter information. But rather it 
needs to be part of the therapy that's being given and the 
monitoring of the patient.
    Mr. Janklow. Doctor, if you had the money you needed, how 
long would it take to get a system in place?
    Dr. Fleming. Again, there is a working system in place. We 
do have the ability to detect these events. We can make 
substantial progress over the next year to 2 to 3 years, but I 
don't want to make it sound like it is an on/off----
    Mr. Janklow. Are people like me then unnecessarily 
concerned that we don't have a coordinated system in place?
    Dr. Fleming. I think that I've tried to express the level 
of concern we have, which is we see that this is important, and 
substantial progress has been made. The system is working. We 
can make it better. It's not broken, but it can be improved.
    Mr. Janklow. In terms of improving it, are we where we need 
to be in a world that deals with terrorism focused toward us?
    Dr. Fleming. That's the critically important question we 
need to address, as we've been talking about. There are things 
that can and do need to be done to improve our security.
    Mr. Janklow. Is that a yes or a no, sir?
    Dr. Fleming. Ask your question again, please.
    Mr. Janklow. Pardon?
    Dr. Fleming. Ask your question again.
    Mr. Janklow. In terms of the world that we live in where 
terrorism is directed toward us, are we where we need to be?
    Dr. Fleming. No.
    Mr. Janklow. OK. Thank you.
    Mr. Shays. Let me just--before we go to our next panel, 
this is Emerging Infectious Diseases. I think it is a peer 
review journal tracking and analysis disease trends, and it's 
done by the CDC; is that right? In the first article it has 
Planning Against Biological Terrorism: Lessons From Outbreak 
Investigations. Is this an article you're familiar with at all?
    Dr. Fleming. I've not looked at it.
    Mr. Shays. In the first paragraph it says, for six 
outbreaks in which intentional contamination was possible, 
reporting was delayed for up to 26 days. We confirm that the 
most critical component for bioterrorism outbreaks detection 
reporting is the frontline health care professional and the 
local health departments. Bottom line, though, it--you know, 
I'm going to take a better look at this article. Well, actually 
I have to take a look at it. I haven't looked at it other than 
that quote. But you can't respond to that issue of----
    Dr. Fleming. I would also need to review the article to 
respond in detail.
    Mr. Shays. Well, why don't we just submit it for the record 
then.
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    Mr. Shays. You both have been wonderful witnesses, and we 
realize we're also wrestling with this. I think that what I am 
wrestling with is that I see this as the whole package. So when 
you talk about your not being able to talk about the technology 
to present this, you know, rather than its--you know, some of 
these are paper transactions. For me, I don't really--I don't 
like the feeling that I'm getting that we're not--I guess what 
I'm beginning to think is who's in charge? I don't mean that in 
a disparaging way, but who is taking ownership of this? 
Ultimately who takes ownership of making sure that this 
reporting happens quickly, that it's not paper transactions, 
that we're asking for the right things? Who ultimately, in your 
judgment, has that responsibility?
    Dr. Fleming. Well, the short answer is that CDC can and is 
taking a leadership role in this, and if I haven't conveyed 
that clearly, I sincerely apologize. I want you to know that 
our organization is committed to making this happen.
    Mr. Shays. I get a feeling that you're content that a lot 
of progress is being made. And maybe what I'm hearing as well 
is that from a scientific standpoint, you know, we just--we 
study it, we check it, and we just--and so it'll happen when it 
happens. That's kind of the feeling, that we're making 
progress, but that's the kind of feeling I'm getting. From a 
politician and public policy standpoint, I'm thinking should we 
be tasking you to just make sure in a year or two it's done. 
And then you're probably saying, hello. You know, what do you 
mean it's done? So the process begins, you know, continues 
here.
    Any last comment that you'd like to make before--OK. You 
both have been excellent witnesses, and I thank you.
    Excuse me. Let me just say this. Is there anything, Dr. 
Tornberg or Dr. Fleming, that you want to put on the public 
record before we adjourn? A question maybe you had prepared for 
that you think we should have asked, and we just didn't have 
the common sense to ask it?
    Dr. Tornberg. No, sir. I think both my oral and written 
statement cover the areas that we would like to address for the 
committee's attention.
    Mr. Shays. Dr. Fleming.
    Dr. Fleming. No. We will get back to you on the record on 
the issues that we talked about.
    Mr. Shays. OK. And on this article.
    Dr. Fleming. Yes.
    Mr. Shays. OK. Thank you both very much.
    Let me just announce the second panel. I'm going to ask 
three people to come up to be sworn in: Ms. Mary Selecky, Dr. 
Seth L. Foldy, and Ms. Karen Ignagni. And then afterwards I'll 
invite Dr. Julie Hall to sit down at the desk as well. We're 
swearing in three of our four witnesses.
    [Witnesses sworn.]
    Mr. Shays. And at this time we'll also invite Dr. Julie 
Hall, medical officer of the World Health Organization, to join 
us. Evidently we didn't make it clear to the World Health 
Organization we swear our witnesses in, and they have a policy 
as an international agency not to be sworn in. So we'll accept 
the way it is.
    And Ms. Selecky is Secretary, Washington State Department 
of Health, president of the Association of State and 
Territorial Health Officials.
    Dr. Seth L. Foldy--am I saying it right?
    Dr. Foldy. Foldy.
    Mr. Shays. Foldy--commissioner of health, city of 
Milwaukee; Chair, National Association of County and City 
Health Officials, Information Technology Committee.
    And Ms. Karen Ignagni is president and CEO of American 
Association of Health Plans.
    And Dr. Julie Hall, as I said, is medical officer of the 
World Health Organization.
    We'll go in the order that you're sitting. And again, 5 and 
then another 5. Your testimony is very important to us. And I 
think that I would say that if you want to ad lib a bit, and 
given that you sat through this first panel, that you may want 
to jump in and make some points, because I think some of the 
questions we've asked you you're well prepared to answer.
    So we'll start with you, Ms. Selecky.

  STATEMENTS OF MARY C. SELECKY, SECRETARY, WASHINGTON STATE 
 DEPARTMENT OF HEALTH, PRESIDENT, THE ASSOCIATION OF STATE AND 
  TERRITORIAL HEALTH OFFICIALS; SETH L. FOLDY, COMMISSIONER, 
   MEDICAL DIRECTOR, CITY OF MILWAUKEE, HEALTH COMMISSIONER, 
     CHAIR, NATIONAL ASSOCIATION OF COUNTY AND CITY HEALTH 
  OFFICIALS, INFORMATION TECHNOLOGY COMMITTEE; KAREN IGNAGNI, 
 PRESIDENT AND CEO, AMERICAN ASSOCIATION OF HEALTH PLANS; AND 
     JULIE HALL, MEDICAL OFFICER, WORLD HEALTH ORGANIZATION

    Ms. Selecky. Thank you, Mr. Chairman, distinguished----
    Mr. Shays. Is your mic on?
    Ms. Selecky. Thank you, Mr. Chairman and distinguished 
members of the subcommittee. My name is Mary Selecky. I'm the 
Secretary of Health in Washington State, and I'm honored to be 
testifying before you today as president of the Association of 
State and Territorial Health Officials. And also having been a 
local health department director for 20 years and having the 
experience of, on the ground, working local, State and working 
with our Federal colleagues, we certainly can address some of 
the issues that came up earlier.
    I certainly would like to thank the committee for your past 
support of work that goes on with public health, but most 
particularly your attention to the issue. It has not been in 
the recent past that we've had the opportunity to bring public 
health issues before you. This hearing focuses on one of our 
most important, although invisible and forgotten, public health 
tools, and that is public health surveillance. It's not 
something people think about every day. As early as 1878, 
Congress recognized that this is an important issue when it 
authorized the U.S. Marine Hospital Service to collect 
morbidity reports concerning cholera, smallpox, plague and 
yellow fever from U.S. Consuls overseas.
    Now the diseases may have changed, but the issues are very, 
very similar. In 1928, all States, the District of Columbia, 
Hawaii and Puerto Rico were participating in national 
surveillance and reporting on 29 diseases. And in 1950, ASTHO, 
my organization, created its affiliate, the Council of State 
and Territorial Epidemiologists [CSTE], to determine and work 
together, States, local and Federal, to see which diseases 
should be reported to the U.S. Public Health Service. All 
States now voluntarily provide information to the Centers for 
Disease Control and Prevention [CDC] on nationally notifiable 
diseases.
    One of the core functions of State health departments is to 
collect, analyze, interpret and disseminate public health data. 
