<DOC>
[108th Congress House Hearings]
[From the U.S. Government Printing Office via GPO Access]
[DOCID: f:89547.wais]
HOMELAND SECURITY: IMPROVING PUBLIC HEALTH SURVEILLANCE
=======================================================================
HEARING
before the
SUBCOMMITTEE ON NATIONAL SECURITY,
EMERGING THREATS AND INTERNATIONAL
RELATIONS
of the
COMMITTEE ON
GOVERNMENT REFORM
HOUSE OF REPRESENTATIVES
ONE HUNDRED EIGHTH CONGRESS
FIRST SESSION
__________
MAY 5, 2003
__________
Serial No. 108-55
__________
Printed for the use of the Committee on Government Reform
Available via the World Wide Web: http://www.gpo.gov/congress/house
http://www.house.gov/reform
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COMMITTEE ON GOVERNMENT REFORM
TOM DAVIS, Virginia, Chairman
DAN BURTON, Indiana HENRY A. WAXMAN, California
CHRISTOPHER SHAYS, Connecticut TOM LANTOS, California
ILEANA ROS-LEHTINEN, Florida MAJOR R. OWENS, New York
JOHN M. McHUGH, New York EDOLPHUS TOWNS, New York
JOHN L. MICA, Florida PAUL E. KANJORSKI, Pennsylvania
MARK E. SOUDER, Indiana CAROLYN B. MALONEY, New York
STEVEN C. LaTOURETTE, Ohio ELIJAH E. CUMMINGS, Maryland
DOUG OSE, California DENNIS J. KUCINICH, Ohio
RON LEWIS, Kentucky DANNY K. DAVIS, Illinois
JO ANN DAVIS, Virginia JOHN F. TIERNEY, Massachusetts
TODD RUSSELL PLATTS, Pennsylvania WM. LACY CLAY, Missouri
CHRIS CANNON, Utah DIANE E. WATSON, California
ADAM H. PUTNAM, Florida STEPHEN F. LYNCH, Massachusetts
EDWARD L. SCHROCK, Virginia CHRIS VAN HOLLEN, Maryland
JOHN J. DUNCAN, Jr., Tennessee LINDA T. SANCHEZ, California
JOHN SULLIVAN, Oklahoma C.A. ``DUTCH'' RUPPERSBERGER,
NATHAN DEAL, Georgia Maryland
CANDICE S. MILLER, Michigan ELEANOR HOLMES NORTON, District of
TIM MURPHY, Pennsylvania Columbia
MICHAEL R. TURNER, Ohio JIM COOPER, Tennessee
JOHN R. CARTER, Texas CHRIS BELL, Texas
WILLIAM J. JANKLOW, South Dakota ------
MARSHA BLACKBURN, Tennessee BERNARD SANDERS, Vermont
(Independent)
Peter Sirh, Staff Director
Melissa Wojciak, Deputy Staff Director
Rob Borden, Parliamentarian
Teresa Austin, Chief Clerk
Philip M. Schiliro, Minority Staff Director
Subcommittee on National Security, Emerging Threats and International
Relations
CHRISTOPHER SHAYS, Connecticut, Chairman
MICHAEL R. TURNER, Ohio
DAN BURTON, Indiana DENNIS J. KUCINICH, Ohio
STEVEN C. LaTOURETTE, Ohio TOM LANTOS, California
RON LEWIS, Kentucky BERNARD SANDERS, Vermont
TODD RUSSELL PLATTS, Pennsylvania STEPHEN F. LYNCH, Massachusetts
ADAM H. PUTNAM, Florida CAROLYN B. MALONEY, New York
EDWARD L. SCHROCK, Virginia LINDA T. SANCHEZ, California
JOHN J. DUNCAN, Jr., Tennessee C.A. ``DUTCH'' RUPPERSBERGER,
TIM MURPHY, Pennsylvania Maryland
WILLIAM J. JANKLOW, South Dakota CHRIS BELL, Texas
JOHN F. TIERNEY, Massachusetts
Ex Officio
TOM DAVIS, Virginia HENRY A. WAXMAN, California
Lawrence J. Halloran, Staff Director and Counsel
Kristine McElroy, Professional Staff Member
Robert A. Briggs, Clerk
David Rapallo, Minority Counsel
C O N T E N T S
----------
Page
Hearing held on May 5, 2003...................................... 1
Statement of:
Fleming, David, M.D., Deputy Director for Public Health
Science, Centers for Disease Control and Prevention, U.S.
Department of Health and Human Services; and David
Tornberg, M.D., M.P.H., Deputy Assistant Secretary, Health
Affairs, U.S. Department of Defense........................ 4
Kelley, Patrick W., M.D., Dr. PH, Colonel, Medical Corps,
Director, Department of Defense, Global Emerging Infections
Surveillance and Response System........................... 134
Selecky, Mary C., secretary, Washington State Department of
Health, president, the Association of State and Territorial
Health Officials; Seth L. Foldy, commissioner, medical
director, city of Milwaukee, health commissioner, chair,
National Association of County and City Health Officials,
Information Technology Committee; Karen Ignagni, president
and CEO, American Association of Health Plans; and Julie
Hall, medical officer, World Health Organization........... 62
Letters, statements, etc., submitted for the record by:
Bell, Hon. Chris, a Representative in Congress from the State
of Texas, prepared statement of Dr. Hearne................. 122
Fleming, David, M.D., Deputy Director for Public Health
Science, Centers for Disease Control and Prevention, U.S.
Department of Health and Human Services:
Article from Emerging Infectious Diseases................ 56
Information concerning estimate for fiscal year 2004..... 40
Information concerning moneys spent on the National
Electronic Disease Surveillance System................. 42
Prepared statement of.................................... 7
Foldy, Seth L., commissioner, medical director, city of
Milwaukee, health commissioner, chair, National Association
of County and City Health Officials, Information Technology
Committee, prepared statement of........................... 77
Hall, Julie, medical officer, World Health Organization,
prepared statement of...................................... 88
Ignagni, Karen, president and CEO, American Association of
Health Plans, prepared statement of........................ 108
Selecky, Mary C., secretary, Washington State Department of
Health, president, the Association of State and Territorial
Health Officials, prepared statement of.................... 66
Tornberg, David, M.D., M.P.H., Deputy Assistant Secretary,
Health Affairs, U.S. Department of Defense, prepared
statement of............................................... 25
HOMELAND SECURITY: IMPROVING PUBLIC HEALTH SURVEILLANCE
----------
MONDAY, MAY 5, 2003
House of Representatives,
Subcommittee on National Security, Emerging Threats
and International Relations,
Committee on Government Reform,
Washington, DC.
The subcommittee met, pursuant to notice, at 2:01 p.m., in
room 2154, Rayburn House Office Building, Hon. Christopher
Shays (chairman of the subcommittee) presiding.
Present: Representatives Shays, Murphy, Janklow, and Bell.
Staff present: Lawrence Halloran, staff director and
counsel; Kristine McElroy, professional staff member; Robert A.
Briggs, clerk; David Rapallo, minority counsel; and Jean Gosa,
minority assistant clerk.
Mr. Shays. A quorum being present, the Subcommittee on
National Security, Emerging Threats and International Relations
hearing entitled, ``Homeland Security: Improving Public Health
Surveillance,'' is called to order.
As we convene here today, the world is conducting an
involuntary, live-fire exercise of public health capacity
against bioterrorism. Severe acute respiratory syndrome [SARS],
emerged from the microbial hothouse of the Far East through the
same vulnerabilities and vectors terrorists would exploit to
spread weaponized, genetically altered disease.
The global response to SARS underscores the vital
significance of sensitive disease surveillance in protecting
public health from natural and unnatural outbreaks. It also
discloses serious gaps and persistent weaknesses in
international and U.S. health monitoring.
The lessons of the West Nile virus and mail-borne anthrax
have not gone unheeded. Substantial enhancements have been made
to the accuracy, speed, and breadth of health surveillance
systems at home and abroad. The limited impact of SARS here can
be attributed in part to increased preparedness to detect,
control, and treat outbreaks of known and unknown diseases.
But the public health surveillance system at work today
against SARS is still a gaudy patchwork of jurisdictionally
narrow, wildly variant, and technologically backward data
collection and communications capabilities. Records critical to
early identification of anomalous symptom clusters and disease
diagnoses are not routinely collected. Formats for recording
and reporting the same data differ widely between cities,
counties, and States. Many key records are still generated on
paper, faxed to State or Federal health authorities, and
entered manually one or more times into potentially
incompatible data bases.
In a world made smaller by the speed of international
travel and the rapid mutation of organisms in our crowded
midst, the interval between local outbreak and global epidemic
is shrinking. Virulent, drug-resistant organisms easily
traverse the geographic and political boundaries that still
define and inhibit public health systems.
Efforts to build a more modern ``system of systems,''
envision routine collection and rapid dissemination of real-
time data from public and private health systems and
laboratories. Early warning capabilities would be enhanced
through the fusion of innovative syndromic surveillance--
automated screening of emergency room traffic, pharmacy sales,
news wires, and other public data streams--for potentially
significant signs of an outbreak.
Pieces of this planned health monitoring system can be
assembled at different times and places, but no fully national
system yet integrates the observations and communications
needed to protect public health from rapidly emerging
biological hazards. Successfully operating the elaborate,
elegantly sensitive surveillance network of the future will
require unprecedented levels of human skill, fiscal resources,
medical information, and intergovernmental cooperation.
At this moment, sophisticated radars scan the skies and the
seas to detect the approach of forces hostile to the peace and
sovereignty of this Nation. A similarly unified, sensitive
system of disease sensors is needed to detect the advance of
biological threats to our health and prosperity.
Testimony today will describe civilian and military
programs under way in the United States and abroad to overcome
the natural and man-made barriers to health monitoring. We
deeply appreciate the dedication and expertise all our
witnesses bring to this important discussion, and we welcome
their participation in our oversight.
At this time, we will call on Mr. Bell, who is the acting
ranking member today.
Mr. Bell. Thank you, Mr. Chairman.
I would like to thank you and those who are providing
testimony before the committee here today.
Today's hearing is critically important to this Nation's
security and the safety of its health in general. We are all
aware of the need to detect the outbreak of disease and respond
immediately and effectively. This could be no clearer than in
my congressional district, which is home to the world's largest
medical center in the world in Houston, TX.
Public health surveillance has been described as ``the
cornerstone of public health decisionmaking and practice.'' The
events of September 11, 2001, and the subsequent anthrax
attacks raise the profile of this issue significantly, so much
so, President Bush proposed the creation of ``a national public
health surveillance system to monitor public and private data
bases.'' He argued that the anthrax attacks of October 2001
prove that quick recognition of biological terrorism is crucial
to saving lives; and he proclaimed an urgent need to integrate
the Federal interagency emergency response plans into a single,
comprehensive, governmentwide plan.
But what concerns me most is that there has been no
evidence of any attempt to follow through on this proposal.
Additionally, the administration's fiscal year 2004 budget
slashes funding in core Centers for Disease Control functions.
I would hope that our witnesses can clear up the
discrepancies between the administration's rhetoric and its
proposed funding levels, and I look forward to your testimony.
Thank you, Mr. Chairman.
Mr. Shays. Thank you, Mr. Bell.
At this time, the Chair would recognize Mr. Janklow.
Mr. Janklow. Thank you very much, Mr. Chairman. I am going
to be extremely brief.
If you go back to the period of time just a couple of short
years ago when those anthrax letters were mailed around the
country, they had the anthrax outbreak, the situation down in
the Carolinas, the reality of the situation is, from and after
that point in time, phenomenal things have been accomplished.
But as you indicated, Mr. Chairman, in your opening
remarks, we still have a patchwork in this country that we have
a responsibility to overcome very, very quickly. We have cities
that have public health laboratories and counties with public
health laboratories. We have prisons with public health
laboratories. We have States that have public health
laboratories; we have private health laboratories.
The Federal Government has Indian health service
laboratories, they have public health service laboratories,
they have military laboratories. We have a whole host of
different laboratories, reporting centers in this country, and
still a large amount of it is based upon paperwork. And it is
incredibly important, it is really incredibly important that in
today's day and age, when it is not that difficult to put
together reporting systems based upon electronic means--and not
facsimile, but far more modern electronic means--that this be
done in the most expeditious manner.
The Centers for Disease Control frankly have accomplished
phenomenal efforts in terms of working with local communities,
working with States and communities over the last couple of
years. But notwithstanding all the accomplishments that have
been made, Mr. Chairman, the fact of the matter is, we are not
where we have to be, we are not where we want to be, and we are
not where we should be. And so anything that can be done to
speed that process up can only be of a beneficial nature to the
people of America.
Thank you very much, Mr. Chairman, for giving me this
opportunity.
Mr. Shays. I thank the gentleman for this statement.
Mr. Murphy.
Mr. Murphy. I will wait and ask questions.
Mr. Shays. Wonderful to have you all here. You all are such
wonderful, active members of this committee.
Before recognizing our witnesses, let me just get some
housekeeping in place here, and ask unanimous consent that all
members of the subcommittee be permitted to place an opening
statement in the record, and the record remain open for 3 days
for that purpose. And without objection, so ordered.
I ask further unanimous consent that all witnesses be
permitted to include their written statements in the record.
And without objection, so ordered.
At this time, we will recognize our first panel. We have
two panels. Our first panel is Dr. David W. Fleming, Deputy
Director for Public Health Science, Centers for Disease Control
and Prevention; and Dr. David Tornberg, Deputy Assistant
Secretary of Defense for Clinical and Program Policy,
Department of Defense.
Gentlemen, as you know, we swear in our witnesses, all our
witnesses. If you would stand, raise your right hands, and then
we will take your testimony.
[Witnesses sworn.]
Mr. Shays. Note for the record that both our witnesses have
responded in the affirmative.
I should have asked, is there anyone else that might help
you respond that might have to say something publicly? If so,
we will swear them in.
We will start with you, Dr. Fleming, and then we will go to
you Dr. Tornberg.
Let me just tell you what we do. We do a 5-minute, and then
we roll it over for the next 5 minutes. Stop sometime between
the first 5 minutes and the second 5 minutes. Please don't go
over the second 5-minute.
I've never figured out what would happen if you did.
Dr. Fleming. I don't want to be the first. Thank you.
Mr. Shays. I'm using a little poetic license. It's happened
once or twice.
OK.
STATEMENTS OF DAVID FLEMING, M.D., DEPUTY DIRECTOR FOR PUBLIC
HEALTH SCIENCE, CENTERS FOR DISEASE CONTROL AND PREVENTION,
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES; AND DAVID
TORNBERG, M.D., M.P.H., DEPUTY ASSISTANT SECRETARY, HEALTH
AFFAIRS, U.S. DEPARTMENT OF DEFENSE
Dr. Fleming. Mr. Chairman, members of the subcommittee, I'm
Dr. David Fleming. I'm the Deputy Director of CDC for Public
Health Science. Good afternoon. On behalf of CDC, thank you for
inviting us here today. We very much appreciate your leadership
and attention to the issue of public health surveillance.
You know, this weekend when I was preparing my testimony,
my 10-year-old asked me what I was doing. And when I told her I
was working on a talk about public health surveillance, she
said, Wow, I didn't know anybody was interested in that. And,
you know, she had a point. Public health surveillance isn't an
issue that most people know they should care about; and for
that reason, we doubly appreciate your interest in this issue.
And in some ways it's funny.
Mr. Shays. Given her great insight, would you give her full
name for the record.
Dr. Fleming. Sure. Absolutely. Her name is Whitney Lynn
Fleming.
Mr. Shays. Well, she gets it.
Dr. Fleming. Thank you.
And it's funny, because I think all of us would be fairly
concerned if we walked into our personal doctor's office and he
or she suddenly started treating us without taking a history or
without doing a physical or without doing any diagnostic
testing.
For public health, our patient isn't a person, it's the
community. And just as clinicians need to know about blood
pressure and about blood chemistries to diagnose the patients,
public health practitioners must have the eyes and the ears and
the tools to get the information that's needed to diagnose
what's going on in their communities.
