[Senate Hearing 109-574]
[From the U.S. Government Publishing Office]
S. Hrg. 109-574
ROUNDTABLE ON PUBLIC HEALTH PREPAREDNESS IN THE 21ST CENTURY
=======================================================================
HEARING
OF THE
SUBCOMMITTEE ON BIOTERRORISM AND PUBLIC HEALTH PREPAREDNESS
OF THE
COMMITTEE ON HEALTH, EDUCATION,
LABOR, AND PENSIONS
UNITED STATES SENATE
ONE HUNDRED NINTH CONGRESS
SECOND SESSION
ON
EXAMINING PUBLIC HEALTH PREPAREDNESS IN THE 21ST CENTURY, FOCUSING ON A
NATIONAL PUBLIC HEALTH INFRASTRUCTURE WITH REAL-TIME SITUATIONAL
AWARENESS, AND RESPONDING TO THREATS BY TERRORISM OR NATURAL DISASTERS
__________
MARCH 28, 2006
__________
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COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS
MICHAEL B. ENZI, Wyoming, Chairman
JUDD GREGG, New Hampshire EDWARD M. KENNEDY, Massachusetts
BILL FRIST, Tennessee CHRISTOPHER J. DODD, Connecticut
LAMAR ALEXANDER, Tennessee TOM HARKIN, Iowa
RICHARD BURR, North Carolina BARBARA A. MIKULSKI, Maryland
JOHNNY ISAKSON, Georgia JAMES M. JEFFORDS (I), Vermont
MIKE DeWINE, Ohio JEFF BINGAMAN, New Mexico
JOHN ENSIGN, Nevada PATTY MURRAY, Washington
ORRIN G. HATCH, Utah JACK REED, Rhode Island
JEFF SESSIONS, Alabama HILLARY RODHAM CLINTON, New York
PAT ROBERTS, Kansas
Katherine Brunett McGuire, Staff Director
J. Michael Myers, Minority Staff Director and Chief Counsel
__________
Subcommittee on Bioterrorism and Public Health Preparedness
RICHARD BURR, North Carolina, Chairman
JUDD GREGG, New Hampshire EDWARD M. KENNEDY, Massachusetts
BILL FRIST, Tennessee CHRISTOPHER J. DODD, Connecticut
LAMAR ALEXANDER, Tennessee TOM HARKIN, Iowa
MIKE DeWINE, Ohio BARBARA A. MIKULSKI, Maryland
JOHN ENSIGN, Nevada JEFF BINGAMAN, New Mexico
ORRIN G. HATCH, Utah PATTY MURRAY, Washington
PAT ROBERTS, Kansas JACK REED, Rhode Island
MICHAEL B. ENZI, (ex officio)
Wyoming
Robert Kadlec, M.D., Staff Director
David C. Bowen, Minority Staff Director
(ii)
C O N T E N T S
__________
STATEMENTS
TUESDAY, MARCH 28, 2006
Page
Burr, Hon. Richard, Chairman of the Subcommittee on Bioterrorism
and Public Health Preparedness, of the Committee on Health,
Education, Labor, and Pensions, and a U.S. Senator from the
State of North Carolina, opening statement..................... 1
Besser, Richard, M.D., Director, Coordinating Office for
Terrorism Preparedness and Emergency Response, Centers for
Disease Control and Prevention................................. 2
Caldwell, Michael C., M.D., Commissioner of Health, Dutchess
County Health Department, and Immediate Past President,
National Association of County and City Health Officials
(NACCHO)....................................................... 12
Prepared statement........................................... 13
Honore, Peggy A., Chief Science Officer, Mississippi Department
of Health...................................................... 16
Prepared statement........................................... 16
Lurie, Nicole, M.D., Senior National Scientist and Paul O'Neil
Alcoa Professor of Policy Analysis, The RAND Corporation....... 21
Prepared statement........................................... 22
Gursky, Elin A., Principal Deputy for Biodefense, ANSER/Analytic
Services, Inc.................................................. 27
Prepared statement........................................... 27
O'Toole, Tara, M.D., Director and Chief Executive Officer, Center
for Biosecurity, University of Pittsburgh Medical Center....... 31
Prepared statement........................................... 32
Kaplowitz, Lisa G., M.D., Deputy Commissioner, Emergency
Preparedness and Response, Virginia Department of Health....... 36
Prepared statement........................................... 37
ADDITIONAL MATERIAL
Statements, articles, publications, letters, etc.:
Response to Questions of the Senate HELP Committee by CDC.... 54
(iii)
ROUNDTABLE ON PUBLIC HEALTH PREPAREDNESS IN THE 21ST CENTURY
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TUESDAY, MARCH 28, 2006
U.S. Senate,
Subcommittee on Bioterrorism and Public Health Preparedness
of the Committee on Health, Education, Labor, and Pensions,
Washington, DC.
The subcommittee met, pursuant to notice, at 10:04 a.m., in
Room 430, Dirksen Senate Office Building, Hon. Richard Burr,
chairman of the subcommittee, presiding.
Present: Senator Burr.
Opening Statement of Senator Burr
Senator Burr. Good morning. This roundtable will come to
order. I want to take this opportunity to welcome everybody
here this morning, most importantly the panels of witnesses
that we will have. I am sure we will be joined on and off by
other members of the subcommittee and full committee as we go
through.
As has been the practice of this subcommittee, it is
extremely important for us to get as much testimony on the
record as we try to prepare for the reauthorization of the
bioterrorism bill and as we continue to develop a blueprint.
This is another in a series of hearings and formal roundtables
that we will have to have in exchange of ideas for members and
for staff to hopefully guide us on the way.
This roundtable is an important part of our discussion as
we move forward to reauthorize the Public Health Security and
Bioterrorism Preparedness Response Act, legislation that was
passed in 2002. It moved the country in the right direction,
but as we have seen from the effects of Hurricane Katrina, it
has not done enough. Katrina exposed an unstable public health
infrastructure at all levels of government during an emergency
event.
The Public Health System that I envision for the 21st
century is a robust partnership between Federal, State, and
local levels and is flexible enough to prepare for and
adequately respond to disasters such as Katrina. As you all
know firsthand, the response to disasters begins and ends at
the local level. It is our responsibility at the Federal level
to ensure that every local public health department has the
capacity to protect the health of its citizens and that Federal
resources are available to draw upon as needed.
Additionally, we need to think systematically about how
best to address situational awareness, including surveillance
systems, epidemic monitoring, and reporting risk communication
and health threat alerts, as well as laboratory and hospital
reporting.
Regarding a competent workforce, we need a national
strategy for developing a prepared workforce and how to best
recruit, train, and retain public health workers. We also need
to exercise our plans regularly. We need to ensure security and
preparedness through science-based strategies and public health
research. The task before us is difficult, but it is not
impossible.
Five decades ago, when President Eisenhower contemplated
the need for national commerce and defense, he created the
National Highway System. Our task today is similar. For the
purpose of our national public health and defense, we need a
national standardized Public Health System to promote general
public health within and between the various States and enable
the investigation and containment of disease, including defense
against biologic, chemical, and radiological attack.
I look forward to hearing from each of you regarding your
insights. I know that we have a number of different
perspectives. Please know that we will use what you tell us in
this committee, and attempt to make the necessary changes to
improve our national Public Health System so that the response
to the next health emergency is better than our experience with
Katrina.
I will make sure, by unanimous consent, that the record is
left open so that members who read the transcripts but don't
have an opportunity to be here can also submit questions, and I
hope all of our witnesses today will make themselves available
for the answers to those questions.
At this time, it is the chair's prerogative to recognize
Dr. Richard Besser from CDC, who is the Director for the
Coordinating Office for Terrorism Preparedness and Emergency
Response. Richard, it is a delight to have you here today and I
recognize you.
STATEMENT OF RICHARD BESSER, M.D., DIRECTOR, COORDINATING
OFFICE FOR TERRORISM PREPAREDNESS AND EMERGENCY RESPONSE,
CENTERS FOR DISEASE CONTROL AND PREVENTION
Dr. Besser. Chairman Burr, it is a real pleasure to be here
today. I want to commend you and the committee for taking on
such an important topic as public health preparedness. I am the
Director of the Coordinating Office for Terrorism Preparedness
and Emergency Response at the Centers for Disease Control and
Prevention. I assumed this position on August 29, the day
Katrina hit, and in that regard have had an opportunity to see
a lot of the strengths of the system, but also many of the
gaps.
At CDC, we take an all-hazards approach to preparedness and
response. We agree that having systems that are able to respond
to a hurricane such as Katrina will also leave us with the
systems that we need to be able to respond to everyday public
health events as well as manmade events related to terrorism.
My office at the CDC has overall responsibility within CDC
for preparedness and response activities, so that involves the
strategic direction across the agency, allocation of resources,
of linking our budget to accountability, and then serving as
the point of contact to stakeholders within the government and
outside groups around the area of preparedness and response.
All of our activities at CDC in the area of preparedness
and response are linked to nine preparedness goals that deal
with issues of prevention. Clearly, preventing the consequences
of natural disasters or preventing terrorism is the best public
health intervention that we could make. Detection and
reporting, making sure we are able to detect events quickly and
determine whether or not they are manmade or natural;
investigating events, having the systems in place to rapidly go
out and determine the scope of an event and determine the
control strategies; implementing those control strategies; and
then assessing what more needs to be done; recovering from an
event; and then learning. It is essential that our systems that
are in place have the ability to look back and see what worked
well and implement that as an ongoing practice and look at what
did not go so well and correct that.
I don't have any more formal comments to make and am happy
to answer the questions that you forwarded or other questions.
Senator Burr. Great, Richard. Thank you. Thank you so much.
Clearly, you sit in a very pivotal spot at CDC relative to
prevention or preparedness and response, and I think that
sometimes we forget it is the Centers for Disease Control and
Prevention. I think we need to make sure that everybody over at
CDC as well as us up here gives the full name in the future.
Can you explain how the Biosense program works presently
and how it interacts with the local public health departments
for their situational awareness?
Dr. Besser. The issue of situational awareness is key. It
is essential. When you talk about situational awareness, it is
the simple concept of knowing what is going on on the ground,
knowing what your current public health situation is, knowing
the health status of your community, being able to detect
events early, so there is a component of early event detection,
and then being able to follow an event as it unfolds in your
community.
So, for example, each year with seasonal influenza, it is
very important that we have systems in place that are able to
determine when it arrives in the community, how it progresses
through the community, who is affected by that, and then as it
moves through, what other populations are going to be affected.
There is an acute awareness that when it comes to public
health emergencies, and even every day public health, there is
a need for real-time data. You need to know what is going on at
the moment. And Biosense is an attempt to try and implement a
national system that will give us both early event detection as
well as ongoing ability to track events. Biosense is a
partnership between Federal, State, and local government. It is
a partnership with local hospitals. It is a tool that I think
will be very effective for use at all of those different
levels.
The current status of Biosense--it began with the ability
to analyze not real-time data, but data sets looking at
encounters. So it is able to look at data from the Department
of Defense and VA clinics. It is able to look at tests that are
ordered from one of the largest laboratory companies in the
country whose able to look at poison control data. And what it
does, by analyzing that data over time--getting the data is
only the first part. Once you have the data, you need to be
able to analyze that and look for trends. You need to be able
to analyze that and look for something new that we call
aberrations. And what you want to be able to do is, if you see
these blips or aberrations or something new, you need to have a
system in place to be able to investigate that quickly.
Now, public health is local, and so the key to that
investigation has to be on the ground. It has to be with the
local health departments. So the way Biosense is structured,
this data flows up using existing data systems. It taps into
systems that are in place in hospitals and clinics. This data
flows up through a large data pipe and is then ready for
analysis simultaneously at the local--at the hospital, local,
State, and Federal levels.
At CDC, we are in the process of standing up and expanding
a bio-intelligence group, Bio-Intelligence Center, and what
that will be doing is learning as we go, but analyzing this
data as we come in so that we are able to use it for everyday
public health needs as well as for future events. We envision--
currently, there are 10 localities that have real-time data
flow coming to CDC as well as their own use and the goal is
that by the end of 2006, an additional 21 localities will be on
board. And when you say a locality, there is more than one
hospital in a locality that is participating in the system.
You can envision a situation where the entire country at
some point is covered by real-time data systems.
Senator Burr. When is that point? What is that date?
Dr. Besser. Well, you know, I can't give you a date on that
and I think it is important that before we decide on the level
of expansion of that system, we evaluate as we go along and we
determine what are the key components, what is the scale that
you need to be able to do both early event detection and
situational awareness, and then scale it up accordingly. If
there are existing systems in place, we need to work to
continue to incorporate the data that is coming from those
systems into the Biosense system.
Senator Burr. Is the inability to lay out the timeline
effecting our ability to evaluate what we are trying to do and
how effective it is? Is it funding? Is it challenges that need
to be addressed legislatively? Is there anything you can put
your finger on?
Dr. Besser. I think that we have learned a lot from the
system so far, and this year is going to be a critical year. As
we have more real-time data flow coming in, we will be able to
get a better sense of what an appropriate time table should be.
I am very excited. I am in charge of our Division of
Emergency Operations and our Emergency Operations Center, where
we are putting a hub of Biosense linked directly to our
Emergency Operations Center so that information that is coming
in through Biosense will be able to help us during an event.
So, for instance, during a large hurricane, we will be able to
get Biosense information, if those systems are still flowing,
right into our Emergency Operations Center. We are looking to
build within that same surveillance-evaluation unit a hub for
our global disease detection system, which is a network of
centers around the globe that will be able to provide us with
situational awareness from parts of the world where it is very
difficult for those countries to provide that information.
Senator Burr. Post-911, I think we were shocked to wake up
and look for the first time, I think in quite a while, at the
public health infrastructure in this country. We found that we
did the bioterrorism bill that--correct me if I am wrong--about
two-thirds of our public health infrastructure was not
electronically connected to the Centers for Disease Control and
Prevention. Are we 100 percent connected to our public health
infrastructure today?
Dr. Besser. When we talk about connectivity, there are
different types of connectivity. There is the Biosense type of
connectivity that I was talking about, where you are having
encounter data, clinical encounter data from those locales
coming in.
The other type of connectivity has to do with
communications, and yes, we are there now. We have a system in
place where we have a number of tools. We have something called
the EPI-X, which connects the CDC and local health departments
and State health departments around the country. It is a system
that we use to alert States and locals of outbreaks taking
place across the country. It provides forums for those entities
to speak with each other. So that is an important part of
connectivity.
Senator Burr. And that exists nationwide?
Dr. Besser. That is a nationwide system. I can get you
information in terms of the numbers of State and local health
departments that are on board with that. It is a system that is
continuing to expand, and as we identify appropriate partners,
I think there is more we can do to build that out.
We also have a system called the Help Alert Network, which
is a system, as well, for alerting States and locals of
emergent health events. It is a system that health departments,
State health departments are using to alert clinicians in their
community as to events that they need to be concerned about.
So, for example, last month, there was a case of
inhalational anthrax in Pennsylvania. The EPI-X system was used
to alert health departments to this. The HAN system was used to
alert doctors and emergency rooms so that they would know to
look for additional patients if they were presenting.
Senator Burr. And as we both know, isolated area gives us
tremendous latitude as to how we can focus on the threat
presented with one case of anthrax. We are at a point in time
that pandemic flu is the most talked about threat that exists
around the corner, enough so that part of the supplemental
funding will be used to accelerate Biosense. Share with me, if
you will, the description of how you see those additional funds
being applied to the Biosense program.
Dr. Besser. You know, as you mentioned, Senator, there are
significant resources coming for--that have been given for
pandemic flu preparedness. We are putting money to State and
locals for their preparedness activities, money for the
Strategic National Stockpile, and resources to expand the
Biosense system.
Biosense, as I mentioned, is a tool for situational
awareness, and while it would be unlikely to be the tool to
identify the first case of pandemic flu, it would be a system
that would allow us to track in areas that are connected
electronically, track cases as flu could potentially spread
across the country.
You know, the key to detecting the first case of most
diseases is people. I think it is very important that, as we
talk about Biosense, we don't forget that the most essential
piece of our public health system is the personnel, making sure
there are people there at the clinical level who know what to
look for, making sure that there are trained, skilled public
health professionals who understand what that means when they
get a call from a hospital or clinician, know how to
investigate that, know how to work with people on the ground in
other disciplines. These are the real building blocks and
fundamentals of our public health system.
Senator Burr. Today, the reality is that our public health
infrastructure has a different face, depending upon which
community you go into. Some mirror what I think we would
suggest should be the face of 21st century. Others for a number
of reasons might be no more than a vaccination point for low-
income children. How did we let it get to this point and how
long will it take for us to bring that level of expertise
across the board?
Dr. Besser. Senator Burr, that is a great question. I think
how did we get to this point is a tough one to answer, but it
is clear to me that there is not the constituency there for
prevention that there needs to be. The vast majority of work
that a public health department does, you don't see unless they
are doing it poorly. You don't see outbreaks of pertussis,
whooping cough, diphtheria. You don't see outbreaks of
tuberculosis because they are doing their job. When you are not
seeing those, when those aren't coming to the forefront, there
isn't always the resources there at the State and local level
to maintain them.
I think that the investment that we have seen over the past
5 years in our public health system has been dramatic. It has
been extremely important toward rebuilding our laboratory
system, rebuilding our epidemiological capacity. These building
blocks for emergency preparedness and response will leave us in
much better shape for all of the work that public health does.
Senator Burr. Do you envision a public health
infrastructure that is, in fact, the entity that should be in
charge of a public health emergency in a given community?
Dr. Besser. I think that the question of who is in charge
is dependent on what the event is. I think that we are moving
in the right direction in terms of implementation of the
National Response Plan, implementation of incident management
systems around the country. There is a lot of work going on to
train people so that they understand their roles and
responsibilities.
I think more important than who is in the driver's seat,
who is in that primary seat, is do we know what we are going to
be doing? Have we exercised our roles and responsibilities for
an event? Do we know how to work across other sectors? Do we
know how to work with police and fire? These are very important
things for us to work on.
CDC feels this is very important and is working to develop
training courses in what we call meta-leadership. This is based
on a training program that CDC and others have developed with
Harvard in meta-leadership. It focuses on the tools you need to
be able to work across sectors. How do you work with not just
other sectors of government, but with the business community so
that we all understand what we are going to do during a
response.
Senator Burr. I commend CDC for the progress that they have
made, but just based upon your numbers, 31 localities have yet
to be defined online in a year with Biosense. If, in fact,
human-to-human transmission of pandemic flu is 6 months down
the road versus a year, if it chooses to go outside of those 21
localities, which the likelihood is it will, or if there is
another natural threat right around the corner behind this one,
what ensures us that we are going to build out a model versus
continually trying to respond to these isolated threats that
seem to come more often now?
Dr. Besser. You know, I----
Senator Burr. I understand what you said about the specific
type of threat dictating what the decision might be, as to who
is in charge, but I have a difficult time understanding how the
one entity that you have control of, that you have input in,
and that you have said, ``this is the entity we need to drive
real-time data to,'' is not automatically the default person in
charge, that somebody else might trump them by a decision that
somebody has made about the type of threat, and the likelihood
is they are going to make a decision not knowing the community
whatsoever.
Dr. Besser. I think it is essential that whoever is in
charge, public health is at that table and is providing the
appropriate input----
Senator Burr. I agree with you, but if public health was at
the table equally today, we wouldn't have the disparity between
some of them. The reality is that the health care delivery
system invites public health to the table to do what they
perceive public health capable of doing. The disparities that
we see--[ringing microphone]--clearly, I am in an area where
somebody doesn't like me.
[Laughter.]
Clearly, we can't have that range of disparities in the
future. Hopefully, you would agree on that.
Dr. Besser. Yes, I definitely agree on that. You know, I
think that we have some gaps--you can look at some systems and
say, ``This system is broken. This really isn't working well.''
But we do have a lot of gaps in our ability to measure state of
preparedness of our systems. One of the issues that is on the
agenda today to talk about is areas of research, and I think
one of the areas where we really do need to support research is
in the ability to measure preparedness, determine where we are,
determine what the gaps are so that we can say, ``Here is where
the investment should be going. Here is where the system is
broken and here is how we can use our resources in the best way
to move forward.''
Senator Burr. Well, in a simplistic overview of the Gulf
Coast, what we found was that one State chose to use Federal
resources to enhance their surge capabilities. Another State
chose to use their Federal resources to actually put together a
plan and to practice that plan. The devastation was similar.
The challenges of the flood in Louisiana were unique to
Louisiana, but the response between two neighboring States was
incredible from the standpoint of how the one that practiced
response responded and how the one who put the resources into
surge and, in fact, couldn't use that surge capability had not
necessarily focused on the plan and the preparation.
I might say that they did exactly what the Federal
Government asked them to do with the money. It was actually
Mississippi that went outside the box and said, ``no, this is
what we need,'' and they were willing to invest in it and to
spend the time and, in fact, they were the right ones.
What are we doing to track disease internationally and
where should we direct our resources in regard to that?
Dr. Besser. The issue of disease tracking globally is a
very important one. CDC participates in networks with the World
Health Organization. They have a global response network that
CDC and the Federal Government participates in.
CDC is also building a network called Global Disease
Detection, and the vision of this is to have highly-trained
regional laboratories in all of the WHO regions so that we are
able to provide advanced laboratory diagnosis in those
settings, we are able to have personnel who can train others
locally to do investigations so that we are able to detect
more. This is one part of a strategy for gathering situational
awareness globally.