States do this to identify health problems, determine the 
programs or other responses needed to address the problems, 
specific health concerns, and evaluate the effectiveness of the 
responses. Health departments depend upon the receipt of 
quality public health data to identify and track emerging 
infectious diseases such as already mentioned, SARS and West 
Nile virus. Equally important, although often overlooked, is 
the collection of public health surveillance data that 
identifies the burden and causes of the Nation's leading causes 
of death. That's chronic diseases, heart disease, diabetes, 
injury and risk factors. We may have more attention paid at 
times to communicable disease, but we must do the same with the 
noncommunicable.
    State health departments have a unique role to play in 
public health surveillance. Public health threats do not 
respect political boundaries, be it the local level or the 
State level. Reporting of disease entities, therefore, needs to 
be uniform within any given State in order to work with Federal 
and local colleagues to assure an adequate immediate response 
to public health emergencies. In many parts of the country, 
only the state Health Department has the sophisticated 
laboratory and highly trained laboratorians, epidemiologists 
and other public health professionals needed to tackle the most 
serious public health challenges.
    I had that personal experience. I was in northeast rural 
Washington, Colville, Washington, up in Representative George 
Nethercutt and formerly Speaker Tom Foley's district. We didn't 
have the levels of sophistication that perhaps our colleagues 
in Seattle did, and, in fact, Seattle might be very busy with 
the work going on with their own communicable diseases. Work we 
did from our rural community was dependent on our State 
colleagues helping us and opening the door, if needed, to the 
Federal kinds of resources available.
    In this testimony I'd like to make four points. Since the 
1988 Institute of Medicine's Future of Public Health Report 
recognized the inadequacy of our public health infrastructure 
in general, and public health surveillance in particular, we've 
made great strides, and you have heard some of those. 
Substantial congressional investments in preparedness funding 
have enabled States and local to expand our surveillance 
capacities.
    We must continue our efforts to integrate and coordinate 
public health surveillance systems. You've already heard that.
    While tremendous efforts are focused on developing high-
tech surveillance systems, and technology is critically 
important, a computer without the right software and without a 
trained user is just an expensive paperweight. We must proceed 
with caution and ensure that any new systems are tested by 
local and State health agencies and determined to be usable and 
effective.
    Despite the progress made since the Institute of Medicine 
report, much more needs to be done, and you've already heard 
some of that. We have a number of health professionals, and Dr. 
Fleming already mentioned that, that are due to retire in the 
next 5 years. We must pay attention to our work force.
    To illustrate my points about the importance of public 
health surveillance, I'll give you three quick examples from 
Washington State. SARS, in Washington State today we have 24 
cases; 22 of those are suspected, 2 are probable. That's a 
fairly high number across the United States when you look at 
our map. The systems that we have in place now were dealing 
with rapid identification; using common case definitions; the 
reporting mechanisms we have in place from our local health 
departments, from our clinicians to our local health 
departments, to us at the State and us in real time to the 
Federal Government, so that we all got a handle on this. We've 
been able to use the systems that we have enhanced over our 
State's emergency preparedness efforts.
    West Nile virus. Washington State has not yet been hit with 
a human case occurring in our State. We know the mosquito is 
there. We've had dead birds. We've had dead horses. But for 
West Nile what we're doing right now is we're doing that real-
time educating. We are using Webcast. We're using our 
information systems to enhance what people need to watch for, 
how to diagnose, how to report to our colleagues at the local 
level, and what it is we need to do as a State and work with 
the Federal Government at the Centers for Disease Control and 
Prevention [CDC].
    And one other example is E. Coli O157:H7. Washington State 
unfortunately has a lot of practice. It was Burger King back in 
the early 1990's. It actually was a number of cases in 1985. 
Our public health lab created the 1-day test, what used to take 
5 days, in Washington State. We were working together with the 
scientists at the Centers for Disease Control, because the 
real-time reporting, that happens through PulseNET, through our 
public health laboratory system, and then to capitalize on that 
with the National Electronic Disease Surveillance System really 
means that we deal with this very quickly.
    Last summer we had a multistate outbreak that had to do 
with a meat packer in Colorado. We worked very closely together 
with the systems that are in place to make sure the public is 
protected.
    In closing, I want to reiterate a few points. First, thank 
you to Congress for investments. They hadn't come in the near 
past. The investments have become more real more recently. They 
must be sustained. State and local public health working 
together with our partners at the Federal level need to have 
that investment.
    Second, public health work force issues must be addressed, 
whether it's through our schools of public health, whether it's 
through routine training available using, for example, Webcast 
satellite downlinks or whatever the case is.
    And the third is the continuing effort to coordinate the 
systems. A clinician and a local community is the first place 
where this starts, the local health department connectivity to 
that local clinician and to us at the State and at the Feds.
    Now, there are systems in place, and the reason you don't 
have a one-size-fits-all is the fact that you have had things 
develop; whether it's in Pittsburgh or an area of Texas, we've 
got to have common standards so that we can report commonly.
    Again, thank you for the opportunity to be here, and I'd be 
happy to answer questions when we're done with the panel.
    Mr. Shays. Thank you Ms. Selecky.
    [The prepared statement of Ms. Selecky follows:]
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    Mr. Shays. And Dr. Foldy.
    Dr. Foldy. Yes. Good afternoon, Mr. Chairman, members of 
the subcommittee. I'm Seth Foldy, health commissioner of the 
city of Milwaukee, WI, and I speak today on behalf of the 
National Association of County and City Health Officials, which 
represents the Nation's nearly 3,000 local public health 
agencies. I'm glad to share a local perspective with you 
regarding the urgent need to support and to upgrade America's 
disease surveillance capabilities.
    I share your urgency. I certainly hear it. My remarks will 
be tailored considerably, given the advanced level of 
discussion you've already achieved previously. I believe I 
understand some of the sources of your impatience and some of 
your confusion about how to proceed.
    I would be remiss not to begin by just pointing out that 
the reporting of diseases to public health is but one part of 
the surveillance network and the surveillance resources that 
are greatly needed. Among those, of course, are resources for 
global surveillance, such as WHO has provided. I shudder to 
think what SARS would have been like in the United States 
without the advanced warning, or ``heads up,'' from the World 
Health Organization and the critical importance of the public 
health laboratory in permitting public health to speedily 
confirm what might be an epidemiologic suspicion.
    We have heard it often from Washington out in the hustings; 
we have heard it asked, ``Does the United States have the 
ability to fight two wars simultaneously?'' And perhaps the 
most important--more important--and cogent question is ``Do we 
have the ability to fight two, three or four epidemics 
simultaneously?'' In the last few weeks, severe acute 
respiratory syndrome [SARS], has been added to the plate of 
local health departments not through--who do not have different 
divisions to deal with each of these problems, but it is one 
team typically who are all struggling with smallpox 
vaccination, West Nile Virus, influenza season--on its way out, 
we hope--resurgent HIV and AIDS and sexually transmitted 
infections, and increasing rates of obesity, diabetes and 
asthma.
    It is important for the committee to understand that the 
local health departments are the eyes and ears for surveillance 
of the Nation. They are also the hands and feet for the 
emergency public health response. Without the local public 
health agencies being a true part of the picture, we have a 
giant public health entity without eyes, ears, hands or feet. 
However, the local public health agency is at the bottom of the 
funding chain, often at a low priority for local tax dollars, 
and, very importantly, many are now downsizing during the 
current fiscal crisis. You need to be aware of this.
    Also, because the authority for communicable disease 
reporting really derives in common law from local police powers 
and nuisance enforcement, there is typically no extrinsic 
funding or little extrinsic funding for disease surveillance at 
the local level, the most fundamental process that you are 
speaking about today.
    We thank you very much for soliciting the local public 
health view from NACCHO. The international SARS epidemic has 
clearly underscored the importance of disease surveillance, and 
you can just look at how everyone at USA Today is trying to 
learn how to read an epi curve. It also underscores the 
importance of having integrated and flexible disease 
surveillance, and it points out weaknesses of our current 
system and opportunities for improvement.
    In terms of integration, Milwaukee began enhancing disease 
surveillance systems long before we were worried about 
bioterrorism. It really dates back to a massive outbreak of a 
common but then little known bug called Cryptosporidium. This 
waterborne outbreak sickened more than 400,000 people suddenly 
in our city. We had little idea that an outbreak was taking 
place. Traditional surveillance systems would not report a 
disease that was not mandated for legal reporting. Similarly, a 
spate of deaths during the 1995 heat outbreak makes it clear 
that it was also under the radar of health surveillance 
systems.
    This makes it clear that health surveillance can't be 
designed for one problem in isolation of others, and in 
particular, that very finely defined health surveillance 
systems that might be applicable for the agents we think are 
going to be responsible for a bioterrorism attack will really 
not serve us well. We need integrated systems that bring 
together information of various types, various diseases that 
are integrated in the public health world and not set up as 
some separate entity, some separate department of government.