Although the range of information that's needed to monitor
community health is broad, today we are focusing on one piece,
the piece that's needed to respond to a biologic threat in a
community, to detect an epidemic or a bioterrorist event. And
the problem here is that in the early phases of an outbreak,
affected people don't turn to public health because no one
realizes there is an epidemic. Rather, one by one, affected
people seek health care for their symptoms. And to overcome
this problem requires a system that, first, recognizes and
diagnoses cases as they occur; second, transfers information
about those cases to the public health system, where, third,
it's analyzed, investigated, and acted on.
Now, in this country this critical function is performed by
our reportable disease surveillance system. Every physician,
every laboratory in this country is required to report specific
diseases and conditions to their public health authorities.
And, you know, remarkably this system generally works.
Thousands of disease reports are initiated each day and
investigated each day, resulting in the detection of routine
and exotic epidemics.
This is the system that identified the anthrax attacks, and
odds are it's the system that will identify the next
bioterrorist attack on this country. Is it perfect? No. It is
the best in the world. But not all reports are complete, not
all are timely, and not all are appropriately acted on. It is,
however, the core of our detection capacity, and it is the one
to work on to make us more prepared.
And there is good news here. The bioterrorism resources
recently appropriated for building public health capacity have
strengthened the system through a wide range of activities,
such as increased provider training, improved laboratory
diagnostic capacity throughout the country, better linkages
between the clinical system and the public health system, and
improved public health department 24/7 ability to receive and
investigate reports. And these investments are paying off. Our
remarkable success in detecting and responding to West Nile
last summer and SARS right now are good examples.
In addition to these general improvements, let me just
mention three specific enhancements that we are working on, and
all of them capitalize on the fact that we are at a critical
moment of opportunity regarding the use of information
technology.
First, our current system emphasizes that providers
recognize an event so that they can report it. In today's
electronic age, there is a new potential that some of you have
already alluded to, to use preexisting electronic data bases
like nurse call lines or pharmacy records to check for
clustering of events that might indicate an unrecognized
problem. This type of monitoring is sometimes called syndromic
surveillance, and it can supplement our existing disease
reporting system. It holds promise for potentially detecting
some kinds of events sooner and for providing a richer set of
information to monitor and respond to any recognized problem.
Second, we are working to improve the transfer of
information from providers to public health. Though our
National Electronic Disease Surveillance System [NEDSS],
program, CDC is moving to move reporting from a paper system to
an electronic system by establishing secure connectivity, by
agreeing on those critical data standards, and by developing
public health expertise that is necessary to make this system
work.
And, third, we are working on our ability to integrate
real-time information from a wide range of sources. You know,
our detection methods have to be sensitive, but the price for
that is the potential for false alarms. Creating the capacity
to rapidly look across a range of inputs to see if one is
confirmed by the others is an increasingly critical capacity.
And the scope and speed with which a bioterror event could
evolve also puts a premium on our ability to monitor the
emergence of an epidemic and the response capacities that are
needed to fight it.
I know the committee is also interested in surveillance at
the international level. Let me just quickly say that the
detection and tracking of SARS is an example of the
international system working right, particularly given the
resources that are available in most of the affected countries,
and particularly given the fact that the very basics that we
are beginning to take for granted here, like laboratory
diagnostic capacity and personnel trained in case investigation
and response are the rate-limiting need in most of the
developing world.
So, in conclusion, public health surveillance is as
critical to public health as clinical information and
diagnostic testing is to the practicing physician. The basic
elements of our system to detect a bioterrorist event are
operational and increasingly robust as a result of the recent
investments that we have made. More can be done, however. In
particular, enhancements with a strong information technology
component, accessing existing electronic data bases,
facilitating electronic reporting, and improving our ability to
rapidly analyze a wide range of information sources, once only
dreams, are now possible. The challenge now is to make them a
reality.
Thank you very much. And I would be happy to answer
questions.
Mr. Shays. Thank you, Dr. Fleming.
[The prepared statement of Dr. Fleming follows:]
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Mr. Shays. Dr. Tornberg.
Dr. Tornberg. Good afternoon, Mr. Chairman, distinguished
committee members. I am grateful for this opportunity to
discuss the activities of the Department of Defense military
health system, and to focus today on those activities engaged
in medical surveillance.
The military health system, with over 8.7 million
beneficiaries, has a global mission that's continually involved
in health surveillance. Our medical treatment facilities are
daily collaborating, planning, training, and participating in
homeland defense operations with our civilian community
partners. Our military bases coordinate in the development of
mutually supportive surveillance, defense, and consequence
management plans. These efforts will be part of the Joint
Services installation pilot project demonstrations.
Integral to this project is ESSENCE II, the electronic
surveillance system for early notification of community-based
epidemics. This program is a cooperative venture between the
Defense Advanced Research Projects Agency [DARPA], and the
Johns Hopkins University applied physics laboratory.
ESSENCE II is an outgrowth of ESSENCE I, which was
developed for DOD-GEIS. ESSENCE II monitors the National
Capital Area and performs syndromic surveillance based on
school absenteeism, pharmacy prescription, over-the-counter
transactions, emergency room and hospital clinic visits, and
other disparate data sources to detect natural disease
outbreaks or possibly covert biological weapons attack. A rapid
display of clusters of suspicious symptoms or findings provides
decisionmakers with outbreak information not currently
available. This program shows great promise for providing early
detection and response to numerous public health challenges.
Medical surveillance of our new recruits and our Active
Duty population presents us with the unique opportunity to
detect the emergence of infectious illness. This knowledge can
impact public health strategies by national authorities. In the
past 2 years, virus isolates from military sources have twice
driven the composition of the influenza vaccine used throughout
the Nation in both the military and civilian communities.
Development of vaccines to counter the relentless spread of
old and newer biologic threats is a major contribution by
Department of Defense laboratories. Current studies include
working on improving vaccines for anthrax, Venezuelan equine
encephalitis, plague, botulism, and toxins such as
staphylococcal enterotoxins, and ricin.
Medical oversight and surveillance of our military members
from the moment they are recruited until the day they die
provides unprecedented opportunity to monitor the potential
impact of occupational, environmental, and geographical
exposures. The defense medical surveillance system, a
longitudinal surveillance data base, allows the Department to
capture and then track significant events and exposures
throughout a members' accession, training, deployment, and
retirement. Improved occupational environmental surveillance
programs protect forward-deployed service members' health by
providing improved monitoring. The Theater Army Medical
Laboratory, the Navy's Forward Deployable Preventive Medicine
Unit, and the Army's Center for Health Promotion and Preventive
Medicine provide rapid analysis and risk assessment
information.
To facilitate rapid biologic identification, DOD has
supported development of the Ruggedized Advanced Pathogen
Identification Device [RAPID], as we call it. This device is a
miniaturized polymerase chain reaction [PCR], technology. It's
a bioagent detection system that can frequently identify the
cause of the outbreak or bioterror attack within 2 hours. This
process could possibly take 4 days using standard laboratory
techniques to identify agents.
DOD has implemented weekly tracking of field clinic visits
for various diseases and nonbattle injuries during deployments,
and has increased such daily monitoring for current operations
in all field clinic reports through command channels at least
daily on the current situation, so notification of an outbreak
or development of an unusual pattern is relatively immediate.
The value to the Nation of these systems extends beyond DOD to
industrial agents whose work forces parallel those in the
military by providing valuable insight and methods to prevent
or mitigate long-term disability.
The Department of Defense partners with a number of civil,
military, and international partners. The Armed Forces Medical
Intelligence Center, an arm of the Defense Intelligence Agency,
performs classified and unclassified global medical
intelligence to arm theater commanders with the latest
environmental, biological, and medical threat assessments.
Their unclassified assessment is available to citizens and
agencies.
Enhanced Federal agency sharing and knowledge exchange is
achieved by assigning military epidemiologists to the Centers
for Disease Control. Public health service experts are also
assigned from CDC to DOD. This sharing of our joint resources
and expertise enhances the national response to both local and
global threats.
In like manner, we have detailed a military medical
specialist to the World Health Organization. In the recent
severe acute respiratory syndrome outbreak [SARS], the
Department detailed a military expert in epidemiology to CDC
from DOD-GEIS--and GEIS, as we know, is the Global Emerging
Infection Surveillance response system--to provide our unique
perspective. Additionally, DOD-GEIS experts were detailed from
our laboratories in Indonesia to Vietnam in the outbreak's
earliest days. Our experts contributed essential knowledge in
the acquisition of specimen collection and biologic
identification, and provided skill in transporting specimens.
The existing infrastructure of the GEIS global laboratory
influenza-based surveillance program was rapidly expanded to
facilitate the transport of these specimens.
A daily executive summary is issued by DOD-GEIS to
communicate not only news with respect to general SARS issues,
but also specific DOD information on possible cases, policy
guidance, referenced laboratory resources, and surveillance
data from ESSENCE and other DOD sources. DOD and service-
specific clinical disease control and air evacuation guidance
has been disseminated to our forces. To date, we have had no
active confirmed cases of SARS.
GEIS's mission is directed by Presidential Directive 7, and
includes support of global surveillance training and research
and response to emerging infectious disease. Recognized by the
Institutes of Medicine in 2001 as a critical, unique resource
of the United States in the context of global affairs, and as
the only U.S. entity that is devoted to infectious disease
globally that has broad-based capacity in the overseas setting,
DOD-GEIS stands as our commitment to surveillance for emerging
infectious diseases in direct support of our national security
efforts.
Emerging infections, as has been discussed, are a threat to
global security and have the ability to harm U.S. interests
through reversing economic growth, fomenting social unrest, and
complicating our response to refugee situations.
Biological terrorism and warfare are additional concerns.
The recent emergence of SARS and the inextricable progress of
the HIV/AIDS epidemic in Africa have provided ample evidence of
the economic and societal damage that infectious disease can
cause.
During our continuing operations in Afghanistan and Iraq,
the military health system has applied the lessons of 12 years'
experience since the first Persian Gulf operations. Through a
force-held protection strategy, the Department promotes and
sustains the health of our service members prior to deployment,
protects personnel from disease and preventable injury during
deployment, and provides comprehensive followup treatment for
deployment-related conditions. A deployment health surveillance
program with pre and post-deployment health assessments
validates each individual's medical readiness to deploy, and
addresses health concerns upon his return.
Improved deployment health protection measures are designed
to counter an increasingly broad range of threats. Such
measures include the fielding of new biological and chemical
warfare agents, detection alarm systems, and the operational
testing of integrated electronic medical surveillance and
emergency response networks. Current vaccines and antimalarial
drugs and research on the next generation of vaccines and
pharmaceuticals are but some of the many efforts we are engaged
in.
DOD has coordinated with the VA to address deployment,
health-related concerns of both service members and veterans in
developing a post-deployment health guideline. This practice
guideline and the use of it through electronic information
sharing through the Federal Health Information Exchange
provides significant improvement in the care of our veterans'
health.
The military health system participates in the National
Science Foundation's multiagency project to prioritize national
research agenda for information systems to detect and respond
to natural outbreaks or intentional release of biologic agents
that target not only humans but plant and animal resources.
Economic and health strains and vulnerabilities are being
mapped, while requirements for information systems to track,
alert, and notify disturbances are being developed. A national
strategy involving combining Federal and civil agencies to
combat bioterror will strengthen the national response.
In conclusion, I am proud to say that the Department of
Defense military health system is a solid partner in support of
the national public health security through daily medical
surveillance and support of the continuing war on terror. I
believe that you will find that the military health
surveillance has many complementary and overarching systems
that cooperate with both other Federal agencies and the
civilian medical community. These activities are enhanced
through outstanding programs such as DOD-GEIS and the ESSENCE I
and II programs.
Thank you, Mr. Chairman, and distinguished committee
members.
[The prepared statement of Dr. Tornberg follows:]
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Mr. Shays. I am stunned by the timing of your speech. You
had 5 seconds left. Thank you. It was a thoughtful statement.
Both of your statements were very helpful.
I am going to recognize Mr. Janklow, and then we will go to
Mr. Bell and Mr. Murphy. We are going to do 10-minute segments.
Mr. Janklow. Thank you very much, Mr. Chairman.
Dr. Tornberg, the system that you described, DOD-GEIS, is
that suitable for civilian use in America?
Dr. Tornberg. It is, sir. It's a developing system. The
ESSENCE II is in fact a system that is involved with the
civilian community. ESSENCE II is a lab data base analysis and
recognition that we are conducting in conjunction with Johns
Hopkins. It is based on the National Capital Area and the 21
jurisdictions surrounding it.
Mr. Janklow. Dr. Fleming, as I look at your testimony, you
cite 30 States that have asked for funding under the NEDSS
strategy. Is the NEDSS strategy, is that an end result or is it
just part of a process?
Dr. Fleming. N.E.D.S.S., or NEDSS as the jargon, is a
program that's designed to transfer at the State and local and
national level from a paper reporting system to an electronic
reporting system.
Mr. Janklow. Can you tell me why 20 States have not yet
requested funding for that?
Dr. Fleming. In fact, there may be a misunderstanding or a
misinterpretation. All States are getting funding for NEDSS.
Some States, approximately 20, have bought into the concept,
but are using the standards that have been developed to develop
their own software and process for making this happen. Thirty
States have said, no, we don't think we have that technical
capacity, and we want to jointly invest in the system that CDC
is developing that will allow this to happen.
Mr. Janklow. Sir, help me with this. And I understand, you
know, interest in open architecture and competitive
marketplaces. But why in the world would we be encouraging what
looks like maybe one system, based upon 30, that CDC is
developing--30 States, in reporting--major reporting
jurisdictions, and then 20 more separate ones that all have to
be tied together?
Frankly, sir, what sense does that make?
Dr. Fleming. The fundamental principle that NEDSS is
operating on is to say that, independent of whether systems are
homegrown or developed outside, that they have to conform to an
agreed-upon set of strict standards that assures
interoperability.
Mr. Janklow. That makes my point, sir. I mean, that's the
very point that I'm making.
If you have strict standards and criteria that people have
to meet, why aren't the other 20 part of the first 30 and all
in the same system? Is there a reason, other than good feelings
or, you know, good relationships that this is being done?
Is this a sovereignty issue or is it a competency issue or
what, sir?
Dr. Fleming. I think it's actually a good public health
practice issue.
At the end of the day, these systems will be
indistinguishable and transparent from each other as far as
enabling the needed transfer of information. But the reality
is--is that in different jurisdictions there are different
needs and issues such that it does make sense for a particular
jurisdiction adhering to a set of standards to say, we want to
be able to customize this to meet not only the national needs
but our local needs as well.
Mr. Janklow. Doctor, if I could, and I'm referencing page 6
of your written testimony: You give examples of different
States, the Michigan example, the Missouri example, the
Pennsylvania example, and then Virginia, Maryland, and
Washington, citing that they are buying into the Pennsylvania
example.
Where you have an example like, let's just take Michigan.
Michigan is implementing a secure Web-based disease
surveillance system to improve the timeliness and accuracy of
disease reporting. Why would that be any different than what
Missouri is doing?
And I know the answer is going to be Missouri is doing it,
too. But why do they all have to be done in different ways?
Because what we are going to end up with is, some jurisdictions
are going to be more comprehensive and more thorough than
others. And when we're dealing with national information that's
coming from all over America, different jurisdictions are going
to be reporting or not reporting certain data based on what it
is they decide to do.
Dr. Fleming. Let me draw a distinction. First, I understand
the point that you're making. And rest assured that CDC, as
well as State and local governments, are working very hard to
prevent what you are talking about from happening.
Mr. Janklow. But it doesn't indicate here it's happening.
And I'm not trying to interrupt you, sir, but the testimony
here indicates that may not be happening.
But go ahead, please.
Dr. Fleming. And there are really two different systems
that we are talking about. In my oral testimony I talked about
the reportable disease system that is standardized across the
country and which NEDSS is seeking to make electronic with
strict standards.
In addition, with the availability of electronic medical
records and other electronic data bases out there, there is now
a new potential as you heard about, for example, in essence to,
independent of that system, develop syndromic surveillance that
accesses these data bases.