Currently, CDC has an International Center for Emerging
Infectious Diseases in Thailand, in Kenya, and is establishing
one in Egypt. The goal would be by the end of 2006 to have five
of these, with an addition of one in Guatemala and one in
China. It is very important that we continue to foster the open
participation in data sharing by countries around the world,
and I think that the CDC is particularly well poised to be able
to provide scientific expertise to countries so that there is
an understanding that sharing information about a disease
outbreak can lead to faster control of that outbreak and can
mitigate some of the economic consequences that we have seen
from things such as SARS.
Senator Burr. Globally, these are CDC facilities?
Dr. Besser. Those are CDC facilities. They are done in
partnership, though, with the national ministries of health. In
Cairo, it is in partnership with NAMRU, the naval facility. We
are also working with the Department of Defense to get
information that they have on the health of troops in various
parts of the country. With the number of U.S. personnel
stationed around the globe, this can be, again, another way of
identifying a site where a sentinel event may occur. We are in
discussions with business.
Global business has the ability to know what is going on
with their employees around the world and where diseases may be
cropping up. That is another surveillance tool. And our
Division of Quarantine has a network of travel clinics around
the world which might be a place where a patient with an exotic
disease would be presenting, again, a potential sentinel for a
disease event that we might want to keep out of our borders.
Senator Burr. CDC uses accredited labs across the country
to do work so if there were the fear of a biological or
chemical attack, that the local lab could run the tests.
However, CDC still requires a sample to be flown to Atlanta
before they send out an alert because they believe that it is
the only place they can be assured of the validity of that
test. Is that an accurate statement?
Dr. Besser. I would not take that as an accurate statement.
There are quite a number of laboratories around the world that
provide high-quality----
Senator Burr. I am talking about the domestic network that
we set up.
Dr. Besser. Excuse me?
Senator Burr. I am talking specifically about the domestic
laboratory network that we set up.
Dr. Besser. Oh, the Laboratory Response Network?
Senator Burr. Correct.
Dr. Besser. There are certain tests that are only run at
the laboratories in Atlanta, but there are--the Laboratory
Response Network, one of the major advantages of that is that
it provides high-quality standardized assays around the
country.
Senator Burr. It is my understanding that their results
today would not necessarily trigger a regional or national
alert, that wouldn't be done until the test had actually been
done again in a CDC facility in Atlanta. If I am wrong on this,
I am wrong and you can correct me. I guess my comment would be,
isn't it disingenuous that we are having some conversations
about doing things in real time, yet we have got some paradigms
in place that don't allow us to trust--[ringing microphone]. It
is just a magnetic personality on the part of Dr. Besser.
[Laughter.]
That doesn't allow us to trust the assets that we have got
out there, and I would only ask you, if we really want to do
things in real time, if that is such an important step, and I
believe it is absolutely vital, especially for the unknown in
the future, don't we have to be willing to trust the labs that
we have accredited?
Dr. Besser. I agree with you fully, that the value of the
response network is greatly diminished if we are not going to
believe the results that come out of that network. You know, I
would be happy to address any specific examples that are of
concern.
With, for example, the Pennsylvania anthrax event that took
place recently, it was essential that the islets get to Atlanta
for different testing, the sorts of testing that we could do in
Atlanta that aren't done at the regional labs, or we can
compare the strain of anthrax there with other strains to
determine, is it most likely a laboratory-based strain which
might indicate something more likely to beg a terrorism event,
or is it a wild-type strain? We are able to do testing to
determine what antibiotics could be used to treat that strain.
Those are not assays that are available at the other end.
So from my perspective, you have things going in parallel.
You have the LRN, which is identifying that, which triggered
the response, and I think quite appropriately, but we at the
same time moved to get that islet as quickly as possible down
to Atlanta.
Senator Burr. I certainly understand the need to mine down
the sample to learn as much as we can. I just believe it is
vital that we not delay notification because we haven't
physically done the test in Atlanta, and clearly one would
want, even before you have mined it, to put out an alert, if
you know there was an anthrax attack.
You mentioned CDC's role in workforce training through the
EIS program and the meta-leader courses. How many State and
local public health officials get trained in these programs and
what is the capacity to expand these programs in the future?
Dr. Besser. The EIS program--I am a graduate of Epidemic
Intelligence Service. That was my entry into public health. It
is the entry point for a lot of people who go on to leadership
positions in Federal, State, and local public health. There are
roughly 60 to 80 people who are trained, who enter each class
each year. It is a 2-year applied field epidemiology training
program. I don't have the statistics in terms of how many of
the people at State and local levels came through the EIS
program, but that is something we would be able to provide.
The program itself though, just with those very numbers, is
not the way that we are going to be able to achieve training of
our entire public health workforce. Currently, with the
preparedness funds that CDC receives, we fund 52 Centers for
Public Health Preparedness. One of the main functions of these
Centers for Public Health Preparedness is to try to link
together academic universities and schools of public health
with State and local public health practitioners.
It has been recognized that there is a real gap, that there
hasn't been as strong a tie as there should be between the
academic public health community and the applied public health
community, and the Centers for Public Health Preparedness is
just one way to try and bridge that, by providing training on
the ground, developing certificate programs in preparedness so
that there are set skills that are accepted that people should
have if they are going to be practicing in public health.
Senator Burr. Well, clearly, that is a partnership that we
need to focus on and expand because that is the next generation
of our public health infrastructure, which are the workers that
potentially come out of that academic surrounding.
Our Nation has been expanding our capacity to research
existing and emerging biologic threats, including biosafety
Level 4 labs. We have a limited number of researchers with the
expertise to work in those labs. What steps can we take to
ensure that the research at these labs are safe and the highest
quality possible?
Dr. Besser. Chairman Burr, the CDC has a very important
role in terms of making sure that the individuals who are
working in these laboratories are appropriate and that the
procedures that are followed ensure safety. The Select Agent
Program is one of the divisions located in my office, and the
Select Agent Program is responsible for working jointly with
the Department of Agriculture and the Department of Justice to
ensure that individuals who are working in those labs have the
appropriate clearance and for developing standards for how
agents should be handled by individuals working in those labs
to maintain the safety of the individuals and the security of
the agents.
Senator Burr. I remember when we did the Select Agent
Program. I remember very vividly that the CDC did not want that
program housed at CDC. I won't ask you for your preference
today, but I would take for granted that we are in a much
better situation today than we were in 2002 when we passed the
legislation and gave CDC the responsibility, is that a fair
statement?
Dr. Besser. I think that is a fair statement. I think that
CDC is committed to making that program successful and I think
that since its implementation, the safeguards that are in place
are making the country much safer.
I think that one of the challenges that we now face is
putting in place mechanisms for appropriately sharing the
information on Select Agents with trusted agents in each State
health department. It is very important if we are going to hold
the locality responsible for preparedness that they know
whether or not there is a laboratory in their locale that is
working with an agent so they can have response plans in place,
and we are committed to working to achieve that in a safe way.
Senator Burr. Great. Again, I hope that you will make
yourself available to any questions that staff or members, in
addition to what we have had this morning, provide to you.
I am going to end with a statement and not a question. As I
said earlier, we have got a mighty big task in front of us, one
that will require a level of cooperation between DHS, HHS, CDC,
all the partners, quite frankly, all the public health entities
across the country regardless of how big or small the locality
that they might be in.
I think if one looked at the progress that we have made, I
am not sure where the grade would be. The passion has certainly
increased in the past 6 months about the need to get this done,
I think in large part because of the fear of pandemic flu.
Having just come off of Katrina and having had the opportunity
to see what worked and what didn't work, I would hope that
disaster would give us a degree of passion. I would have hoped
after September 11 that the concerns of chemical, biological,
and radiological attacks would have given us the passion to go
at a much faster pace.
I am not concerned with what the trigger is that forces us
to finally design what the 21st century should be from a
standpoint of us addressing all threats and potential attacks,
be it deliberate, natural, or accidental, but I am confident
that we have got to have willing partners, and for the role
that CDC will play in that and specifically your leadership
there, we are grateful for your insight. We are grateful for
the passion that you bring to that job. I encourage you to be a
full partner in this process as we go through trying to design
the blueprint for the future. It will, hopefully, address the
needs that we have for the threats that we know about today.
The question is, are we smart enough to design a template
that enables us to address the threats that we don't know about
for tomorrow. I believe we can do that, and I believe that we
owe it to the American people to do it. But again, it will take
a leap of faith on the part of all of us to find the common
ground that puts us there.
Thank you for your testimony today.
Senator Burr. At this time, I would like to call up the
second panel. I will wait for them to come up to introduce them
individually.
If everybody has gotten settled, I understand that the
structure for this part of it is that we have submitted
questions to everybody and that rather than extend the
opportunity for a lengthy opening statement, individuals will
have an opportunity to respond to a set of questions that were
supplied. Clearly, we have 1 hour and 15 minutes targeted for
this piece of the hearing. I will certainly give you the
latitude for whatever statement any of you would like to make
in addition to the questions that were provided for you.
At this time, let me just introduce everybody en bloc and
then we will work our way around the table, starting to my
right. Michael Caldwell is Commissioner of Health, Dutchess
County Health Department, Immediate Past President of the
National Association of County and City Health Officials.
Michael, welcome.
Peggy Honore, Chief Science Officer, Senior Deputy Advisor,
Mississippi State Department of Health. Welcome.
Nicole Lurie, Senior National Scientist and Paul O'Neil
Alcoa Professor of Policy Analysis--that is a long one. Welcome
and congratulations.
Elin Gursky--Elin is the Principal Deputy for Biodefense,
National Strategies Support Director. Welcome.
Tara O'Toole, CEO and Director, Center for Biosecurity at
the University of Pittsburgh Medical Center. Welcome again,
Tara.
And Lisa Kaplowitz, Deputy Commissioner for Emergency
Preparedness and Response, the Virginia Department of Health.
Dr. Kaplowitz, welcome.
Dr. Caldwell, let us start with you.
STATEMENT OF MICHAEL C. CALDWELL, M.D., COMMISSIONER OF HEALTH,
DUTCHESS COUNTY HEALTH DEPARTMENT, AND IMMEDIATE PAST
PRESIDENT, NATIONAL ASSOCIATION OF COUNTY AND CITY HEALTH
OFFICIALS (NACCHO)
Dr. Caldwell. Good morning, Mr. Chairman, Senator Burr. It
is a special distinct honor for me to be here with you today,
especially knowing that my grandparents are in good hands in
Pinehurst, North Carolina.
Senator Burr. We are delighted to have them there.
Dr. Caldwell. I am here as a local public health official.
I have been one for 12 years now in Dutchess County, New York.
I am an internal medicine physician and I serve under our
county executive, William Steinhouse. We are the home, as you
probably know, of Franklin Delano Roosevelt, so we get a lot of
inspiration in difficult times, right on the Hudson River.
We were greatly impacted by September 11, just north of New
York City. Our mayor of the city of Poughkeepsie lost her
husband that day. Right afterwards, an anthrax--when the NBC
studios were hit, people came home to Dutchess County and went
to their local hospitals and I got phone calls asking me, as
the local health official, how could I help them? I distinctly
remember a father of an Eagle Scout who called me saying he got
a congratulatory letter from Senator Daschle. What should he do
with the letter? It was dated the same day the anthrax came
about.
So we deal on the local public health departments with
unusual events, but we also, more importantly, deal with day-
to-day events--outbreaks at schools, outbreaks in swimming
pools, and also outbreaks that might just be of a major public
health concern, like meningitis that we just had in Marist
College, where we lost a young freshman girl and we had to be
there to respond.
The most important message that I would like to bring to
you today is that we need to integrate all of our new
surveillance systems into our daily activities. I thought you
made an excellent point in the first panel where you said that
there were two States that responded to Katrina, and you saw
how one had a surge capacity plan and one had an integrated
plan where they were constantly practicing their drills, and I
think you really hit the nail on the head where you saw how you
had a State that was integrative, practicing, and making sure
that they were communicating.
After September 11, I became a card-carrying member of the
Dutchess County Chiefs of Police Association. I don't think you
would have seen that before September 11. The main point is
that we are building relationships and we are working together
and we are conducting exercises together in ways we have never
done before. Thank you.
[The prepared statement of Mr. Caldwell follows:]
Statement of Michael C. Caldwell, M.D., M.P.H., Commissioner of Health,
Dutchess County Department of Health, New York
Chairman Burr, Senator Kennedy and other distinguished Senators,
Good Morning. My name is Dr. Michael C. Caldwell, MD, MPH and I am the
Commissioner of Health in Dutchess County, NY, home of Franklin &
Eleanor Roosevelt, and I serve under County Executive William R.
Steinhaus. I come before you today as an internal medicine physician
and a public health officer with 12 years of experience in local public
health practice. I also currently serve as the Immediate Past President
of the National Association of County & City Health Officials (NACCHO)
and so my views are informed from my contacts with my colleagues from
across our country. I'm pleased to present you with some of my thoughts
and insights today as you prepare to reauthorize the Public Health
Security and Bioterrorism Preparedness & Response Act of 2002.
Strengthening our public health infrastructure (local, State and
Federal) is essential to our preparation for and response to health
threats to our citizens. Expanding our public health capabilities will
serve to protect the overall health of our Nation.
Paramount to this effort should be the investment in the expansion
and continued training of our public health workforce. As this
workforce is strengthened, it also needs to train and be further
integrated with our traditional emergency response partners in police,
fire, emergency medical services, as well as our colleagues in the
broader health-care, educational, business, intelligence and criminal
justice communities. Public health practitioners cannot and do not work
alone. Public health departments are the community leaders in improving
preparedness for public health emergencies but they are wholly
dependent on the participation of a full range of community partners
who will be engaged in the local response to such an emergency. This
includes the partners noted above as well as local emergency managers,
elected officials, hospitals, physicians and other health care
providers. Overall, the functionality of a public health infrastructure
in protecting communities is highly dependent on skilled, trained
people from many disciplines who plan and exercise their plans together
and engage in a process of continuous relationship building and
improvement based on the outcomes of each exercise or each real event.
I have responded to the three specific questions that the subcommittee
has requested below.
Question 1. How do we best make progress towards a national public
health infrastructure with real-time situational awareness?
Answer 1. No disease surveillance system can work without our
workforce of clinicians as a core foundational component. The astute
clinician is the source of most pertinent data on the occurrence of
symptoms and the diagnosis of disease, regardless of how that data are
subsequently reported and analyzed. Clinicians are often the first
persons in a position to set off a public health alarm if they note an
unusual finding. One of the best-known examples of the benefits of
strong clinician/public health department relationships was the early
identification of the first case of anthrax in Palm Beach County,
Florida in October 2001. An alert physician who treated the first
victim was immediately suspicious and alerted the director of the
county health department, who expedited a laboratory diagnosis and the
initial response, which then led to prompt activation of the local
emergency response system. This was a success resulting from conscious
efforts to develop good working relationships between clinicians and
public health. It did not happen by chance. More common is a call that
my staff or I will receive from an infection control nurse or doctor at
one of our local emergency rooms about suspected infectious diseases
such as meningitis. This happened to us in Dutchess County two times
since November. Our most notable case was when we lost a young 19-year-
old student from Marist College. This resulted in a swift and
comprehensive public health investigation and response, not only in our
community, but in the student's hometown over 100 miles away. We
reacted quickly with well-practiced communication and coordination.
These skills will be put to use in any similar or more challenging
incident that our County may face.
The elements of situational awareness, including lab and hospital
reporting, interconnected surveillance systems, consistent epidemic
monitoring and reporting, are all important tools and we fully support
their further development. Local, State and Federal public health
practitioners alike would benefit from improvement in the availability
and analysis of real-time information on the occurrence of symptoms and
diagnoses. However, we must be mindful not to rely on them exclusively.
For instance, lab reporting is important to confirm clinical
observations and track trends, but it usually comes too late to
identify an outbreak early. Similarly, hospital reporting depends on
personnel entering accurate clinical data on a timely basis. Some of
the most effective local disease surveillance systems have made use of
public health personnel who are out-stationed or in regular contract
with hospital emergency rooms. They have the ability either to observe
events or to discuss them directly with the ER staff. In some
jurisdictions, they can then enter information into a system that
aggregates the data and provides a real-time picture of the patterns of
disease that are occurring in the community. Hospital-based
surveillance also has its limitations, however, because it does not
detect disease until it has grown serious enough to require a hospital
visit.
Physicians and other health care providers are essential in
reporting clinical suspicions early. Until we have a universal
electronic medical record, interoperable health information systems and
accessibility by public health officials to real-time data that
provides protections for patient's personal information, the astute
clinician who knows when and how to notify the health department is our
best defense. As a local practitioner, I believe strongly that skilled
people and the relationships among them are the backbone of any disease
surveillance system. Electronic systems are the tools that help them
but cannot replace them. It is critical that we recognize that our
human public health professionals and affiliated colleagues are the
linchpin to make our growing dependence on sophisticated technology for
biosurveillance both reliable and functional.
The health department itself must have sufficient trained personnel
to receive and respond to disease reports 24/7. This represents a
fundamental change for public health practice, which traditionally has
been able to perform its duties during the work week. Unlike police and
fire departments, which have always worked in shifts to enable 24-hour
protection, public health has transformed dramatically over the past 5
years. We have changed the expectations of our workforce and we have
found ways to stretch and augment existing personnel to provide 24-hour
coverage. Federal funding has provided some assistance but not enough
to get where we need to be.
As a local public health practitioner, I know that real-time
situational awareness will always be dependent on trained people,
effective relationships and easy, prompt communication among them. I
urge the subcommittee to give equal weight to this essential dimension
of local situational awareness, as well as to the continued development
of technologies that will facilitate the rapid acquisition and
management of knowledge about disease in a community.
Question 2. How do we recruit, train, and retain a prepared public
health workforce with the ability to respond to national threats--
whether acts of terrorism or by Mother Nature?
Answer 2. Expanding and improving the public health workforce has
two dimensions. The first is the ``pipeline''--the motivation and
number of individuals wanting to enter a public health profession and
the availability of mentors and an education to do so. The second, and
often over-looked, is the training of persons who are already employed
in health departments or in other sectors of the community.
In a public health emergency, the entire workforce of a public
health department and many other public sector employees will engage in
a response, aided by volunteers and other community partners in the
private sector. Locally, we need the flexibility to relieve all such
potential responders of their normal duties long enough to train and
exercise for emergencies. Police, fire and military personnel systems
routinely plan for ongoing training and expansion of skills to prepare
for the worst. Public health departments have traditionally been
chronically understaffed and have not been able to do this. When
personnel spend time preparing for their emergency roles, the work they
would ordinarily do does not get done in a timely fashion, if at all.
Establishing a scholarship and loan forgiveness program for public
health professionals who complete academic programs in shortage areas
and enter public service is one approach to expanding the pipeline. The
Public Health Preparedness Workforce Development Act proposed by
Senators Hagel and Durbin is a good model. However, we cannot expect it
to solve all shortages. Indeed, most local health department personnel
have come to public service through routes other than professional
training in public health. Therefore, we must in tandem rely on
retraining and cross-training our current workforce. This will require
extra funds for this purpose and some greater flexibility in the uses
of our personnel.
The key to a prepared workforce is to define systematically the
roles and responsibilities of each person in an emergency and the
skills or competencies that they need to fill those roles. We must then
set standards for achievement of those skills, train them in those
skills and then test the training through exercises. We must recognize
that gaining the competencies necessary for an emergency role should be
an element of each health department employee's primary job, whether
that job is restaurant inspector or clinic nurse.
Question 3. How do we develop public health systems research,
paramount for developing evidence-based best practices and benchmarks,
for an all-hazards public health response?
Answer 3. There can be no substitute for public health system
research based on real experience in real communities. Moreover,
developing an evidence base for public health response requires
examining not how the public health system operates in isolation but
how it operates in the context of the entire community response.
The best way we know to develop evidence of what is needed for a
successful public health response is an iterative process of planning
and exercising. Such a process entails making a community-wide plan
that involves all the relevant responders, training all responders for
their role in executing the plan, exercising the plan on a large scale,
doing an after-action report to identify where and why the plan didn't
work, changing the plan accordingly and exercising it again to
determine whether the changes made a difference. It will then be
possible to identify the inputs into the response that generated the
outcome.
It is essential to recognize that the public health response never
involves just public health and medical personnel. Our partners in
police, fire, emergency management, schools, and businesses, as well as
our community's health care providers, will have important roles in a
large-scale event, such as widespread influenza. Best practices and
benchmarks for public health performance will not be meaningful unless
that performance is evaluated in the context where it will really
happen--in an exercise that involves a community's entire emergency
management system that is operating as required under the National
Response Plan and is compliant with the National Incident Management
System.
Public health systems research would benefit from involving other
disciplines not commonly associated with public health. For instance,
the health department in Montgomery County, Maryland engaged systems
engineers from the University of Maryland in applying queuing theory to
the problem of how to organize a mass vaccination clinic most
efficiently. The result of their collaborative research and development
was software that they and others are using to streamline their systems
for mass dispensing of pharmaceuticals and mass vaccination.
Overall, our public health infrastructure has improved since 2001
but it still requires further investment, development and evaluation. I
appreciate the thorough and serious effort that you are making to
understand and strengthen our country's public health capacity and
capability. Protecting and defending our citizens health is of
paramount importance for our society to function in a time of crisis.
The time to prepare and strengthen our public health infrastructure is
now at hand.
I wish you all the very best as you work to improve the Public
Health Security and Bioterrorism Preparedness & Response Act of 2002.
Thank you for the opportunity to present my thoughts to you this
morning.
Senator Burr. Peggy.