    In terms of flexibility, you're going to hear in my 
presentation that ideas and innovations are bubbling up as well 
as down, and the creation of very highly standardized systems 
is important. What we really hope to achieve, I think, in our 
Nation today are standardized methods of coding information and 
standardized ways of transmitting information that--such that 
the information can talk to itself, and agencies and 
information systems can talk to each other in such a way that 
it actually encourages innovation.
    What is important is if you were, for example, to ask the 
Federal Government to mandate that all health care providers 
begin to report certain information immediately up at the 
Federal level, and that all local health providers and State 
departments do the same, the easiest way to do that is to 
create a single Web-based entry system where we all spend all 
of our time filling in the blanks on the instrument that has 
been provided from above. But what that denies us the 
opportunity to do is to create flexible instruments we carry 
into the field that, because of standard transmission of health 
care information, can then up link to the Federal system.
    That is a decision, an important decision, that has to be 
made, and yet I agree with you. We cannot dilly dally too long 
in seeking the right balance between mandates and innovation. 
The weakness of the traditional reporting systems have been 
pointed out, although they remain absolutely crucial. They are 
slow. They often give us incomplete information. They rely on 
paper forms that often sit around in piles, which should 
surprise no one. Furthermore, it is increasingly being 
pressured by the fact that a laboratory specimen obtained in 
Milwaukee may well be analyzed in Atlanta or in Santa Cruz, and 
that information somehow has to find its way back to the 
doctor's office and subsequently to the local public health 
authority.
    I agree very much with Dr. Fleming's catalog of 
improvements in the traditional reporting system: educating the 
providers, improving our laboratory infrastructure, creating a 
24/7 response. But, in addition to this, I think the real low-
hanging fruit for the traditional disease surveillance system 
is electronic laboratory reporting.
    There are huge numbers of laboratories out there. If each 
of their laboratory information systems could report data in a 
standardized fashion so that it would find its way to and 
through the different health information systems that come 
between them and the local public health authority, this 
information could reach quickly, be routed to us, could 
automatically alert us, could be stored, displayed, analyzed, 
and tracked, greatly reducing the work of local public health.
    My colleague, Rex Archer in Kansas City, has established 
such electronic lab reporting with a large number of 
laboratories in Kansas City and has demonstrated increased 
timeliness of reporting, increased completeness of reporting, 
reduced time wasted. However, as with all surveillance and 
public health, we know that it also gives us more complete 
reporting. He is chasing a lot more disease than he ever knew 
about before, and that has its real implications.
    The real point here is that the standardization of 
electronic health information is really a critical step. HIPAA 
really created a basement, a foundation for doing this by 
creating accountability, about confidentiality, security, and 
mandating certain standardization; and we really need to let 
this take root.
    The second topic that has been discussed is enhanced or 
syndromic surveillance. We know that we can look at a lot of 
different patterns of illness such as symptoms in emergency 
departments, pharmacy dispensing, test orders. It is very 
important to recognize that this is a young science, easily 
oversold, hard to prove how well it works. However, it is very 
important that we begin to explore these capabilities. This 
will require again standardized health information, information 
that can flow electronically so that we are not adding 
constantly to the workload of busy health care providers.
    In addition, it requires connectedness; and I will tell you 
a brief story from Milwaukee. On their own initiative, because 
they needed it for their own reasons, all of the local 
emergency departments established a secure, live Internet site 
that told them when different emergency rooms were on divert 
status. When we learned about that this resource was in each of 
our emergency rooms, we politely asked access to the system and 
have used it since to post alerts to the emergency medicine 
community. My pager goes off when more than three emergency 
rooms at a time go on ambulance divert. I can draw down 
statistics to see why emergency rooms are going on diversion 
and what the temporal pattern is.
    And, most recently, we have solicited the emergency rooms 
to provide us with daily updates of certain types of diseases, 
not on an ongoing basis, because they don't have the labor to 
do this continuously, but on an as-needed emergency basis. We 
performed such surveillance for bioterrorism-like syndromes 
during the All-Star game last summer. But beginning with the 
SARS epidemic, given this experience, we were able within 3 
days to have 13 emer-
gency rooms in our community both screening their patients 
routinely for possible SARS-related symptoms and then providing 
us with daily counts of what they were seeing.
    Mr. Shays. Thank you, Dr. Foldy.
    [The prepared statement of Dr. Foldy follows:]
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    Mr. Shays. Dr. Hall.
    Dr. Hall. I am Dr. Julie Hall.
    Mr. Shays. I am going to have you move it a little closer.
    Dr. Hall. OK.
    I am Dr. Julie Hall. I am a medical officer with the World 
Health Organization. I work in the headquarters in Geneva where 
I work as part of the Global Outbreak and Alert Response Team 
and have helped to coordinate the international response to 
SARS.
    Mr. Chairman, Congressman Bell and members of the 
subcommittee, on behalf of the World Health Organization and 
Dr. David Heymann, Executive Director for Communicable 
Diseases, thank you very much for the opportunity to brief you 
today on improving surveillance for infectious diseases at the 
global level and to brief you on the lessons that we are 
learning particularly with regards to SARS. Dr. David Heymann 
asked me to convey his regrets for not being able to be here in 
person today.
    I have submitted a written statement for use by the 
committee. At the back of that written statement there is 
several charts that I will refer to during my verbal testimony.
    As has already been mentioned before, the threat of 
infectious diseases, of emerging and reemerging diseases is an 
ever present threat. And the first slide at the back of the 
written testimony shows a map of the world and a number of the 
infectious diseases that have emerged or reemerged in the past 
5 years. It doesn't, as you will note, show SARS on there.
    The threats of infectious diseases is indeed an issue of 
security. Infectious diseases have the potential to damage not 
just the health of the population but to cause social 
disruption, particularly when frontline staff or health care 
facilities are affected, as is the case with SARS, and also to 
cause economic damage, again something clearly evidenced with 
SARS.
    Our traditional defenses against infectious diseases cannot 
always be relied upon. National borders do not protect against 
the emergence of diseases. And the second slide at the back 
there will show very graphically how quickly, within days, SARS 
had spread from one hotel in Hong Kong to over eight different 
countries around the world.
    Anti-microbial drugs, one of our previous defenses against 
infectious diseases, are becoming increasingly ineffective as 
antibiotic resistance increases; and scientific advancements in 
the development and productions of vaccines cannot always keep 
up with the pace of change for infectious disease. So the 
emergence of an infectious disease in one part of the world is 
a threat to the entire world; and our key defense is early 
detection, early dissemination of that information, and early 
implementation of the protective measures that are required to 
stop the spread of disease.
    The aim of global surveillance then is to provide the world 
with a window of opportunity early in the course of the disease 
when it is possible to potentially control and eliminate that 
disease.
    Surveillance at the global level allows the compilation of 
data from different sources. This is particularly important 
when looking at the emergence of a new disease, because quite 
often it is a jigsaw puzzle. Piece A may come from one country, 
piece B in terms of information may come from another. 
Surveying the world and having surveillance at the global level 
allows these pieces to be put together, and in the case of SARS 
this was absolutely crucial. We knew with SARS that there was 
ongoing problems in Guangdong. This was in early February. We 
knew also that there were problems with H-5 influenza in Hong 
Kong. So when one single case occurred in Vietnam, we were 
alert to a potential problem of pandemic proportions.
    Surveillance at the global level also allows us to put out 
the early warnings that have been so effective in terms of 
controlling SARS, and it allows us to get a global picture to 
assess the need for further action, whether that be at global 
level in terms of producing travel advisories or at local level 
to provide international support to countries that are affected 
by the disease.
    How does global surveillance work? Well, it works in much 
the same way that you have heard how surveillance works at 
local level, at State level, and at national level. There are 
four key components: the gathering of information, the 
verification of that information, further assessment of that 
information, and then a response is mounted. And it is key that 
surveillance should not be seen as separate from response. The 
two things are interlinked and critically important.
    In terms of global surveillance, we have a number of 
systems in place at WHO to collect the information. The first 
and about a third of our information comes from the WHO system 
itself. WHO has a headquarters in Geneva. It also has six 
regional offices and 141 country offices, and this provides a 
great deal of information about the emergence and reemergence 
of diseases of potential international harm.
    In addition to that, Health Canada runs the global public 
health information network that constantly scans nearly 1,000 
media feeds and electronic discussion groups to look for hints 
of the emergence of diseases; and this gives us real-time and 
very accurate information of what is going on all around the 
world.
    Another key source of information for us is through the 
Global Outbreak Alert and Response Network. This is a network 
of over 150 different organizations from around the world--
laboratories, epidemiology groups, other health institutions; 
and, again, this can provide key early information.
    However, much of the information that's received at WHO 
comes in the form of rumor, and this must be verified. WHO is 
in a good position to be able to do this with its 141 country 
offices and regional offices who work quickly with local health 
authorities to verify information that has been provided to us. 