We are right now at a stage where pilots and demonstrations
and experiments are needed in that syndromic surveillance part
of how we detect diseases. We do not yet know for sure how
effective that system will be or what the best way to do it is.
In that context, we are allowing innovation at the State and
local level, under the guidance of CDC, to assess different
ways of conducting not this reportable disease surveillance
that NEDSS is standardizing, but rather this new enhanced,
complementary approach of syndromic surveillance.
Mr. Janklow. Doctor, given the history, I will call it in
the nonwarfare sense, whether it's botulism, whether it's
measles, whether it's other types of clusters--I remember an
incident involving the Schwan's trucks several years ago with
respect to the ice cream that was nationwide in scope. CDC and
the systems in America have done a tremendous job of getting on
top of that, meningitis, very, very quickly.
What's the difference between the system in place for that
and the systems you are describing now, sir?
Dr. Fleming. OK. And it's two different approaches that are
complementary, that are both designed to try to detect one of
these events as soon as they are happening. The system that's a
standard system that detects the salmonella outbreak is one
where people with salmonella go to see their physician, a
diagnosis is made, those cases are reported to the health
department, and as a result of cases coming in from multiple
physicians, there's a recognition that there is an outbreak of
salmonella that is happening, and the appropriate investigation
is occurring.
Now, there are some conditions. Let's take anthrax as an
example, where before someone gets to the point where it would
be possible to diagnose the disease anthrax, they have several
days of milder symptoms that are influenza-like, if you will,
with fever and other illnesses. One potential way of jump-
starting our recognition of an anthrax attack would be not to
wait for people to come in at the stage where you could
diagnose anthrax, but by monitoring reasons that people are
coming into emergency rooms or in pharmacy records, seeing that
there is a sudden upswing in the nonspecific seeking of
attention for an influenza-like syndrome.
Mr. Janklow. But isn't that done now?
Dr. Fleming. Actually, that's what we are talking about
trying to implement with respect to this jargon, ``syndromic
surveillance.'' Which is to say, is it possible to implement
systems that could pick up earlier in the course of an epidemic
some of these nonspecific illnesses that aren't yet diagnosed,
and by seeing an uptick, put the public health and the clinical
health system on alert? We are right now in the phase, though,
of figuring out how best to do that.
Mr. Janklow. One thing that the Department of Defense
excels at is educating their people. They have a worldwide
system that's in place.
Recognizing that the traditional method that we follow in
this country is to bring a lot of people together for a
conference, would it not make sense to start using to a far
greater extent, for example, satellite television, recognizing
that in a lot of instances it will be video one-way and audio
two-way, but that you could really reach an awful lot of people
and, frankly, a lot of general public?
I think where you are dealing with, especially the new
world we live in of terror, the more the general public knows,
the more equipped we are as a nation, one. And, two, the better
it is in terms of reporting things to their physicians and
their medical providers. I mean, it isn't like grandmas and
mothers can't look at the symptoms. By the time you get to be a
grandma, you know them pretty well. The school of hard knocks
has taught you an awful lot.
Is there any approach being looked at to more effectively
use--like direct broadband, direct broadcast satellites, as
opposed to specialty satellites like SS and direct TV?
Dr. Fleming. You are absolutely right that with the new
technologies we have available to us, we need to be creative
and make sure we are staying ahead of the curve of how best to
communicate----
Mr. Janklow. Are you doing any of that?
Dr. Fleming [continuing]. With people. And so there are a
number of avenues that CDC, along with State and local health
departments, are doing. One you mentioned is that many people
now have access to the Internet, and one of the most effective
ways to educate people is by putting information on Web sites,
including interactive Web sites. CDC's Web sites gets millions
of hits each month. And you can watch it uptick when West Nile
comes, or with SARS, when SARS came. So people are using the
Internet.
Second, we need to take advantage of distanced-based
learning techniques, as you have alluded to, via satellite
transmissions, Webcasting, via even old-fashioned, if you will,
videocassettes that allow people to learn at the time that they
are able to do it, rather than going to the expense of bringing
people all into the same place. There are many of these kinds
of technologies that are now available to us, and we need to be
smart and use them, and we are trying.
Mr. Janklow. Thank you.
Mr. Shays. I thank the gentleman.
Mr. Bell.
Mr. Bell. Thank you, Mr. Chairman.
Dr. Fleming, we've obviously all heard about the anthrax
scare in 2001. We read constantly about the threat of
bioterrorism, and we pick up a newspaper or turn on the
television just about every day to hear another story or see
another story about SARS and the spread thereof.
I think, given all of that, everybody recognizes the need,
the very pressing need, for a national surveillance system. And
many, certainly, on this side of the aisle are quite curious to
see the cut to CDC in the President's budget to offset a $550
billion tax cut, or what would appear to be a cut in order to
offset the $550 billion tax cut--and I'm very curious as to why
these cuts to CDC--what impact the cuts would have on the
efforts to establish a national surveillance program.
Dr. Fleming. Thank you, Congressman. I think there has been
a bit of confusion about the nature of the reductions you are
talking about. In fact, in the President's 2004 budget compared
to the President's 2003 budget, there was actually a proposed
increase of $125 million in chronic disease, $50 million for
HIV prevention, $10 million for a public health information
network, initial development, $5 million for health statistics,
$17 million for pay raises.
What happened though is that the President's 2003 request
was modified by Congress and increased. So if you look at the
President's 2004 request compared to what it was that Congress
authorized in 2003, there is this difference.
From our perspective, it does make sense for the President
to operate off the budget that he proposed in 2003. And in that
budget there are not any programmatic reductions. Obviously,
when the budget comes to you all, you are going to need to sort
this out as far as what you authorized in 2003 compared to what
you authorized in 2004.
Mr. Bell. What about moneys spent on the National
Electronic Disease Surveillance System?
Dr. Fleming. The dollars that were requested by the
President in 2003 for that system match the dollars that were
requested by the President in 2004 for that.
Mr. Bell. That's been going down every year since 2002, has
it not?
Dr. Fleming. I could get back to you on the record with the
specifics. My understanding is that the amount has been
constant, with the exception of an earmark that was deleted.
But let me get back to you on the record.
[The information referred to follows:]
FY 2002 Actual--$27.8 million
FY 2003 Enacted--$28.6 million
FY 2004 Request--$27.6 million
Mr. Bell. Well, let's discuss in a more positive light what
progress has been made in bringing the 100 district
surveillance systems together under a more comprehensive
program.
Dr. Fleming. There has been remarkable progress made. Let
me say that more can and needs to be done, but within the last
year many States have begun actually operationalizing a system
where clinical laboratories in their jurisdictions are now
automatically and electronically forwarding disease reports so
those reports are coming in a more complete and timely fashion.
And States like Hawaii have performed brilliant analyses of
this that show that they are now better able to detect
outbreaks more rapidly and more efficiently than they were
before.
In addition, there has been absolute commitment at CDC and
agreement with our State and local partners that we need to
establish a uniform set of standards for developing our
information technology systems, and especially those systems
that are relevant to biosurveillance.
And so, over the last year, for the first time there is a
comprehensive list of standards that all of the public health
partners have bought into that said, as we move forward, these
are the standards that we agree we're going to abide by to
assure that a clinical laboratory that reports to multiple
jurisdictions only has to do it one way because there will be
one set of standards and to assure that, as information passes
from one jurisdiction to another, that passage will be
transparent, because it will be sent and received in a standard
format.
In addition, there has been good initial work done on what
we are calling the public health information network, which is
the underlying information architecture that we need to do all
of our business, not just surveillance, but also alerting of
providers through routine e-mail communications and training
and informing the public. So, we build one system with multiple
functionalities rather than multiple independent systems. We
have gone a long way.
Mr. Bell. OK. But we don't have one system right now as we
sit here today; is that fair?
Dr. Fleming. That is correct. We are moving toward that
single system. But we need to recognize that we were starting
from a baseline of many disparate systems, and we need to keep
the trains running as we move forward.
Mr. Bell. Sure. And I agree with that and I understand
that. But what challenges still exist in order to get to that
one system? Because I assume from your comments that is the
ultimate goal.
Dr. Fleming. There are several challenges. I won't deny
that resources is certainly part of it. Information technology
and these systems are expensive. And in this era where there
are finite resources available, tough decisions are going to
have to be made.
Second, though, we need to look critically at the human
capacity, because in fact you can have the best computers and
the best information system in the world, but unless there is
somebody sitting behind that computer that is knowledgeable and
competent and trained and knows how to act on that information,
you haven't bought anything. And I think at CDC we are most
concerned perhaps about whether or not there is this pipeline
of trained public health professionals out there to use this
new technology.
And, in fact, there may not be. So, a major area that we
are looking at in conjunction with our State and local health
departments is, what does need to be done with respect to
schools of public health and other educational institutions,
preparing public health professionals to assure that the work
force that we are generating is one that is competent and knows
how to take maximum advantage of the system that we are
building?
Mr. Bell. Dr. Fleming, given the fact that, as you state,
resources are one of the challenges we face, is it fair to say,
when the amount of money is decreasing that is being spent on
the surveillance system, we are not going to get there anywhere
fast toward the one system?
Dr. Fleming. Moving toward the one system certainly is
going to be both resource and people-dependent.
Mr. Bell. What kind of money are we talking about?
Dr. Fleming. Right now, we are engaging with OMB according
to the Klinger-Cohen Act to develop the business case for
exactly what it is with respect to this overall vision that we
are going to need in the next few years. When that process is
complete, we will have a specific target amount that will be
needed, and we will get back to you with that. We are working
through exactly that issue right now.
Mr. Bell. So we don't even know how much it would cost at
this point in time?
Dr. Fleming. We need to complete our discussions with OMB
and under the rules of the Klinger-Cohen Act.
Mr. Bell. Is there any kind of estimate available at this--
has anyone made any sort of estimate how much one system might
cost?
Dr. Fleming. Let me get back to you on record for that.
Mr. Bell. I'm sorry?
Dr. Fleming. I will get back to you on the record.
[The information referred to follows:]
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Mr. Bell. I would appreciate it.
It is not your impression--and, Dr. Tornberg, you can
comment on this as well--that the administration has stepped
away from its earlier desire to see this national surveillance
system? Do any of you all get that impression?
Dr. Fleming. Dr. Tornberg can comment. I certainly do not.
If anything, the administration, and especially the Vice
President's office, has been very supportive of the notion of
doing what needs to be done to make sure that we have a
surveillance system that's competent and, particularly, a
surveillance system that can detect not only naturally
occurring events but bioterrorist events as well.
Mr. Bell. Dr. Tornberg.
Dr. Tornberg. I would agree. I think that there is a full
commitment to providing a national surveillance system. I have
not detected any variance from that point.
Mr. Bell. Has everybody made it clear that more money is
going to have to be committed to the project if we are going to
be able to realize one system?
Dr. Fleming. We made it clear that resources are needed to
make systems work and that we need to balance the expectations
for what those systems are against the resources that are
available.
Mr. Bell. Thank you very much.
Mr. Shays. I thank the gentleman.
Before recognizing Mr. Murphy, what I'm wrestling with is
one country, 50 States, thousands of local governments, and the
comment is made, it's a question of resource and people. It's
not a question of legislation that would allow you to mandate
one system throughout?
Dr. Fleming. Mr. Chairman, I don't think so.
Mr. Shays. OK. We will come back to it.
OK, you've got it, Mr. Murphy.
Mr. Murphy. Thank you, Mr. Chairman. Actually, you were
reading my mind. My mind is working along the same lines.
In Pittsburgh, we have a system called the Real-time
Outbreak and Disease Surveillance System [RODS] system, which
has been operating pretty well. And in southwestern
Pennsylvania--and, also, Utah used some of this during the last
Olympics where they do monitor those very things you were
talking about, over-the-counter supplies and pharmacies, etc.
And that's one sort of system, and you are looking at others.
I just want to make sure I understand this. Are you at this
point testing different systems that are being used to
determine which one is the best system? Have you determined
that yet as different universities are involved in these
functions?
Dr. Fleming. The RODS system that you are referring to
would fall into that category of syndromic surveillance
systems, where in fact right now a number of different
systems--ESSENCE would be an example; ESSENCE I and II would be
examples--are being tried in different jurisdictions. I
personally think that the outcome of this is not going to be
that one of those systems is going to be proven best, but
alternatively we will see the aspects of each that provide the
most functionality. And by combining the best of all of them,
we will create that, if you will, one system that serves our
needs.
But we are really right now in a phase of piloting and
demonstrating and, to a certain extent, experimenting, because
this is new ground for the public health community.
Mr. Murphy. So you are working with different places like
the University of Pittsburgh and others to monitor the kinds of
parts that are in place, so you can pull out of each one what's
the best?
Dr. Fleming. Exactly right. And in addition, I mean, a key
to these--the underlying notion here is that these systems can
detect problems more effectively and more rapidly in some
instances than our existing reportable disease system, and can
be a complement to it.
That's a concept that has not been totally proven yet, and
before investing a whole lot of resources in a nationwide
system, we do need to see the evidence that these systems are
able to do what they, in theory, might be able to.
Mr. Murphy. Let's walk through what happens next. Say you
come up with a national system that's been working in the
cities and rural areas, etc. The thing about bioterrorism, it
moves slow enough that you can detect and then implement
strategies to quarantine, to have public education, to
immunize, whatever. But, of course, the drawback is that it
also moves slow enough that it can be spread throughout the
Nation in a matter of a few days before anybody has a sense
that they need to take some steps.
When that happens--and we have had some other hearings
here, for example, with NORTHCOM, some wonderful hearings and
discussing some of the aspects taking place.
But let's go--let's say there is some disease that begins
to be picked up in multiple cities around the country, it's
spreading by whatever mechanism, through contact, it's around.
Can you walk us through what happens once you get this data, in
particular, the plans in place to notify physicians and
hospitals, coordinate efforts, get products to communities,
notify the Defense Department, even to the level of local
emergency responders, EMS people, etc?
Can you walk us through what happens once you identify that
there appears to be something out there?
Dr. Fleming. It's a complicated question. Let me try to
answer it in a couple of ways.
First and most basically, the health department needs to be
the nerve center for making this happen. What we are talking
about is gathering the information through the surveillance
systems to allow competency in making the decisions that need
to occur. Then, the different arm needs to come in action. The
health department, as you have said, works with providers and
works with appropriate policymakers to make the right things
happen.
A fair amount of the dollars that have gone out over the
last year for enhancing bioterrorism preparedness have been put
in place through plans and exercises, exactly the kind of thing
that you're talking about. So even as we speak, health
departments around the country are, in fact, making plans,
drilling, making sure that they have the ability to connect
with the providers that they need to connect with, testing
that, making sure that they're connected with the policymakers
and others.
Mr. Murphy. Is this part--there'll continue to be drills
around the Nation? There's funding available for that aspect
that communities can also apply and work with health--because
you also have State health departments in some--I know in
Pennsylvania many counties don't have a health department. They
have to rely on the State. It's a slow system. And so it will
require some drills and exercise to take care of that. Is that
a part of the States as well?
Dr. Fleming. Absolutely correct. And let me point out that
one of the ways that we are really focusing on using these
resources is to invest them in the same systems that are used
every day to detect naturally occurring outbreaks and to mount
the responses that are necessary to combat those. So in
addition to exercises and drills, in fact, we are, because of
Mother Nature, constantly being drilled in this country and
around the world through the natural everyday public health
emergencies that our health departments are facing.
Mr. Murphy. Was this 5 or 10 minutes that I have?
Mr. Shays. Ten minutes.
Mr. Murphy. Ten minutes? Oh good. Let me continue to pursue
this.
With this kind of data out there, the question becomes one
of Big Brother and how do you protect confidentiality of
records. And let me add to this, a lot of hospitals are
concerned now about HIPAA regulations and problems with
confidentiality. So now they can't get the information that
they need to track what's happening with patients.