STATEMENT OF PEGGY A. HONORE, CHIEF SCIENCE OFFICER,
MISSISSIPPI DEPARTMENT OF HEALTH
Ms. Honore. Thank you, Mr. Chairman and other distinguished
committee members. Thank you for this opportunity to present to
you today. I am Peggy Honore, Chief Science Officer of the
Mississippi Department of Health. I currently also lead a
national Robert Wood Johnson-funded initiative to advance
fields of study in public health systems research and public
health finance.
The challenges facing the public health system today are
daunting, particularly since the system was characterized
nearly 20 years ago as being in disarray by the Institute of
Medicine. Even since then, preparedness has emerged as an
additional critical function. Numerous reports over the past
decade have warned of an imminent workforce crisis. Very little
is known about the finances that fund the system. And reports
have consistently said that public health has struggled to
clearly and concisely articulate its role to the public.
The Mississippi Department of Health has taken a leadership
role to implement technology statewide for real-time diagnosis
of disease and other threats, to increase biosurveillance
activity. This was probably most evident during the recent
Katrina events. However, we also feel that a national real-time
situational analysis system is contingent upon the confluence
of a number of factors. These include establishment of national
evidence-based guidelines for implementation, sufficient levels
of funding, clear government roles, and appropriate workforce
competencies, all of which I will address at the appropriate
time.
Senator Burr. Great.
[The prepared statement of Ms. Honore follows:]
Prepared Statement of Peggy A. Honore, DHA, MHA, Chief Science Officer,
Mississippi Department of Health
EXECUTIVE SUMMARY
Public Health Preparedness in the 21st Century
Daunting challenges facing the public health system
Institute of Medicine characterization as in disarray
Challenges and unanswered questions are growing
exponentially
1. How do we best make progress towards a national public health
infrastructure with real-time situational awareness?
Voluntary jurisdiction disease reporting is not adequate
to protect all Americans
Biosurveillance must be the standard public health
practice
Automated electronic disease surveillance systems for near
real-time disease detection adopted throughout the United States and
particularly the State of Mississippi Department of Health (MDH)
Situational-awareness systems implemented in MS for timely
notification and investigation, increased diagnostic capabilities for
common and exotic conditions utilizing high quality photographic
imagery, exposure identification and reporting system in 400 ambulances
and 75 hospital ERs, electronic surveillance technology in all
hospitals
Assurance of a national system contingent on confluence of
interrelated factors that include evidence-based guidelines, adequate
funding, clearly defined governmental roles at all levels, sufficient
workforce competencies
Evidence through research needed to assess organizational
structure compatibility with desired systems, identification of
performance metrics, establishment of workforce competencies
2. How can we recruit, train and retain a prepared public health
workforce with the ability to respond to threats?
64 percent of MDH employees deployed in aftermath of
Katrina
Comprehensive training in disasters nursing and special
needs sheltering for MDH staff and 2,000 First Responders
Dire assessments of workforce such as lack of education,
non-competitive salaries, and high turnover rates threatens stability
Assessment of workforce capacity to support vision for
complex situation-awareness systems
Educational level for 60 percent of MDH workforce less
than bachelors degree
Void in career track below MPH level
MPH curriculum insufficiency to address needs in public
health finance
No datasets on jurisdiction funding levels similar to what
is available for school districts in America
IOM unable to provide guidance on workforce and funding
due to scarcity of research and evidence
Borrow models from other disciplines such as psychology,
pharmacy, and engineering
Partner with nation's Community College Systems
Shift from training to educating the workforce--MDH
Collaboration for Workforce Education with the MS Community College
System
Support for Public Health Preparedness Workforce
Development Act
3. How do we develop public health systems research, paramount for
developing evidence-based best practices and benchmarks for an all-
hazards public health response?
Research documented as one of the 10 Essential Public
Health Services
National research provided valuable insights into
variability of preparedness spending and impacts
Lack of standardized performance metrics
Examinations needed for funding prioritization and
guidelines, public health system impact to 75 percent not receiving
antivirals, system capacity to implement all-hazards plans, assessment
of public health funding sources, uses, and effectiveness
Modeling needed to assist mass evacuation, staff
deployment, special needs sheltering
Public health system lacks evidence for best practices and
datasets for benchmarking
Research as a QI fabric issue woven through all aspects of
the system including and particularly practice
Lack of attention 10 years after observation of little
research and measures to examine performance
National initiative to strengthen public health systems
research is fundamental, urgent, and essential
Mr. Chairman, other distinguished subcommittee members and meeting
participants, thank you for the opportunity to present at the March 28,
2006 roundtable titled Public Health Preparedness in the 21st Century.
I am Peggy A. Honore, Chief Science Officer for the Mississippi
Department of Health. In this role, I currently lead a national Robert
Wood Johnson Foundation funded initiative to advance fields of study in
public health systems research and public health finance as a means of
bridging knowledge gaps between science and the practice of public
health. Support for this work is viewed as critical to ensuring a
robust public health infrastructure grounded in sound evidence-based
practices to ensure the safety and well-being of all Americans.
The practice of public health in America is delivered through a
complex system of organizations and industries working to ensure
conditions in which all citizens can be safe and healthy. This enormous
operational structure makes understanding the connected dynamic
relationships in the system a complex challenge. My observations on
this challenge and the three questions that we are to address today
come from the unique perspective of having served in the three diverse
areas of private industry, government (State and Federal) and academia,
primarily as a practitioner and transitioning into practice-based
research.
The challenges facing the contemporary public health system are
daunting particularly since the system was characterized nearly 20
years ago by the Institute of Medicine (IOM) as being in disarray.
Since then, preparedness has emerged as an additional critical
function. Numerous reports for over a decade have warned of an imminent
workforce crisis. Very little is known about the finances that fund the
system and the profession has struggled to clearly and concisely
articulate its role to the public. Open dialogue on these issues that
put all Americans at risk are fundamentally essential and my remarks
are offered with the highest degree of appreciation for being included
in the discussion.
(1) How do we best make progress towards a national public health
infrastructure with real-time situational awareness?
In the post 9-11 era, it has become apparent to the public health
community that voluntary disease reporting by jurisdictions is simply
not adequate to protect Americans from the current threat of
intentional and naturally-occurring disease outbreaks. The recent
anthrax attacks via the postal system and global concerns about an
influenza pandemic are good examples of this ever-changing threat. In
response, a much more proactive approach to disease detection has been
adopted throughout the United States and specifically in the State of
Mississippi. Now, automated, electronic syndromic disease surveillance
systems are beginning to be used to supplement the historically proven
and still critical reporting by physicians, hospitals, and clinical
laboratories.
As a direct benefit of Bioterrorism Preparedness and Response Act
funding, the Mississippi Department of Health (MDH) has taken a
leadership role to implement technologies throughout the system for
near real-time diagnosis of disease and other threats. Most important,
the only practice and academic partnership in the Nation for syndromic
surveillance that I am aware of is with the MDH and University of
Mississippi Medical Center. The MDH working with vendors have
implemented several systems in Mississippi as listed below.
TheraDoc--technology that integrates individual electronic
patient records with clinical data, global medical knowledge and
institutional protocols. The system has been implemented at the
University of Mississippi Medical Center in Jackson and will facilitate
timely notification and investigation of reportable diseases and
suspect conditions directly to authorized MDH staff.
Visual Dx--diagnostic reference software that includes
continuously updated high quality photographed images of diagnostic
possibilities. This system was developed for military and first
responder field use. It will assist front-line clinicians to correctly
identify and differentiate clinical syndromes resulting from the
intentional use of biological agents. For example, few physicians
currently practicing in the United States have ever seen an actual case
of smallpox or anthrax, and this system is being deployed to the local
hospitals that will likely serve as the entry point into the healthcare
system of the first case of an illness that might result from a
terrorism attack. The training value of this system to clinicians will
be immeasurable if we ever have a biological event in our State.
ThreatScreen--an exposure/identification, data collection,
and reporting tool used to quickly access victims to determine
chemical, biological, or nuclear agent exposure and where data is
shared in real-time through a wired or wireless connection. The system
is being installed throughout the entire Mississippi Emergency Medical
Services Trauma Care System. The application will be available in all
480 licensed ambulances and 75 hospital emergency rooms.
Early Aberration Reporting System (EARS)--an electronic
syndromic surveillance system that is being installed in hospitals
throughout the State. This system will provide sensitive and timely
notification of both intentional and naturally-occurring disease
outbreaks anywhere in the State that will permit a more timely, life-
saving response.
These information technologies have greatly enhanced the
department's capacity for Biosurveillance. However, ensuring a national
real-time situational awareness system is contingent upon the
confluence of a number of interrelated factors. These include
establishment of national evidence-based guidelines for the
implementation of such systems, sufficient levels of funding for
implementation, clear roles and responsibilities for Federal, State,
and local agencies, and appropriate competencies at all levels in the
public health workforce to operationalize and maintain the systems.
While much has been accomplished at the Federal level to develop IT
situational-awareness systems, it is unclear if examinations, through
research or evaluations, have been conducted to document best practices
or to facilitate course corrections. Examinations are warranted to
address questions such as: what is the impact of organizational
structure (e.g. centralized, decentralized, or regionalized) at the
State and local levels to effective implementation of situational-
awareness systems; what metrics determine organizational capacity to
implement such systems; and what are the workforce competencies and
skills needed prior to implementation to operationalize an effective
system?
Biosurveillance must be a standard practice in public health and
the knowledge acquired through research and evaluation would provide
some degree of assurance that the system is truly evidence-based and
capable of protecting us all.
(2) How do we recruit, train, and retain a prepared public health
workforce with the ability to respond to national threats--whether acts
of terrorism or by Mother Nature?
Over 64 percent (1,400 employees) of the MDH workforce was deployed
to respond in the aftermath of hurricane Katrina. A comprehensive
workforce-training program was established over the past 3 years using
Bioterrorism Preparedness funding. Statewide disaster nursing and
preparedness training was provided to all nurses and environmental
health specialist through the University of Mississippi Medical Center
and State community college system. Training was focused on building
competencies for disaster nursing and management of special need
shelters during disasters. Besides the MDH employees trained, we also
provided training to over 2,000 first responders across the State.
From a system-wide perspective, a reality that threatens the
stability of the public health system is the dire assessments of its
workforce. Key findings documented through various research efforts
include lack of formal education and training in core public health
education, recruiting difficulties, non-competitive salaries and high
turnover rates. Unlike other professions, there is no common skill set
established for entrants into the profession of public health. And the
lack of professional licensure and credentialing in key functions
serves to weaken the system. Without attention to this problem, do we
know if the workforce is capable of supporting the vision for all-
hazards preparedness utilizing complex situational awareness systems?
The Master of Public Health (MPH) is touted as the entry into the
field. Ironically, in the MDH over 60 percent of employees have
educational levels less than a bachelor's degree. These workers have
already entered the profession but lack opportunities for public health
education at the undergraduate level because the entry degree is the
MPH. Also, recent research into finance courses of MPH curriculums
found that the content is directed more to the medical care delivery
system than to providing finance skills needed in public health
settings. Because attention in academia has been focused on the
financial components of the medical care delivery system, is this a
contributing factor to why we know so little about the sources, uses,
and effectiveness of funding for public health? Unlike data for every
school district in America, data are not readily available to determine
county level funding allocations to public health services in each
jurisdiction. In 2003 the IOM even reported that attempts to provide
guidance on workforce and funding for the public health infrastructure
was not possible due to a scarcity of research and evidence to support
such recommendations.
A significant research finding by the IOM and others is the lack of
collaboration between schools of public health and health departments.
This gap between practice and education serves as a chasm that further
divides science from practice. Strategies should be formulated, funded
and implemented that provide opportunities for more structured
collaborations between health departments and schools of public health
based on models from academic medical centers.
Public health should also research workforce models implemented in
other professions to bridge gaps between practice and science. The
community psychology doctorate degree, focused on population and
organizational level interventions, emerged in the 1960s. Leaders in
that profession recognized the need for professionals to be trained in
population level evaluation and analysis compared to the more
traditional clinical or individual level.
An additional strategy that can be borrowed from other professions
such as pharmacy and engineering is to reach out to the Nation's system
of community colleges. Over 65 percent of all healthcare workers have
some level of training at community colleges. Both professions have
collaborated with community colleges and universities for joint
programs leading to doctorate degrees. This could serve as an ideal
mechanism to expand diversity in the public health workforce since 40
percent of community college students are from underrepresented
populations. The MDH is currently developing a model to educate the
existing and future public health workforce through the State's
community college system. The program will provide opportunities for
public health tracked associate degrees that articulate to 4-year
institutions. This movement from training to educating the workforce
creates a paradigm shift that serves to the benefit of public health,
the individual, and society.
The Nation should also invest in the current and future public
health workforce by enacting the Public Health Preparedness Workforce
Development Act (S. 506). Public Health simply cannot attract the
talent needed for a sustainable public health system without this level
of Federal commitment. The best and brightest of physicians,
epidemiologist, laboratory technologist, information specialist,
researchers and others critical to a robust system will simply go
elsewhere.
(3) How do we develop public health systems research, paramount for
developing evidence-based best practices and benchmarks, for an all-
hazards public health response? Do issues ranging from disease
forecasting to financial modeling of Federal and State public health
investments need further study? How is ``public health preparedness''
best defined and what are the metrics for measuring success?
The function of research was identified as one of the 10 Essential
Services of public health agencies in the early 1990s. The role of
research and its relevance to effective preparedness is valued by the
MDH. The MDH is one of only a few health departments in the Nation with
an Office of Science dedicated to ensuring that evidence-based
practices are embedded throughout the agency. The function is practice-
based and aligned with goals of using research combined with a
development function to implement effective practices and services.
After many decades of inadequate funding, the Public Health
Security and Bioterrorism Preparedness Act of 2002 provided valuable
funding to build disaster preparedness and response capacity at the
State and local level. A few national research projects have provided
valuable insights on the wide variability of how the funding has been
utilized while also trying to assess the impact on system preparedness.
Lack of available data has made some examinations particularly
challenging. And it has not been abundantly clear how preparedness
performance could be systematically measured given the lack of widely
accepted standardized performance metrics. There are many other
critical areas of research that warrant attention as well. In addition
to some research topics laced throughout this document, others include:
(a) modeling to assist with prioritizing State and local level
funding decisions
(b) examinations of lessons learned from Katrina and other
disasters to determine the impact of funding decisions to effective
preparedness
(c) determination of system impact on 75 percent of the population
that will not receive antivirals
(d) comprehensive examinations of national, State and local
spending on preparedness
(e) examinations to identify system preparedness as well as
programmatic performance metrics
(f) comprehensive datasets to facilitate benchmarking
(g) comprehensive examinations at the Federal, State, and local
level of the composition, utilization, and sources of funding for the
public health system
(h) modeling to assist with mass evacuation planning, staff
deployment, and special sheltering needs
(i) impact to the public health system of staff redirected to acute
care during disasters
(j) impact to traditional public health functions during disasters
(k) examinations to determine system capacity to implement Federal
all-hazards disaster plans
We cannot build, let alone sustain, a public health system lacking
the evidence for best practices for traditional functions as well as an
all-hazards public health response. Research is the instrument for
examinations to understand the complex system dynamics of public health
practice. It is a quality improvement fabric issue that should be woven
throughout all components of the system. However, it seems somewhat
ironic that Federal preparedness grant guidelines prohibit utilization
of any funding for research. The Center for Studying Health Systems
Change noted in 1996 that the public health sector, unlike the medical
care system, had very little research and measures that could be used
to examine the performance of the system. A decade later, very little
progress has been made to address the problem.
A powerful method to defining, measuring, and sustaining capacity
for public health system preparedness would be to establish a national
initiative dedicated to strengthening research efforts. The primary
purpose should be to coordinate national preparedness research efforts
and to ensure that the public health infrastructure is intact to
protect the safety and health of all Americans. The program should be
structured to primarily fund collaborations between academia and
practice agencies (to ensure practicality, relevance, and translation)
with the intent of establishing demonstration projects for replication
nationwide. Insuring preparedness through science is fundamental,
urgently needed and essential. Research has been noted as a fundamental
service of public health practice. Every disaster creates an elevated
sense of urgency. And shared interests for a safe and secure America
make it essential.
Senator Burr. Dr. Lurie.
STATEMENT OF NICOLE LURIE, M.D., SENIOR NATIONAL SCIENTIST AND
PAUL O'NEIL ALCOA PROFESSOR OF POLICY ANALYSIS, THE RAND
CORPORATION
Dr. Lurie. Thank you, Senator Burr, for the opportunity to
be here today. I won't reiterate what my colleagues here have
said, and many of my comments obviously are in the written
testimony. I do want to point out that my comments today and my
testimony are based largely on research that my colleagues and
I at RAND have done over the past 3 years. This has included
evaluations of public health preparedness in two States,
California and Georgia, as well as a series of projects we have
done for the Office of the Assistant Secretary for Public
Health Preparedness at HHS.
In the course of this work, we have conducted 32 tabletop
exercises around the country in different local health
departments on topics ranging from smallpox and anthrax to
pandemic flu. We have also site visited and done key informant
interviews with people in 44 different communities and 17
States. So I think we are getting a pretty good sense of what
the lay of the land is with regard to public health
preparedness.
First, I want to say that over the time that we have been
doing this, we have seen evidence of substantial improvement
and we are very encouraged by the fact that, by and large, this
investment appears to be paying off. What I want to focus my
remarks on this morning are on the sort of commonly seen gaps
that we see across the country, because I think it is fair to
say that we see them over and over and over again. Some of them
are things we have discussed this morning and some of them
aren't.
The first is the continued set of gaps in public health
epidemiology and investigational capacity, the issues related
to shared situational awareness and workforce competency to be
able to evaluate EPI information and to go ahead and
investigate and outbreak.
The second relates to persistent confusion at all levels
about who does what, when in an emergency, and we see this in
almost every exercise we have done. There is a lot of confusion
about when you stand up an incident command structure, open an
Emergency Operations Center, when it is a local, State, or
Federal responsibility to handle the issue at hand.
And along with that, there is persistent confusion about
what the role of public health is in responding to some of
these public health events. I think we have done much better in
the relationships, looking at the relationships between public
health, fire, police, and other emergency responders, but I
think there is still an awful lot of gray area and fuzziness
about what to do there.
The next area that I want to highlight is the one of
vulnerable populations, and I will use the term vulnerable
fairly loosely. But by and large around the country, special
needs populations, vulnerable populations, ethnic and minority
groups have been, by and large, left out of the public health
preparedness discussion. In an emergency, it is going to be
critical that everybody is able to be reached, that everybody
trust their government to the extent possible to do what needs
to be done. We know there are large groups of people that can't
be reached, largely because of language issues or sometimes
because they are remote or because they don't necessarily trust
government, and so special efforts need to be made in the
planning phase to be able to work on the response phase that we
need to work on.
The next area I would like to highlight is obviously one in
the area of questions and that is workforce development, and to
highlight two things. First is to say, we are only going to get
good people to join the public health workforce if they see a
career path ahead of them, and if the funding for this isn't
stable, people aren't going to see a career path ahead of them
and are going to choose to do other things.
The second, which I highlighted in my written testimony,
are two big gaps, one in leadership development, and I am
delighted to hear that the CDC is starting to address this, and
the other is quality improvement. Time and time again, we do
exercises with people who discover the same gaps that they
discovered in the last exercise, or the exercise before. And by
and large, there hasn't been an institutional culture or
potentially the know-how about how to fix those gaps.
And finally, the other issue that we can talk about later
is the criticality of defining preparedness and being able to
measure it. We are now 3 or 4 years into this effort. We still
don't have a set of performance measures that we are really
happy with and a set that can be objectively tested, so there
is work to do there both on the research side and the
implementation side. Thank you.
Senator Burr. Thank you.
[The prepared statement of Dr. Lurie follows:]
Prepared Statement of Nicole Lurie,\1\ M.D., M.S.P.H., Physician and
Public Health Researcher, The RAND Corporation
My name is Nicole Lurie, M.D., M.S.P.H. I am a physician and public
health researcher at RAND. As you know RAND is a non-profit, non-
partisan think tank whose mission is to improve public policy. Health
is our fastest growing and largest unit and many of us are passionate
about making a difference in public policy. I am happy to have the
opportunity to share my thoughts on public health preparedness in the
21st century. My comments will be based largely on the research that my
colleagues and I have done at RAND in the past 3 years. This includes
evaluations of public health preparedness in two States--California and
Georgia, as well as a series of projects we have done for the Office of
the Assistant Secretary for Public Health Preparedness at HHS. In the
course of this work we have conducted 32 tabletop exercises on a range
of issues, including smallpox, anthrax, botulism, plague and pandemic
influenza. In addition, our team has visited and interviewed key
officials from 44 communities in 17 States. Over the 3 years we have
been doing this work, we have seen clear evidence of progress in
preparedness across a range of dimensions, although I'll also be the
first to tell you that we have miles to go before we sleep, especially
as we face the threat of pandemic influenza. It is from this
perspective that I address your specific questions.
---------------------------------------------------------------------------
\1\ The opinions and conclusions expressed in this testimony are
the author's alone and should not be interpreted as representing those
of RAND or any of the sponsors of its research. This product is part of
the RAND Corporation testimony series. RAND testimonies record
testimony presented by RAND associates to Federal, State, or local
legislative committees; government-
appointed commissions and panels; and private review and oversight
bodies. The RAND Corporation is a nonprofit research organization
providing objective analysis and effective solutions that address the
challenges facing the public and private sectors around the world.
RAND's publications do not necessarily reflect the opinions of its
research clients and sponsors.