This can allow rapid confirmation that an outbreak is occurring 
and the ability to share information, but it can also provide 
rapid ability to refute information and clarify the situation, 
and that can ensure that panic does not ensue unnecessarily and 
economic damage does not occur. On a daily basis, the 
information that is received by WHO is assessed in terms of its 
risk for international health concern; and additional 
information such as geographical, political, and other social 
information is included as part of that process.
    Responses can be mounted very rapidly by WHO, and within 24 
hours we are able to get field teams into virtually any country 
around the world. We are also able to disseminate the 
information very quickly through our cascade of country 
offices, through the production of information on our web, and 
other sources of information. If assistance is required by any 
country, any member state of WHO, this can be coordinated by 
WHO and with its headquarters and assisted by regional offices 
and the country offices itself.
    Expertise and field teams can be quickly organized, as I 
mentioned before, by calling upon our partners within the 
Global Outbreak Alert and Response Network of who CDC is a key 
player. WHO's neutrality and ability to get laissez-passer 
status to any member of our international team means that we 
have privileged access to 192 countries around the world.
    The fourth slide at the back of my written presentation 
gives an overview of the extent to which WHO and the activities 
at WHO has been coordinating in response to SARS. This included 
not just operational support in terms of field teams in Hong 
Kong, Vietnam, Singapore, Beijing, and now to be in Taiwan as 
well, the production of supplies and the creation of logistic 
bases in Vietnam, Thailand, Manila, and rapid response 
capabilities in Geneva, but it is also being--a considerable 
amount of energy and effort has gone into international 
collaboration, laboratory collaboration. Twelve laboratories 
around the world have collaborated to identify the virus in 
record time, clinical collaboration to share information, 
epidemiological and environmental collaboration as well. WHO 
has produced recommendations for the control of the disease, 
management of the patients, and prevention of international 
spread.
    However, there are areas for development, and these fall 
into two areas. Developments are needed in terms of capacity 
and developments in terms of commitment.
    In terms of capacity, global surveillance will only be as 
good as the national surveillance systems that it depends upon; 
and, as you can see in the final slide that's attached to the 
written statement, in terms of FluNet and other surveillance 
systems, there are clear holes in many countries around the 
world that need to be supported and developed if we are to have 
a truly global system.
    We also need commitment to global reporting, transparency, 
and commitment to global collaboration, for these are the key 
things that will defend us against infectious diseases. The 
true cost of SARS will be if we don't learn the lessons of 
SARS; and the true benefits that we have seen from SARS and the 
lessons that we have learned are that rapid detection, rapid 
implementation of protective measurements and also multilateral 
global collaboration can protect us from infectious diseases.
    Mr. Shays. Thank you very much.
    [The prepared statement of Dr. Hall follows:]
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    Mr. Shays. I'm just going to say to our last witness that 
sometimes when I have discussions with my staff I am right and 
sometimes they are right. They think they are right more often. 
You can be a really major player here. I say I pronounce your 
name Ignagni, and one of my staff says it's Ignagni. Who is 
right?
    Ms. Ignagni. Well, the Italian is Ignagni. So----
    Mr. Shays. Neither of us are.
    Ms. Ignagni. The Anglicized version is Ignagni. Thank you, 
sir.
    Mr. Shays. Thank you.
    Ms. Ignagni. Mr. Chairman, thank you for the opportunity to 
testify. I want to commend you and the members of the 
subcommittee for taking this leadership. It is my pleasure and 
honor to be part of these distinguished panels, and I hope we 
might make some contribution to the endeavor of improving our 
Nation's homeland readiness. As you will see, our members have 
unique capacities to contribute to this readiness effort, and I 
am pleased to have the opportunity today to discuss those 
capabilities.
    What distinguishes us in the health plan arena, 
irrespective of plan model, insurance type, or what have you, 
are four characteristics: First, we are providing coverage to 
defined populations, and the meaning of that is that we can get 
a sense of statistical significance of symptoms and what they 
mean as a percentage of a particular universe.
    Second, we have real-time de-identified data that we are 
reporting into a system. I make that point because, in response 
to Mr. Murphy's question earlier about HIPPA and patient 
confidentiality, we have taken steps in our program to make 
sure that we are fully compliant with HIPPA; and I will 
describe that more fully in a moment.
    Third, we have case managers collecting information from 
patients that are going into the system.
    And, finally, we have rapid-response outbound calling 
technology, so, to the extent messages need to get quickly to 
patients, we have the ability to do that.
    What we are testing in our program, which is described 
fully in our testimony, is whether or not we can leverage these 
capabilities to strengthen the public health surveillance 
systems, which has generally depended upon passive collection 
of data. What you have been talking about throughout the 
afternoon is in fact collecting data once individuals go to 
emergency rooms, once they go to the hospitals, once public 
health gets ahold of those individuals in terms of collecting 
that information. There is often a gap between the time 
individuals have symptoms and the time they actually seek 
treatment. So we are trying to see whether or not we can 
contribute to the transition to real-time data collection.
    After the tragedy of September 11, our members began an 
intense process of discussing how we could contribute to the 
effort to improve homeland readiness. We realized these unique 
capabilities could lead us to making a substantial 
contribution. We spent a great deal of time collaborating among 
our medical directors who are on the ground providing health 
care services to large numbers of people throughout the country 
and collaborated with the CDC, with ASO, with the county 
organizations; and indeed, we put together a very large 
advisory committee, including with international 
representatives, to make sure that the design of this 
particular proposal is rigorous and effective.
    What we began with is a process that draws data from plans 
covering more than 20 million people in 50 States. Since we 
have begun, and we are only months into it now, several health 
plans in Texas have been added to the system, and we are in 
major discussions with national plans all around the country. 
But I wanted you to get a sense of where we start in terms of a 
baseline.
    Here is how it works. There are five steps. First, there is 
a criteria established; and I am pleased to tell you, in light 
of the discussion earlier, that we are in compliance with the 
NEDSS system, the CDC system. So that's the first thing. You 
know what you are looking for.
    Second, each night a computer program at the participating 
plans captures clinical encounters for the preceding 24 hours, 
and it meets those specific criteria. These aggregate--and I 
want to stress--de-identified data are reported to a research 
center at Harvard University. The research center has a program 
that contains specific thresholds for notifying public health 
of particular occurrences. Now, obviously, I'm oversimplifying 
in an effort to make this as clear as possible, but there are 
decision rules in this program that flag certain collections of 
symptoms.
    Fourth, an epidemiologist will then analyze any spikes in 
information to make sure that the computer program has worked 
as expected, that we are not overly sampling particular 
clusters of symptoms, etc.; and the epidemiologist then will 
coordinate the reporting of a specific disease or illness in 
geographic areas, the manifestation of those, to the 
appropriate public health agencies and departments. For 
example, if the epidemiologist gleans that there are five 
individuals in a particular geographic area with pneumonia, 
that might be in compliance with the threshold and that might 
indicate that is something that needs to be reported. So that 
would be basically the way the system works.
    The public health departments then, my colleagues on the 
panel, in receiving this information would make a decision as 
to whether or not that would engender further investigation. Do 
they need to have more information about particular patients 
and the symptoms that are occurring in particular geographic 
areas?
    The system has several important features, as you can see. 
Specific populations are being measured. It is done in real-
time. The system can be modified to capture new symptoms. So 
it's very interactive, if you will, to the extent that--to the 
extent when SARS became something that was not anticipated when 
we designed the system, we are now in discussions with CDC in 
terms of moderating the system and modifying it so we can 
capture those symptoms as well. The data are already being 
collected, so we don't have to actually go out and collect new 
data.
    And then, finally, I do want to stress, because of the 
emphasis in the questioning earlier, that we are in full 
compliance with HIPPA confidentiality rules.
    Health plans have for a number of years been at the 
forefront of population-based care, and what we are trying to 
do is to take a leadership role in constructing a system that 
can be expanded, and we hope that we can make a significant 
contribution to our homeland readiness. We have a lot to learn. 
We think that we can contribute something important, something 
unique, and we are going to be working very, very closely in 
our advisory committee with representatives from the 
organizations who are represented very well on this panel to 
make sure that the design is adequate and we are doing what we 
need to do to make sure that we can add a new contribution to 
the important efforts that were already described this 
afternoon.
    Thank you, Mr. Chairman.
    Mr. Shays. Thank you.
    [The prepared statement of Ms. Ignagni follows:]
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    Mr. Shays. Before asking Mr. Janklow to begin his 
questioning, I am just going to make an observation. I made the 
analogy of Kmart, and my counsel said the challenge is--I'm not 
sure I'm doing it justice. But it's if Kmart had to get a lot 
of mom and pop operations into their network, they might not be 
able to do it in real-time. And I thought that is very 
intuitive, I think.