Let me continue to build this. As we're working on such
things as other aspects of pharmaceutical care for the elderly,
without some openness of sharing some records, you run the
continued risk of the problems that there are with prescription
and nonprescription drugs. Some estimates have been out there
about 10 percent--I'm sure you're aware that about 10 percent
of emergency room admissions they say are related to some
pharmaceutical problems; perhaps the person took the double
doses they weren't supposed to. Perhaps a physician did not
know what else was being prescribed. They didn't know that the
patient was taking over-the-counter products. Someone forgot
their medication for 2 days, they took it all at once. The list
goes on. And in aspects where pharmacists have data available
or where the pharmacy benefits manager may have information
available of what else that person is on, it helps them prevent
a lot of those accidents.
Now, we're looking, too, here at collecting data on
symptoms. If it is just looking at sales, numbers for what's
happened with antihistamines and pharmacists, that's one thing,
but ultimately you have to get down to the level of who has
this? That's been part of the elegance of tracking SARS around
the world, that you were able to track it down to a hotel in
Hong Kong, ninth floor, who was there, and tracking them around
the world. Clearly you're going to need some sort of records
like this, too, but it has to be looming over people's minds
of--on the one hand they want to know if there are symptoms in
a town, they want action to be taken to identify that, but also
protect confidentiality. How do you walk that line?
Dr. Fleming. OK. An excellent question. Let me say first
that I think most people in public health would not see it as
public health versus privacy, but rather only by protecting
privacy can we expect this information to be made available,
and so we're on the same side of this.
There's a couple of strategies that are used. First there
are some kinds of surveillance where you don't need identifying
information, and so the first question that we always ask in
any of these surveillance systems is can we get what we need
without having identifying information there, and if so, let's
not get it.
But as you pointed out, there are some places where, in
fact, identifying information is needed so you can track back
to the individual or the individual's provider to get more
information to assure that the right things are happening to
that person and to take the appropriate actions in the
community.
This is an issue that public health has been dealing with,
you know, for 100 years. And, in fact, on a day-to-day basis,
personal identifying information is routinely relayed from the
medical community to the public health system, and that
information is guarded very carefully both from a legal
standpoint and from a security standpoint so that there have
been few, if any, breaches in the history of public health
where an individual's confidentiality has been compromised, and
that's by maintaining attention to the sanctity of privacy and,
when information that is identified is obtained, making sure
that it's used wisely. That's the answer.
One last thing about HIPAA is that there is a lot of
confusion out there, obviously, and we're working in the health
care sector, but HIPAA, in fact, does give an exemption to
public health, so--providing information from the clinical
sector to the public health sector for public health purposes
and says in that situation it is OK to transfer identifying
information.
Mr. Murphy. Well, I certainly hope as all this is gathered
a great deal of training information is available to
physicians, hospitals, emergency responders, police, etc.,
because a lot of them still don't know what to do.
And let me ask one final quick question. Who is ultimately
in charge when a disease outbreak is determined? Who is the top
of the chain of command?
Dr. Fleming. Well, the President, obviously.
Mr. Murphy. I mean, is it where the thing occurs first?
Oftentimes first responders, whoever's first on the scene in
that community, is now in charge either nationwide, or it
begins in some State----
Dr. Fleming. I'm sorry. I misunderstood your question.
Health is a State's right, and so it will be the State health
department at which there is legal jurisdiction for the health
events going on in the State. If an event crosses State
boundaries, then it becomes also from a legal perspective a
Federal jurisdiction issue.
Mr. Murphy. And so such actions as quarantining, other
information then becomes through--Health and Human Services,
HHS and CDC begin to take control and begin to tell States what
they should do in communities and travel, etc?
Dr. Fleming. The short answer is yes. The more accurate
answer is that we really do have a good partnership in public
health, and so CDC and State and local health departments
routinely, every day, in the absence of who is in charge, make
critically important decisions about what needs to be done.
Mr. Murphy. Thank you.
Thank you, Mr. Chairman.
Mr. Shays. I thank the gentleman.
In our two panels we have the national looking at the
civilian and the military, and then we have basically State and
local and international, and we're also looking at the private
in our second panel.
I was just curious, Dr. Tornberg, as you're hearing the
questions being asked to Dr. Fleming, besides thinking what
you're going to do this evening or tomorrow or on the weekend
as it related to this hearing, what kinds of things go through
your thoughts? I'm just trying to figure out how you interface
with CDC.
Dr. Tornberg. Well, we interact extensively with CDC and I
have with Dr. Fleming on issues. The collaboration extends not
only to CDC, but to a host of other Federal agencies and the
World Health Organization. As I indicated in my earlier
statement, we have representatives assigned to CDC, military
epidemiologists. We are currently assigning an individual to
represent--Dr. Winkenwerder--at the--to Dr. Gerberding's office
as we speak.
So the collaboration is very close, and there's an ongoing
active discussion. Particularly with the SARS outbreak, there's
been really intense collaboration between CDC and the World
Health Organization and our assets, the assets of DOD-GEIS, in
addressing this issue, and I think we have a really fine
working relationship.
Mr. Shays. Now, if there wasn't the terrorist threat, you'd
still be in business, and why would that be true? In other
words, if you never had to worry or--not just the terrorist
threat, but a sanctioned military effort on the part of an
adversary to use biological agents, if you didn't have that
concern, whether it was sanctioned by a government or
individual terrorist attack, one used against the military or
one used against civilians, would you still be in business, and
why?
Dr. Tornberg. Yes, sir, we would be. In fact, our ongoing
efforts and our fight to preserve the health and safety of our
personnel demands that we be very active and proactive in this
arena, as we have been from the earliest days of the Department
of Defense. Our forces are expeditionary in nature and exposed
to a host of----
Mr. Shays. I get the gist of that. Thank you. That's clear
to me.
Let me ask you, Dr. Fleming, though, so you have Dr.
Tornberg, who's focused on a national and international, tell
me how your focus becomes international in terms of the fear--
in other words, we have representatives from our military all
around the world. Is your focus international as well as
national?
Dr. Fleming. Absolutely. And it is for several reasons. The
spector of infectious disease is perhaps the most obvious
threat. A case of drug-resistant tuberculosis or SARS is simply
a plane ride away in today's world. And one of the best ways to
prevent the emergence of both known and unknown diseases in
this country is to make sure that we have a strong global
network and a U.S. presence, a CDC presence, overseas fighting
those diseases in the countries that they're occurring,
minimizing the chance that they will come here.
Mr. Shays. How many laboratories would CDC have overseas?
Dr. Fleming. CDC's primary expertise is in people and
epidemiologists, so we have a handful of field stations, but in
my opinion, the real international resource, the resource that
CDC provides for the world, is in the trained epidemiologists,
and we currently have approximately 60 CDC medical
epidemiologist in various countries working with local
ministries of health on critically important issues, be it
polio eradication, or HIV prevention, or surveillance for
infectious diseases.
Mr. Shays. Dr. Tornberg, how many--is that classified
information?
Dr. Tornberg. No, sir, it's not. We have five overseas
laboratories.
Mr. Shays. And where are they located?
Dr. Tornberg. We have a laboratory in Thailand, in Jakarta,
Indonesia. We have one in Peru, Kenya and Cairo.
Mr. Shays. OK. Now, getting to where Mr. Bell is, in
Congress, we have to wrestle with a constituent who will say we
need to do this, and they want a State law because they don't
like what their--they want a Federal law because they don't
like what their State is doing, and we get into this issue of,
you know, do we overrule State law and have a uniform law. And
I try explain that you sometimes can end up with a common
denominator, and you might want a stronger law in one State
versus another.
But when you get into health care and you get into this
issue of collecting data, I'm really unclear as to what
restraints there are. I mean, is there an untold story here
that Republicans don't want to get into this because there is
the States rights issue, and Democrats may not want to get into
this because of the personal privacy? I mean, is party
ideology, conservative or liberal, getting into play here
besides the issue of resources and people-dependent and money,
because I'm thinking, good grief, we're not going to have a
vaccine for every potential pathogen, every potential illness
inflicted on us. So one of the ways that we are going to deal--
and we wouldn't want to necessarily even if we could, because
there's always some side effects with that.
So we want to--it seems to me our strategy is identify
quickly, isolate it, contain it, and deal with that as we find
it. And I'm unclear from you, Dr. Fleming, as to, you know, are
we going here and there, or are we just trying to say, well,
given this disparate kind of system we have, we'll make the
best of it? Or should we say this is absurd, this is
ridiculous, we want to have unified information, we want to
have every local community send it up to the State on real
time, we want it available to the Federal Government on real
time, just like K-Mart might know what they have in their
inventory and what they sold in the last 15 minutes? In my
mind, that's kind of the way I'm thinking, but I'm not sensing
that's the way the Federal Government's thinking.
Dr. Fleming. First off, I think--just so that you'll know,
I have about 20 years experience. Most of that is actually
working at the State level. I have been at CDC for about 3
years, and so I have a little bit of history here. And I think
if you'd asked me this question 20 years ago, I would have said
you're absolutely right, because I would think that the rate-
limiting step is the fact that people don't want to work with
each other, and we can do it more quickly if we mandate it.
That has changed dramatically, particularly in the last
couple of years, such that there is now essentially uniform
agreement that what the vision you just articulated is where we
need to be heading. So the rate-limiting step isn't that people
don't agree to that, the rate-limiting step is getting there
through resources and planning and people, as we've talked
about.
Mr. Shays. And you said we don't need a law. You said CDC
has the power to mandate a standard form, standard information.
Do you have the capability under law to say we want it within
an hour of your knowing, etc?
Dr. Fleming. I'm sorry, I may have misunderstood your
question. When I said we don't need a law, it is not because we
have the authority to mandate it, but rather because it's my
perception that it doesn't need to be mandated; that the system
out there agrees with the vision and is trying to move toward
it. We don't need the stick in this instance to get people
where they need to be. They are there on their own. There is so
much logic to it, and now there's now the information
technology that enables it to happen, that with more and more
people working at the State and local level, seeing the need
for cross-jurisdiction communication and coordination, there is
essentially uniform agreement out there that this is the way we
need to go.
Mr. Shays. If it's not a law requiring it, and someone
doesn't provide it, then is there any liability?
Dr. Fleming. Well, first off, in individual States, as you
know, there are laws that mandate the provision of this
information, and those are enforced generally through the
licensure acts so that an agency or a laboratory that does not
submit required information can be acted upon through their
licensure. So there is a governmental stick, if you will. I'm
just saying I don't see the need for a Federal stick.
Mr. Shays. Let me go through just--you said our
surveillance--on page 2 of the statement I had--it was 3 on
another one, so I guess a different copy--but it said our
surveillance systems generally use paper facsimile reporting by
health care providers to health--if a case of illness is
particularly unusual or severe, such as in the case of anthrax
or rabies, the provider may call the local health department
immediately. You had the word ``may,'' which I think is
interesting. Then you say, as mentioned, health care provider
recognition of the illness and awareness that certain health
events require immediate notification of public health
authorities is critical to our ability to detect problems and
mount a public health response. Such reporting requirements are
mandated at the State level. But aren't they mandated in
different ways, different timeframes, etc?
Dr. Fleming. There is currently some State-to-State
variability around the specific conditions and the timing. I
think my experience has been that the right things are
happening, though, so regardless of whether you say a case of
anthrax should be reported immediately in one State or within
an hour in another State, if you look across States, the
bottom-line message is the same, is that there is a common list
of conditions for which immediate action is warranted, and then
another category of diseases for which you can have a little
bit more time to do the steps.
I'm not trying to make it sound like it is a perfect world
out there. What I am saying, though, is that tremendous
progress has been made such that, at least in my opinion----
Mr. Shays. You know, I agree with the tremendous progress,
and I do think that if you can get things to happen voluntary--
and I'm going to just roll my 5 minutes over and start a second
round of just 5 minutes, if I could. So I'm going to begin the
second round of questioning.
I guess this is what I'm wrestling with. I kind of have
been listening to Representative Bell, and I'm thinking, as
he's asking these questions, we are safer than we were before
September 11, but we don't feel as safe because we had a false
sense of safety before September 11.
But we've had--you know, SARS is an interesting kind of
process here that just kind of makes us alert to the fact that
both of you are dealing with defense against the pathogens that
may attack us. You know, for the nonscientist, me, the
nondoctor, me, when I hear there are mutations of SARS, and you
think, you know, this thing is like an interesting threat to
say the least, I'm just wondering, what in the world it is
going to look like in a year or two? Will Mr. Bell or Mr.
Janklow or Mr. Murphy and I be able to say a year from now when
there is an outbreak, one--excuse me--if there is an illness in
one place and an illness in another place and an illness
somewhere else, and they don't see the severity of it, but if
you put it all together, we would see it clustered, will we
know within an hour of that, or will we know 5 days later? And
if one or two States don't have the same requirements, will it
be incomplete information? Or are we going to have a good
system in a year from now?
That's kind of what I'm asking. And I'd like, Dr. Tornberg,
even though this isn't your direct responsibility because it's
CDC, I want you to tell me what you think is going to happen,
and then I want you, Dr. Fleming, to tell me what you think.
Dr. Tornberg. I think we are moving clearly in the
direction that you described. Will that be a year from now?
Difficult to say. But the recognition time of a syndromic event
is really somewhat based on the kinetics of the event itself
and how rapidly it travels. But we clearly are moving in that
direction and would hopefully have that capability and make
this a much safer place.
Mr. Shays. What would be wrong for me to say that we should
be able to say, all right, we will have it ready in a year, or
we will have it ready--what is the puzzlement that says that we
won't? I mean, what--if everybody realizes we should have it,
why are we talking this way?
Dr. Tornberg. Well, what we are gaining in part of the
growth phase--and we are in--with syndromic surveillance
itself, and that's what we're talking about, we are in the
toddler stage, if you will, in the development and the
maturation of the process, and it's clearly a process that has
to mature from a--data acquisition is part of the problem, but
a bigger part of the problem is the analysis of the data we
have, because there's, as we discussed, many disparate sources
of information, and there can be data overload. The key in the
challenge is to analyze that data to allow it to be--have a
meaningful pattern, and subsequently to allow us to----
Mr. Shays. You're telling me that it is going to be very
difficult, and it is just not going to be adding numbers. I
hear you.
Dr. Tornberg. We can't identify aberrations if we don't
know our baseline. That's critical for early detection. And we
are very much right now in the phase of developing our
baselines and noting exceptions from that.
Mr. Shays. Well, basically I'm just trying to make--this is
kind of like telling me we have a learning curve?
Dr. Tornberg. Yes, sir.
Mr. Shays. OK. And you're not able to tell me how long that
learning curve is going to take.
Dr. Tornberg. I would be hard pressed to give you a year
timeframe on that, but certainly within several years.
Mr. Shays. Dr. Fleming.
Dr. Fleming. In some ways I don't think it is a yes/no
answer either. We have already around the country a system that
works and that does identify these events. It does need to be
improved, but how long that takes depends on what level of
improvement and what we are trying to get to. A year from now
our system will be better than the system we currently have
today, and if we at CDC are doing our job right, 2 years from
now it'll be better than the system a year from now.
Mr. Shays. OK. Let me just real quickly, in the 40 seconds
I have left, have you explain to me what would be a good
system, a really good system. In other words, is the analogy of
a K-Mart being able to tell me what's in their inventory,
what's sold in the last--real time, is that just totally
unrealistic?
Dr. Fleming. Absolutely not. Real time is an aspect of
this. But the true measure of a system is how responsive it is
not in detecting the event, but in responding to the event and
putting the actions in place that need to be put there to keep
people healthy. And so my definition of the perfect system, if
you will, is a system that is rapid enough such that the
preventive actions that need to be put in place will happen
before individuals become sick or die.
Mr. Shays. Thank you.
Mr. Bell, do you have any questions you want to ask?
Mr. Bell. Can we do another round?
Mr. Shays. Yes, another 5 minutes, and then we're going
to----
Mr. Bell. Thank you, Mr. Chairman.
I'm curious, Dr. Fleming, because in your original
statement you said that there are reports, or your--I believe
it was your strong-held belief that there are reports that are
not completed or acted upon.