Question 1. Situational awareness is based on timely lab and
hospital reporting, interconnected surveillance systems, consistent
epidemic monitoring and reporting, and appropriate risk communication.
Currently, there is wide variability across the country in these
capabilities. How do we best make progress towards a national public
health infrastructure with real-time situational awareness?
Answer 1. Our findings corroborate your assessment that the
capabilities to promote situational awareness vary widely across the
country. While we have seen clear evidence of strengthened syndromic
surveillance systems and a much more robust Laboratory Response Network
(LRN), the level of sophistication of information technology, as well
as the ability to analyze and use it, varies widely.
Our research points to two areas of particular need: ongoing
investment in technologies to make possible shared situational
awareness, as well as support for building the human and organizational
relationships needed to get the most out of these technologies.
A key priority is the need for continued investment in
interoperable information technology for routine and enhanced
surveillance, provider notification, outbreak investigation and event
management. The current proliferation of new, siloed systems is
unlikely to accomplish the goal of improving shared situational
awareness. Many are not linked, either within or across States, and
some bypass State and local health departments in the early phases of
data capture and transmittal. Some health departments report challenges
in monitoring multiple systems, particularly those with frequent
``false positives'', while others do not yet have even basic
technologic capabilities in place. Ultimately, these information
systems need to link not only our health departments and laboratories,
but also our hospital emergency and inpatient departments and our
outpatient practices and community clinics. Key to improved situational
awareness continues to be the astute clinician, who in almost every
important outbreak or public health emergency has been the first
reporter. Hence, continuing to strengthen relationships between public
health and the clinician community--linking public health and clinical
practice through robust information systems and communication
networks--remains of paramount importance. I anticipate that continued
building in this area will be needed for at least several years,
followed by support that maintains the gains we make, rather than
falling back into a cycle of disinvestment that will force public
health to backslide once again.
But these investments will be effective only if there is greater
consistency in technological capabilities across public health and
improved linkages among public health departments and between public
health and other organizations with responsibilities for shared
situational awareness and emergency response. While technological
solutions are part of the answer, we also need to recognize the limits
of what technology can do. For example, we need to maintain the ability
to function in a Katrina-like situation, in which Mother Nature
disabled electronic and cellular communication for a prolonged period
of time. We also need to continue to look for solutions to problems
that are unlikely to be touched by improved technology. For example, we
should remember that the Nation's 45 million uninsured may be more
likely to delay seeking care, even in a public health emergency, and
that signals from some populations may be completely missed no matter
what systems are in place for monitoring and reporting. And finally,
the astute clinician is still more likely to pick up the phone and call
the State or local health department than to rely on electronic
reporting.
Priority also needs to be given to strengthening relationships and
improving lines of communication within public health and between
public health and other entities involved in emergency response. Our
research has consistently found confusion about who is supposed to do
what in a public health emergency, and when responsibility shifts from
local to State or Federal entities. And there are still communities in
which public health and other first responders lack equipment to
communicate with one another in an emergency. Strengthened
relationships and improved communication will help mitigate these
problems, but technology alone will not make them go away.
Continued support for relationship building across entities--
including health and public health, emergency response, etc.--to
develop and enhance shared situational awareness--is needed. The
transformation of public health is bringing together people from very
different cultures, including military and first responder communities
and public health. Technology puts people in touch with each other, but
relationships, shared mental models and shared language and vocabulary
is what allows them to ``communicate.'' Fortunately, relationship
building can be facilitated through continuing support for the process
of planning and continued exercising. Moreover, one clear area in which
Congress can help is to insist on greater congruence and consistency
among program guidance from different agencies, including DHS, CDC and
HRSA and others. Currently, the guidance provided by these
organizations is often confusing, inconsistent, and at times
contradictory. These organizations should be strongly encouraged to
focus guidance on shared, crosscutting capabilities. Future funding
should be structured in ways that forces these agencies and their many
stove-piped programs to work more closely together.
Question 2. How do we recruit, train, and retain a prepared public
health workforce with the ability to respond to national threats--
whether acts of terrorism or by Mother Nature?
Answer 2. A well-trained, prepared public health workforce is
paramount to our Nation's ability to deal with the wide array of
threats to the public health. While, in the course of our work, we
found some fabulous public health professionals, we also found problems
across the areas of recruitment, training, and retention. In our
research we found that numerous health departments had people in
critical functions about to retire with no ability to replace them. In
other departments, we found people in critical positions who had
absolutely no training to do the jobs they were expected to do. In
almost every community we heard that salaries for public health
professionals, especially laboratorians and epidemiologists are not
competitive enough to recruit and retain high-quality staff. Many lose
their best staff to the private sector over these issues.
Stability in funding is needed to support recruiting and retention
efforts. The pipeline for those wanting to enter public health practice
is quite small. While the prestige and salary of such positions is
clearly an issue, so too, is the uncertainty about whether there is
long-term support for public health preparedness. The initial
enthusiasm spurred on by early investment has clearly been dampened by
continued cuts to the program. Without stability in funding, market
forces will give incentives to the best and brightest--and even those
who are simply ``good enough''--to go elsewhere, rather than to our
Nation's public health agencies.
More attention should be given to defining public health
responsibilities. You will doubtless hear from other panelists about
the need to define develop and maintain a database with which to
monitor the status of the public health workforce, as well as the need
to define workforce competencies for public health. In addition, there
needs to be more frank discussion of what are proper public health
responsibilities and what should be done by other disciplines in
collaboration.
Just because an event concerns a health threat or requires some
sort of medical countermeasure doesn't necessarily mean that a public
health professional should sit in the incident command chair, although
it will be critical to have public health personnel working closely
with others in a unified command structure. Indeed, once the existence
of an emergency is clear, the early stages of many responses focus on
logistics issues that require expertise other than that possessed by
most public health professionals. For example, my colleagues have most
recently shared with me their frustration at watching highly educated
health scientists struggle to learn how to use pallet jacks in medical
warehouses to deliver components of the SNS. Clearer thinking about
what functions public health professionals do and don't need to do, as
well as a set of financial ground rules about how they tap into
components of the workforce funded by other non-preparedness sources to
address day-to-day work, needs to be reflected in program guidance,
provisions concerning funding fungibility, maintenance of effort, etc.
More attention is also needed to two areas of workforce development
that our team has consistently noted as major gaps. The first is
leadership development. Our research found that, more than any single
thing, strong leadership distinguished those organizations that
performed well on exercises from those that did not, and the better
prepared, integrated public health agencies from those that were less
prepared. While the willingness to take charge--command and control--is
one aspect of leadership, strong leadership requires many other
capabilities, including a clear vision, willingness to make decisions
and assume responsibility, development of staff that can function
independently, ability to collaborate across disciplines, ability to
function in an inherently political environment, and superb
communication skills. I believe that a significant investment in
leadership development is essential, and that leadership development
and training must become an essential element of public health
training. Some health departments have understood the importance of
this, and have even used preparedness monies for leadership development
in their health departments. Let me also point out that such
development also helps train the workforce of tomorrow, and is
essential to succession planning.
The second area of substantial need is the development of quality
improvement skills. Time and time again in our site visits and
exercises, we found that health departments rediscovered problems that
they had encountered in prior exercises, but that nothing had happened,
often because staff lacked the time, knowledge and skills to act on
them. Implementing quality improvement (QI) requires that staff at all
levels of the organization have both theoretical knowledge and
practical skills in quality improvement. While the need to improve
public health emergency preparedness is widely recognized, less
investment has been made in creating the organizational capacity needed
to support that improvement. Leaders and managers must have an
understanding of QI in order to be able to formulate and communicate a
vision for improvement. They, as well as program directors and staff,
must have fundamental QI skills to translate this vision into practice.
Vehicles for increasing QI capacity could include development
grants, education and training, technical assistance, tool development
(including information technology), leadership and management training,
and grants that incentivize and reward QI practices and continuous
improvement in performance. While I am encouraged that the CDC
preparedness goals now include ``improvement,'' there is no explicit
funding tied to developing the skills or programs to achieve this. To
the extent that funding is seen as a ``zero sum game,'' an emphasis on
``improvement'' without specific funding attached suggests that other
things will need to be put aside to support this goal.
Question 3. How do we develop public health systems research,
paramount for developing evidence-based best practices and benchmarks,
for an all-hazards public health response?
For example, do issues ranging from disease forecasting to
financial modeling of Federal and State public health investments need
further study?
How is ``public health preparedness'' best defined and
what are the metrics for measuring success?
Answer 3. We are facing a serious knowledge gap in relation to
public health systems research, and especially the components that have
to do with emergency response and situational awareness. One problem is
that those who typically fund science research do not consider public
health systems research to be either ``science'' or ``health services
research,'' and much of the public health community does not yet accept
systems research as part of public health research. Furthermore, public
health systems research is a very new field with almost no funding.
One area that should be given priority for funding is research to
identify evidence-based best practices in emergency preparedness. Our
work has identified a near total void in this area. Indeed, such
research is necessary to provide the evidence base to support the
development of guidelines, or performance measures and metrics. We have
been fortunate to be able to use our work with HHS to break new ground
in this important area. And our research has produced important
findings that have helped advance the field. Let me give you just a few
examples. Our work in California highlighted the fact that not all
Americans are afforded the same level of public health protection. Our
work on the ability of public health departments to receive and respond
to emergency case reports highlighted serious system deficiencies in
health departments, as well as the fact that perfect performance is
achievable. And, our case studies have identified repeated ``systems
failures'' in non-bioterrorism outbreak investigation and response.
This research gap can be addressed. Let me remind the committee
that a similar gap once existed in the areas of quality of care and
patient safety. It took significant investment in research to get the
job done. A similar effort needs to be mounted here. Both AHRQ and CDC
would be appropriate agencies to entrust with funding such research.
Research on evidence-based practices can help in the development of
truly objective measurable performance measures. These are critical for
assessing progress, generating improvement, and accountability.
Evidence-based research can help to decompose the issues into
identifiable components so that we can develop performance measures
based on structure, process, and outcome. We would maintain that a
smaller number of strong measures are probably more usable in the long
run than hundreds of more difficult-to-measure items. Our work has made
abundantly clear the need for greater alignment across guidance areas
and the importance of focusing scarce measurement resources on these
areas. Indeed, there is already quite a bit of overlap across guidance
documents, but turf battles and measurement philosophies get in the way
of progress. Even better would be more attention to examining response
processes and pulling out crosscutting capabilities right from the
beginning. We have been doing such work with the SNS and other areas of
the Cooperative Agreement guidance, and are encouraged by the emphasis
on capabilities-based and all-hazards planning is great (HSPD-8, NPG,
etc).
It is important to recognize that the development of appropriate
and effective metrics will require time--as well as trial and error--
and research. In this area, we cannot let the perfect be the enemy of
the good. For example, early measures in the area of quality
measurement in the health care system--outcome reporting of cardiac
surgery, and early HEDIS measures--were, by today's standards, fairly
crude. However, the use of these measures over time, as well as a
commitment to taking these measures seriously, made them get better. We
can and should use a similar approach here.
Finally, let's not forget that assessments and standards just tell
us where we need to be, but that we probably also need some real
mechanisms to assure accountability to ensure that these things remain
at the top of people's agendas. In closing, from our vantage point at
RAND, the recent Federal investment in public health preparedness is
paying off. This investment has injected new life into what was widely
considered to be a moribund public health system. Our research, for
example, indicates that State and local public health departments have
made significant progress in their efforts to improve disease
surveillance systems; to enhance laboratory capacity; and to
communicate more effectively with hospitals, physicians and other
community partners, the media, and the public. But as I have indicated
above, many important gaps remain, and I am happy to discuss those that
go beyond the questions that are the focus of this particular
discussion. Investments in the areas of information technology,
workforce development and public health systems research continue to be
needed to sustain and build upon these gains and to create a public
health system capable of minimizing morbidity and mortality associated
with a wide range of public health threats.
______
Summary
Question 1. Situational awareness is based on timely lab and
hospital reporting, interconnected surveillance systems, consistent
epidemic monitoring and reporting, and appropriate risk communication.
Currently, there is wide variability across the country in these
capabilities. How do we best make progress towards a national public
health infrastructure with real-time situational awareness?
Answer 1.
Continued investment in interoperable information
technology for routine and enhanced surveillance, provider
notification, outbreak investigation and event management.
These investments will be effective only if there is
greater consistency in technological capabilities across public health
and improved linkages among public health departments and between
public health and other organizations with responsibilities for shared
situational awareness and emergency response.
Technology alone will be insufficient. Continued support
is needed to strengthen relationships and improve lines of
communication within public health and between public health and other
entities involved in emergency response.
Question 2. How do we recruit, train, and retain a prepared public
health workforce with the ability to respond to national threats--
whether acts of terrorism or by Mother Nature?
Answer 2.
Stability in funding to public health preparedness is
essential for students to see a clear career path in public health
preparedness.
Defining public health responsibilities more clearly.
Emphasize workforce development, including leadership
development and quality improvement skills.
Question 3. How do we develop public health systems research,
paramount for developing evidence-based best practices and benchmarks,
for an all-hazards public health response?
Answer 3.
For example, do issues ranging from disease forecasting to
financial modeling of Federal and State public health investments need
further study?
How is ``public health preparedness'' best defined and
what are the metrics for measuring success?
Funding for research to identify evidence-based best
practices in emergency preparedness is critical, and ultimately
underpins the next generation of truly objective measurable performance
measures.
The development of appropriate and effective metrics will
require time--as well as trial and error--and research.
Assessments and standards just tell us where we need to
be, but that we also need some real mechanisms to assure accountability
to ensure that public health preparedness remains at the top of
people's agendas.
Ten critical areas for performance measure development are
attached.
Senator Burr. Dr. Gursky, good morning.
STATEMENT OF ELIN A. GURSKY, PRINCIPAL DEPUTY FOR BIODEFENSE,
ANSER/ANALYTIC SERVICES, INC.
Ms. Gursky. Good morning. Thank you for the privilege of
being here, and thank you, Mr. Chairman, for your leadership in
this area.
The Public Health Security and Bioterrorism Preparedness
and Response Act of 2002 represented a profound change for the
public health sector. It is a great investment in revitalizing
the public health sector. It focused the importance of public
health to society and to security. And it certainly advanced
the knowledge of threats and understanding to the public health
workforce.
I think, as you mentioned earlier this morning on the first
panel, the issue of security and preparedness for threats has
been broadly interpreted across our States and across our
communities. There are a number of gaps that I think are quite
evident. Clearly, you have mentioned some of those, the absence
of significant numbers of trained workforce, a lack of good
interoperable systems, technology gaps that are not giving us
the kinds of real-time health intelligence, health information,
situational awareness that we need to respond to events.
I think as Dr. Lurie has just mentioned, not only do we
have difficulty measuring preparedness, I don't think we have
clearly defined what preparedness looks like. I think we have
people who say, ``I have a computer. I think I must be
prepared. I have a three-ring binder with plans in it. I did an
exercise this year.'' I don't think the vision of preparedness
has been clearly defined, and specifically at the local level.
The preparedness that we need to achieve for pandemic
influenza, for bioterrorism, really cannot be achieved on a
part-time level. We have local health agencies where we have
people doing vaccination clinics on Tuesdays and Thursdays,
rabies clinic on Friday, and perhaps working on preparedness
Wednesday afternoons.
We need to rethink health security and preparedness for
this country. We need to look at systems of governance, for
collaborating the various streams of funding, how we build the
workforce, and how we test and measure the performance and
preparedness systems that we put in place. Thank you.
Senator Burr. Thank you very much.
[The prepared statement of Ms. Gursky follows:]
Prepared Statement of Elin A. Gursky, Sc.D., Principal Deputy
for Biodefense ANSER/Analytic Services Inc.
Thank you for the opportunity to respond to your questions
regarding our Nation's continued investment in preparedness for
catastrophic and large-scale health emergencies, including acts of
terrorism and pandemics. Civil unrest and anti-American sentiment in
many parts of the world and the westward movement of H5N1 avian
influenza across Asia, Africa, and Europe reinforce the urgent need to
develop, install, and incorporate the technologies and systems that
support the earliest possible detection, situational awareness, and
mitigation of diseases that have the potential to cause high rates of
morbidity and mortality and to erode our economic and social
structures.
Thank you, too, for your leadership and support in the areas of
health security and public health. Since 2001, the United States has
instituted enormous structural and operational modifications to ensure
the safety of its citizens from chemical, nuclear, radiological, and
explosive threats to its borders, its airlines, and its critical
infrastructure. The single most outstanding threat, however, as the
subcommittee well recognizes, is that of disease. In the hands of a
biotechnologically sophisticated enemy or Mother Nature, the ominous
combination of novel disease and susceptible human or animal hosts can
swiftly reverse increasing trends in America's lifespan and standard of
living.
The legacy of public health in the 20th century recalls the
sanitation efforts that controlled typhoid and cholera and the
development of vaccines that eradicated smallpox, eliminated
poliomyelitis in the Americas, and erased from memory the childhood
scourges of scarlet fever and rubella. Seatbelt legislation reduced
highway fatalities, antibiotics controlled infections, and mass anti-
tobacco campaigns reduced the numbers of youth who began smoking.\1\ In
fact, as public health's successes reduced the visibility of disease
and illness in society, the agencies erected to fulfill the public
health mission were successively retasked to address non-acute health
issues. With the problem of infectious diseases ``solved,'' \2\ a large
component of the primary mission of State and local health departments
was refocused to address social and clinical services for the poor and
vulnerable. The public health agencies now facing the threats of
evolving pathogens and bioterrorism are generally ill prepared for this
mission and attempt to balance these new responsibilities with an
overflowing array of other responsibilities that include community
outreach and health education, programs for the homeless, substance
abuse services, and environmental health services.\3\
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\1\ ``Ten Great Public Health Achievements--United States, 1900-
1999,'' Morbidity and Mortality Weekly Report, 48(12), April 2, 1999.
\2\ In the post-Depression days of the 1930s, a surge of
progressivism engulfed national policy. This period of widening social
responsibilities was embraced by the public health sector, which
diminished its role in infectious disease fighting (especially as acute
communicable diseases were viewed as a waning threat) to assume a
larger role in providing social and clinical services for the poor and
vulnerable. See Elin Gursky, Drafted to Fight Terror: U.S. Public
Health on the Front Lines of Biological Defense (ANSER, 2004).
\3\ National Association of County and City Health Officials, Local
Public Health Agency Infrastructure: A Chartbook, October 2001.
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My responses to your questions reflect a broad base of research and
operational experience as a clinical epidemiologist. I have held senior
positions in governmental public health at the State and local levels
and in the private healthcare-hospital sector. I was director of
Epidemiology and Communicable Disease Control for Prince George's
County (Maryland) in the days when Parris Glendening was County
Executive. Subsequently I served as deputy commissioner for Public
Health Prevention and Protection in the New Jersey Department of Health
and Senior Services under Governor Christine Todd Whitman. In this
period, from 1986 through 1998, I enacted robust initiatives to reverse
high rates of multiple-drug-resistant tuberculosis, sexually
transmitted diseases, and vaccine-preventable diseases (among others).
I developed successful programs to build and train the public health
workforce (up to 530 professional medical and public health,
paraprofessional, and support personnel), implemented systems of
program and workforce accountability, installed new technologies and
systems, and provided the citizens whose health we pledged to protect
with a rapidly deployable and responsive effort 24/7. These initiatives
were successful and forward-thinking in the pre-9/11 days when
bioterrorism was unthinkable and State and local public health budgets
were severely constrained. By installing strong leadership, pursuing
public-private partnerships, and embracing a tenet well-founded in the
military--unity of effort--our successes wrought professional
satisfaction, increased funding, and decreased the incidence of
communicable diseases.
Since those relatively halcyon days of public health practice, I
have turned my attention to studying and writing about the new demands
on the public health sector within the context of 21st-century health
threats. Reports I authored in 2002 and 2003 examined our response to
the first deliberate biological attack on a national scale (Anthrax
2001: Observations on the Medical and Public Health Response) and our
efforts to build the public health infrastructure with the first wave
of funding from Public Law 107-188, the Public Health Security and
Bioterrorism Preparedness and Response Act of 2002 (Progress and Peril:
Bioterrorism Preparedness Dollars and Public Health). Two more recent
reports are based on studies of the public health sector's ongoing
efforts to build preparedness capabilities and capacities. One is
titled Drafted to Fight Terror: U.S. Public Health on the Front Lines
of Biological Defense (2004). The other and most recent, Epidemic
Proportions: Building National Public Health Capabilities to Meet
National Security Threats (2005), was undertaken on behalf of your
subcommittee.
By way of this background, let me preface my answers to your
questions by stating my belief that this Nation must view the
preparedness challenge through a new lens. Although a number of this
country's 3,000 local and 50 State public health departments have made
concerted inroads into revising practices and accommodating the
preparedness mission, it has been at the expense of fulfilling their
historic social compact with the communities to whom they ensure the
provision of essential healthcare ``safety net'' and community health
services. Our Nation's governors are fully committed to protecting the
health of their citizens and the security of their States. Yet it seems
unlikely that, within even the next 5 to 10 years, the diversity of
public health efforts and workforce capabilities resident within our 50
States can be harmonized to constitute uniformly responsive, robust,
and durable capabilities to protect this country. With the preparedness
experience of the past almost 5 years, it is appropriate to apply the
lessons learned to our future efforts to protect the health security of
this Nation. Let me elucidate further.