    One of the things that I'm noticing with health care is 
that--I use the word stepchild as if stepchild is a bad thing, 
but not always getting the attention that it deserves. We did 
one major tabletop experience in Bridgeport, and the fire, the 
police, they all--there were weaknesses in the connection, but 
our local health care providers were really caught without 
communications, without resources, and so on.
    So maybe what I'm hearing from the panelists are, my gosh, 
this is where we were and this is where we are, so we have made 
such great progress. But I think, in terms of the consequence, 
if there was an induced terrorist activity planned, located in 
certain ways, that we wouldn't be happy with the results. So 
that's kind of where I'm--I'm kind of wrestling with this, 
because I feel like there is almost a sense of contentment on 
the part of our panelists because we have made a lot of 
progress.
    Mr. Bell. Mr. Chairman, Kmart also went bankrupt. So I 
don't know if that's really one that we want to be using.
    Mr. Shays. That was another one, but then my staff spared 
me that analogy since I was the one who brought it up. And I 
will just say, Ms. Ignagni, I gave you the opportunity to be 
right with the chairman, and you declined.
    Ms. Ignagni. But, sir, you swore me in.
    Mr. Shays. That's true, I did. What a good answer.
    You have the floor.
    Mr. Janklow. Mr. Chairman, thank you very much.
    You know, I've--the hearing today, Homeland Security: 
Improving Public Health Surveillance, you know, and I recognize 
that public health surveillance, adequately done, truly 
contributes to homeland security. But I want to focus my 
questions, if I can, to the war on terrorism, you know; and I 
realize that, with respect to West Nile and SARS and hepatitis 
and measles and mumps and rubella and polio and I mean all 
kinds of other reporting things, the system works pretty good.
    When I say pretty good, I am making that with a small P and 
a small G, because, Dr. Foldy, I couldn't agree more with you: 
Because we are a Nation of 1,700 different sovereigns all the 
time, nobody is going to tell me what to do. So we have 
thousands of people that feel that way, and so that's why some 
are in paperwork and some aren't even reporting, and I think 
it's far worse than some of our colleagues at CDC think it is.
    But I'm going to focus on homeland security, if I can. 
World War II from start to finish for us took 3\1/2\ years. How 
many years is it going to take for us to design a reporting 
system that will catch deliberate acts of terrorism? Because if 
the good Lord doesn't or nature spreads diseases around, 
there's a pattern that WHO, that the whole world can figure out 
rather quickly. It's when human beings are deliberately helping 
the process move that we have never really been tested, ever, 
as to whether or not we have the ability to deal with it.
    Doctor, let me ask you first. If 1993 were replicated in 
Milwaukee, you would be on top of it in literally minutes if 
not hours, if not minutes. Isn't that correct?
    Dr. Foldy. That's correct.
    Mr. Janklow. And I have to believe throughout this country 
there are processes all over. What does it take to get them 
together to come up with a system? And you are next, Ms. 
Selecky.
    Dr. Foldy. I have little doubt that a deliberate act of 
bioterrorism would be detected within days. We've done things 
like make sure doctors know what they are looking for, make 
sure labs can do----
    Mr. Janklow. But I'm talking about process, sir.
    Dr. Foldy. But what we want to do is shorten that window to 
hours----
    Mr. Janklow. Can it be done without mandating it in some 
form? And I don't know if States do it or counties do it, the 
Federal Government does it. But isn't it possible to really get 
from here to there in a--recognizing a world war, is it 
possible to get from here to there during the war without 
mandating something?
    Dr. Foldy. I'm sure there will be mandates. I would add to 
those mandates, helping the health care sector move from paper 
and pencil to electronic----
    Mr. Janklow. Isn't that the most important thing?
    Dr. Foldy. The latter? Yes.
    Mr. Janklow. Yes, sir.
    Do you agree with that, Ms. Selecky, that the most 
important single criteria is how do we get from paper to 
electronics?
    Ms. Selecky. I would add a criteria that has to do with the 
knowledge base of the people who are using----
    Mr. Janklow. I agree with that. I understand getting the 
right people and training them. I appreciate that. But is 
that--is there anything--let me put it this way. Is there 
anything more important than the ability to get it from paper 
to electronics?
    Ms. Selecky. When we think about the health care system in 
this State, in this Nation, you look at relying on a local 
clinician, whether they are in a community clinic or a private 
office, to get the word to a local health department. And----
    Mr. Janklow. And that's under the normal system, the way 
nature spread diseases.
    Ms. Selecky. Well, even under a bioterrorism event. 
Actually, the city of Seattle and the city of Chicago this next 
week will be participating in TopOff2, the top officials 
exercise. I just spent my morning with the Federal Cabinet in 
preparation for the work that will go on. In Washington State 
it will be a radiological----
    Mr. Janklow. Can I interrupt you for 1 second? You are 
getting prepared for that tabletop. When they hit you with 
terrorism, you're not going to have--you're not knowing it's 
coming, what day, what hour, and what teams to assemble.
    Ms. Selecky. No disagreement. And these aren't tabletops. 
We actually are doing exercising. And you are right, we do have 
information ahead of time. The point is, where are the flaws in 
the system or the weaknesses.
    Mr. Janklow. OK.
    Ms. Selecky. The learning from this is what's essential in 
that whether----
    Mr. Janklow. Will that be shared with people all over the 
country?
    Ms. Selecky. Yes, the results of that will be. Yes.
    Mr. Janklow. OK.
    Ms. Selecky. In terms of the communicable disease, for 
example, that will be used in the Chicago venue--and it will be 
pneumonic plague--it's a matter of what systems are in place, 
are people reporting electronically now? No, not everywhere; 
and it will be as important in a rural area as it will be in an 
urban area.
    Mr. Janklow. Excuse me for a second.
    Ma'am, you look shocked. You are sitting there looking at 
me shocked. Is there a reason? Ms. Ignagni.
    Ms. Ignagni. Well, I didn't mean to interrupt. But you did 
read me correctly. And it's not shock. It's I think that there 
is something in addition to the electronic issue. But I would 
be happy to wait until our colleagues finish answering their 
question. But you registered my being perplexed as I was 
thinking about your question. I think there is something that 
we have been missing all afternoon, frankly. But I don't want 
to be rude and interrupt your----
    Ms. Selecky. No. If you've got it, go for it.
    Ms. Ignagni. Well, no. I don't know if I have it. I 
wouldn't want to be presumptuous. I'm the only one on the panel 
that isn't a physician. But in my humble opinion, in looking at 
the reports by the Institutes of Medicine, the General 
Accounting Office, the World Health Organization reports, where 
we are going wrong in our country in terms of bioterrorism 
readiness is that for too long we have thought of the health 
care system as what happens in the hospital.
    Now that's a very important part of the health care system, 
but I can tell you that what we did--and we're just beginning 
our demonstration program. But we did a dry run in 
Massachusetts, and what we found is that people were reporting 
symptoms into our system a full 2 weeks before people ended up 
in the hospital. So, sir, when you asked the question is there 
something more important than electronic, I was sort of shaking 
my head and intuitively going through all this information. And 
I didn't want to sound presumptuous in sharing with the 
committee the idea that I do think the comments that have been 
made, particularly by the GAO about their reliance on passive 
reporting, is something that we really have to get our hands on 
and we have to figure out how do we go to real-time. It's not 
just about electronic, though.
    Mr. Janklow. If I could ask that the three of you from 
American organizations, and just whoever wants to answer first 
or only--be the only one, what do we need to do to fix this? If 
your children's lives depend on it, your neighbors' lives depen 
on it, is this a congressional fix? Is it a Presidential fix? 
It is a health community fix?
    I've heard people say that lawyers and judges can't fix 
what's wrong with the legal system, and that doctors and 
hospitals can't fix what's wrong with the medical system. It 
takes outsiders who have a different perspective, who are 
really not the producers but the consumers that contribute.
    Let me ask you. What does it take to fix this? Because we 
are all frustrated.
    Dr. Foldy. Well, until the information can flow rapidly, we 
are missing an essential part of the fix. Ms. Ignagni brings 
this up.
    The next point, which is do we really know--there is a lot 
of science that needs to be done and needs to be done ideally--
--
    Mr. Janklow. You said--I think your quote was, young 
science easily oversold.
    Dr. Foldy. So, for example, she raises one of many very 
interesting and answerable questions: What part of the health 
system or other human behavior----
    Mr. Janklow. OK. But, sir, how do we get there?
    Dr. Foldy [continuing]. Serves as an early detector.
    Mr. Janklow. We are in the third year of the war. How do we 
get there? How do we wind this up?