Dr. Fleming. That's correct. The system we have is not yet
perfect. It works, it's good, but it can be improved.
Mr. Bell. But let's say someone in Texas sees a case of
SARS and decides not to, for whatever reason.
Probably wouldn't be true today, but several--a couple of
months ago--and chooses not to report that. Then certainly it
would be your strong desire that they would report it, but if
they didn't, there's absolutely no law in place to punish that
individual in any way, shape or form, correct?
Dr. Fleming. Certainly within the State of Texas, providers
are licensed and are required by law to report.
Mr. Bell. To you.
Dr. Fleming. No, to the State health department.
Mr. Bell. OK. And so--good. That's helpful. Where is the
breakdown coming in the reporting mechanism then?
Dr. Fleming. There are several places. First off, I think
not everybody that's sick sees a doctor, so there's illnesses
out there that may never be diagnosed.
Second, some of the diagnoses that happen are--happen in
such a way that the provider forgets to report. It is just--you
know, it's not a willful act, but it just doesn't happen. The
NEDSS system that we're putting in place, which basically says
when a provider, clinician or a laboratory, as part of their
clinical records, indicate they have just diagnosed this case
of salmonella or E. Coli or whatever it is, they don't have to
report it to the health department at that point. The computer
system automatically recognizes it as a condition that requires
reporting and automatically instantaneously transports it to
the health department. That's a big part of the fix of the
system.
The third part is to make sure that when that report is
received, that there's somebody at the health department to
look at it and to investigate it. The bioterrorism resources
that have been made available go a ways in making that happen.
Mr. Bell. As the chairman alluded to, what would be--I'm
just curious. What do you all see as the downside to having
some sort of law that would mandate reporting to have that in
place?
Dr. Fleming. Well, first, I do think that there are
different diseases that are of greater or lesser importance in
different parts of the country. And so, for example, some of
the fungal diseases that are common in the Southwest need to be
reported there, but because they're not prevalent in other
parts of the country don't need to be reported there. There is
need and room for local flexibility. In addition, within the
confines of a system that's trying to accomplish these agreed-
upon goals, there is some flexibility about the best way to get
things done. And in one--in all aspects of the government, the
thing that will work best in one part or one jurisdiction isn't
necessarily the thing that'll work as well in another. So we
need to allow, in my opinion, for local flexibility around the
process so that the agreed-upon outcomes that we're striving
for can be achieved as best as possible.
Mr. Bell. And one final question. It would appear, going
back also to the--if we can get there in 1 year, it would
appear that would be somewhat impossible. We don't know how
much--as far as having one unified system, we don't know how
much that would cost as we sit here today. You said you'll get
back to us on that. If that price figure comes back, and it's
obvious with the money that is presently allotted there's no
way to get there, or do you all plan to advocate for more
funding to go toward a national surveillance system?
Dr. Fleming. We will make it clear within the
administration and to you what can be done for what level of
resources, recognizing that it's you all's decision where the
tradeoffs need to come from.
Let me just make one other comment, if I might. I would
hate for you to leave thinking that we're talking about only
one system; there's only one thing that needs to be done.
Public health surveillance, including infectious disease
surveillance, is a system of systems. We're talking about one
today. But clearly the vital records system in this country for
looking at births and deaths; the systems that we have in place
for figuring out who's been vaccinated and who isn't, vaccine
registries; the system that on a real-time basis surveys people
out there to find out what they know about SARS, etc., are also
critically important parts of our surveillance. And so we need
to be thinking about ensuring that the system of systems is as
robust as possible, not focusing on only one element.
Mr. Bell. Thank you, Mr. Chairman.
Mr. Shays. I thank the gentleman.
Mr. Janklow.
Mr. Janklow. Thank you, Mr. Chairman.
Dr. Fleming, I've got several questions. I'm going to try
to be really quick with them. One, does DOD have a good--in the
words of the chairman--a truly good system?
Dr. Fleming. The ESSENCE system has promise. I mean, I
would say it's in evaluation, so I can't tell you yet.
Mr. Janklow. How long has it been in evaluation?
Dr. Tornberg. ESSENCE II has been in operation, I believe,
for the last 2 years.
Mr. Janklow. Dr. Fleming, in your testimony you talk about
several years ago you initiated development of the NEDSS
System. How long does it take to develop a system? Aren't we
talking about two things? One, we're talking about software;
and, two, we're talking about baseline or the data for the
information you're going to gather on the software and how it
is going to be utilized, correct?
Dr. Fleming. That is correct.
Mr. Janklow. In terms of developing the software, when--how
long did it take to do that?
Dr. Fleming. The software development process takes about a
year to 18 months, but you also need to have the standards,
agreement on what that software needs to do, and in addition--
--
Mr. Janklow. Excuse me. I thought you had the standards,
and you've already told people what they're going to be that
they have to meet to come out of the system.
Dr. Fleming. No. Right. But what I'm saying is those needed
to have been developed, in essence, before software can be
developed.
Mr. Janklow. How long have they been out?
Dr. Fleming. It's an iterative process. We started work on
it several years ago, and they're still being refined.
Mr. Janklow. Let me ask if I can, picking up on Mr. Bell's
question from before, can you tell me what hasn't been done
because you haven't had enough money? What hasn't been done?
What's lagging?
Dr. Fleming. There's two things. One is the capacity on the
clinical laboratory side, to computerize and send their
information. So even if a public health department is equipped
to receive information, that information can't be received if
it can't be sent on the clinical side.
Mr. Janklow. Why do you think it can't be sent? What's
holding that up?
Dr. Fleming. There's a wide range of systems that are out
there, and, in fact, some aspects of the health care system
still aren't computerized.
Mr. Janklow. Isn't that what we started out talking about
today? Does that take a mandate to get that done? If we've
still got some aspects of the health care system that aren't
computerized, and if there are no mandates in place, how's it
ever going to get there?
Dr. Fleming. I was hearing the question about mandates
relative to a mandate on the public health system from the
Federal level relative to the State level. There's a separate
question about the need for electronic medical records and the
development of clinical standards to create those records.
That's a bit beyond my domain of expertise, but it is an active
part of this, active part of this process.
Mr. Janklow. But, sir, aren't we--what--we're talking about
a reporting basically, either a diagnosis or a symptom; isn't
that correct?
Dr. Fleming. It's actually a bit more complicated, when you
think about the range of information that is being collected in
the health care setting.
Mr. Janklow. I understand. But when we're talking about
looking at this from a national sense, aren't we really talking
about, one, diagnoses that have been made, and, two, symptoms
that would lead one to the conclusion someplace else as you
gathered this from all over that there may be a problem that we
need to look into?
Dr. Fleming. I think you might hear from the clinical
sector that they would want that system integrated into their
overall way of doing business so that they did not have to go
off just for this purpose to enter information. But rather it
needs to be part of the therapy that's being given and the
monitoring of the patient.
Mr. Janklow. Doctor, if you had the money you needed, how
long would it take to get a system in place?
Dr. Fleming. Again, there is a working system in place. We
do have the ability to detect these events. We can make
substantial progress over the next year to 2 to 3 years, but I
don't want to make it sound like it is an on/off----
Mr. Janklow. Are people like me then unnecessarily
concerned that we don't have a coordinated system in place?
Dr. Fleming. I think that I've tried to express the level
of concern we have, which is we see that this is important, and
substantial progress has been made. The system is working. We
can make it better. It's not broken, but it can be improved.
Mr. Janklow. In terms of improving it, are we where we need
to be in a world that deals with terrorism focused toward us?
Dr. Fleming. That's the critically important question we
need to address, as we've been talking about. There are things
that can and do need to be done to improve our security.
Mr. Janklow. Is that a yes or a no, sir?
Dr. Fleming. Ask your question again, please.
Mr. Janklow. Pardon?
Dr. Fleming. Ask your question again.
Mr. Janklow. In terms of the world that we live in where
terrorism is directed toward us, are we where we need to be?
Dr. Fleming. No.
Mr. Janklow. OK. Thank you.
Mr. Shays. Let me just--before we go to our next panel,
this is Emerging Infectious Diseases. I think it is a peer
review journal tracking and analysis disease trends, and it's
done by the CDC; is that right? In the first article it has
Planning Against Biological Terrorism: Lessons From Outbreak
Investigations. Is this an article you're familiar with at all?
Dr. Fleming. I've not looked at it.
Mr. Shays. In the first paragraph it says, for six
outbreaks in which intentional contamination was possible,
reporting was delayed for up to 26 days. We confirm that the
most critical component for bioterrorism outbreaks detection
reporting is the frontline health care professional and the
local health departments. Bottom line, though, it--you know,
I'm going to take a better look at this article. Well, actually
I have to take a look at it. I haven't looked at it other than
that quote. But you can't respond to that issue of----
Dr. Fleming. I would also need to review the article to
respond in detail.
Mr. Shays. Well, why don't we just submit it for the record
then.
[The information referred to follows:]
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Mr. Shays. You both have been wonderful witnesses, and we
realize we're also wrestling with this. I think that what I am
wrestling with is that I see this as the whole package. So when
you talk about your not being able to talk about the technology
to present this, you know, rather than its--you know, some of
these are paper transactions. For me, I don't really--I don't
like the feeling that I'm getting that we're not--I guess what
I'm beginning to think is who's in charge? I don't mean that in
a disparaging way, but who is taking ownership of this?
Ultimately who takes ownership of making sure that this
reporting happens quickly, that it's not paper transactions,
that we're asking for the right things? Who ultimately, in your
judgment, has that responsibility?
Dr. Fleming. Well, the short answer is that CDC can and is
taking a leadership role in this, and if I haven't conveyed
that clearly, I sincerely apologize. I want you to know that
our organization is committed to making this happen.
Mr. Shays. I get a feeling that you're content that a lot
of progress is being made. And maybe what I'm hearing as well
is that from a scientific standpoint, you know, we just--we
study it, we check it, and we just--and so it'll happen when it
happens. That's kind of the feeling, that we're making
progress, but that's the kind of feeling I'm getting. From a
politician and public policy standpoint, I'm thinking should we
be tasking you to just make sure in a year or two it's done.
And then you're probably saying, hello. You know, what do you
mean it's done? So the process begins, you know, continues
here.
Any last comment that you'd like to make before--OK. You
both have been excellent witnesses, and I thank you.
Excuse me. Let me just say this. Is there anything, Dr.
Tornberg or Dr. Fleming, that you want to put on the public
record before we adjourn? A question maybe you had prepared for
that you think we should have asked, and we just didn't have
the common sense to ask it?
Dr. Tornberg. No, sir. I think both my oral and written
statement cover the areas that we would like to address for the
committee's attention.
Mr. Shays. Dr. Fleming.
Dr. Fleming. No. We will get back to you on the record on
the issues that we talked about.
Mr. Shays. OK. And on this article.
Dr. Fleming. Yes.
Mr. Shays. OK. Thank you both very much.
Let me just announce the second panel. I'm going to ask
three people to come up to be sworn in: Ms. Mary Selecky, Dr.
Seth L. Foldy, and Ms. Karen Ignagni. And then afterwards I'll
invite Dr. Julie Hall to sit down at the desk as well. We're
swearing in three of our four witnesses.
[Witnesses sworn.]
Mr. Shays. And at this time we'll also invite Dr. Julie
Hall, medical officer of the World Health Organization, to join
us. Evidently we didn't make it clear to the World Health
Organization we swear our witnesses in, and they have a policy
as an international agency not to be sworn in. So we'll accept
the way it is.
And Ms. Selecky is Secretary, Washington State Department
of Health, president of the Association of State and
Territorial Health Officials.
Dr. Seth L. Foldy--am I saying it right?
Dr. Foldy. Foldy.
Mr. Shays. Foldy--commissioner of health, city of
Milwaukee; Chair, National Association of County and City
Health Officials, Information Technology Committee.
And Ms. Karen Ignagni is president and CEO of American
Association of Health Plans.
And Dr. Julie Hall, as I said, is medical officer of the
World Health Organization.
We'll go in the order that you're sitting. And again, 5 and
then another 5. Your testimony is very important to us. And I
think that I would say that if you want to ad lib a bit, and
given that you sat through this first panel, that you may want
to jump in and make some points, because I think some of the
questions we've asked you you're well prepared to answer.
So we'll start with you, Ms. Selecky.
STATEMENTS OF MARY C. SELECKY, SECRETARY, WASHINGTON STATE
DEPARTMENT OF HEALTH, PRESIDENT, THE ASSOCIATION OF STATE AND
TERRITORIAL HEALTH OFFICIALS; SETH L. FOLDY, COMMISSIONER,
MEDICAL DIRECTOR, CITY OF MILWAUKEE, HEALTH COMMISSIONER,
CHAIR, NATIONAL ASSOCIATION OF COUNTY AND CITY HEALTH
OFFICIALS, INFORMATION TECHNOLOGY COMMITTEE; KAREN IGNAGNI,
PRESIDENT AND CEO, AMERICAN ASSOCIATION OF HEALTH PLANS; AND
JULIE HALL, MEDICAL OFFICER, WORLD HEALTH ORGANIZATION
Ms. Selecky. Thank you, Mr. Chairman, distinguished----
Mr. Shays. Is your mic on?
Ms. Selecky. Thank you, Mr. Chairman and distinguished
members of the subcommittee. My name is Mary Selecky. I'm the
Secretary of Health in Washington State, and I'm honored to be
testifying before you today as president of the Association of
State and Territorial Health Officials. And also having been a
local health department director for 20 years and having the
experience of, on the ground, working local, State and working
with our Federal colleagues, we certainly can address some of
the issues that came up earlier.
I certainly would like to thank the committee for your past
support of work that goes on with public health, but most
particularly your attention to the issue. It has not been in
the recent past that we've had the opportunity to bring public
health issues before you. This hearing focuses on one of our
most important, although invisible and forgotten, public health
tools, and that is public health surveillance. It's not
something people think about every day. As early as 1878,
Congress recognized that this is an important issue when it
authorized the U.S. Marine Hospital Service to collect
morbidity reports concerning cholera, smallpox, plague and
yellow fever from U.S. Consuls overseas.
Now the diseases may have changed, but the issues are very,
very similar. In 1928, all States, the District of Columbia,
Hawaii and Puerto Rico were participating in national
surveillance and reporting on 29 diseases. And in 1950, ASTHO,
my organization, created its affiliate, the Council of State
and Territorial Epidemiologists [CSTE], to determine and work
together, States, local and Federal, to see which diseases
should be reported to the U.S. Public Health Service. All
States now voluntarily provide information to the Centers for
Disease Control and Prevention [CDC] on nationally notifiable
diseases.
One of the core functions of State health departments is to
collect, analyze, interpret and disseminate public health data.
States do this to identify health problems, determine the
programs or other responses needed to address the problems,
specific health concerns, and evaluate the effectiveness of the
responses. Health departments depend upon the receipt of
quality public health data to identify and track emerging
infectious diseases such as already mentioned, SARS and West
Nile virus. Equally important, although often overlooked, is
the collection of public health surveillance data that
identifies the burden and causes of the Nation's leading causes
of death. That's chronic diseases, heart disease, diabetes,
injury and risk factors. We may have more attention paid at
times to communicable disease, but we must do the same with the
noncommunicable.
State health departments have a unique role to play in
public health surveillance. Public health threats do not
respect political boundaries, be it the local level or the
State level. Reporting of disease entities, therefore, needs to
be uniform within any given State in order to work with Federal
and local colleagues to assure an adequate immediate response
to public health emergencies. In many parts of the country,
only the state Health Department has the sophisticated
laboratory and highly trained laboratorians, epidemiologists
and other public health professionals needed to tackle the most
serious public health challenges.
I had that personal experience. I was in northeast rural
Washington, Colville, Washington, up in Representative George
Nethercutt and formerly Speaker Tom Foley's district. We didn't
have the levels of sophistication that perhaps our colleagues
in Seattle did, and, in fact, Seattle might be very busy with
the work going on with their own communicable diseases. Work we
did from our rural community was dependent on our State
colleagues helping us and opening the door, if needed, to the
Federal kinds of resources available.