Our public health departments provide--in steady state--a
range of routine health promotion, health screening, and medical
services to many vulnerable populations, offering invaluable efforts to
screen for asthma and hypertension, intervene in substance abuse and
behavioral health problems, and reverse rising rates of obesity and
diabetes.\4\ Preparedness requires a rapid surge in response to
investigate and identify a disease outbreak, deploy the strategic
national stockpile, stand up mass immunization and prophylaxis clinics,
and contain the spread of an epidemic.
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\4\ Ibid.
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Our public health departments aggregate the skill sets of
over 24 professions, including nursing, social work, sanitation and
restaurant inspection, and health education and outreach, to provide a
wide range of health and human services.\5\ Few have a common
educational background, licensing and credentialing requirements, or
formal or unifying training in public health practice.\6\ Preparedness
systems must bring together the correct mix of skill sets, such as
experts in infectious-diseases, epidemiology, and data analysis to
rapidly identify, track, and contain disease transmission--who carry
out this work in well-practiced synchrony.
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\5\ Lloyd Novick and Glen Mays, Public Health Administration:
Principles for Population-Based Management (Sudbury, MA: Jones and
Bartlett, 2005).
\6\ Ibid.
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Electronic health records will reduce medical errors,
prevent costly duplication of medical services, and relieve the
burdensome reimbursement process between payer and patient. These same
systems when employed for early disease detection will serve the
critical needs of disease outbreak monitoring, health intelligence and
surveillance, and situational awareness underpinning the preparedness
and response effort. These systems will also play a critical function
by linking the population health protection sector with the medical and
hospital patient health sector to halt an infectious disease event.
Public health departments perform a vital role in crafting
and disseminating health education information to promote healthy
lifestyles and have been successful in efforts such as reducing teenage
drinking and smoking and increasing breast and prostate cancer
screening.\7\ The preparedness effort requires the abilities to swiftly
craft and disseminate an accurate risk communication message to reduce
further exposure to pathogens, direct exposed persons to appropriate
venues of urgent health care, and convey other time critical
information to impede disease transmission.
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\7\ Council on Scientific Affairs, ``Education for Health: A Role
for Physicians and the Efficacy of Health Education Efforts,'' Journal
of the American Medical Association, April 4, 1990.
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The public health sector has historically served the needs
of the medically disenfranchised, the indigent, and the vulnerable with
an unwavering egalitarian approach.\8\ The unprecedented challenges of
deliberately disseminated and novel pathogens, combined with few or
limited supplies of vaccines and medical countermeasures, will require
difficult ethical decisions, possibly denying protection to society's
most vulnerable in order to assure protection of society's most
critical.
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\8\ As the proportion of U.S. physicians providing charity care
continues its decade-long decline, the public health sector will
continue to become providers of last resort for uninsured patients and
those Medicaid patients rejected by or simply beyond the reach of
private providers and institutions. ``U.S. Physician Charity Care
Continues Decade-Long Decline,'' Center for Studying Health System
Change news release, 3/23/06; http://www.hschange.com/CONTENT/827/.
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The preparedness mission has been broadly interpreted by
our Nation's governors with respect to the perception of their States'
vulnerabilities and risks and the competing healthcare needs of their
constituents. The health security of the United States requires a
common strategy and uniformly consistent capabilities to detect and
deter catastrophic health events and assure continued social and
economic functioning of the Nation.
The overriding mission of our public health sector is to promote
healthy Americans. The threats of pandemics and terrorism demand a
system capable of assuring secure Americans.
The Public Health Security and Bioterrorism Preparedness and
Response Act of 2002 has provided an invaluable benefit toward
increasing awareness and education about the threat environment among
the Nation's State and local public health sector. To now move forward,
we must shift our focus from individual local communities toward the
health security of the Nation. The system required to protect Americans
against 21st-century threats must evolve from and hold harmless the
sector that serves traditional public health needs. The system required
cannot be retrofit on top of a sector widely acknowledged to have
``fallen into disarray'' \9\ and that has historically eschewed
specific (``prescriptive'') direction, guidance, and accountability
from central organizations such as the CDC.\10\ In fact, leadership
from a higher level within HHS is required to constitute a health
security system that will protect fully and equally the Nation's
States, cities, and communities and that will work in harmony with
other critical guardians of domestic security, such as the Department
of Defense, the Department of Veterans Affairs, and the Department of
Homeland Security.
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\9\ The Future of the Public's Health in the 21st Century
Washington, DC: Institute of Medicine, 2002).
\10\ See Elin Gursky, Epidemic Proportions: Building National
Public Health Capabilities to Meet National Security Threats, Findings,
p. 11.
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The system of health security in which this country must invest,
and which I humbly recommend as the focus of the reauthorization of the
Public Health Security and Bioterrorism Preparedness and Response Act,
will have several components.
Situational awareness. The effectiveness of situational
awareness stems from building on historical knowledge (such as what the
background disease rates have been) with multisector, real-time,
continually updated flows of new information to characterize disease
escalation within a population. In most cases this approach will not
demand new technologies but, rather, the systematic integration of
existing technology, tools, and processes through cooperative efforts
at the local, regional, State, national, and cross-border levels. These
systems must be in place to serve day-to-day operations so that they
also offer familiarity and scalability in the event of an outbreak.
Some States and localities across the country have installed effective
community-centric disease surveillance systems. Nationally, however,
many fail to achieve the breadth and speed of data flows to support the
widest and most timely situational awareness, to inform 24/7
decisionmaking by key leaders, and to operationalize the response of
appropriate professionals. Implementing this system--one of the most
critical investments toward health security--will require rigorous
oversight and sustained funding. A trust fund will ensure the wisest
and swiftest use of Federal dollars to fulfill this goal.\11\
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\11\ Trust funds are accounts established by law to hold receipts
collected by the government and earmarked for specific purposes and
programs as approved by the trustee. The Highway Trust Fund was created
by the Highway Revenue Act of 1956 to ensure a dependable source of
financing for the National System of Interstate and Defense Highways
and for the Federal highway program. Funds are reserved for transit
capital projects and related purposes. See the Northeast Midwest
Institute, ``What Is the Highway Trust Fund?''; http://www.nemw.org/
HWtrustfund.htm.
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The workforce. The health security workforce must be
constituted by experts who bring to bear the education, training, and
expertise in closely allied fields and specialties focusing on the
detection and mitigation of disease threats. Medical and other clinical
experts (nursing, laboratory, veterinary), epidemiologists,
agriculture, food, water, and environmental specialists will both
analyze and intervene in disease outbreaks and atypical disease events.
Most of their professions already require terminal advanced degrees and
national credentialing.\12\ A foundation of uniform basic training
could easily be built and offered to harmonize the effort of this
highly skilled workforce. Recruitment and retention of this workforce
will not be difficult: Many practicing public health officials and
workers have been frustrated because the health security mission has
had to coexist with other demands at local and State health
departments.
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\12\ The 2005 CDC/Council of State and Territorial Epidemiologist
draft document ``CDC/CSTE Development of Applied Epidemiology
Competencies'' establishes core competencies for applied
epidemiologists; http://www.cste.org/competencies.asp.
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Research. In sad fact, unlike the practice of medicine,
which is guided by best practices, and clinical pathways and is
evidence-based,\13\ there is almost no body of research to affirm that
our public health interventions and dollars expended have achieved
their intended outcomes or that our monies have been well spent.\14\
Empirical evidence notwithstanding, the Federal investment to prepare
the Nation against health security threats must be validated through
objective confirmation of the accuracy and efficacy of our efforts.
Health security must embrace a foundation of research that assesses the
cost-benefit of our efforts, quantifies specific obstacles, guides the
solution set, informs the interventions (medical and nonmedical) and
best practices, analyzes and forecasts threats and vulnerabilities, and
develops metrics for performance.
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\13\ Center for Evidence-Based Medicine.
\14\ Within the evidence-based models, there is no or little
attention paid to the best practices for population-based (public)
health. See the Evidence-Based Practice for Public Health Project;
http://library.umassmed.edu/ebpph/.
In closing, let me again thank the subcommittee for its focus on
this serious concern and for the privilege of lending my voice and
perspective. Few issues facing this country are graver than that of
health security. As Dr. Dale Klein, Assistant Secretary of Defense for
Nuclear, Chemical, and Biological Defense Programs, noted at a meeting
to discuss the Quadrennial Defense Review,\15\ the issue of weapons of
mass destruction, in which biology plays a large role, reflects the
generational dimensions of a long war. This is true also of the war
that health security experts must fight against deliberate and
naturally occurring threats; the latter have resulted in 30 new or
emerging pathogens in the past 20 years.\16\
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\15\ National Defense University, March 17, 2006.
\16\ World Health Organization, ``Globalization, Trade and Health:
Emerging Diseases'';
http://www.who.int/trade/glossary/story022/en/.
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The system we build for tomorrow, not that we conscript from
yesterday, will lead us to successfully overcome the threats we face
with the least impact on human lives, lifespan, and quality of life.
Senator Burr. Dr. O'Toole, welcome.
STATEMENT OF TARA O'TOOLE, M.D., DIRECTOR AND CHIEF EXECUTIVE
OFFICER, CENTER FOR BIOSECURITY, UNIVERSITY OF PITTSBURGH
MEDICAL CENTER
Dr. O'Toole. Thank you. Thank you for holding these
roundtables, which I think are very informative and allow a lot
of people the option of stating their views. If it is okay, I
would like to respond to the questions the staff posed, since
they were very well crafted and comprehensive. Is that okay?
Senator Burr. That is fine. I thought I would let anybody
that wanted to make a general statement at the beginning to go
ahead and do it and I will leap back----
Dr. O'Toole. Thank you.
Senator Burr [continuing]. And the next round will go
specifically to the questions.
Dr. O'Toole. Okay. I will not turn down any opportunity to
make a general statement here, certainly. My colleagues and I
have been re-reading the 2002 Act in anticipation of this
year's reauthorization of the bill, and we come to the
conclusion again and again that this was a really good piece of
legislation. It is quite comprehensive, and even in view of
today's perspective, post-Katrina, post-the tsunami, et cetera,
et cetera, it is a very sound bill.
Its major flaw is that it is not sufficiently ambitious. I
think creating the Public Health System that you seek, Senator,
is going to be the work of a generation and it is going to cost
billions and billions and billions and billions of dollars.
This is a national security program and we have to start
thinking of it in terms of that scale. We have the scale wrong.
This is not another public health program, and this is not just
another mission of CDC's many important tasks. This is
something entirely different. That is the first thing I would
say.
Our second observation about the bill of 2002 is that when
you look at why there hasn't been more progress since the 2002
bill was passed, one comes to the conclusion that most of the
problems we have encountered, as Dr. Lurie has alluded to, are
programmatic issues. It really reflects too few people with too
little experience trying to do too much under ferocious
pressures. We are going to have to fix this public health
workforce problem and we are going to have to do it
strategically, and that brings me to my last point.
We need to have a strategy for public health preparedness.
We are going to have to stand up big programs. Situational
awareness is going to be a system of systems, and right now, we
have no vision of success. We have no strategy. We have no
priorities. We are in the same predicament when it comes to
building the workforce, and my third point would be that we
have completely left out, for the most part, how we are going
to engage citizens and using the great talent of the American
people as an asset rather than worrying about them becoming a
liability.
Senator Burr. Thank you very much. I might also add that
one of the architects of the 2002 Act from the House Commerce
Committee sits behind me and has joined us today for this
roundtable. Nandan was instrumental in the crafting of that
piece of legislation, so I believe in giving credit where
credit is due.
[The prepared statement of Dr. O'Toole follows:]
Prepared Statement of Tara O'Toole, M.D., M.P.H., Director and CEO,
Center for Biosecurity of UPMC
INTRODUCTION
The capacity to mitigate the consequences of a large-scale,
naturally occurring epidemic or bioterrorist attack is a pressing
national defense need. Since passage of the Public Health Security and
Bioterrorism Preparedness and Response Act of 2002, the United States
has achieved important, though limited, progress towards this goal.
Viewed from the perspective of 2006, the aims and architecture of the
2002 Act still appear sound and quite comprehensive. But as the
experience of the past 4 years has demonstrated the project of creating
the institutional capabilities to care for the sick, protect the well
and minimize economic and social disruption during lethal epidemics
must overcome some fundamental obstacles.
This paper focuses on three fundamental aspects of epidemic
preparedness:
How to build a strong and competent public health
workforce;
How to create information systems and information exchange
process that ensure decisionmakers and the public have sufficient
situational awareness to make informed decisions during public health
emergencies, especially large-scale epidem-
ics; and
How to establish an ethos and institutional capacity that
engages the American public as partners in the response to and recovery
from public health emergencies.
strengthening the public health workforce
Background
Building a 21st century U.S. public health system that is capable
of managing potentially destabilizing epidemics cannot happen without a
competent public health workforce. There are smart, committed people
working their hearts out in public health agencies at the Federal,
State and local level. But there are too few of them, and in most
instances, the agencies assigned to implement the 2002 Act lack the
necessary skill mix, experience and authority. Efforts to hire more
people have been frustrated by the small pool of qualified candidates,
cumbersome State and Federal hiring procedures, and non-competitive
salaries, especially for State government positions.
The failure to achieve more significant progress towards public
health preparedness in the past 4 years is largely due to inadequate
program management.--i.e. insufficient leadership; poor project design
and execution, including inadequate consultation and communication;
implementation failures; and failure to assess progress and to redirect
efforts based on such assessments. These shortcomings are largely the
direct result of too few people, many with limited experience, trying
to do a great deal under ferocious time pressures. Efforts to improve
accountability for program results by demanding progress towards poorly
conceived ``metrics'' will not fix this problem; it will merely further
burden overtaxed officials.
The Nation must make significant investments in building the public
health workforce. This will require a long-term commitment to creating
the educational opportunities, curricula and career paths needed to
attract smart, committed people. We must take immediate steps to bring
qualified health professionals into government service. And we must
construct efficient organizational mechanisms to catalyze a continuous
dialogue between policymakers at HHS and medical and public health
practitioners in the field.
Recommendations
1. HHS Needs More Staff, More Robust Management Structure.--The
problem of agencies having too few people with appropriate skills and
authority to achieve critical public health preparedness goals is
highly apparent within HHS and CDC. After the terrorist attacks of
2001, HHS was tasked to take on a welter of new missions related to
homeland security; the management structure and staffing of HHS has not
kept pace with these assignments. HHS is larger in dollar terms than
the Department of Defense--and yet HHS does not have a single
undersecretary. Secretary Leavitt has noted that he has 27 direct
reports--a situation he recognizes as ``not at all an ideal
organizational structure.''
Cabinet Secretaries should have broad discretion in how their
agencies are organized, but I believe that Congress should approve at
least one--or better, two or three--Undersecretary positions to HHS.
This would provide the agency with increased senior managers capable of
coordinating HHS' vast programmatic span of control. In the realm of
public health preparedness, an Undersecretary for Public Health (which
could be combined with the present Assistant Secretary for Health or
the position of Surgeon General) could better coordinate the varying
HHS programs now spread among the Assistant Secretary for OPHEP, CDC,
HRSA, NIH, AHRQ, and ONCHIT. In addition, an Undersecretary would be
better able to represent HHS in the interagency process.
Build a Public Health Workforce with Necessary Educational Background
and Project Management Skills
There is considerable evidence that there are too few people
trained in public health practice to meet current needs of Federal,
State and local agencies. As long ago as 1999, the National Commission
on National Security in the 21st Century (the so-called ``Hart Rudman
Report'') warned of a ``crisis in competency'' within the Federal
government due to a generation-long failure to recruit promising young
people into government service and the accelerating retirement of
today's senior civil servants. One study by an independent non-
governmental organization estimated that half of Federal employees now
working on biodefense-related issues will be eligible for retirement in
the next 3 years. Moreover, biosecurity issues and management of
destabilizing public health emergencies have not until recently been a
focus of government efforts. Hence the workforce available to lead and
manage biosecurity programs in particular, but homeland security issues
generally has been quite small. This must change.
Long term
2. Create a program to provide tuition for students of medicine,
public health and nursing in exchange for commitments to serve in
government public health post.--Past experience has shown that the most
efficient and effective way for the Nation to induce young people to
study public health and related disciplines and to enlist them in
critical government positions is to establish tuition pay-back
programs. Students in medicine, nursing or public health would have
their full or partial tuition paid by the government in exchange for a
commitment to serve in public health positions at the local, State or
Federal agencies. Students who know they are going to serve in such
jobs upon graduation will act to drive schools of public health in
particular to offer relevant training in public health practice.
Midterm
3. Double the current size of the CDC's Epidemic Intelligence
Service, and ensure that at least two thirds of all EIS assignments are
to State and local health departments.--The CDC's Epidemic Intelligence
Service (EIS) was established during the Korean War as an early warning
system against biological warfare. It has now expanded into
surveillance and response for all types of epidemics including chronic
diseases, but provides hands-on postgraduate training in epidemiology
and public health practice. Approximately 70 health professionals per
year enter this 2 year program, including 15 officers from countries
other than the United States. Importantly, 70 percent of EIS officers
continue in public health careers. Currently however, only 25 percent
of incoming EIS officers are assigned directly to State and local
health agencies; the great majority work at CDC headquarters in Atlanta
on a wide range of issues.
[ref: accessed at http://www.cdc.gov/eis/applyeis/applyeis.htm, 3/24/
06].
Near Term
4. Create a special senior EIS fellows program that would provide
up to 3 year assignments under IPA agreements for experienced, talented
individuals from academia and the private sector who could serve as
mentors and provide a stimulus for documentation of experiences in
epidemic preparedness program building. Such a program would create an
opportunity for experienced medical and public health professionals and
seasoned program managers to work in government posts.
5. Provide funds to State and local public health practitioners to
write up and share experiences with epidemic preparedness program
building.--Such officials are currently too busy to document what works
and what does not; consequently many localities are repeating mistakes
made elsewhere and failing to benefit from others' successes. It would
be useful to have both publications and a CDC Web site that could
provide detailed information about program design and implementation.
Expanding the annual meeting of bioterrorism directors to include
program managers and frank exchange would also be most useful.
6. Reconstitute the Secretary's Advisory Council on Public Health
Preparedness.--This Council provided the Secretary with advice from a
wide spectrum of experts with interest in different aspects of
biopreparedness and organized the successful HHS effort to refine the
use of disease modeling in epidemic planning. The Council was formed in
accordance with the Federal Advisory Committee Act (FACA) and as such
operated in full public view. It is possible to create working groups
or subcommittees that report to FACA committees, thereby ensuring
transparency, but such subcommittees, which are themselves not subject
to FACA, can be rapidly assembled to respond to issues as the need
arises. The working groups could not make decisions themselves but
reported back to the committee for final resolution and
recommendations, thereby ensuring transparency. This mechanism could
provide an efficient way for HHS to link to outside expertise in a
variety of disciplines and across panoply of topics such as
biosurveillance, hospital preparedness, countermeasure selection, etc.
improving situational awareness during public health emergencies
Background
Maintaining situational awareness during public health
emergencies--i.e. an accurate, real-time understanding of what is
happening on the ground and what options for intervention are
feasible--is a critical function of public health. For example, during
an epidemic, public health officials must be able to determine the
scope of a disease outbreak, how many are sick, who and where they are,
who is at risk, whether the situation is worsening or improving, what
interventions to care for the sick or protect the well are viable,
etc., as well maintain real-time logistical knowledge regarding
available resources, their location, etc.
The 2002 Act implicitly recognized the importance of situational
awareness by mandating the creation of an array of surveillance
programs, including syndromic surveillance, aimed at disease detection,
sharing of information among public health, the medical community and
emergency response agencies, and communication with the public. A large
amount of money and effort has been lavished on various electronic
``surveillance systems'' to unknown effect. Most such systems have
focused on initial detection of disease outbreaks or bioterrorist
attacks, not on collection or analyses of information essential
epidemic management.
Recommendations
1. HHS Must Develop a Strategy for Ensuring Situational
Awareness.--The Department of Health and Human Services (HHS) should
establish a national strategy for ensuring situational awareness during
public health emergencies, including epidemics. Such a strategy should
include explicit goals and performance specifications to ensure rapid
integration of data from different localities, including government
health agencies, hospitals and other large health care delivery
organizations.
2. HHS Should Explicitly Assign Responsibility for Designing and
Executing Such a Strategy.--HHS should establish an Office of Public
Health Information Technologies within either Office of Public Health
Emergency Preparedness (OPHEP) or Office of the National Coordinator
for Health Information Technology (ONCHIT) to oversee the design and
implementation of disease surveillance systems and other public health
data flows and to establish performance expectations for such systems
and share lessons learned. Given that hundreds of millions of dollars
have already been spent on such systems, and even larger expenditures
are planned, HHS should establish a single office with clear
accountability for ensuring situational awareness, perhaps within the
ONCHIT.
3. HHS should explicitly and consistently seek input and feedback
from users (Federal, State and local health agencies, health care
institutions) of electronic surveillance systems and should consult and
employ appropriate technical experts (bioinformatics and information
technology scientists) in system design and testing.--Because these
systems are so complex and costly, and because their success depends
critically on local users and data inputs (e.g. hospitals) a national
advisory body, perhaps reporting to the Secretary's Council on Public
Health Preparedness, should be formed to provide counsel on strategic
direction, user needs and means of assessing these systems.
4. Regularly monitor surveillance systems' performance.--All
surveillance systems maintained or funded by the Federal Government
should be subject to independent assessment by objective evaluators.
State-based systems should be periodically assessed for efficacy and
cost-effectiveness as a condition of Federal support.