    Dr. Foldy. I would like to see a lot of the best people in 
Federal agencies, including the different agencies within the 
Centers for Disease Control, be given an office and some money 
and some contact with the best people in informatics, 
intelligence, Defense Department, even financial systems. I 
mean, I can draw cash out in Taiwan, but I can't see 
surveillance figures in my own den. And there is a lot that can 
be learned quickly if people can be brought together, apply 
sustained attention to the problem over the next few years, 
while having--starting to get the electronics information 
that----
    Mr. Janklow. If I could ask you, sir, if you would just 
submit to the committee a list of who you think ought to be at 
that table by organization.
    Dr. Foldy. My local perspective, and therefore very 
imperfect perspective.
    Mr. Janklow. Sure.
    Dr. Foldy. Yes.
    Mr. Janklow. Ours is perfect, sir. Yours isn't. No, we 
understand that. In the most base sense, we all understand 
that.
    But if you would, because you can tell by our questions, 
all of us, we don't know what to do, but we don't think what's 
being done necessarily is working. If someone is going to 
attack us tomorrow, are we ready? The answer is, no, we are not 
if they are going to be spread around--if they were to spread 
this around. We have seen what hoof and mouth disease can do to 
Europe, to the livestock industry. I can't believe that 
something wouldn't be akin to human beings if they had the same 
type of disease for people. I know they do have that one, but 
I'm not talking about Banks disease.
    Thank you, Mr. Chairman.
    Mr. Shays. I would just point out, though, that's one form 
of terrorism; and that's not just the attacks on human beings 
but the attacks on livestock could be devastating.
    Mr. Bell, you have the floor.
    Mr. Bell. Thank you very much, Mr. Chairman.
    First of all, Dr. Shelley Hearne could not be here to 
testify today,
and I would ask unanimous consent for her written testimony to 
be submitted for the record.
    Mr. Shays. Without objection. And she is with----
    Mr. Bell. Trust for America's Health.
    Mr. Shays. Thank you.
    [The prepared statement of Dr. Hearne follows:]
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    Mr. Bell. I want to go back for just a minute to this idea 
that was discussed with the previous panel of trying to create 
one unified system for reporting; and you all, I think, were 
all present during that testimony. I'm curious as to where you 
would rate the importance and if you are as troubled as I am by 
the fact that we at the present time don't know how much it 
would cost and really don't have any time line for getting 
there, and the amount of money being committed toward spending 
on that type of surveillance system is decreasing rather than 
increasing. And I will begin with you, Ms. Selecky.
    Ms. Selecky. As the other nonphysician on the panel and a 
person of great practicality, as many of us are, the issue is 
that we really don't have sort of a uniform system like you 
would call a Kmart, regardless of whether they went bankrupt or 
not. There are multiple plans, they're private and public, and 
having a one system fits all doesn't cut it in this country 
very often. That's why I think that you hear us talking about 
common standards so that the information that's collected can 
speak and give us the information that we need to take quick 
and rapid action. That's one.
    Two, I think that your colleague who was here earlier 
talked about a reporting system in southwestern Pennsylvania 
that's been under development, that works there, works under 
the State laws of the State of Pennsylvania, is a good model 
for many of us to look at as to whether it would work in 
Washington State or in other States, and learn the best things 
from it, as long as we all have the common format of reporting 
in a way to get the information again real.
    In Washington State, we still have very rural parts of the 
State that don't have Internet or electronic reliable 
capability, so that we do have to have redundant systems. And 
you would falsely rely on the ability for everybody to have 
access to T-1 lines, etc. We are not the only State like that. 
There are other rural States like that, also. Cell phones don't 
work in many places. Fax machines usually can be relied on. The 
Internet goes down when that backhoe digs up the one line to 
Ferry County or whatever the case is. So we have got to make 
sure that we continue to work on what the reality is.
    The reality is, are people informed at the closest level to 
where a client shows up with a symptom, be it at a doc's 
office, a clinic, or an ER--is that person informed to get that 
information to the folks who need to have it at the local 
level, as they see increasing activity get the information to 
the State level and we work together with the Feds? We would 
all like to have it done in that real-time, rapid way that 
allows us to rely on the electronics. But having experienced 
the earthquake in Washington State, we could not then rely on 
the electronics. We did have to rely on the person-to-person 
reporting. You've always got to have both of those things in 
place.
    So by virtue of the fact of making sure that what's in 
place now works, that you parallel, then grow it up, the infant 
system Seth talks about that needs to be developed across the 
Nation with common standards, that would be my goal.
    Mr. Bell. Dr. Foldy.
    Dr. Foldy. I think this was well summed up. I do 
sometimes--and I'm not a software engineer--but I do sometimes 
look at the way the Internet was able to develop. Nobody could 
figure out ever to design something that is like the Internet, 
but once people learned that they were going to--that they had 
the benefit of communicating through a few very simple 
standards so that it didn't matter what kind of computer you 
were on or what kind of browser you were using or anything 
else, the kind of capabilities that developed out of that were 
very great. So I have some hope for that.
    I do think that Ms. Selecky's points are very well taken 
about not overestimating the capability of the people in the 
field at either the State or the local level. I hasten to 
remind the committee that, prior to Congress creating specific 
health alert network funding that was earmarked to local health 
departments, the majority of health departments had no Internet 
connections in this country. We do have a severe backlog of 
information infrastructure and people development, bringing 
them along both in terms of skills, technical, epidemiological, 
and laboratory in our local health departments. It is not 
impossible--it is impossible to overlook that deficiency, 
because there is no State or national organization that has the 
people to fill in where local health departments need to play 
their role. So you are looking also at strengthening the 
infrastructure at the local level so that a lot of information 
isn't simply released that results in an inadequate response.
    Mr. Bell. Dr. Hall.
    Dr. Hall. I think the most important thing, as I said 
before, is about commitment and also about capacity. I think 
that the most important take-home message really is that a 
disease occurring anywhere in the world within hours can affect 
any other country around the world. And when we have a map that 
looks like this, the very back of the written statement, where 
we have great big holes in terms of surveillance around the 
world, then nowhere in the world, no matter how good their 
national reporting and surveillance system is, is going to be 
safe from the threat of infectious diseases.
    So I think it's about investing in capacity, both in the 
countries that already have some in terms of improving the 
capacity they have but key to it is investing in capacity in 
areas where there simply is nothing, where we would not be able 
to--it would take a very long time before we detected that a 
problem was emerging in that area. And it's about investing in 
the commitment to that and investing in the commitments of 
transparency in terms of reporting from all those countries and 
constantly building up capacity so that all around the world we 
at least have a basic minimum level so that we can find out 
exactly what's happening.
    Mr. Bell. And Ms. Ignagni.
    Ms. Ignagni. Thank you, Mr. Bell. We crossed this bridge as 
we were developing our demonstration program, and we would not 
have developed it without a consensus on what was being 
measured, how we were going to measure, and how we were going 
to retrieve data. It simply wouldn't provide anything that was 
useful. And that's caused me to listen to my colleagues, and I 
think the comments have been very, very thoughtful, and I 
largely agree with them.
    I do think, however, there is an opportunity to achieve 
uniformity in a productive way here without necessarily killing 
the innovation and the public health kinds of activities. You'd 
want to be nimble at the local level, and I think that's--if I 
could draw out what I heard--while at the same time having some 
consistency across different systems and States to measure, 
because we know that there are no geographic boundaries for 
infectious disease.
    Our community has committed to transparency. We are the 
only stakeholders in the health care arena measuring anything, 
which may surprise you in light of 5, 6 years of discussions 
about so-called patient protection. We are not measuring in any 
other areas. So for us, perhaps we crossed this bridge a long 
time ago, and we have consensus in our community about 
measuring. But I do think it's important now to think about 
drawing that out across the delivery system and particularly in 
this area.
    Mr. Bell. Ms. Selecky and Dr. Foldy, a number of national 
associations and organizations, one being the American Public 
Health Laboratory Association, have found that financing for 
many State health laboratories would be reduced this year and 
that few cities had enough hospital space to quarantine 
patients in the event of a large-scale outbreak of an 
infectious disease like SARS. I'm curious if you share those 
beliefs; and, if so, what recommendations would you make to 
rectify the situation.
    Ms. Selecky. The answer is, yes; and the recommendation is 
continued and increased support to State and local public 
health is absolutely needed from Congress. This is not about a 
part of the body disease. It's not about a singular kind of 
action. It's about the investment in the public health system. 
Our laboratories need to have up-to-date information but up-to-
date equipment.
    Technology changes quickly. What used to take days to grow 
a culture on now can have rapid testing within hours. We've got 
to have those kinds of investments. The bioterrorism 
preparedness money helped us make a major shift, but there 
needs to be continuation on that and particularly our work with 
our facilities. You know, our hospitals in this country have 
come down to a much smaller operating margin. There isn't much 
room available for the emergency kind of planning that goes on.
    Again, Congress has done some investments. We in public 
health at the State and local level are working very closely, 
for example, in Washington State, with our 91 hospitals to work 
at the community level to deal with surge capacity. You don't 
make beds overnight, but you can work on plans how to deal with 
people if you have a major event.