In this testimony I'd like to make four points. Since the
1988 Institute of Medicine's Future of Public Health Report
recognized the inadequacy of our public health infrastructure
in general, and public health surveillance in particular, we've
made great strides, and you have heard some of those.
Substantial congressional investments in preparedness funding
have enabled States and local to expand our surveillance
capacities.
We must continue our efforts to integrate and coordinate
public health surveillance systems. You've already heard that.
While tremendous efforts are focused on developing high-
tech surveillance systems, and technology is critically
important, a computer without the right software and without a
trained user is just an expensive paperweight. We must proceed
with caution and ensure that any new systems are tested by
local and State health agencies and determined to be usable and
effective.
Despite the progress made since the Institute of Medicine
report, much more needs to be done, and you've already heard
some of that. We have a number of health professionals, and Dr.
Fleming already mentioned that, that are due to retire in the
next 5 years. We must pay attention to our work force.
To illustrate my points about the importance of public
health surveillance, I'll give you three quick examples from
Washington State. SARS, in Washington State today we have 24
cases; 22 of those are suspected, 2 are probable. That's a
fairly high number across the United States when you look at
our map. The systems that we have in place now were dealing
with rapid identification; using common case definitions; the
reporting mechanisms we have in place from our local health
departments, from our clinicians to our local health
departments, to us at the State and us in real time to the
Federal Government, so that we all got a handle on this. We've
been able to use the systems that we have enhanced over our
State's emergency preparedness efforts.
West Nile virus. Washington State has not yet been hit with
a human case occurring in our State. We know the mosquito is
there. We've had dead birds. We've had dead horses. But for
West Nile what we're doing right now is we're doing that real-
time educating. We are using Webcast. We're using our
information systems to enhance what people need to watch for,
how to diagnose, how to report to our colleagues at the local
level, and what it is we need to do as a State and work with
the Federal Government at the Centers for Disease Control and
Prevention [CDC].
And one other example is E. Coli O157:H7. Washington State
unfortunately has a lot of practice. It was Burger King back in
the early 1990's. It actually was a number of cases in 1985.
Our public health lab created the 1-day test, what used to take
5 days, in Washington State. We were working together with the
scientists at the Centers for Disease Control, because the
real-time reporting, that happens through PulseNET, through our
public health laboratory system, and then to capitalize on that
with the National Electronic Disease Surveillance System really
means that we deal with this very quickly.
Last summer we had a multistate outbreak that had to do
with a meat packer in Colorado. We worked very closely together
with the systems that are in place to make sure the public is
protected.
In closing, I want to reiterate a few points. First, thank
you to Congress for investments. They hadn't come in the near
past. The investments have become more real more recently. They
must be sustained. State and local public health working
together with our partners at the Federal level need to have
that investment.
Second, public health work force issues must be addressed,
whether it's through our schools of public health, whether it's
through routine training available using, for example, Webcast
satellite downlinks or whatever the case is.
And the third is the continuing effort to coordinate the
systems. A clinician and a local community is the first place
where this starts, the local health department connectivity to
that local clinician and to us at the State and at the Feds.
Now, there are systems in place, and the reason you don't
have a one-size-fits-all is the fact that you have had things
develop; whether it's in Pittsburgh or an area of Texas, we've
got to have common standards so that we can report commonly.
Again, thank you for the opportunity to be here, and I'd be
happy to answer questions when we're done with the panel.
Mr. Shays. Thank you Ms. Selecky.
[The prepared statement of Ms. Selecky follows:]
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Mr. Shays. And Dr. Foldy.
Dr. Foldy. Yes. Good afternoon, Mr. Chairman, members of
the subcommittee. I'm Seth Foldy, health commissioner of the
city of Milwaukee, WI, and I speak today on behalf of the
National Association of County and City Health Officials, which
represents the Nation's nearly 3,000 local public health
agencies. I'm glad to share a local perspective with you
regarding the urgent need to support and to upgrade America's
disease surveillance capabilities.
I share your urgency. I certainly hear it. My remarks will
be tailored considerably, given the advanced level of
discussion you've already achieved previously. I believe I
understand some of the sources of your impatience and some of
your confusion about how to proceed.
I would be remiss not to begin by just pointing out that
the reporting of diseases to public health is but one part of
the surveillance network and the surveillance resources that
are greatly needed. Among those, of course, are resources for
global surveillance, such as WHO has provided. I shudder to
think what SARS would have been like in the United States
without the advanced warning, or ``heads up,'' from the World
Health Organization and the critical importance of the public
health laboratory in permitting public health to speedily
confirm what might be an epidemiologic suspicion.
We have heard it often from Washington out in the hustings;
we have heard it asked, ``Does the United States have the
ability to fight two wars simultaneously?'' And perhaps the
most important--more important--and cogent question is ``Do we
have the ability to fight two, three or four epidemics
simultaneously?'' In the last few weeks, severe acute
respiratory syndrome [SARS], has been added to the plate of
local health departments not through--who do not have different
divisions to deal with each of these problems, but it is one
team typically who are all struggling with smallpox
vaccination, West Nile Virus, influenza season--on its way out,
we hope--resurgent HIV and AIDS and sexually transmitted
infections, and increasing rates of obesity, diabetes and
asthma.
It is important for the committee to understand that the
local health departments are the eyes and ears for surveillance
of the Nation. They are also the hands and feet for the
emergency public health response. Without the local public
health agencies being a true part of the picture, we have a
giant public health entity without eyes, ears, hands or feet.
However, the local public health agency is at the bottom of the
funding chain, often at a low priority for local tax dollars,
and, very importantly, many are now downsizing during the
current fiscal crisis. You need to be aware of this.
Also, because the authority for communicable disease
reporting really derives in common law from local police powers
and nuisance enforcement, there is typically no extrinsic
funding or little extrinsic funding for disease surveillance at
the local level, the most fundamental process that you are
speaking about today.
We thank you very much for soliciting the local public
health view from NACCHO. The international SARS epidemic has
clearly underscored the importance of disease surveillance, and
you can just look at how everyone at USA Today is trying to
learn how to read an epi curve. It also underscores the
importance of having integrated and flexible disease
surveillance, and it points out weaknesses of our current
system and opportunities for improvement.
In terms of integration, Milwaukee began enhancing disease
surveillance systems long before we were worried about
bioterrorism. It really dates back to a massive outbreak of a
common but then little known bug called Cryptosporidium. This
waterborne outbreak sickened more than 400,000 people suddenly
in our city. We had little idea that an outbreak was taking
place. Traditional surveillance systems would not report a
disease that was not mandated for legal reporting. Similarly, a
spate of deaths during the 1995 heat outbreak makes it clear
that it was also under the radar of health surveillance
systems.
This makes it clear that health surveillance can't be
designed for one problem in isolation of others, and in
particular, that very finely defined health surveillance
systems that might be applicable for the agents we think are
going to be responsible for a bioterrorism attack will really
not serve us well. We need integrated systems that bring
together information of various types, various diseases that
are integrated in the public health world and not set up as
some separate entity, some separate department of government.
In terms of flexibility, you're going to hear in my
presentation that ideas and innovations are bubbling up as well
as down, and the creation of very highly standardized systems
is important. What we really hope to achieve, I think, in our
Nation today are standardized methods of coding information and
standardized ways of transmitting information that--such that
the information can talk to itself, and agencies and
information systems can talk to each other in such a way that
it actually encourages innovation.
What is important is if you were, for example, to ask the
Federal Government to mandate that all health care providers
begin to report certain information immediately up at the
Federal level, and that all local health providers and State
departments do the same, the easiest way to do that is to
create a single Web-based entry system where we all spend all
of our time filling in the blanks on the instrument that has
been provided from above. But what that denies us the
opportunity to do is to create flexible instruments we carry
into the field that, because of standard transmission of health
care information, can then up link to the Federal system.
That is a decision, an important decision, that has to be
made, and yet I agree with you. We cannot dilly dally too long
in seeking the right balance between mandates and innovation.
The weakness of the traditional reporting systems have been
pointed out, although they remain absolutely crucial. They are
slow. They often give us incomplete information. They rely on
paper forms that often sit around in piles, which should
surprise no one. Furthermore, it is increasingly being
pressured by the fact that a laboratory specimen obtained in
Milwaukee may well be analyzed in Atlanta or in Santa Cruz, and
that information somehow has to find its way back to the
doctor's office and subsequently to the local public health
authority.
I agree very much with Dr. Fleming's catalog of
improvements in the traditional reporting system: educating the
providers, improving our laboratory infrastructure, creating a
24/7 response. But, in addition to this, I think the real low-
hanging fruit for the traditional disease surveillance system
is electronic laboratory reporting.
There are huge numbers of laboratories out there. If each
of their laboratory information systems could report data in a
standardized fashion so that it would find its way to and
through the different health information systems that come
between them and the local public health authority, this
information could reach quickly, be routed to us, could
automatically alert us, could be stored, displayed, analyzed,
and tracked, greatly reducing the work of local public health.
My colleague, Rex Archer in Kansas City, has established
such electronic lab reporting with a large number of
laboratories in Kansas City and has demonstrated increased
timeliness of reporting, increased completeness of reporting,
reduced time wasted. However, as with all surveillance and
public health, we know that it also gives us more complete
reporting. He is chasing a lot more disease than he ever knew
about before, and that has its real implications.
The real point here is that the standardization of
electronic health information is really a critical step. HIPAA
really created a basement, a foundation for doing this by
creating accountability, about confidentiality, security, and
mandating certain standardization; and we really need to let
this take root.
The second topic that has been discussed is enhanced or
syndromic surveillance. We know that we can look at a lot of
different patterns of illness such as symptoms in emergency
departments, pharmacy dispensing, test orders. It is very
important to recognize that this is a young science, easily
oversold, hard to prove how well it works. However, it is very
important that we begin to explore these capabilities. This
will require again standardized health information, information
that can flow electronically so that we are not adding
constantly to the workload of busy health care providers.
In addition, it requires connectedness; and I will tell you
a brief story from Milwaukee. On their own initiative, because
they needed it for their own reasons, all of the local
emergency departments established a secure, live Internet site
that told them when different emergency rooms were on divert
status. When we learned about that this resource was in each of
our emergency rooms, we politely asked access to the system and
have used it since to post alerts to the emergency medicine
community. My pager goes off when more than three emergency
rooms at a time go on ambulance divert. I can draw down
statistics to see why emergency rooms are going on diversion
and what the temporal pattern is.
And, most recently, we have solicited the emergency rooms
to provide us with daily updates of certain types of diseases,
not on an ongoing basis, because they don't have the labor to
do this continuously, but on an as-needed emergency basis. We
performed such surveillance for bioterrorism-like syndromes
during the All-Star game last summer. But beginning with the
SARS epidemic, given this experience, we were able within 3
days to have 13 emer-
gency rooms in our community both screening their patients
routinely for possible SARS-related symptoms and then providing
us with daily counts of what they were seeing.
Mr. Shays. Thank you, Dr. Foldy.
[The prepared statement of Dr. Foldy follows:]
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Mr. Shays. Dr. Hall.
Dr. Hall. I am Dr. Julie Hall.
Mr. Shays. I am going to have you move it a little closer.
Dr. Hall. OK.
I am Dr. Julie Hall. I am a medical officer with the World
Health Organization. I work in the headquarters in Geneva where
I work as part of the Global Outbreak and Alert Response Team
and have helped to coordinate the international response to
SARS.
Mr. Chairman, Congressman Bell and members of the
subcommittee, on behalf of the World Health Organization and
Dr. David Heymann, Executive Director for Communicable
Diseases, thank you very much for the opportunity to brief you
today on improving surveillance for infectious diseases at the
global level and to brief you on the lessons that we are
learning particularly with regards to SARS. Dr. David Heymann
asked me to convey his regrets for not being able to be here in
person today.
I have submitted a written statement for use by the
committee. At the back of that written statement there is
several charts that I will refer to during my verbal testimony.
As has already been mentioned before, the threat of
infectious diseases, of emerging and reemerging diseases is an
ever present threat. And the first slide at the back of the
written testimony shows a map of the world and a number of the
infectious diseases that have emerged or reemerged in the past
5 years. It doesn't, as you will note, show SARS on there.
The threats of infectious diseases is indeed an issue of
security. Infectious diseases have the potential to damage not
just the health of the population but to cause social
disruption, particularly when frontline staff or health care
facilities are affected, as is the case with SARS, and also to
cause economic damage, again something clearly evidenced with
SARS.
Our traditional defenses against infectious diseases cannot
always be relied upon. National borders do not protect against
the emergence of diseases. And the second slide at the back
there will show very graphically how quickly, within days, SARS
had spread from one hotel in Hong Kong to over eight different
countries around the world.
Anti-microbial drugs, one of our previous defenses against
infectious diseases, are becoming increasingly ineffective as
antibiotic resistance increases; and scientific advancements in
the development and productions of vaccines cannot always keep
up with the pace of change for infectious disease. So the
emergence of an infectious disease in one part of the world is
a threat to the entire world; and our key defense is early
detection, early dissemination of that information, and early
implementation of the protective measures that are required to
stop the spread of disease.
The aim of global surveillance then is to provide the world
with a window of opportunity early in the course of the disease
when it is possible to potentially control and eliminate that
disease.
Surveillance at the global level allows the compilation of
data from different sources. This is particularly important
when looking at the emergence of a new disease, because quite
often it is a jigsaw puzzle. Piece A may come from one country,
piece B in terms of information may come from another.
Surveying the world and having surveillance at the global level
allows these pieces to be put together, and in the case of SARS
this was absolutely crucial. We knew with SARS that there was
ongoing problems in Guangdong. This was in early February. We
knew also that there were problems with H-5 influenza in Hong
Kong. So when one single case occurred in Vietnam, we were
alert to a potential problem of pandemic proportions.
Surveillance at the global level also allows us to put out
the early warnings that have been so effective in terms of
controlling SARS, and it allows us to get a global picture to
assess the need for further action, whether that be at global
level in terms of producing travel advisories or at local level
to provide international support to countries that are affected
by the disease.
How does global surveillance work? Well, it works in much
the same way that you have heard how surveillance works at
local level, at State level, and at national level. There are
four key components: the gathering of information, the
verification of that information, further assessment of that
information, and then a response is mounted. And it is key that
surveillance should not be seen as separate from response. The
two things are interlinked and critically important.
In terms of global surveillance, we have a number of
systems in place at WHO to collect the information. The first
and about a third of our information comes from the WHO system
itself. WHO has a headquarters in Geneva. It also has six
regional offices and 141 country offices, and this provides a
great deal of information about the emergence and reemergence
of diseases of potential international harm.
In addition to that, Health Canada runs the global public
health information network that constantly scans nearly 1,000
media feeds and electronic discussion groups to look for hints
of the emergence of diseases; and this gives us real-time and
very accurate information of what is going on all around the
world.
Another key source of information for us is through the
Global Outbreak Alert and Response Network. This is a network
of over 150 different organizations from around the world--
laboratories, epidemiology groups, other health institutions;
and, again, this can provide key early information.
However, much of the information that's received at WHO
comes in the form of rumor, and this must be verified. WHO is
in a good position to be able to do this with its 141 country
offices and regional offices who work quickly with local health
authorities to verify information that has been provided to us.
This can allow rapid confirmation that an outbreak is occurring
and the ability to share information, but it can also provide
rapid ability to refute information and clarify the situation,
and that can ensure that panic does not ensue unnecessarily and
economic damage does not occur. On a daily basis, the
information that is received by WHO is assessed in terms of its
risk for international health concern; and additional
information such as geographical, political, and other social
information is included as part of that process.
Responses can be mounted very rapidly by WHO, and within 24
hours we are able to get field teams into virtually any country
around the world. We are also able to disseminate the
information very quickly through our cascade of country
offices, through the production of information on our web, and
other sources of information. If assistance is required by any
country, any member state of WHO, this can be coordinated by
WHO and with its headquarters and assisted by regional offices
and the country offices itself.