5. Urgently establish mandatory, minimum electronic communication
links between hospitals and local public health agencies.--At minimum,
and as a matter of great urgency, public health agencies at the local
and State level and hospitals within respective regions should
collaborate to establish robust electronic communications that include
disease reporting, laboratory reports and emergency department
surveillance data as well as logistical information related to
available bed capacity, ventilator supply, etc. Creating and
maintaining such linkages between public health agencies and hospitals
should be a condition of Federal grant awards related to any aspect of
homeland security.
Most of the fundamental information pertinent to epidemic
management originates in hospitals or other large health care delivery
organizations. Few health agencies currently have electronic links to
hospital in a region. The creation of a truly efficient information
flows between public health and health care entities must await the
development of a secure, nationally integrated electronic health record
such as now exists in France, Britain, Singapore, Hong Kong, Taiwan and
elsewhere.
6. Obtain independent evaluation of Biosense goals and cost-
effectiveness.--The CDC Biosense Program, which now connects 30
hospitals in 10 cities directly to CDC, acknowledges the importance of
the exchange of information between public health and hospitals. Before
additional funds are invested in this stopgap system (there are plans
to connect to 100 hospitals nationwide), the specific goals of Biosense
need to be spelled out and examined in light of the actual operational
capabilities. Connecting more hospitals to more State and local health
agencies--i.e. linking the local response network which will actually
respond to emergencies--may be a better use of funds in the near term.
7. Establish redundant communication links between hospitals and
public health authorities.--Hospitals should have redundant
communication systems that provide the capability to communicate with
other regional hospitals and with public health authorities via non-
electronic means. The importance of such systems was dramatically
demonstrated during Hurricane Katrina. Competitive grants should be
established to demonstrate innovative approaches to the design and
implementation of communication links between hospitals and public
health.
ENCOURAGING AND ENABLING PUBLIC ENGAGEMENT IN PUBLIC HEALTH DISASTER
PREPAREDNESS, RESPONSE AND RECOVERY
Background
Recent disasters such as the Asian Tsunami and Hurricanes Katrina
and Rita have made clear that in large-scale disasters community
members are a mainstay of immediate response and are critical to
community recovery and resilience. HHS should translate this well-
documented reality into practice and establish a strategy for and
administrative focal point for Citizen Engagement in Public Health
Preparedness. HHS should collaborate with DHS to better coordinate and
emphasize the efficient recruitment and coordination of volunteers for
disaster preparedness and response.
Recommendations
1. Create an Office of Citizen Engagement within the OPHEP of
HHS.--The Director of this office must have experience in disaster
volunteer management, community organizing, and/or health risk and
crisis communications. Functions of the Office of Citizen Engagement
will include, but not necessarily be limited to:
Develop a national strategy for, and evidence-based
policies regarding the integration of individual citizens and
community-based organizations in preparing for, responding to, and
recovering from a public health emergency. Programmatic options that
would contribute to an informed and involved citizenry could include
but not be limited to pre-event public education and outreach,
influential public participation in emergency planning, volunteer
training and mobilization, and health risk and crisis communications;
Serve as inter-agency coordinator for all Federal health
agency programs that bear upon citizen engagement in health
emergencies, with special attention upon integrating the diverse
efforts at recruiting, registering, training, credentialing, and
mobilizing volunteers for public health emergencies.
Act as liaison between HHS, DHS, the American Red Cross
and other disaster-interested NGOs (e.g., Voluntary Organizations
Active in Disaster), broadening the scope of work of organizations that
have a disaster preparedness, response and recovery mission to include
large-scale outbreaks of infectious disease and other health
emergencies;
Provide guidance to DHS in equipping State, county, local,
and Tribal Citizen Corps Councils to play a larger role in community
preparations for a public health emergency.
Serve as clearinghouse for best practices and principles
regarding citizen engagement in public health emergencies and ``lessons
learned'' from demonstration projects administered by the Office.
Develop and offer--in collaboration with CDC, FEMA, and
other relevant agencies--a training curriculum for emergency response
and health officials in best principles and practices of public
involvement
2. The Office of Citizen Engagement--in consultation and
collaboration with DHS--will establish and administer competitive State
and local grants for demonstration projects that provide ``proof of
principle'' for active participation of citizens in public health
preparedness.--Grants will require joint application from health
departments, local and regional hospitals, emergency management
offices, and Citizen Corps Councils. Grant recipients must devise a
communications and outreach strategy for publicizing, and accepting
public commentary upon, the innovative activities supported by this
Federal program. Initially, HHS should fund pilot projects in 10
geographically and demographically diverse locales, funded $1 million
annually for 3 years.
Priority areas include:
Deliberative processes that solicit the public's input
into the ethical and rational distribution of scarce vaccines,
antibiotics, and other life-saving medical resources;
Innovative partnerships between health agencies,
hospitals, community-based organizations and businesses to handle the
complex logistics of prompt, mass prophylaxis among large, diverse
populations including hard-to-reach individuals and groups;
Local and regional volunteer management systems that
mobilize both medically and non-medically trained individuals to
enhance the response capacity of medical, public health, mental health,
and social service institutions.
Senator Burr. Dr. Kaplowitz, welcome.
STATEMENT OF LISA G. KAPLOWITZ, M.D., DEPUTY COMMISSIONER,
EMERGENCY PREPAREDNESS AND RESPONSE,
VIRGINIA DEPARTMENT OF HEALTH
Dr. Kaplowitz. Good morning and thank you for the
opportunity to be here and address this important issue, Mr.
Chairman.
Virginia, like New York, was enormously impacted by both 9/
11 and anthrax. I came on board right after that, with the
beginning of this Federal funding, and I can tell you that in
Virginia, it has made an enormous difference in our planning
and our efforts.
We have a unified, what I would call a unified health
system in Virginia where virtually all the local health
departments are part of the State. Most of our Federal funding
did go to support the local health departments to bring on a
number of people--epidemiologists, planners, laboratorians--and
these people have made all the difference. The need for
continued funding is clear because we need to keep the people
on board.
What we have been able to do in terms of key issues, we
built partnerships that didn't exist before. When you mentioned
who is in charge in an emergency event, it is the partnerships
that make all the difference. With NIMS, it is who is in charge
of what and who has the expertise to make the right decisions.
So our partnerships with emergency management, with fire, with
rescue, with our Emergency Operations Center, fusion center,
and law enforcement, have made all the difference in the world.
In terms of metrics, clearly, we need metrics and we have
been working very closely with DHS in terms of developing
metrics as well as with the CDC and DHHS. But we need to assure
that we have the exercises and events to test our plans, and
that is really the test of preparedness.
What we have done in Virginia is used every event as an
opportunity to test our plans, and we have had many. Not only
have we had hurricanes and floods, but we have anthrax events
very frequently, either through the Pentagon, through other
Federal facilities. In northern Virginia and the National
Capital Region, every event is analyzed with an after-action
report. We change the plans. We use all these events as a real-
life exercise, in addition to our frequent exercises, and this
is absolutely essential. I couldn't agree more. It also brings
all our partners into the picture when we have our exercises.
These are never done solely with the Health Department or our
health care partners, but with all our emergency response
groups.
One other comment I wanted to make in terms of situational
awareness and surveillance is the need for the close connection
to the health care community. I know others have mentioned
other partnerships with citizens, with business, with our other
emergency responders, but it is the links between public health
and the health care community that are absolutely essential on
any number of levels, including identifying problems as they
arise.
We can learn a great deal from data systems, from
surveillance systems, but often, it is the call from the astute
clinician that is going to make all the difference in the
world, and building those bridges in the past few years has
made an enormous difference, to the point where we are partners
with the health care community. They call on us frequently.
They depend on public health to work closely with them in this
partnership.
The other comments were mentioned by other folks, so I will
just leave it at that.
Senator Burr. Thank you very much.
[The prepared statement of Dr. Kaplowitz follows:]
Prepared Statement of Lisa G. Kaplowitz, M.D., M.S.H.A., Deputy
Commissioner, Emergency Preparedness and Response, Virginia Department
of Health (VDH)
Question 1. Situational awareness is based on timely lab and
hospital reporting, interconnected surveillance systems, consistent
epidemic monitoring and reporting, and appropriate risk communication.
Currently, there is wide variability across the country in these
capabilities. How do we best make progress towards a national public
health infrastructure with real-time situational awareness?
Answer 1. The most important thing would be to continue funding the
infrastructure that Federal funds have allowed us to put in place over
the past 5 years. Great strides have been made in the area of disease
surveillance thanks to Federal support for epidemiologists, the
National Electronic Disease Surveillance System (NEDSS), and syndromic
surveillance systems such as ESSENCE and BioSense. These efforts can
continue to be developed only with continued support at the Federal
level.
With public health preparedness funds in Virginia we have hired
epidemiologists in each of our 35 local health districts, to serve on
each of 5 regional teams, and to enhance our central office operations.
These epidemiologists are tracking and responding to the occurrence of
disease daily. They have strengthened relationships with local medical
care providers to ensure more timely and complete reporting of disease.
They monitor hospital emergency department activity daily through our
ESSENCE system for syndromic surveillance.
They also are entering data into our NEDSS system to make more
timely information available statewide. These epidemiologists also
follow up on reported cases of disease to prevent the spread to others
and investigate outbreaks to identify and control their spread. NEDSS
implementation has taken years of work, and much progress is evident.
We have found that the system requires continued IT support both in
terms of staffing and hardware and software infrastructure.
Syndromic surveillance systems allow public health staff to keep
their fingers on the pulse of their communities, especially with
respect to monitoring visits to emergency departments. We plan to use
our system to help us monitor the impact of pandemic influenza, as
well. Having systems in place that allow public health staff to monitor
data that are already being collected in the health care system is a
great benefit to disease surveillance. These systems have allowed VDH
to identify and track diseases of public health importance, including
cases of meningococcal meningitis, norovirus outbreaks, rash syndromes
and animal bites, that either may not have been reported or reported
many days after the event.
Additional systems could be built based on the syndromic
surveillance model, that help us collect the same sorts of information
from other parts of the medical care system, such as private physician
practices and hospital admissions. That would allow surveillance to be
conducted in various outpatient and inpatient settings.
States strongly believe it is vitally important that local and
State health departments be involved in the initial receipt and
interpretation of disease surveillance data. Local public health
workers need to act promptly on reports received to verify the
diagnosis, intervene to protect the contacts of the ill individual, and
gather information to determine potential sources of exposure.
Surveillance is not just about counting; rather, it is an important
tool that allows us to act to protect the health of communities by
responding immediately at the local level to prevent the spread of
disease. Additionally, we ask Congress to realize that local and State
systems have been built to detect the occurrence of disease and it is
not efficient or effective to scrap these systems only to replace them
with others that may not provide as much information as needed at the
local level. A great deal of good work has been done in disease
surveillance in recent years, and we ask you to please help protect the
public health infrastructure that has been built.
Common operating picture and realtime situational awareness require
that everyone has the same accurate information at the same time, as
well as interoperable systems to assure that this happens. This can be
accomplished through close collaboration among localities, between
localities and States, among States, as well as between States and the
Federal Government, using interoperable systems. These systems need to
use established protocols, must be based on sound science, assure
timeliness of information sharing and safeguard patient privacy and
security.
In Virginia, the Virginia Department of Health collaborates closely
with the Virginia Department of Emergency Management and all other
response agencies and organizations, both public and private. VDH works
closely with the Virginia Office of Commonwealth Preparedness, is an
active member of the Commonwealth Preparedness Working Group and has
close links to Virginia Fusion Center and the Emergency Operations
Center, assuring that information essential to public health and safety
is shared among all response agencies in Virginia in a timely manner.
Question 2. How do we recruit, train and retain a prepared public
health workforce with the ability to respond to national threats--
whether acts of terrorism or by Mother Nature?
Answer 2. The ability of the public health system to respond
adequately to potential terrorist events, emerging infectious diseases,
and other public health threats and emergencies depends on a well-
trained, diverse, and adequately staffed public health workforce at the
Federal, State and local levels. Recruiting, training and sustaining
the public health workforce is the preparedness crisis. Some States are
experiencing retirement rates of up to 45 percent over the next 5
years. The average age of a State public health professional is 47. The
current scenario is a rapidly aging workforce that will experience high
rates of retirement over the next 5 years with no clearly identified
source of qualified public health professionals to fill the void.
ASTHO urges you, in the strongest way possible, to include the
provisions of the Public Health Preparedness Workforce Development Act
of 2005 (S. 506) in your reauthorization legislation. This bill would
provide incentives for health professionals to enter the practice of
governmental public health, ensure these individuals commit to a
designated number of years of service in public health agencies, and
help to retain current employees in the field of public health.
We continue to face new challenges each year, from anthrax to
smallpox to SARS to pandemic influenza. One of the lessons of Hurricane
Katrina is that we cannot focus too narrowly on specific threats.
Instead, an all-hazards approach is needed. We must ensure that
essential public health resources--personnel, laboratories,
surveillance systems, communications, well thought out response plans--
are available to address ongoing and new public health threats.
In Virginia, the biggest challenge has been recruitment and
retention of experienced epidemiologists, laboratorians and information
technology experts. Nationally, there is a shortage of all 3 groups of
professionals; in addition, States frequently cannot match the salaries
offered by the private sector. Virginia has used national searches and
advertised multiple times for successful recruitment of epidemiologists
and scientists. In addition, continued training has increased the
expertise of epidemiologists, resulted in increased job satisfaction
and improved the chances that people will continue to work within the
Virginia Department of Health. Laboratory scientist positions have
often been difficult to fill; the excellent reputation of Virginia's
State laboratory has assisted with recruitment.
Many positions in VDH's Emergency Preparedness and Response
Programs have been filled by people making mid-life career changes,
often from the military but also from local government, health
administration, and non-profit groups. This has resulted in an influx
of people who have little or no background in public health. In
Virginia, this influx has been valuable for EP&R as well as for the
Virginia Department of Health in general, bringing both needed
expertise and a broad range of emergency response experience. Those who
have come to VDH from other areas have developed a strong commitment to
public health in general, as well as an interest in linking public
health to the healthcare and emergency response communities at both
State and local levels.
Question 3. How do we develop public health systems research,
paramount for developing evidence-based best practices and benchmarks,
for an all-hazards public health response?
Answer 3. No reply.
Question 3a. Do issues ranging from disease forecasting to
financial modeling of Federal and State public health investments need
further study?
Answer 3a. Yes. Research in public health preparedness must involve
close collaboration between Schools of Public Health and State and
local health departments to assure that research findings are
applicable to public health preparedness.
Question 3b. How is ``public health preparedness'' best defined and
what are the metrics for measuring success?
Answer 3b. ASTHO supports the development and implementation of
performance Metrics and measures to assess progress in preparedness.
Accountability is essential and best measured against a limited set of
performance measures that are evaluated over time and flexible enough
to allow States to match their individualized strategic plans to
national goals. State and local public health has been very involved in
assisting the Department of Homeland Security in developing Performance
Measures for the 37 Target Capabilities List in accordance with HSPD
#8, as well as working with the CDC on specific grant performance
metrics. In many respects, this is uncharted territory, requiring full
engagement and collaboration of all disciplines, relevant agencies and
levels of government to minimize the potential for incomplete,
conflicting or ``siloed'' performance measurement tools and processes
that fall short of the mark.
We must look beyond metrics to be certain we are also using
effective performance measures. The best method of determining if an
emergency response plan is effective is to test it under real or
simulated emergency situations, during actual emergencies or well-
designed exercises. Each event or exercise must be followed by a full
after action report, which results in appropriate changes to plans that
will then again be tested through real events or exercises. Exercises
must be structured so they stress the response system, as well as
collaboration with other emergency response agencies and organizations,
in order to serve as effective tests of plans. In Virginia, exercises
are planned and implemented by VDH staff, with very infrequent use of
consultants. As a result, Virginia has built extensive internal
expertise in public health emergency response.
Successful public health preparedness and response requires the
recruitment and retention of qualified public health professionals to
be knowledgeable about public health, emergency response plans, as well
as incident command and NIMS. This is not possible in an environment
where there are concerns about the future of program funding. I cannot
emphasize enough how important it is that Federal bioterrorism and
emergency preparedness funding to State and local health agencies be
predictable and sustainable.
Senator Burr. I am going to ask for the indulgence of our
panel for two minutes for a slight interruption while I go make
a telephone call that I just got e-mailed on, and it will be no
longer than that, so if we could, we will temporarily suspend
and I will be right back.
[Recess from 11:07 a.m. to 11:09 a.m.]
Senator Burr. I thank you very much.
I know that staff provided three questions to everybody,
and if I may, I would like to go down those three and anybody
who would like to respond to the questions in order, please
feel free to do so. In addition to that, I am going to have
some other questions that I would like to spend the remainder
of the time attempting to mine down for my own purposes, such
as, specific information that we are either looking at,
considering, or in response to potentially something that you
or others have mentioned today.
The first question on situational awareness is based on
timely lab and hospital reporting, interconnected surveillance
systems, consistent epidemic monitoring and reporting, and
appropriate risk communications. Currently, there is wide
variability across the country in these capabilities. How do we
best make progress toward a national public health
infrastructure with real-time situational awareness? Is there
anybody who would like to tackle that?
Tara.
Dr. O'Toole. Well, I think situational awareness is one of
those core functions that is essential to responding to all
hazards. I also think that it is going to be very difficult to
achieve the kind of situational awareness across the country on
local levels as well as the Federal level that we need, and
this is an area that is really ripe for an overall national
strategy. I think we wasted a lot of money on various kinds of
surveillance systems as people in good faith tried to invent
different sorts of syndromic surveillance systems and put
systems in place that weren't well thought out.
I think what we need, first of all, is a national strategy.
There ought to be an office in HHS, not in CDC, that is
responsible for creating a national surveillance system at all
levels and over a period of time, and that program ought to be
accountable for building the systems we seek, and there ought
to be priorities as well as a very rich interconnection between
that office and the private sector and the users of these
systems.
We have seen with the FBI how difficult it is to build
these electronic systems, and what we need in terms of
situational awareness electronically is going to be bigger and
more complicated than anything the FBI is trying to stand up.
Asking CDC to do this or asking State health departments to do
this is crazy. It just isn't going to work. Some places are
succeeding. New York, for example, is making progress, but the
places that succeed are either going to by happenstance have
great IT expertise on board or they are going to have more
resources than others. So we need to figure out what the
priorities are here and how to put them in place.
My first priority is to connect, as Dr. Kaplowitz said,
public health to the health care sector. We ought to set a
clear date, I would say no later than 18 months from now, for
connecting all hospitals to State public health agencies so
that we can at least flow real-time data about patient census,
about bed logistics, and about laboratory reports from the
hospitals to public health. That, I think, would make more
difference in terms of our ability to manage an epidemic than
any other kind of connectivity we could do, and we could put
that in place.
I would not spend another penny on Biosense until we had a
very clear notion of what the strategy for Biosense was and
what it was going to get us. Right now, it doesn't make sense
to me to connect CDC to the hospitals before we connect the
locals to the hospitals. It just isn't going to give you much
more operational reach, and I think right now it is confusing
the hospitals, who are being asked by CDC and then by their
locals to connect their systems and it is basically dissipating
our resources.
But we need a strategy and we need a way of getting the
best minds in IT, which America has, working on these programs,
and we shouldn't lay the burden of designing the programs on
local public health. That is a strategic error.
Dr. Lurie. I concur entirely with Tara's comments and maybe
want to amplify this a little bit more. In addition to the
technology needs, we still have to remember that the health
care provider and the public are the first lines of defense.
They are probably not going to be as hooked into the technology
for a very long time as we want them to be, including the
health care provider who sees a patient in a clinic. I think it
is okay to get hospitals linked in, emergency departments and
laboratories linked in, but if you look at almost every event,
as Lisa said, it is the astute clinician who makes the phone
call.
The second thing I want to highlight is that we in America
have this incredible infatuation with technology, and
technology alone is not going to be sufficient here. Look at
what happened in Katrina. Our power was out. Our phones were
out. Our satellites were out. We have got to have a system in
place that has adequate backup so that if we have another
disaster like that when everything is out, we are not so
dependent on the technology that we can't function. I am a
little bit worried that we are throwing away some tried and
true things that probably need to remain in place while we
build the system of the future.
And finally, I just want to say I entirely agree with the
comments about Biosense. I wouldn't spend another penny on it,
either. Bypassing State and local health departments, I think
is problematic. There are huge problems with data quality. Many
public health departments, as you probably know, refer to it as
Bio-Nonsense, and we have a long way to go before we get that
right.
Senator Burr. I was asked to speak at a tabletop held by
Speaker Gingrich last night. I started off my remarks by
saying, have you figured out how to design a model that at any
given point in time, 40 percent of the employees won't be
there?
And all of a sudden, the reality sinks in that everything
that you would design--it is sort of like looking at the model
of New Orleans and saying, ``Would you have ever designed
something that addressed the degree of flooding?'' Only at a
real weird moment would you have thought something like that
could happen. Should we? Maybe so.
The question is, don't replicate the same mistake by not
being creative enough as to what can happen. I think the only
true mistake that we could make is to design a response to
pandemic flu or a response to anything that doesn't take into
account the realities of what we know the effects might be on
the population. The population can't just be those people who
work at a given location. It is everybody across the board.
So if you look at the general population and say at any
point in time, 40 percent cannot attend, that is 40 percent of
law enforcement. That is 40 percent of health care workers.
That is 40 percent of public health workers. It is 40 percent
of everybody and the system has to be designed to take that
into account. If not, the system fails.
Ms. Honore. Just to follow up on your excellent comments,
that are very well taken because in Katrina, a vast majority of
the responders were also victims themselves who still had to
respond.