    Mr. Bell. Dr. Foldy.
    Dr. Foldy. I would concur. I would also add that issues 
like isolation are particularly thorny for local government. I 
believe that Wisconsin is typical of many States where the 
responsibility for bearing the cost of isolation lay in the 
local jurisdiction, which means that a single case of 
tuberculosis can wipe out the budget of a small health 
department overnight. It seems somewhat ridiculous. Those kinds 
of costs need to be socialized in some manner over a larger 
territory than the small local jurisdiction.
    Mr. Bell. Thank you, Mr. Chairman.
    Mr. Shays. I thank the gentleman.
    Dr. Hall, when I look at that map at the back, it has 
surveillance of human influenza. And I look at India and it has 
one--I guess just greater than one laboratory. But how many? 
Not many? It's not a network. Is that your point?
    Dr. Hall. Yes. I mean, what's missing there is, yes, a 
national network so that all areas within that country can be 
detected, that some polls can be taken from patients and that 
they can be assessed and evaluated properly.
    Mr. Shays. I look at the two largest in terms of 
population, China and India, and that they don't have a network 
system yet. Walk me through really--I'm not looking in great 
detail, but I will tell you I am somewhat haunted by--maybe 
others as well, but this was one story, the story of the mom 
leaving Hong Kong, going to Toronto. She's infected. She dies. 
Her son dies. I mean, what a horrible--not only do you lose 
your life, but someone who you brought into life loses their 
life. And that could have been prevented--correct--had we known 
sooner in China, had China participated sooner and acknowledged 
the problem, correct?
    Dr. Hall. Well, certainly what we have seen is that within 
24 hours of that occurring, of the cases landing in Toronto, 
WHO put out a global alert. And since the global alert, because 
of the heightened vigilance all around the world, with the 
exception of Taiwan we haven't seen that rapid transmission of 
disease anywhere else. So, yes, the early detection and the 
early release of information and the heightened vigilance that 
has occurred has meant that, while cases have occurred, say, in 
the United States, they are isolated cases, and we haven't seen 
that level of transfer.
    So that the real lesson of SARS is that the more 
transparent countries are, the quicker they report the cases, 
the quicker the international assistance can get there to look 
and help with the diagnosis if that's necessary, then the 
greater the window of opportunity for the rest of the world to 
be able to protect themselves against these diseases that can 
in a matter of hours fly around the world.
    Mr. Shays. Right. What I'm trying to sort out, though, is 
we up on the panel are thinking we could do so much better. But 
you say we have a network; and we are looking at this network 
and saying, it could be so much better. Correct?
    Dr. Hall. Um-hmm.
    Mr. Shays. So even when I look at the dark-colored parts 
and all of Russia and the Scandinavian countries and most of 
Europe, I'm looking at some of the European nations I guess 
not--I am--you do agree that, when you look at this network, 
this network could be so much better. Correct?
    Dr. Hall. Absolutely. Yes. I mean, it's just an example of 
just the FluNet, but it's pretty reflective of surveillance on 
the global level for virtually any disease.
    Mr. Shays. When you talked about early detection and early 
intervention. And I think that's kind of where my colleague Mr. 
Janklow and I are wrestling, as well as Mr. Bell. The question 
is, we have a system now that may not provide for early 
intervention. When you look at those countries that have a 
network, what don't they have? In other words, you could 
compare to the network ones and say, compared to China and 
India, you know, they are way ahead. But what don't we have in 
the United States, as far as you can tell?
    Dr. Hall. I mean, I think the rest of the panel have been 
explaining exactly where the problems are.
    Mr. Shays. But I'm using your--I'm taking advantage of your 
global view to say how much better it could be.
    Dr. Hall. Right. I mean, I think the key issues are about 
the timeliness of reporting and standardizing reporting as 
well, so that you get a similar report from all around the 
world. And that I'm sure will probably apply to the States 
within the United States. So that you can actually compare and 
you can compile that information to get a much better picture.
    Quite often, in the emergence of a disease--and this would 
be the same, the bioterrorist threats--it's unknown, it's 
different, it follows a pattern you have not seen before. So 
what is key is to be able to rapidly piece little pieces of the 
jigsaw puzzle together? And I would imagine that in the United 
States, as most countries around the world, suffering the 
problems of reporting in a standardized manner so it can be 
compared from different bits of the States and reporting in a 
timely manner so that those pieces can be very rapidly put 
together in a better picture.
    Mr. Shays. Now, you talk about a learning curve, but I'm 
struck by the fact that--I've been chairman now for 9 years of 
either--the first 4 years was overseeing CDC and FDA and HHS, 
among other departments and agencies; and now I'm involved with 
my colleagues on the national security side. But there is some 
real compatibility. I mean, thank goodness I had that knowledge 
to bring in here.
    One of the things I wrote down is, you can't push science. 
You know, when we were looking at Gulf War illnesses, they 
said, you know, it make take 10, 15 years for us to understand 
why people are sick. And I'm thinking up here, well, they are 
dying and they are sick and so on, and it's going to take 15 
years. And it's like, we can't push science.
    But I wonder, this isn't pushing science. This is different 
than pushing science. This is saying we have information. We 
need to find a way to identify it sooner. We need to find a way 
to identify the illnesses sooner, have a standard. This to me 
isn't science. This is like logic. And yet I think I'm hearing 
scientists saying, thinking like that this is going to be a 
long process.
    Ms. Ignagni, how are you reacting to what I'm saying?
    Ms. Ignagni. I think it is like putting down pylons. If you 
think about creating the architecture, doing something here 
that collects the system of systems, you really just--in 
constructing a building, you construct buildings the same way 
all around the world and all around our country. And so, just 
to be very simple about it, I think you are on the right track. 
I think that what we've learned is there's a real value in 
consistency.
    I think Dr. Hall is making a very compelling point here. I 
think what--our colleagues from the States and the local area 
are sending messages, let's figure out a way to have the 
consistency of drawing the data but at the same time not quash 
their ability to be nimble in reacting to that. And I think 
that--so the question is, where do you put the fulcrum on those 
two--on the continuum? And I think you are on the right track.
    Mr. Shays. I also am thinking that--and this is a slight 
exaggeration. But health departments have been so beaten down 
in terms of the contest with other departments in the cities 
and in the States that they have low expectations, and they 
have learned to be very patient people. Maybe the science tells 
you to be patient, but it strikes me that the expectation 
should be a lot higher; and I didn't really come to that 
conclusion until really wrestling with the first panel now and 
the second. There is really no reason why--I mean, some of 
this, as I am struck thinking about it, is some of this is just 
common sense stuff. And Ms. Selecky, do you want to just 
comment?
    Ms. Selecky. We in public health have to be ready to move 
on a moment's notice, because communicable disease does not 
work. We can't----
    Mr. Shays. Does not what?
    Ms. Selecky. Does not wait. Excuse me. We can't wait for 
someone to say, here is the perfect system that is going to be 
used nationally. So that's why I think you have things that 
grow up like the one that's in southwest Pennsylvania, as was 
described earlier, or other places, in the local community to 
say how do we get our arms around Milwaukee, Seattle, eastern 
Washington, whatever it is. How do we get ourselves to talk to 
one another in real-time to work on instant reporting of 
something that is a terrorist event? It's an unusual disease 
that's showing up. We are all starting to see it, and we need 
to move on it.
    I guess I'm struggling with how to answer your questions 
about should we nationalize and have a common data reporting 
system. How do you then get everybody using the same software 
in the local doctor's office that's part of a health plan who 
also have four or five other health plans there because they 
have requirements, the local health department, who is part of 
the city infrastructure, or the county infrastructure? And we 
can't wait for that, because communicable disease does not 
wait.
    Whether it is electronically, whether it is by the 
telephone, whether it is by paper, public health is impatient 
to get the information. The sense of urgency is that our 
science is based on early detection, quick action and 
prevention. Otherwise, we wouldn't have some of the good health 
that we do experience in this country or the ability to begin 
to look at the work that the World Health Organization, all of 
a sudden connected to me in my job in Washington State and in 
my community.
    So if we haven't talked about urgency, it's about--it's not 
about the sense of urgency of participating in a good, 
thoughtful discussion about what's the best system. The urgency 
exists by virtue of a public health or an organism problem that 
we have to act on, regardless of what system exists.
    Mr. Shays. Go ahead.
    Dr. Foldy. Well, just since--over the last several years, 
we have done everything possible we can do without spending a 
lot of money; and that included getting 15 local health 
jurisdictions to all report to a one-stop location and which 
can rapidly take in the report, determine that something is 
going on.
    Our first--you know, E-coli operated--the first five cases 
came from five suburbs. Fortunately, they all report to one 
location. We could put it together and act immediately. Our use 
of this regional emergency medical Internet, it simply fell 
into our hands.