Expertise and field teams can be quickly organized, as I
mentioned before, by calling upon our partners within the
Global Outbreak Alert and Response Network of who CDC is a key
player. WHO's neutrality and ability to get laissez-passer
status to any member of our international team means that we
have privileged access to 192 countries around the world.
The fourth slide at the back of my written presentation
gives an overview of the extent to which WHO and the activities
at WHO has been coordinating in response to SARS. This included
not just operational support in terms of field teams in Hong
Kong, Vietnam, Singapore, Beijing, and now to be in Taiwan as
well, the production of supplies and the creation of logistic
bases in Vietnam, Thailand, Manila, and rapid response
capabilities in Geneva, but it is also being--a considerable
amount of energy and effort has gone into international
collaboration, laboratory collaboration. Twelve laboratories
around the world have collaborated to identify the virus in
record time, clinical collaboration to share information,
epidemiological and environmental collaboration as well. WHO
has produced recommendations for the control of the disease,
management of the patients, and prevention of international
spread.
However, there are areas for development, and these fall
into two areas. Developments are needed in terms of capacity
and developments in terms of commitment.
In terms of capacity, global surveillance will only be as
good as the national surveillance systems that it depends upon;
and, as you can see in the final slide that's attached to the
written statement, in terms of FluNet and other surveillance
systems, there are clear holes in many countries around the
world that need to be supported and developed if we are to have
a truly global system.
We also need commitment to global reporting, transparency,
and commitment to global collaboration, for these are the key
things that will defend us against infectious diseases. The
true cost of SARS will be if we don't learn the lessons of
SARS; and the true benefits that we have seen from SARS and the
lessons that we have learned are that rapid detection, rapid
implementation of protective measurements and also multilateral
global collaboration can protect us from infectious diseases.
Mr. Shays. Thank you very much.
[The prepared statement of Dr. Hall follows:]
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Mr. Shays. I'm just going to say to our last witness that
sometimes when I have discussions with my staff I am right and
sometimes they are right. They think they are right more often.
You can be a really major player here. I say I pronounce your
name Ignagni, and one of my staff says it's Ignagni. Who is
right?
Ms. Ignagni. Well, the Italian is Ignagni. So----
Mr. Shays. Neither of us are.
Ms. Ignagni. The Anglicized version is Ignagni. Thank you,
sir.
Mr. Shays. Thank you.
Ms. Ignagni. Mr. Chairman, thank you for the opportunity to
testify. I want to commend you and the members of the
subcommittee for taking this leadership. It is my pleasure and
honor to be part of these distinguished panels, and I hope we
might make some contribution to the endeavor of improving our
Nation's homeland readiness. As you will see, our members have
unique capacities to contribute to this readiness effort, and I
am pleased to have the opportunity today to discuss those
capabilities.
What distinguishes us in the health plan arena,
irrespective of plan model, insurance type, or what have you,
are four characteristics: First, we are providing coverage to
defined populations, and the meaning of that is that we can get
a sense of statistical significance of symptoms and what they
mean as a percentage of a particular universe.
Second, we have real-time de-identified data that we are
reporting into a system. I make that point because, in response
to Mr. Murphy's question earlier about HIPPA and patient
confidentiality, we have taken steps in our program to make
sure that we are fully compliant with HIPPA; and I will
describe that more fully in a moment.
Third, we have case managers collecting information from
patients that are going into the system.
And, finally, we have rapid-response outbound calling
technology, so, to the extent messages need to get quickly to
patients, we have the ability to do that.
What we are testing in our program, which is described
fully in our testimony, is whether or not we can leverage these
capabilities to strengthen the public health surveillance
systems, which has generally depended upon passive collection
of data. What you have been talking about throughout the
afternoon is in fact collecting data once individuals go to
emergency rooms, once they go to the hospitals, once public
health gets ahold of those individuals in terms of collecting
that information. There is often a gap between the time
individuals have symptoms and the time they actually seek
treatment. So we are trying to see whether or not we can
contribute to the transition to real-time data collection.
After the tragedy of September 11, our members began an
intense process of discussing how we could contribute to the
effort to improve homeland readiness. We realized these unique
capabilities could lead us to making a substantial
contribution. We spent a great deal of time collaborating among
our medical directors who are on the ground providing health
care services to large numbers of people throughout the country
and collaborated with the CDC, with ASO, with the county
organizations; and indeed, we put together a very large
advisory committee, including with international
representatives, to make sure that the design of this
particular proposal is rigorous and effective.
What we began with is a process that draws data from plans
covering more than 20 million people in 50 States. Since we
have begun, and we are only months into it now, several health
plans in Texas have been added to the system, and we are in
major discussions with national plans all around the country.
But I wanted you to get a sense of where we start in terms of a
baseline.
Here is how it works. There are five steps. First, there is
a criteria established; and I am pleased to tell you, in light
of the discussion earlier, that we are in compliance with the
NEDSS system, the CDC system. So that's the first thing. You
know what you are looking for.
Second, each night a computer program at the participating
plans captures clinical encounters for the preceding 24 hours,
and it meets those specific criteria. These aggregate--and I
want to stress--de-identified data are reported to a research
center at Harvard University. The research center has a program
that contains specific thresholds for notifying public health
of particular occurrences. Now, obviously, I'm oversimplifying
in an effort to make this as clear as possible, but there are
decision rules in this program that flag certain collections of
symptoms.
Fourth, an epidemiologist will then analyze any spikes in
information to make sure that the computer program has worked
as expected, that we are not overly sampling particular
clusters of symptoms, etc.; and the epidemiologist then will
coordinate the reporting of a specific disease or illness in
geographic areas, the manifestation of those, to the
appropriate public health agencies and departments. For
example, if the epidemiologist gleans that there are five
individuals in a particular geographic area with pneumonia,
that might be in compliance with the threshold and that might
indicate that is something that needs to be reported. So that
would be basically the way the system works.
The public health departments then, my colleagues on the
panel, in receiving this information would make a decision as
to whether or not that would engender further investigation. Do
they need to have more information about particular patients
and the symptoms that are occurring in particular geographic
areas?
The system has several important features, as you can see.
Specific populations are being measured. It is done in real-
time. The system can be modified to capture new symptoms. So
it's very interactive, if you will, to the extent that--to the
extent when SARS became something that was not anticipated when
we designed the system, we are now in discussions with CDC in
terms of moderating the system and modifying it so we can
capture those symptoms as well. The data are already being
collected, so we don't have to actually go out and collect new
data.
And then, finally, I do want to stress, because of the
emphasis in the questioning earlier, that we are in full
compliance with HIPPA confidentiality rules.
Health plans have for a number of years been at the
forefront of population-based care, and what we are trying to
do is to take a leadership role in constructing a system that
can be expanded, and we hope that we can make a significant
contribution to our homeland readiness. We have a lot to learn.
We think that we can contribute something important, something
unique, and we are going to be working very, very closely in
our advisory committee with representatives from the
organizations who are represented very well on this panel to
make sure that the design is adequate and we are doing what we
need to do to make sure that we can add a new contribution to
the important efforts that were already described this
afternoon.
Thank you, Mr. Chairman.
Mr. Shays. Thank you.
[The prepared statement of Ms. Ignagni follows:]
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Mr. Shays. Before asking Mr. Janklow to begin his
questioning, I am just going to make an observation. I made the
analogy of Kmart, and my counsel said the challenge is--I'm not
sure I'm doing it justice. But it's if Kmart had to get a lot
of mom and pop operations into their network, they might not be
able to do it in real-time. And I thought that is very
intuitive, I think.
One of the things that I'm noticing with health care is
that--I use the word stepchild as if stepchild is a bad thing,
but not always getting the attention that it deserves. We did
one major tabletop experience in Bridgeport, and the fire, the
police, they all--there were weaknesses in the connection, but
our local health care providers were really caught without
communications, without resources, and so on.
So maybe what I'm hearing from the panelists are, my gosh,
this is where we were and this is where we are, so we have made
such great progress. But I think, in terms of the consequence,
if there was an induced terrorist activity planned, located in
certain ways, that we wouldn't be happy with the results. So
that's kind of where I'm--I'm kind of wrestling with this,
because I feel like there is almost a sense of contentment on
the part of our panelists because we have made a lot of
progress.
Mr. Bell. Mr. Chairman, Kmart also went bankrupt. So I
don't know if that's really one that we want to be using.
Mr. Shays. That was another one, but then my staff spared
me that analogy since I was the one who brought it up. And I
will just say, Ms. Ignagni, I gave you the opportunity to be
right with the chairman, and you declined.
Ms. Ignagni. But, sir, you swore me in.
Mr. Shays. That's true, I did. What a good answer.
You have the floor.
Mr. Janklow. Mr. Chairman, thank you very much.
You know, I've--the hearing today, Homeland Security:
Improving Public Health Surveillance, you know, and I recognize
that public health surveillance, adequately done, truly
contributes to homeland security. But I want to focus my
questions, if I can, to the war on terrorism, you know; and I
realize that, with respect to West Nile and SARS and hepatitis
and measles and mumps and rubella and polio and I mean all
kinds of other reporting things, the system works pretty good.
When I say pretty good, I am making that with a small P and
a small G, because, Dr. Foldy, I couldn't agree more with you:
Because we are a Nation of 1,700 different sovereigns all the
time, nobody is going to tell me what to do. So we have
thousands of people that feel that way, and so that's why some
are in paperwork and some aren't even reporting, and I think
it's far worse than some of our colleagues at CDC think it is.
But I'm going to focus on homeland security, if I can.
World War II from start to finish for us took 3\1/2\ years. How
many years is it going to take for us to design a reporting
system that will catch deliberate acts of terrorism? Because if
the good Lord doesn't or nature spreads diseases around,
there's a pattern that WHO, that the whole world can figure out
rather quickly. It's when human beings are deliberately helping
the process move that we have never really been tested, ever,
as to whether or not we have the ability to deal with it.
Doctor, let me ask you first. If 1993 were replicated in
Milwaukee, you would be on top of it in literally minutes if
not hours, if not minutes. Isn't that correct?
Dr. Foldy. That's correct.
Mr. Janklow. And I have to believe throughout this country
there are processes all over. What does it take to get them
together to come up with a system? And you are next, Ms.
Selecky.
Dr. Foldy. I have little doubt that a deliberate act of
bioterrorism would be detected within days. We've done things
like make sure doctors know what they are looking for, make
sure labs can do----
Mr. Janklow. But I'm talking about process, sir.
Dr. Foldy. But what we want to do is shorten that window to
hours----
Mr. Janklow. Can it be done without mandating it in some
form? And I don't know if States do it or counties do it, the
Federal Government does it. But isn't it possible to really get
from here to there in a--recognizing a world war, is it
possible to get from here to there during the war without
mandating something?
Dr. Foldy. I'm sure there will be mandates. I would add to
those mandates, helping the health care sector move from paper
and pencil to electronic----
Mr. Janklow. Isn't that the most important thing?
Dr. Foldy. The latter? Yes.
Mr. Janklow. Yes, sir.
Do you agree with that, Ms. Selecky, that the most
important single criteria is how do we get from paper to
electronics?
Ms. Selecky. I would add a criteria that has to do with the
knowledge base of the people who are using----
Mr. Janklow. I agree with that. I understand getting the
right people and training them. I appreciate that. But is
that--is there anything--let me put it this way. Is there
anything more important than the ability to get it from paper
to electronics?
Ms. Selecky. When we think about the health care system in
this State, in this Nation, you look at relying on a local
clinician, whether they are in a community clinic or a private
office, to get the word to a local health department. And----
Mr. Janklow. And that's under the normal system, the way
nature spread diseases.
Ms. Selecky. Well, even under a bioterrorism event.
Actually, the city of Seattle and the city of Chicago this next
week will be participating in TopOff2, the top officials
exercise. I just spent my morning with the Federal Cabinet in
preparation for the work that will go on. In Washington State
it will be a radiological----
Mr. Janklow. Can I interrupt you for 1 second? You are
getting prepared for that tabletop. When they hit you with
terrorism, you're not going to have--you're not knowing it's
coming, what day, what hour, and what teams to assemble.
Ms. Selecky. No disagreement. And these aren't tabletops.
We actually are doing exercising. And you are right, we do have
information ahead of time. The point is, where are the flaws in
the system or the weaknesses.
Mr. Janklow. OK.
Ms. Selecky. The learning from this is what's essential in
that whether----
Mr. Janklow. Will that be shared with people all over the
country?
Ms. Selecky. Yes, the results of that will be. Yes.
Mr. Janklow. OK.
Ms. Selecky. In terms of the communicable disease, for
example, that will be used in the Chicago venue--and it will be
pneumonic plague--it's a matter of what systems are in place,
are people reporting electronically now? No, not everywhere;
and it will be as important in a rural area as it will be in an
urban area.
Mr. Janklow. Excuse me for a second.
Ma'am, you look shocked. You are sitting there looking at
me shocked. Is there a reason? Ms. Ignagni.
Ms. Ignagni. Well, I didn't mean to interrupt. But you did
read me correctly. And it's not shock. It's I think that there
is something in addition to the electronic issue. But I would
be happy to wait until our colleagues finish answering their
question. But you registered my being perplexed as I was
thinking about your question. I think there is something that
we have been missing all afternoon, frankly. But I don't want
to be rude and interrupt your----
Ms. Selecky. No. If you've got it, go for it.
Ms. Ignagni. Well, no. I don't know if I have it. I
wouldn't want to be presumptuous. I'm the only one on the panel
that isn't a physician. But in my humble opinion, in looking at
the reports by the Institutes of Medicine, the General
Accounting Office, the World Health Organization reports, where
we are going wrong in our country in terms of bioterrorism
readiness is that for too long we have thought of the health
care system as what happens in the hospital.
Now that's a very important part of the health care system,
but I can tell you that what we did--and we're just beginning
our demonstration program. But we did a dry run in
Massachusetts, and what we found is that people were reporting
symptoms into our system a full 2 weeks before people ended up
in the hospital. So, sir, when you asked the question is there
something more important than electronic, I was sort of shaking
my head and intuitively going through all this information. And
I didn't want to sound presumptuous in sharing with the
committee the idea that I do think the comments that have been
made, particularly by the GAO about their reliance on passive
reporting, is something that we really have to get our hands on
and we have to figure out how do we go to real-time. It's not
just about electronic, though.
Mr. Janklow. If I could ask that the three of you from
American organizations, and just whoever wants to answer first
or only--be the only one, what do we need to do to fix this? If
your children's lives depend on it, your neighbors' lives depen
on it, is this a congressional fix? Is it a Presidential fix?
It is a health community fix?
I've heard people say that lawyers and judges can't fix
what's wrong with the legal system, and that doctors and
hospitals can't fix what's wrong with the medical system. It
takes outsiders who have a different perspective, who are
really not the producers but the consumers that contribute.
Let me ask you. What does it take to fix this? Because we
are all frustrated.
Dr. Foldy. Well, until the information can flow rapidly, we
are missing an essential part of the fix. Ms. Ignagni brings
this up.
The next point, which is do we really know--there is a lot
of science that needs to be done and needs to be done ideally--
--
Mr. Janklow. You said--I think your quote was, young
science easily oversold.
Dr. Foldy. So, for example, she raises one of many very
interesting and answerable questions: What part of the health
system or other human behavior----
Mr. Janklow. OK. But, sir, how do we get there?
Dr. Foldy [continuing]. Serves as an early detector.
Mr. Janklow. We are in the third year of the war. How do we
get there? How do we wind this up?
Dr. Foldy. I would like to see a lot of the best people in
Federal agencies, including the different agencies within the
Centers for Disease Control, be given an office and some money
and some contact with the best people in informatics,
intelligence, Defense Department, even financial systems. I
mean, I can draw cash out in Taiwan, but I can't see
surveillance figures in my own den. And there is a lot that can
be learned quickly if people can be brought together, apply
sustained attention to the problem over the next few years,
while having--starting to get the electronics information
that----
Mr. Janklow. If I could ask you, sir, if you would just
submit to the committee a list of who you think ought to be at
that table by organization.
