[Senate Hearing 109-574]
[From the U.S. Government Printing Office]

                                                        S. Hrg. 109-574



                                 OF THE


                                 OF THE

                          LABOR, AND PENSIONS

                          UNITED STATES SENATE

                       ONE HUNDRED NINTH CONGRESS

                             SECOND SESSION




                             MARCH 28, 2006


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                   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

               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) 

                  Robert Kadlec, M.D., Staff Director

                David C. Bowen, Minority Staff Director


                            C O N T E N T S



                        TUESDAY, MARCH 28, 2006

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





                        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 
    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 
    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 
    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 
    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 
    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.


    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 
    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 
    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 
    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 
    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 
    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 
    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 
    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.
    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 
    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.
    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 
    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 
    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 
    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, 
    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.

                       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 
    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 
    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 
    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 
    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 

    Senator Burr. Peggy.


    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 
    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 

    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 
     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 
     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 
     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 
     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 
    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 
    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 
    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 
    (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 
    (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.


    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 
    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 
    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 
    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 
    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, 
    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.
    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 
     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 
     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 

    Senator Burr. Dr. Gursky, good morning.


    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 
    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 
    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 
    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\
    \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.
    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 
    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.
    \4\ Ibid.
     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.
    \5\ Lloyd Novick and Glen Mays, Public Health Administration: 
Principles for Population-Based Management (Sudbury, MA: Jones and 
Bartlett, 2005).
    \6\ Ibid.
     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.
    \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.
     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 
    \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/.
     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.
    \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.
    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\
    \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/
     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 
    \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.
     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.
    \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; 

    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\
    \15\ National Defense University, March 17, 2006.
    \16\ World Health Organization, ``Globalization, Trade and Health: 
Emerging Diseases''; 
    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.

                         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 
    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 
    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


    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 

     How to build a strong and competent public health 
     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
    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.
    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.


    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/

                               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
    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.
    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 
    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 
    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 
    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 


    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.

    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 
     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 

    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.


    Dr. Kaplowitz. Good morning and thank you for the 
opportunity to be here and address this important issue, Mr. 
    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 
    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 
    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 
    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 
    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 
    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?
    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 
    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 
    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 
    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 
    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 
    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 
    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 
    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 
    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?
    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 
    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 
    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 
    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 
    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 
    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 
    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 
    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 
    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 
    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 
    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 
    Senator Burr. It wouldn't be the first time that somebody 
has given us something that wasn't achievable----
    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 
    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 
    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?
    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 
    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 
    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 
    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 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 

    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 

    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 
    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 

    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.

    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 
    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


     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.


     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.


     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, 
     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.]