    With more resources, we can do great things. However, my 
local tax base, as the support for my department has gone from 
45 percent down to--it's starting to approach--I'm sorry--55 
percent, starting to approach 40. The State is cutting back. We 
are really looking at hard times and sustaining these systems 
can't go on indefinitely.
    Mr. Shays. My time has run out. But, Dr. Hall, what would 
you like to say?
    Dr. Hall. Just to say that certainly, from our point of 
view at Global Alert and Response, we spend far too much time 
being reactive and not enough time being proactive; and that is 
simply because of a lack of investment in the system. It means 
we have enough money to buy the brakes, but we haven't got 
enough money or time to get the motor to stick it all together. 
And what you see--that systems I'm sure all around the world 
building up, building on experience like we have built on the 
experience of ebola and meningitis outbreaks and other things 
but never quite enough time to glue that together so that you 
actually have a system that is stream--that means that 
information can flow very quickly and very rapidly.
    Ms. Ignagni. Mr. Chairman, can I make a quick comment?
    One of the things that I think has probably been implicit 
in the discussion, particularly from the previous panel, but 
wasn't said very specifically is that in the last couple of 
years there has been a dramatic progress in the ability to 
unite the systems and create a system of systems. What now we 
have the capacity to do, like we do in defense where we have 
command centers tracking what's going on around the country, 
the Secretary has created a command center in terms of getting 
the information in, looking and arraying the information. If 
you go into that command center, what you see are different 
geographic locations and the ability just to put up on the wall 
where blips are coming up.
    And I think perhaps what you have been hearing this 
afternoon is a reflection on how far that has gone and come 
from where we were. But I think, just as we have learned in 
this country that we need to take a new approach to thinking 
about defense as well, I think that the consensus in the public 
health community is that we need to think more like that in 
public health. So I think that there has been a dramatic 
progress over the last couple of years and now it's the 
question of how we get to where you are suggesting we need to 
go, and I believe that there is tremendous consensus about that 
objective, and I think we can do it. There is probably more 
interest in achieving that now post SARS and some other 
experiences than there was a year or so ago throughout the 
country.
    Mr. Shays. Thank you very much.
    I appreciate the patience of my colleagues. I don't always 
do this, but Dr. Kelley, Colonel Kelley, do you have any 
observation you would want to put on the record? I would have 
to swear you in, but if you would like to, I would be happy to 
have you come up. So the answer first has to be yes or no.
    Colonel Kelley. Yes.
    Mr. Shays. OK. And with the indulgence of the committee, I 
would just swear you in. If you would raise your right hand, 
please.
    [Witness sworn.]
    Mr. Shays. I appreciate you, Dr. Kelley, staying for this 
hearing. I know your superior was here. I mean--but what 
observation would you like to make?

 STATEMENT OF PATRICK W. KELLEY, M.D., DR PH, COLONEL, MEDICAL 
    CORPS, DIRECTOR, DEPARTMENT OF DEFENSE, GLOBAL EMERGING 
          INFECTIONS SURVEILLANCE AND RESPONSE SYSTEM

    Colonel Kelley. I think I would like to make several 
observations.
    You know, money can go only so far. But what we really need 
is leadership to make it clear that these are our priorities 
that need to be followed. In our various organizations, 
civilian and military, there are many, many issues that we are 
trying to balance back and forth and prioritize. We have to 
prioritize not only budgets but time, and it's very critical I 
think that our leaders understand that this needs to be a 
priority.
    I think one thing we have to realize, too, is that 
surveillance implies a response. I can't put a precise figure 
on this, but I would guess for every dollar you spend on 
surveillance you need several available to fund the response 
that is implied by the generation of this new information, and 
I know various health departments outside the military that 
find that a particular challenge. Now that their surveillance 
systems are getting better, they have to--they find themselves 
constrained in reacting to the wonderful data that they are 
generating.
    Mr. Shays. We will note for the record that Ms. Selecky and 
Dr. Foldy were nodding their heads continuously as you were 
talking about that.
    OK, anything else?
    Colonel Kelley. No, sir. Thank you for the opportunity.
    Mr. Shays. Well, you are welcome. But thank you for 
staying, and thank you for your good work as well.
    Is there anything? Mr. Janklow, any other comments you want 
to make again?
    Mr. Janklow. Could I ask a couple quick questions, Mr. 
Chairman?
    Mr. Shays. You sure can.
    Mr. Janklow. With respect to the--Dr. Foldy, if I could ask 
you--and let me ask you, Ms. Selecky, first. In the State of 
Washington, are you satisfied that you are where you want to be 
in the State with respect to the reporting system for State 
purposes?
    Ms. Selecky. No, and the reason I say no is because we all 
can do better; and I think that last comment is part of that. 
You not only need the way you do the reporting, you need to 
have the foot soldiers to do the work at both the State and 
local level. The communications system's in place to work to 
make sure that the public and private people across the State 
are getting the information to take the action. Can we do it 
better? Absolutely. We need to upgrade electronic capability 
across the State. We have already reviewed our reportable 
diseases in Washington State. We updated them just 2 years ago. 
We updated our quarantine and isolation rules just in December. 
We have those kinds of tools. But we have to continue to work 
on the common data, elements that all of us will agree on come 
together in Washington State. We are doing better than we were.
    Mr. Janklow. Are there a set--do you have common data 
elements in place?
    Ms. Selecky. We have common reporting from all our private 
providers as well as public providers in and around the list of 
communicable diseases that includes emerging diseases like 
SARS, and in real-time in Washington State we have those kinds 
of reports to know what we have going on with that. Whether 
it's E-coli from spouts--we have that from this summer--E-coli 
from lettuce--it was multi-state. We had it this summer. It's 
about getting that information to move into action.
    When I hear you all talk about and when we talk about a 
common system, I get concerned that we are waiting for the 
perfect system when what we really need to have are the 
foundations to be able to use whatever system exists.
    Mr. Janklow. When I talk about electronics, ma'am--I 
understand an earthquake can be disruptive. But I don't see a 
national earthquake coming. I mean, if anything, it would be 
very regional in terms of its scope; and so I don't know of 
another effective means other than electronics in war. If we 
have to go to paper, we can. But to the extent we go to paper, 
we've lost. Once we have to take the war dealing with someone 
deliberately injuring our people with bacteria or a toxin or a 
virus, at that point we have lost.
    So what I'm wondering is, putting a system in place, what 
does it take to do it? Because electronically the world is 
there. It's there. The kids know it. Napster knows it. The only 
people that don't know it most of the time are the governments 
and the adults, but the kids have figured it out, whether it's 
with their chatrooms or whatever.
    Second of all, I don't think it's that difficult. I realize 
there could be arguments, but I don't think it's that difficult 
to come up with a list of sicknesses, diseases, symptoms, 
differential diagnosis, whatever you want to call it, that are 
reportable events.
    The third thing is, there has been a huge amount of Federal 
money, of national money, our money, that has gone in in the 
previous couple of years. All the States received very sizable 
grants, one for their laboratories and two for their planning 
for this type of thing. And so I understand it's not enough, 
but it's a huge amount of money if it was somehow coordinated 
better than we all coordinate it.
    So I realize our time is up on this stuff, but I just--the 
point that I'm trying to raise is, is there--and I realize we 
need more trained people and we need more money. But, absent 
those things, is it OK the way the States and local governments 
are doing it? Or is there something that all of us can do in a 
national wartime scope that would make this more effective and 
more efficient in terms of the wartime side of this issue?
    Ms. Selecky. One of the things we clearly do have to work 
on, and are working on, are secure ways of getting this 
information sent between State and local; and that is using the 
common standards you heard Dr. Fleming talk about. So we are 
working on that.
    You are saying, speed it up. You are saying, get it done 
because we are in a wartime kind of thing. It's not about 
laissez-faire. And I would absolutely agree with you, your 
point about it makes sense to come up with a common list of 
diseases. States have those. States work with State and local. 
We are based on that. So that one you rest assured on.
    Your point about the earthquake is well made. What we have 
to do is not falsely rely on it as the exclusive way of doing 
things. The investments made by Congress over 2 years have 
moved us along, but I want to have a digital signature in every 
clinician's office at some point, that clinician can have 
someone enter the data from their office, from their outlying 
remote clinic or from their ER room so that the local health 
department and the State health department have access to that 
immediately and we transmit it to the Feds.
    Mr. Shays. We can keep going on and on and on, but I think 
this is probably a good time to stop. You have been a wonderful 
panel. You have helped put the whole thing together for us, and 
we appreciate your participation. Thank you very much.
    With that, we will adjourn the hearing. Thank you.
    [Whereupon, at 4:59 p.m., the subcommittee was adjourned.]
    [Additional information submitted for the hearing record 
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