The other thing that we shouldn't forget is that during
Katrina and during some of these other potential emergencies,
the communications systems may just be broken. I mean, there is
no electricity. There is no way to communicate. The phones are
down. The satellite phones are down. So if we are talking about
the situational awareness, we have to take into consideration
the infrastructure of how those communications will happen when
everything is just as Ms. Honore has said over and over and
over again, they are just broken. There are no lines of
communication.
Just a few other points, but not to elaborate too much on
what everybody else has said, but there has been significant
accomplishments at the Federal level. But I think what hasn't
happened is the research and the evaluations to determine best
practices or to facilitate course corrections as we go through
that, and some of those questions might be, what is the impact
of the State and local public health organizational structure
to actively effectively implement the situational analysis
systems?
Other things that were mentioned is what are the metrics to
determine organizational capacity within the agencies
themselves? Workforce competencies stretch all over the place
in State and local public health. We simply don't know what
those are.
Senator Burr. Doctor.
Dr. Kaplowitz. I just wanted to expand on comments made
about dependence on information technology, on IT and on
systems, electronic systems. I am a definite believer in
electronic systems, especially when they are interoperable and
we can talk to each other, not only within health departments,
but across agencies. However, so much depends on our people and
I just want to put in a plea that we have been able to bring on
an incredible amount of expertise with this funding,
epidemiology and planning and laboratories. Those
epidemiologists at the local level make all the difference in
the world. They analyze the data at both the local and the
State level. They are the ones who trigger the immediate
response.
I just know in Virginia, if we were to lose that expertise,
those personnel, it would make an enormous difference in terms
of our response. They have made all the difference in rapid
response to any number of situations--rash syndromes,
infectious disease outbreaks, influenza situations. So I wanted
to put in that plea that while we build our electronic IT
systems, that we make sure that we have the people who can
analyze the data and who can generate the rapid response.
Senator Burr. Dr. Caldwell, you are a little outnumbered
here, aren't you?
[Laughter.]
Dr. Caldwell. Well, I feel that we are all colleagues and
hearing some of the comments, I sense that we are all coming at
this with the same viewpoint.
I want to answer the question about situational awareness
with my experience regarding the whole concept of syndromic
surveillance. I think there are a bunch of smart people who
thought that perhaps, in looking back maybe at intelligence
issues, that if we had had some threat or some clue before
those planes hit the World Trade Center, perhaps we could have
intervened and prevented them. Well, now translating that into
bio-surveillance, perhaps we can look at all of this data and
find some clue or some evidence that something is going on and
we can intervene to prevent either a manmade or a natural
catastrophe.
This is really research that ultimately, I think, its value
is unknown. As a physician, we would always do drug studies and
we would find out that, oh, if you give this certain drug, it
helped this person such-and-such amount. But the next question
always was, well, what is that clinical significance? It may
help your joints move a little better, but what is the clinical
significance?
And I ask you, what is the real significance of getting all
this data? What really is it going to do for us if there is an
event? Are we really going to detect something early enough?
Nobody knows, but yet we are funding and putting tons and tons
of money into trying to get data, data, data. We don't know
really what the data is. We don't know what we are looking for.
And that is another question. What are we trying to detect?
What are we looking for? Maybe stomach upset, maybe shortness
of breath.
I would challenge all of us to think of a house burning in
a community. What happens when there is a house burning? Maybe
somebody smells a little smoke. Maybe somebody sees something
in the distance. But suddenly, somebody calls and we all
respond, and Senator, what is lacking in our conversation
today, but I hear pieces of it, is the concept of bio-response.
We have Biosense, but we need a bio-response. And that is a
concept that the public health officials across our country do
every day. But we need to invest more in it.
We have heard my other colleagues saying that we need
people to respond. We know when to respond, how to respond, and
respond in a coordinated way, not just the health guys but in a
coordinated way with our other partners. When you look back at
our true victories in picking up public health problems, what
did it come down to? An astute clinician, an astute clinician
who is able to see something, call up the local health
department, knew who to call, knew who to call quickly, 24
hours a day.
When I had a case just in November of a girl, 19-year-old
girl at Marist College, the emergency room infectious control
nurse immediately called the communicable disease unit of my
department and said, ``I have a case of meningitis here.'' We
immediately went into action, tried to help that family,
immediately identified the contacts to try to give out
antibiotics.
So I think we need to hear more about bio-response. I think
getting all this data is interesting academically. I would like
to have it. I am not sure what we are doing with it. We need to
certainly integrate it more from the CDC down to the local
level. We are building relationships from the local hospitals
and doctors to the local health department and the State. We
need to integrate all of this, and I think this is something
that I have heard some positive comments from Dr. Besser today
about the concept of leadership training and trying to focus
more on having strategic integration of our work and our daily
activities. But I would like to see more on bio-response, which
is a commitment of workforce as well as continued training.
Senator Burr. Let me assure all of you that we will work
with Dr. Besser to better understand where we are headed and
potentially what the objective is at the end of the day. When I
said that you have to put a plan together that takes the
element of surprise out of it, one of the obvious things is,
what if a clinician--what if a health care professional doesn't
initiate the call? They have got the symptoms, doesn't initiate
the call. The clock hasn't been started. Somebody hasn't been
notified. Whether that is CDC or whether it is local public
health, how long is it before then the system picks it up?
I think to some degree there is a tendency up here for us
to try to take as many elements that are unpredictable out of
the equation and build in some degree of predictability. I also
understand the frustration on your part that we have seen this
tried and, in some cases maybe more than others, have been
unsuccessful and we don't want to replicate a model that has a
likelihood of being unsuccessful.
Ms. Gursky.
Ms. Gursky. I think the issue of information and
information systems has been one of the most fundamental
concerns over the past few years. It is a source of great
opportunity and it has been a great source of frustration.
There were monies put out before there were requirements about
what should be built. We have made a lot of mistakes. We have,
unfortunately, wasted some monies. We have, in some instances,
put the cart before the horse in terms of wanting to collect
more data than is actually usable or practical.
I would like to go back to what Dr. O'Toole mentioned,
which I think is really fundamental to where we need to go
forward, which is a national approach for figuring out what it
is we really need, how we take what we have in existence and
use that to make interoperable systems.
There is nothing that is going to replace the phone call
from a clinician, but obviously, that is not always going to
happen. We really do need these systems. They are ultimately
profoundly useful for a number of reasons. But the approach has
got to be coherent. It has really got to be national. It has
got to be led by experts who know what data, how to stream it,
and how to use it.
I think Dr. O'Toole's timeline is very important. I think
we need to catch up with the time that we have perhaps not
taken the best advantage of, but let me echo Dr. Caldwell and
Dr. Kaplowitz's comment. Eighteen months from now, when hard,
usable data comes into health departments, there has to be
someone on the end who knows how to use that and make informed
decisions.
Senator Burr. Well, clearly, our reauthorization deadline
is before those 18 months and I think we have been given the
task to try to sort through all these issues that have been
raised today and in other conversations in hopes that we can
present a legislative blueprint for how we go forward, and
hopefully it addresses in many cases a lot of the issues that
you have raised and hopefully provides additional insight for
the CDC or HHS or DHS relative to how the pieces need to fit,
or at least how we envision it.
Whether we, in fact, achieve that depends on whether we
will get a reauthorization and that involves a tremendous
amount of work between the House and the Senate and the
administration, and that is why I am delighted that we have got
representatives from the House here today.
Let me raise one question. I know you had your hand up. I
think this is an opportune time for me to ask this and I would
appreciate a very quick answer. Is there a disaster that is
raised to a degree where the Federal Government automatically
trumps State and local response? Yes, ma'am?
Dr. Kaplowitz. I am not sure the correct word might be
``trumps.'' We actually----
Senator Burr. Let me state why I have asked the question.
Everything from Dr. Besser to, Tara, your comments about the
timeline that we have, if we are going to talk real-time, it
has to be real-time. In the case of Katrina, if there had not
been a 48-hour period in Louisiana where there was some
deliberation before the request for Federal aid and you had
expedited the Federal response by 48 hours, you would have been
within the window of response where chaos did not break out.
The challenge was still the same, but I think most of the
additional obstacles that were created after that 72-hour
period might not have existed. I realize we have a
constitutional issue here, so I am not trying to debate the
Constitution.
Dr. Kaplowitz. Well, I was going to use as an example an
exercise that we participated in a year ago August that was
part of a Federal exercise. It was designed to immediately
overwhelm local and State systems. It was Determine Promise
with thousands of deaths and casualties. What I took away from
this is that you weren't going to have a situation where the
Federal Government was going to come in and still run things.
You could call in the resources faster, and we needed to call
on them almost immediately. But still, you had the local
response, you had the State Emergency Operations Center really
being the source of incident command for the response at the
State and then the same thing at the local level.
So I really thought of this as calling on the Federal
resources much more quickly so you could coordinate it better,
and yes, bring in resources more quickly. But I still felt that
it was valuable to stay with the emergency response systems in
place, where you had the localities really deciding how things
were going to work at the local level, the State coordinating
things on the statewide level, the Federal Government, and we
had the Department of Defense bringing in their resources at
the same time, which is why I question the comment of trumping.
I think we have the command system in place to work at all
levels, to bring in resources at all levels, but still not have
a Federal control in that sense, which is really what I was
trying to focus on.
Senator Burr. Well----
Dr. Kaplowitz. There is one situation with the command
system and then calling in the resources.
Senator Burr. In full disclosure, I am trying to flush out
this issue of who is in control from all different angles right
now.
Tara.
Dr. O'Toole. I know that Richard Falkenrath at your hearing
a couple of weeks ago suggested that in the kind of large-scale
calamity you bring up, the DOD ought to be in charge. You know,
beyond a certain scale of badness, you put DOD in charge. I am
sympathetic to Richard's longing for operational competence in
a catastrophe such as Katrina, but I think it would be a big
mistake to assume, to plan to put DOD in charge whenever we
have a big bad thing happening.
I think what we are confronting for the first time in our
history is the need to consider very large-scale disasters
largely as a consequence of the terrorism threat, but also
because of natural disasters that can now afflict millions of
people at one time, and we have to rethink federalism.
In reality, if you look at what happened with Katrina, I
think we are going to find as we piece the response together
that a lot of what happened to the good happened at the local
level. It wasn't well connected, but beyond the locals, what
you got was contiguous States and other States bringing
resources to bear.
We have found in the medical response that lots and lots
and lots of hospitals and States wanted to offer help, but
couldn't plug in. What the Feds have to do is create the
capacity to plug in, and that is where they ought to be
focusing on.
But I don't think we want the DOD to suddenly become
everybody's responder in cases of dire need. I think we have to
get ready to have contiguous States more able to move in and I
think we have to have much more robust communication systems
across the board so we know what is going on, situational
awareness again, and where the resources are and how to deploy
them.
Dr. Lurie. I think the answer to your question also depends
in part on what kind of a disaster we are talking about.
Clearly, if we are talking about a localized disaster, even if
it involves lots and lots of people, it is pretty different
than talking about a national disaster. Where it is feasible
for Federal assets to go to one or two locations, it is not
feasible for the Federal Government to go to and run a response
everywhere in the country, or in half the country as you might,
let us say, in pandemic flu. So I think we have to be careful
not to tar all of this or paint all of this with the same
brush.
Another thing I would say is that in all of the work that
we have done on exercises, two things really make the
difference in response. One is leadership. The other is
practice and partners knowing each other.
When you look at real events and places where people have
gotten into trouble, and we have had an opportunity to look at
some of those, it has been where partners don't know each
other. It has been where people don't practice together.
And so thinking that you are going to have Federal assets
and people who don't know each other come in, not know the lay
of the land, not know the people, not run the show, they are
going to spend a lot of time wasting time, duking it out about
who is in charge and making a lot of mistakes and missteps
because you don't have those relationships built. The
investment needs to be in building and maintaining and
practicing those relationships over and over and over again. In
this case, I think practice makes perfect.
Senator Burr. Well, as a resident of North Carolina, I can
tell you that there are two reasons that Florida and North
Carolina passed the threshold for preparedness, and they were
the only two in the country, and that is because we annually
not only have a plan, but we practice it. Virginia is close
behind us because usually if it comes across our coast, it is
headed for Virginia eventually, just based upon the weather
trend.
Let me move to the second question, if I can. How do we
recruit, train, and retain a prepared public health workforce
with the ability to respond to national threats, whether acts
of terrorism or by Mother Nature? I think some of you have
answered pieces of that in your opening statement. If there are
additional comments that you would like to make, we will
certainly entertain those. Yes, ma'am?
Dr. Kaplowitz. I want to make a comment about shift in
culture, which is what I have been seeing within the Virginia
Department of Health. As of 2001-2002, it wasn't the culture to
be part of an emergency response, and that has changed
dramatically over the past 3 or 4 years. Part of that culture
is to make it clear that everybody is going to have a role to
play in an emergency. This isn't going to be just those folks
funded with these emergency response funds, which I think was
the perception initially, but this is going to involve
everybody who is in the health department, whether it is at a
local or State level for us.
And again, a lot of this is a perception. A lot does depend
on training, bringing people on board so they understand
systems of response.
And in terms of having a devoted, educated workforce, the
need for continued funding is going to be key here because
people won't stay in public health if they sense this is just
going to be a temporary commitment. We have brought a number of
people into the Virginia Department of Health from outside
public health. Many came from the military, some came from
local government, some came from the private sector, some came
from nonprofits because of their expertise in emergency
response, and in a sense, we have melded cultures that way. It
has been valuable for us. It has been valuable for them to
really get a handle on everything that public health does.
Senator Burr. I am curious, when a student today considers
a public health career, what is their perception of such a
career? In North Carolina, UNC School of Public Health is not
only one of the best in the country, but it had one of the best
directors when Bill Roper was there. He is somebody who has a
handle on it, and this is a question that I have written down
that I am going to ask him, but I am curious as to whether
anybody here has a perspective on when someone decides to have
a public health career, what do they envision that being today?
Dr. Lurie. Well, before I was at RAND, I actually taught in
a school of public health and I would say that it was the rare
student who envisioned themselves working in a State or local
health department or even at the CDC. Students who went into
public health by and large envisioned themselves working in the
private sector, working somewhere in the health care delivery
system, working in a foundation, working in research, did not
see themselves at the front line working in a health
department, and I think this is something that has to change.
I think if they saw themselves working in that role, they
saw the fact that this would be a training ground for 1 or 2
years that they would then get gobbled up by some other place
where, frankly, they could be better paid, where they wouldn't
have to work in a difficult bureaucracy, and where they thought
that they could have more of a population health impact. I
think right now the model and the vision of what people are
preparing themselves for, what they are going to go into, is
pretty backwards.
One of the other things that we didn't really talk that
much about is we talked about the fact that the funding needs
to be stable, but also that the jobs people go into are at
least competitive and on a level playing field with the private
sector. People who work in public health departments now are
awfully altruistic to do this.
Senator Burr. I would be the first to tell you that I am
not sure, given all the pressures in health care today, that
one can look at something as aggressive as I think we are going
to look at and say, ``by the way, there is going to be pay
disparity that exists for this type of career more than
anything else in the private sector.''
I am trying to get at what the expectations are of somebody
who decides they want to go into a career of public health and
where we lose them or what the enticement is that draws them
away. Clearly, you have addressed the salary, and I am curious
as to whether we have got a dedicated pool of students that go
into public health for what typically the role of public health
was, and that was to be the tip of the spear, and depending
upon where they end up may determine what type of public health
they actually go into. I am getting back to the need for us to
replicate a public health function around the country that is
all the same.
Dr. O'Toole. I think people go into public health with one
set of aims and they come out with another. I think they go in
very altruistically, either wanting to do research, wanting to
get answers to problems. I was a practicing physician, who got
tired of bringing teaspoons of water to the ocean and got
interested in more preventive approaches. But when you come
out, you enter a market-driven economy and there aren't many
jobs for public health practitioners, and throughout most of
your experience in public health school, you don't hear about
public health practice. You are being taught by people who are
primarily doing research, which is fascinating in and of
itself. So people come out and they look at where the jobs are
and they go into health care administration or research, by and
large.
The most cost-effective way to get the public health
workforce we need for practice is tuition payback. If you pay
people's way through public health schools or through schools
of medicine or nursing--telling them, when you get out, you are
going to owe an equal number of years in public health
practice, you have got to go work for some level of government,
they are going to change the curriculum in the schools of
public health. This happened with primary care in the U.S.
Public Health Service. Medical schools suddenly started paying
attention to family practice and internal medicine and primary
care. I think that could happen with schools of public health,
as well.
It gets around the problem of--please guarantee us we are
going to have funds at the State level for the next 5 years to
keep our people in place. The Congress isn't going to do that,
we all know that. But if you had a tuition reimbursement in
place, you would have not only this market-driven shift in what
is being taught in schools of public health, you would have a
stream of people that you knew were coming out and looking for
jobs. That would change things, I think, fairly fundamentally.
Ms. Honore. One of the things that I would add to some of
the excellent comments that have been made already is that we
need to develop and implement strategies taken from other
professions in order to attract people earlier on in their
career. For instance, like pharmacy and engineering, they have
partnered with even the community college to develop joint
doctorate-level degrees to get people early on in their career.
In public health, the Master of Public Health, the M.P.H.,
is touted as the entryway into the field. Well, in the
Mississippi Department of Health, 60 percent of our workforce
has no Bachelor's degree. Forty percent have no college. If the
M.P.H. is the entryway to public health, how do they get from
no degree to an M.P.H.''
Senator Burr. Dr. Caldwell.
Dr. Caldwell. I think the key word here is incentives, but
it is also, I think, to have inspirational mentor leadership
that is visible in a way to get people interested and motivated
to do what is really community service. Typically, public
health has a difficult time defining itself because we don't
have one particular uniform. We are not as identifiable as our
police and fire colleagues and even our clinical colleagues, as
well, so----
Senator Burr. Do you feel that as we reauthorize
bioterrorism legislation that it is incumbent on us to define
public health for the future?
Dr. Caldwell. I don't know if that is ever achievable
because----
Senator Burr. It wouldn't be the first time that somebody
has given us something that wasn't achievable----
[Laughter.]
But in a perfect world, do you see that as beneficial, I
guess I should say?
Dr. Caldwell. I think that there are a number of groups
that have worked to try to define that as best they can in the
context of redefining this particular legislation that you are
trying to reauthorize. I think it is certainly something that
you can take from the previous work that has been done in
trying to define public health specifically for emergency
preparedness in this regard.
But I think what I am most concerned about is the
recognition that the people who come to serve in public health
come from so many different parts of our society, from so many
different training paths, and I think that actually is a
strength of public health, that we do have so many. What the
weakness is is that we have not had a unifying, overarching
connectedness.
But I can tell you, and what we have heard here is that the
culture is changing in our departments and across our
communities. The unification now of what public health is, at
its core, is that we are there to serve the community in a time
of crisis. That is new. That has never been there before, and
that can blend my lawyer colleagues, my physician colleagues,
the epidemiologists, the engineers, the restaurant inspectors.
We all put on blue shirts when we do a drill. We are all
together. And to me, I would have done this just as a team-
building exercise. But now, we all recognize we are connected.
Before, even within the departments of health, we would
have the nurses over here and the environmental people over
there, and they do their programs and they would respect each
other and they would all realize they were experts and they
also knew they didn't know what the other person really did,
but they knew it was important. But now you take a step back
and you can create this unifying, overarching effort. I think
that is perhaps your way to solve the challenge of defining
public health.
Senator Burr. In the past 5 years, what do you consider the
most significant advances of public health, and in the next 5
years, what do you think should be our specific objectives in
public health?
Dr. Caldwell. Clearly, in the last 5 years, there has been
an awareness that we are the ones to stand up to the challenge.
There is an expectation among other community partners that we
have to be shoulder-to-shoulder with them. The resources that
we have received, the $1 billion or so to State and local
public health departments, have been indispensable. I think we
sold ourselves short, though, when we came up with the $1
billion at the time. If you recall, the first allocation that
we had from this in 1999 was about $36 million. So when you
jumped us up so high, we knew the civil service infrastructure
we were going to have to deal with to try to get us to where we
needed to be.
But we had a vision, and I think over the last 5 years, we
have built the framework of a system that we can carry forward,
and I think a lot of good has happened and I think this has
really been a tremendous advance.
But the next 5 years, I think we need to, first of all,
send the message that we value the success of the past 5 years
and not start reducing that level of appropriations that is
going to this effort, which we saw trickles of and we were
concerned about it. But we need to strengthen that and continue
to have strategic exercises community-wide, not just public
health departments, but every single community drill to include
as many partners as possible so that we can learn from each
other.
So when the fire people are doing their fire drill or the
police are doing their police drill, we should have more of an
integrated approach for all the types of drills so we can learn
better from each other, and I think that is the challenge that
lies ahead of us.
Senator Burr. Dr. Honore, if I remember correctly,
Mississippi had a system in place to track hospital beds, and
space available. Given the experience with Katrina from a
public health standpoint, how valuable was that to you as a
public health entity?
Ms. Honore. That was exceptionally valuable to us,
particularly given the situation on the Mississippi Coast where
for quite a few number of days, the hospitals had to close
down. Some were flooded out. Some were just destroyed. So that
was immensely valuable to us during that crisis. Some of the
other situational analysis and bio-surveillance capacities that
we have put in place also would be the availability for
exposure, identification, and data collection within all 480 of
the ambulances in the State and all 75 hospital emergency
rooms, as well.
Senator Burr. Dr. Lurie, from your specific research and
analysis, what are the two highest priorities that need
attention with regard to public health preparedness for the
21st century?
Dr. Lurie. I guess from my perspective, the things that are
most in need are some of the things we have talked about today.
We have got to get the IT infrastructure right, and I think
that remains critical and will be transformative ultimately to
all of public health.
The other pieces, I think, are in the short term really
dealing with these workforce competency gaps and issues. I
think the issue about leadership is absolutely critical and I
think that the issue about how you improve, and I was really
delighted to hear Dr. Besser talk about the goal of learning
and improvement. But how you do it is really tough.
Senator Burr. Dr. Gursky, what do you envision the 21st
century public health system to look like?
Ms. Gursky. Thank you for that question. How many hours do
I have to answer this?
[Laughter.]
Senator Burr. I felt like I had neglected you.
Ms. Gursky. Not at all, no. I have been enjoying all of the
discussion and excellent points by my colleagues and your very
thoughtful questions, sir.
I believe that what a 21st century public health system
will look like in the next few decades will be exactly what 50
governors and 3,000 mayors want it to be, to serve the purposes
of providing health care and safety net services for its
populations, ensuring better access to health care, improving
health care status. What I would like to hope it would be is
large enough, resourced sufficiently to be able to support the
health security and preparedness mission.
I think it is going to be very tough to do both
simultaneously. I think that the health care needs of 300
million Americans, many of whom don't have good access or don't
have insurance, is going to require continued reliance on
public health departments for their health care and that it is
going to be tough to put the preparedness mission further on
the tip of that sphere.
I am hoping as you reauthorize legislation that--and I do
offer whatever assistance I can provide--that we look at how
those two missions can coexist, how we clearly define the
vision so we can put in place the right information
infrastructure, how we recruit the expertise and the workforce
we need for these specific tasks so that when they get
information, they do respond quickly and appropriately, and
that we get better in our measurement so that we can come back
and tell you, this is what it costs. This is what we are going
to need going further to assure you a secure America, to secure
all Americans a secure America.
Senator Burr. Well, that is ultimately the task in front of
us.
Dr. O'Toole, I sort of took from your opening comments that
we are very much crisis-to-crisis driven from a standpoint of
how we look at public health. I am curious, what do you think
it takes to knock us out of that crisis-to-crisis management
mode that we are in and one that is focused on the creation of
a permanent model that is almost plug-and-play, that allows us
to take whatever the thread is and plug it in and know that the
system works?
Dr. O'Toole. I think it is going to take a really
calamitous crisis. I think America is going to be very
reluctant to spend their treasure and resources on this until
it is very clear to those 3,00 mayors and 50 governors and the
entire U.S. Congress that that is what we need to do. I think
that will happen. I think the reality of this age is that we
are very vulnerable to naturally occurring epidemics and to
bioterrorist attacks, and I think the future of public health
is going to trend in the direction of the rest of human
activities, toward ever more connectedness, and I think we will
get to that kind of plug-and-play piece that you are looking
for, but building the systems that undergird that and the
willingness to figure out what those systems are, I think is
going to have to take a sea change in political consciousness
in America. You accept it, of course, Senator. But I really
think we are still operating on erroneous presumptions of
scale.
Senator Burr. Thank you. Last question, and a short answer,
if you will, but it is an easy one. How do we retain public
health workers? We talked about how tuition forgiving might be
a way that we attract people. You are out there. How do we keep
them?
Dr. Kaplowitz. Well, I am going to give a more general
answer. I think that a key thing that public health has to do
is educate the community on what it does, and the community
meaning from the individual level, to local, and all the way up
to all our partners dealing with security, because public
health will be valued in the sense that it is viewed as being
valued. That will draw more people into public health.
When I went to medical school, I had no clue what public
health was. It is something I had to learn by on the job
training. I think we are doing a much better job now as we do
outreach to the community with pandemic flu, as we do outreach
to all our partners with emergency response. The more value
public health is given in society in general, the more it will
be valued for people to come into the profession and to support
it, as well.
Senator Burr. I would tend to agree with you. I think that
our inability to define for the rest of America what public
health is makes individuals reluctant to ever chime up and ask,
what do you do, ``I work in public health,'' because there can
be a number of different analyses and determinations that one
can derive from that.
I want to thank all of you for your willingness to come
today and for the valuable information that you have shared
with us. I could stay for another hour, as some of you know
because I pick your brain all the time, but somebody has to
preside over the Senate in about 3 minutes and that person
fortunately enough is me today. So once again, I thank you.
This hearing is adjourned.
[Additional material follows.]
ADDITIONAL MATERIAL
Responses to Questions of the Senate HELP Committee by CDC
Question 1. Situational awareness is based on timely lab and
hospital reporting, interconnected surveillance systems, consistent
epidemic monitoring and reporting, and appropriate risk communication.
Currently, there is wide variability across the country in these
capabilities. How do we best make progress towards a national public
health infrastructure with real-time situational awareness?
Answer 1. Situational awareness encompasses many different aspects,
including timely reporting, communicating with all involved agencies,
organizations, and individuals, and ensuring interoperable systems are
available to enhance communications and reporting capabilities.
Traditional public health surveillance and investigations often
involve the manual reporting of cases to public health agencies and
phone calls to healthcare providers for more detailed chart
information. The timeliness, completeness, and breadth of coverage of
this manual process can be problematic and too slow to be effective
during a public health emergency. With increasing volumes of health
data in electronic form, and a national focus on the value of
exchanging those data electronically in a standardized format, a unique
opportunity exists to leverage those existing health data to better
support public health functions.
BIOSENSE
BioSense is a national program intended to improve the Nation's
capabilities for disease detection, monitoring, and real-time
situational awareness through access to existing data from healthcare
organizations across the country. The BioSense application is a CDC-
developed and hosted web-based system for use by healthcare facilities
and State and local public health partners. The surveillance methods in
BioSense address the need for identification, tracking, and management
of rapidly spreading naturally occurring events and potential
bioterrorism events using advanced algorithms for data analysis.
Through its BioInformation Center, CDC provides knowledgeable public
health analysts, epidemiologists, and statisticians to assist partners
in the analysis and use of BioSense data on a daily basis. In addition,
CDC analysts provide support to State and local public health
departments with training on the BioSense application. These staff
members also monitor system performance, identify data quality issues,
and collect feedback and provide input on the user interface design and
operation of the BioSense application. This partnership with State and
local health departments is important in the success of BioSense.
The Real-Time Data Initiative will strengthen BioSense by
emphasizing access to real-time clinically rich data from emergency
departments, outpatient clinics, and other hospital settings. These
data will be useful for both early event detection and situational
awareness. Situational awareness is the ability to monitor disease over
time and geography. Using this data BioSense will inform public health
in a way not previously accomplished. At the time of an emergency
event, hospital and public health officials will have a real-time
picture of how a community is affected. This information can help
characterize and monitor an outbreak, as well as aid in the decision-
making process for appropriate and timely public health interventions.
BioSense uses CDC's Public Health Information Network (PHIN)
architecture for advancing fully capable and interoperable information
systems across public health, its partners, and stakeholders. At the
core of PHIN and BioSense are commonly accepted health data standards.
This standard vocabulary will help to improve data quality,
comparability, and other activities related to the development of an
electronic health record. A key component of this development is the
interoperability between public health and healthcare.
Risk communication is an essential element of this process. When
surveillance systems or other reporting mechanisms signal an unusual
event (natural occurring disease outbreak or bioterrorism related), it
is vital to disseminate effective risk communication messages in a
timely manner. CDC utilizes several different communication mechanisms
in order to release health alerts and updates to those who need them.
Through Epi-X, State and local health departments, poison
control centers, and other public health professionals can access and
share preliminary health surveillance information--quickly and
securely. Users can also receive active notification of breaking health
events as they occur.
The Health Alert Network (HAN) is a nationwide
communications network that uses high-speed Internet connectivity to
rapidly broadcast information and link State and local health
departments to one another and to other organizations that are critical
for preparedness and response, such as community first-responders,
hospital and private laboratories, State health departments, and
Federal agencies.
GLOBAL DISEASE DETECTION
CDC's Global Disease Detection (GDD) program will protect U.S.
citizens and citizens of the world from emerging diseases or terrorist
threats. Where countries are not prepared for a major outbreak,
efficient and effective interventions must be deployed to slow down, or
contain, an emerging health threat. A key defense is to establish
surveillance, epidemiological, and laboratory systems in strategic
overseas locations to quickly detect outbreaks and minimize spread at
the source.
CDC's major contribution to the international response capacity
currently led by the World Health Organization (WHO) is to fund and
provide key staff for GDD Response Centers, which are strategically
placed in each of the six WHO regions. CDC plans to deploy staff to
these centers in five of the six regions by the end of fiscal year
2006. Central to each GDD Response Center will be interventions to
respond to regional outbreaks as they arise through proven, effective
programs and approaches that align with partner countries' identified
priorities:
A. Field-based epidemiology and laboratory science
B. Rapid response to international emerging infections
C. Supplemental interventions determined by partner countries
The GDD Response Centers will provide support to national
laboratories and epidemiology programs in their respective WHO regions.
During emergency outbreaks, the Centers will contribute as members of
the Global Outbreak and Response Network (GOARN) under WHO's
leadership. In non-emergency settings, the GDD Response Centers will
work with country partners to facilitate disease detection and response
interventions. Surveillance data will also feed into the GDD Outbreak
Information Center at CDC's Atlanta headquarters for analysis and
response as appropriate.
The GDD will help to elevate surveillance and monitoring and enable
situational awareness on an international level, leveraging resources
in advanced countries to help in those who have less-advanced
capabilities.
Question 1. How do we recruit, train, and retain a prepared public
health workforce with the ability to respond to national threats--
whether acts of terrorism or by Mother Nature?
Answer 1. CDC emphasizes ``all-hazards'' preparedness. Workforce
development activities for public health preparedness are quite
comprehensive and encompass many issues, including: mental health
preparedness and resiliency, the National Incident Management System,
disease investigation and reporting, weapons of mass destruction, and
risk communication. Utilizing this comprehensive approach ensures that
public health professionals trained in preparedness activities have a
set core of skills that can be utilized for effective response to any
event, natural or terrorism-related. The public health response to SARS
in 2003 is an actual example of how public health utilized preparedness
and emergency response components/elements during a naturally occurring
event.
Public health professionals play an essential role in addressing
the emerging threats and health challenges of the 21st century. CDC is
actively engaged in strengthening State and local public health
workforce through training and activities that will provide workers
with the necessary skills, competencies and resources to accomplish
their mission. Recruitment, training, and retention are key elements of
CDC's role in workforce development. Examples of specific workforce
activities conducted by CDC are listed on the attached Sample of CDC
Workforce Development Activities two-page document.
Recruitment: CDC efforts regarding recruitment focus on three key
areas: identifying preparedness oriented competencies for successive
planning purposes, establishing fellowships, internships, and
scholarships with graduate programs in public health to increase the
number entering the public health workforce pipeline and focusing on
preparedness careers, and increasing the image and awareness of public
health as a career choice. Bringing well-qualified people into the
public health profession will have a positive impact on preparedness
and response activities at all levels.
Training: Due to the need for skilled and competent workforce, CDC
has placed special emphasis on training. Specific strategies to enhance
training include: linking academic expertise to State and local agency
needs, collaborating with health and public health agencies across the
Nation to help them meet preparedness education and learning needs,
maximizing outreach of existing preparedness materials, enhancing the
evidence-base for effective preparedness education, and aligning
training with clearly defined competencies, and the identification of
clear, consistent training requirements. Enhancement of training
programs will help to provide the public health workforce with
necessary skills and competencies needed for effective job performance.
Retention: Retention is a critical element, to ensure that those
who have been recruited and trained remain in the public health
workforce. CDC is helping facilitate retention activities by providing
continuing education opportunities for public health workers engaged in
preparedness and response activities, increasing interstate
collaboration to accomplish equal or greater response capacity without
overburdening understaffed agencies, and encouraging employee and
organizational recognition. All of these activities will help to retain
public health professionals in key positions vital to preparedness and
response.
Question 2. How do we develop public health systems research,
paramount for developing evidence-based best practices and benchmarks,
for an all-hazards public health response?
For example, do issues ranging from disease forecasting to
financial modeling of Federal and State public health investments need
further study?
How is ``public health preparedness'' best defined and
what are the metrics for measuring success?
Answer 2. Preparedness is a relatively new public health
discipline, compared to diseases that are centuries old. Multi-
disciplinary research methods that are entirely consistent with how
public health has functioned in traditional areas of disease and injury
control and health promotion are needed. The traditional public health
model has focused on 4 areas: defining the problem (surveillance);
establishing/identifying risk/protective factors (investigation);
designing prevention and control strategies (environmental, medical,
and behavioral interventions), and; disseminating and evaluating those
strategies to maximize impact. This model is sound, but the investment
takes long-term vision and commitment for success.
CDC is committed to furthering science and best practice regarding
all-hazards preparedness. Nine preparedness goals frame and guide the
science and program priorities. These goals align in six categories:
prevention, detection and reporting, investigation, control, recovery,
and improvement. Specific commitments for CDC science include:
``Studying'' response activities with quality improvement
orientation through after-action reviews and corrective action plans.
(Ex. Katrina AAR and CAP action registry)
Strengthening response to small and large events by
focusing on the detection, enumeration, and characterization of disease
scenarios with an applied orientation to action-steps to reduce impact
and prevent further incidents. CDC has strength in varied experiences
applying multi-disciplinary science teams to characterizing and
responding to health events (epidemiology, laboratory sciences,
behavioral and social sciences, math and statistics).
Balancing the need to fill gaps in operations that may
impede an effective response with the need to make. investments in
research and development to leveraging science and focus programmatic
efforts for maximal effect. A new initiative for the expansion of the
public health science base for preparedness and response is needed.
Forecasting and modeling tools are important areas for investment
and development. A large opportunity to leverage existing knowledge
better and faster using these types of tools, but preparedness planning
should not rely solely on these tools.
CDC will continue to define the public health research agenda and
prioritize research activities to expand our knowledge base and guide
all preparedness activities.
______
Summary
Situational Awareness: Situational awareness encompasses many
different aspects, including timely reporting, communicating with all
involved agencies, organizations, and individuals, and ensuring
interoperable systems are available to enhance communications and
reporting capabilities.
BioSense is a national program intended to improve the Nation's
capabilities for disease detection, monitoring, and real-time
situational awareness through access to existing data from healthcare
organizations across the country. The BioSense application is a CDC-
developed and hosted web-based system for use by healthcare facilities
and State and local public health partners. The surveillance methods in
BioSense address the need for identification, tracking, and management
of rapidly spreading naturally occurring events and potential
bioterrorism events using advanced algorithms for data analysis.
CDC's Global Disease Detection (GDD) program will protect U.S.
citizens and citizens of the world from emerging diseases or terrorist
threats. Where countries are not prepared for a major outbreak,
efficient and effective interventions must be deployed to slow down, or
contain, an emerging health threat. A key defense is to establish
surveillance, epidemiological, and laboratory systems in strategic
overseas locations to quickly detect outbreaks and minimize spread at
the source.
Workforce Development: CDC emphasizes ``all-hazards'' preparedness.
Workforce development activities for public health preparedness are
quite comprehensive and encompass many issues, including: mental health
preparedness and resiliency, the National Incident Management System,
disease investigation and reporting, weapons of mass destruction, and
risk communication. Utilizing this comprehensive approach ensures that
public health professionals trained in preparedness activities have a
set core of skills that can be utilized for effective response to any
event, natural or terrorism-related. The public health response to SARS
in 2003 is an actual example of how public health utilized preparedness
and emergency response components/elements during a naturally occurring
event.
Public Health Systems Research: Preparedness is a relatively new
public health discipline, compared to diseases that are centuries old.
Multi-disciplinary research methods that are entirely consistent with
how public health has functioned in traditional areas of disease and
injury control and health promotion are needed. The traditional public
health model has focused on 4 areas: defining the problem
(surveillance); establishing/identifying risk/protective factors
(investigation); designing prevention and control strategies
(environmental, medical, and behavioral interventions), and;
disseminating and evaluating those strategies to maximize impact. This
model is sound, but the investment takes long-term vision and
commitment for success.
CDC is committed to furthering science and best practice regarding
all-hazards preparedness.
______
Sample of CDC Workforce Development Activities
RECRUITMENT
The Centers for Public Health Preparedness (CPHP) program
is a network of 52 universities and college programs contributing to
readiness through preparedness education and training. The program has
convened collaboration groups focused on defining preparedness-specific
knowledge, skills, and abilities for:
those public health professional disciplines who are
and will be experiencing the greatest shortages--nurses,
sanitarians, laboratorians, and epidemiologist; and
crisis leadership.
For 2004-2005, the CPHP program funded 6 internships and 6
scholarships. The programs recruit and place students in State and
local health departments to assist with outbreak investigations and
other short-term applied public health projects. Getting experience in
a public health practice setting while in graduate school may provide
students with interest in and knowledge about pursuing a career in the
public sector. Providing students with the opportunity to participate
in an epidemiologic response or investigation highlights the role of
epidemiology within the context of applied public health.
CDCs Epidemic Intelligence Service (EIS) is a unique
training, 2-year postgraduate program of service and on-the-job
training for health professionals interested in the practice of
epidemiology. Since 1951, over 2,000 EIS Officers have responded to
requests for epidemiologic assistance within the United States and
throughout the world. Every year, CDC's EIS Program selects 60-80
persons from among the Nation's top health professionals to enter the
EIS and pursue on-the-job training in applied epidemiologic skills--
skills vital to maintenance of public health.
CDC's EXCITE (Excellence in Curriculum Integration through
Teaching Epidemiology) (http://www.cdc.gov/excite/) systematically
integrates current public health crises and issues into K-12 education.
All content aligns with math and science curriculum standards.
TRAINING
The CPHP programs support preparedness education needs in
all 50 States, the District of Columbia, Puerto Rico, U.S. Virgin
Islands, and multiple Tribal Partners. For 2004-2005, the CPHP program
provided 395 preparedness education activities to State, local, and
academic audiences. The estimated reach for all activities and
audiences combined was over 209,000 learners. For 2005-2006, CPHPs are
approved to complete 639 activities, of which 429 will provide
preparedness education and training to an estimated 98,578 learners.
The 2004-2005 and 2005-2006 CPHP cooperative agreement
guidance requires that universities and colleges work in close
collaboration with State and local health agencies to develop, deliver,
and evaluate preparedness education based on community need.
The CPHP web-based Resource Center (http://www.asph.org/
acphp/phprc.cfm) houses 723 educational resources. These resources
include all sharable components of CPHP program activities such as
courses, curricula, training exercises or drills, or other materials
developed and/or delivered with Federal funds.
The CPHPs have developed a set of toolkits to assist State
and local partners locate competency-based preparedness training and
education products. These tool kits include:
Public Health Worker Preparedness Certification.--
Developed an inventory of preparedness training programs that
certify the acquisition and/or demonstration of emergency
readiness and response competencies for public health workers.
Preparedness and Crisis Leadership Education.--
Defined Crisis Leadership competencies and curricula; and
outlined existing CPHP courses related to crisis leadership
workforce development.
Occupational Safety/Worker Preparedness.--Identified
core competencies for worker training related to preparedness
and training materials or programs available to the CPHPs
related to competencies.
The FY 2006 Cooperative Agreement for Public Health
Emergency Preparedness guidance requires that State and local health
departments develop, deliver, and evaluate competency-based
preparedness education in conjunction with Centers for Public Health
Preparedness (CPHP), and academic experts in other schools of public
health, medicine, nursing, and academic health science centers.
The FY 2006 and FY 2007 Cooperative Agreement for Public
Health Emergency Preparedness guidance for State and Local Health
Departments is consistent with FEMA's NIMS Integration Center training
guidelines, thus providing State grantees with a clear, consistent set
of training requirements for NIMS compliance.
CDC utilizes distance learning technologies to mass
distribute live education events as well as archive re-usable
educational products. Examples include:
Public Health Grand Rounds, Learning from Katrina:
Tough Lessons in Preparedness and Emergency Response webcast
and satellite broadcast.
CDC's Pandemic Influenza course, will be videotaped
and made available to a wide State and local audience.
Project Public Health Ready is a collaborative activity
between CDC and the National Association of County and City Health
Officials (NACCHO). The mission of the project is to prepare staff of
local governmental public health agencies to respond to ``all hazard''
emergencies and to protect the public's health through a competency-
based training and recognition program. The project requires that each
site meet certain emergency preparedness criteria, which have been
divided into three main overall goals: Emergency Preparedness and
Response Planning, Workforce Competency Development and Exercises/
Simulations. There are 18 sites around the country that are recognized
as Public Health Ready.
RETENTION
Continuing Education: This year COTPER funded 20
preparedness training and education projects. 15 of 20 projects will be
available to State and local audiences. Specific target audiences
include: public health leaders and emergency responders at the State,
local, and territory levels; clinicians; veterinarians; environmental
health workers; scientists; and laboratory workers.
For 2004-2005, the CPHP program provided 177 preparedness
education activities that specifically targeted the learning needs of
State and local public health workers.
CDC's Hurricane Katrina/Rita Corrective Action Plan will
address public health mutual aid needs and enact processes for
emergency response (including EMAC) through a workgroup consisting of
representatives from CDC, other HHS OpDivs, ASTHO, CSTE, NACCHO, APHL,
NEHA, and NEMA.
The CPHPs provide technical assistance, training, and
exercise support to local governmental public health agencies seeking
Project Public Health Ready recognition.
[Whereupon, at 11:57 a.m., the subcommittee was adjourned.]