Dr. Foldy. My local perspective, and therefore very
imperfect perspective.
Mr. Janklow. Sure.
Dr. Foldy. Yes.
Mr. Janklow. Ours is perfect, sir. Yours isn't. No, we
understand that. In the most base sense, we all understand
that.
But if you would, because you can tell by our questions,
all of us, we don't know what to do, but we don't think what's
being done necessarily is working. If someone is going to
attack us tomorrow, are we ready? The answer is, no, we are not
if they are going to be spread around--if they were to spread
this around. We have seen what hoof and mouth disease can do to
Europe, to the livestock industry. I can't believe that
something wouldn't be akin to human beings if they had the same
type of disease for people. I know they do have that one, but
I'm not talking about Banks disease.
Thank you, Mr. Chairman.
Mr. Shays. I would just point out, though, that's one form
of terrorism; and that's not just the attacks on human beings
but the attacks on livestock could be devastating.
Mr. Bell, you have the floor.
Mr. Bell. Thank you very much, Mr. Chairman.
First of all, Dr. Shelley Hearne could not be here to
testify today,
and I would ask unanimous consent for her written testimony to
be submitted for the record.
Mr. Shays. Without objection. And she is with----
Mr. Bell. Trust for America's Health.
Mr. Shays. Thank you.
[The prepared statement of Dr. Hearne follows:]
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Mr. Bell. I want to go back for just a minute to this idea
that was discussed with the previous panel of trying to create
one unified system for reporting; and you all, I think, were
all present during that testimony. I'm curious as to where you
would rate the importance and if you are as troubled as I am by
the fact that we at the present time don't know how much it
would cost and really don't have any time line for getting
there, and the amount of money being committed toward spending
on that type of surveillance system is decreasing rather than
increasing. And I will begin with you, Ms. Selecky.
Ms. Selecky. As the other nonphysician on the panel and a
person of great practicality, as many of us are, the issue is
that we really don't have sort of a uniform system like you
would call a Kmart, regardless of whether they went bankrupt or
not. There are multiple plans, they're private and public, and
having a one system fits all doesn't cut it in this country
very often. That's why I think that you hear us talking about
common standards so that the information that's collected can
speak and give us the information that we need to take quick
and rapid action. That's one.
Two, I think that your colleague who was here earlier
talked about a reporting system in southwestern Pennsylvania
that's been under development, that works there, works under
the State laws of the State of Pennsylvania, is a good model
for many of us to look at as to whether it would work in
Washington State or in other States, and learn the best things
from it, as long as we all have the common format of reporting
in a way to get the information again real.
In Washington State, we still have very rural parts of the
State that don't have Internet or electronic reliable
capability, so that we do have to have redundant systems. And
you would falsely rely on the ability for everybody to have
access to T-1 lines, etc. We are not the only State like that.
There are other rural States like that, also. Cell phones don't
work in many places. Fax machines usually can be relied on. The
Internet goes down when that backhoe digs up the one line to
Ferry County or whatever the case is. So we have got to make
sure that we continue to work on what the reality is.
The reality is, are people informed at the closest level to
where a client shows up with a symptom, be it at a doc's
office, a clinic, or an ER--is that person informed to get that
information to the folks who need to have it at the local
level, as they see increasing activity get the information to
the State level and we work together with the Feds? We would
all like to have it done in that real-time, rapid way that
allows us to rely on the electronics. But having experienced
the earthquake in Washington State, we could not then rely on
the electronics. We did have to rely on the person-to-person
reporting. You've always got to have both of those things in
place.
So by virtue of the fact of making sure that what's in
place now works, that you parallel, then grow it up, the infant
system Seth talks about that needs to be developed across the
Nation with common standards, that would be my goal.
Mr. Bell. Dr. Foldy.
Dr. Foldy. I think this was well summed up. I do
sometimes--and I'm not a software engineer--but I do sometimes
look at the way the Internet was able to develop. Nobody could
figure out ever to design something that is like the Internet,
but once people learned that they were going to--that they had
the benefit of communicating through a few very simple
standards so that it didn't matter what kind of computer you
were on or what kind of browser you were using or anything
else, the kind of capabilities that developed out of that were
very great. So I have some hope for that.
I do think that Ms. Selecky's points are very well taken
about not overestimating the capability of the people in the
field at either the State or the local level. I hasten to
remind the committee that, prior to Congress creating specific
health alert network funding that was earmarked to local health
departments, the majority of health departments had no Internet
connections in this country. We do have a severe backlog of
information infrastructure and people development, bringing
them along both in terms of skills, technical, epidemiological,
and laboratory in our local health departments. It is not
impossible--it is impossible to overlook that deficiency,
because there is no State or national organization that has the
people to fill in where local health departments need to play
their role. So you are looking also at strengthening the
infrastructure at the local level so that a lot of information
isn't simply released that results in an inadequate response.
Mr. Bell. Dr. Hall.
Dr. Hall. I think the most important thing, as I said
before, is about commitment and also about capacity. I think
that the most important take-home message really is that a
disease occurring anywhere in the world within hours can affect
any other country around the world. And when we have a map that
looks like this, the very back of the written statement, where
we have great big holes in terms of surveillance around the
world, then nowhere in the world, no matter how good their
national reporting and surveillance system is, is going to be
safe from the threat of infectious diseases.
So I think it's about investing in capacity, both in the
countries that already have some in terms of improving the
capacity they have but key to it is investing in capacity in
areas where there simply is nothing, where we would not be able
to--it would take a very long time before we detected that a
problem was emerging in that area. And it's about investing in
the commitment to that and investing in the commitments of
transparency in terms of reporting from all those countries and
constantly building up capacity so that all around the world we
at least have a basic minimum level so that we can find out
exactly what's happening.
Mr. Bell. And Ms. Ignagni.
Ms. Ignagni. Thank you, Mr. Bell. We crossed this bridge as
we were developing our demonstration program, and we would not
have developed it without a consensus on what was being
measured, how we were going to measure, and how we were going
to retrieve data. It simply wouldn't provide anything that was
useful. And that's caused me to listen to my colleagues, and I
think the comments have been very, very thoughtful, and I
largely agree with them.
I do think, however, there is an opportunity to achieve
uniformity in a productive way here without necessarily killing
the innovation and the public health kinds of activities. You'd
want to be nimble at the local level, and I think that's--if I
could draw out what I heard--while at the same time having some
consistency across different systems and States to measure,
because we know that there are no geographic boundaries for
infectious disease.
Our community has committed to transparency. We are the
only stakeholders in the health care arena measuring anything,
which may surprise you in light of 5, 6 years of discussions
about so-called patient protection. We are not measuring in any
other areas. So for us, perhaps we crossed this bridge a long
time ago, and we have consensus in our community about
measuring. But I do think it's important now to think about
drawing that out across the delivery system and particularly in
this area.
Mr. Bell. Ms. Selecky and Dr. Foldy, a number of national
associations and organizations, one being the American Public
Health Laboratory Association, have found that financing for
many State health laboratories would be reduced this year and
that few cities had enough hospital space to quarantine
patients in the event of a large-scale outbreak of an
infectious disease like SARS. I'm curious if you share those
beliefs; and, if so, what recommendations would you make to
rectify the situation.
Ms. Selecky. The answer is, yes; and the recommendation is
continued and increased support to State and local public
health is absolutely needed from Congress. This is not about a
part of the body disease. It's not about a singular kind of
action. It's about the investment in the public health system.
Our laboratories need to have up-to-date information but up-to-
date equipment.
Technology changes quickly. What used to take days to grow
a culture on now can have rapid testing within hours. We've got
to have those kinds of investments. The bioterrorism
preparedness money helped us make a major shift, but there
needs to be continuation on that and particularly our work with
our facilities. You know, our hospitals in this country have
come down to a much smaller operating margin. There isn't much
room available for the emergency kind of planning that goes on.
Again, Congress has done some investments. We in public
health at the State and local level are working very closely,
for example, in Washington State, with our 91 hospitals to work
at the community level to deal with surge capacity. You don't
make beds overnight, but you can work on plans how to deal with
people if you have a major event.
Mr. Bell. Dr. Foldy.
Dr. Foldy. I would concur. I would also add that issues
like isolation are particularly thorny for local government. I
believe that Wisconsin is typical of many States where the
responsibility for bearing the cost of isolation lay in the
local jurisdiction, which means that a single case of
tuberculosis can wipe out the budget of a small health
department overnight. It seems somewhat ridiculous. Those kinds
of costs need to be socialized in some manner over a larger
territory than the small local jurisdiction.
Mr. Bell. Thank you, Mr. Chairman.
Mr. Shays. I thank the gentleman.
Dr. Hall, when I look at that map at the back, it has
surveillance of human influenza. And I look at India and it has
one--I guess just greater than one laboratory. But how many?
Not many? It's not a network. Is that your point?
Dr. Hall. Yes. I mean, what's missing there is, yes, a
national network so that all areas within that country can be
detected, that some polls can be taken from patients and that
they can be assessed and evaluated properly.
Mr. Shays. I look at the two largest in terms of
population, China and India, and that they don't have a network
system yet. Walk me through really--I'm not looking in great
detail, but I will tell you I am somewhat haunted by--maybe
others as well, but this was one story, the story of the mom
leaving Hong Kong, going to Toronto. She's infected. She dies.
Her son dies. I mean, what a horrible--not only do you lose
your life, but someone who you brought into life loses their
life. And that could have been prevented--correct--had we known
sooner in China, had China participated sooner and acknowledged
the problem, correct?
Dr. Hall. Well, certainly what we have seen is that within
24 hours of that occurring, of the cases landing in Toronto,
WHO put out a global alert. And since the global alert, because
of the heightened vigilance all around the world, with the
exception of Taiwan we haven't seen that rapid transmission of
disease anywhere else. So, yes, the early detection and the
early release of information and the heightened vigilance that
has occurred has meant that, while cases have occurred, say, in
the United States, they are isolated cases, and we haven't seen
that level of transfer.
So that the real lesson of SARS is that the more
transparent countries are, the quicker they report the cases,
the quicker the international assistance can get there to look
and help with the diagnosis if that's necessary, then the
greater the window of opportunity for the rest of the world to
be able to protect themselves against these diseases that can
in a matter of hours fly around the world.
Mr. Shays. Right. What I'm trying to sort out, though, is
we up on the panel are thinking we could do so much better. But
you say we have a network; and we are looking at this network
and saying, it could be so much better. Correct?
Dr. Hall. Um-hmm.
Mr. Shays. So even when I look at the dark-colored parts
and all of Russia and the Scandinavian countries and most of
Europe, I'm looking at some of the European nations I guess
not--I am--you do agree that, when you look at this network,
this network could be so much better. Correct?
Dr. Hall. Absolutely. Yes. I mean, it's just an example of
just the FluNet, but it's pretty reflective of surveillance on
the global level for virtually any disease.
Mr. Shays. When you talked about early detection and early
intervention. And I think that's kind of where my colleague Mr.
Janklow and I are wrestling, as well as Mr. Bell. The question
is, we have a system now that may not provide for early
intervention. When you look at those countries that have a
network, what don't they have? In other words, you could
compare to the network ones and say, compared to China and
India, you know, they are way ahead. But what don't we have in
the United States, as far as you can tell?
Dr. Hall. I mean, I think the rest of the panel have been
explaining exactly where the problems are.
Mr. Shays. But I'm using your--I'm taking advantage of your
global view to say how much better it could be.
Dr. Hall. Right. I mean, I think the key issues are about
the timeliness of reporting and standardizing reporting as
well, so that you get a similar report from all around the
world. And that I'm sure will probably apply to the States
within the United States. So that you can actually compare and
you can compile that information to get a much better picture.
Quite often, in the emergence of a disease--and this would
be the same, the bioterrorist threats--it's unknown, it's
different, it follows a pattern you have not seen before. So
what is key is to be able to rapidly piece little pieces of the
jigsaw puzzle together? And I would imagine that in the United
States, as most countries around the world, suffering the
problems of reporting in a standardized manner so it can be
compared from different bits of the States and reporting in a
timely manner so that those pieces can be very rapidly put
together in a better picture.
Mr. Shays. Now, you talk about a learning curve, but I'm
struck by the fact that--I've been chairman now for 9 years of
either--the first 4 years was overseeing CDC and FDA and HHS,
among other departments and agencies; and now I'm involved with
my colleagues on the national security side. But there is some
real compatibility. I mean, thank goodness I had that knowledge
to bring in here.
One of the things I wrote down is, you can't push science.
You know, when we were looking at Gulf War illnesses, they
said, you know, it make take 10, 15 years for us to understand
why people are sick. And I'm thinking up here, well, they are
dying and they are sick and so on, and it's going to take 15
years. And it's like, we can't push science.
But I wonder, this isn't pushing science. This is different
than pushing science. This is saying we have information. We
need to find a way to identify it sooner. We need to find a way
to identify the illnesses sooner, have a standard. This to me
isn't science. This is like logic. And yet I think I'm hearing
scientists saying, thinking like that this is going to be a
long process.
Ms. Ignagni, how are you reacting to what I'm saying?
Ms. Ignagni. I think it is like putting down pylons. If you
think about creating the architecture, doing something here
that collects the system of systems, you really just--in
constructing a building, you construct buildings the same way
all around the world and all around our country. And so, just
to be very simple about it, I think you are on the right track.
I think that what we've learned is there's a real value in
consistency.
I think Dr. Hall is making a very compelling point here. I
think what--our colleagues from the States and the local area
are sending messages, let's figure out a way to have the
consistency of drawing the data but at the same time not quash
their ability to be nimble in reacting to that. And I think
that--so the question is, where do you put the fulcrum on those
two--on the continuum? And I think you are on the right track.
Mr. Shays. I also am thinking that--and this is a slight
exaggeration. But health departments have been so beaten down
in terms of the contest with other departments in the cities
and in the States that they have low expectations, and they
have learned to be very patient people. Maybe the science tells
you to be patient, but it strikes me that the expectation
should be a lot higher; and I didn't really come to that
conclusion until really wrestling with the first panel now and
the second. There is really no reason why--I mean, some of
this, as I am struck thinking about it, is some of this is just
common sense stuff. And Ms. Selecky, do you want to just
comment?
Ms. Selecky. We in public health have to be ready to move
on a moment's notice, because communicable disease does not
work. We can't----
Mr. Shays. Does not what?
Ms. Selecky. Does not wait. Excuse me. We can't wait for
someone to say, here is the perfect system that is going to be
used nationally. So that's why I think you have things that
grow up like the one that's in southwest Pennsylvania, as was
described earlier, or other places, in the local community to
say how do we get our arms around Milwaukee, Seattle, eastern
Washington, whatever it is. How do we get ourselves to talk to
one another in real-time to work on instant reporting of
something that is a terrorist event? It's an unusual disease
that's showing up. We are all starting to see it, and we need
to move on it.
I guess I'm struggling with how to answer your questions
about should we nationalize and have a common data reporting
system. How do you then get everybody using the same software
in the local doctor's office that's part of a health plan who
also have four or five other health plans there because they
have requirements, the local health department, who is part of
the city infrastructure, or the county infrastructure? And we
can't wait for that, because communicable disease does not
wait.
Whether it is electronically, whether it is by the
telephone, whether it is by paper, public health is impatient
to get the information. The sense of urgency is that our
science is based on early detection, quick action and
prevention. Otherwise, we wouldn't have some of the good health
that we do experience in this country or the ability to begin
to look at the work that the World Health Organization, all of
a sudden connected to me in my job in Washington State and in
my community.
So if we haven't talked about urgency, it's about--it's not
about the sense of urgency of participating in a good,
thoughtful discussion about what's the best system. The urgency
exists by virtue of a public health or an organism problem that
we have to act on, regardless of what system exists.
Mr. Shays. Go ahead.
Dr. Foldy. Well, just since--over the last several years,
we have done everything possible we can do without spending a
lot of money; and that included getting 15 local health
jurisdictions to all report to a one-stop location and which
can rapidly take in the report, determine that something is
going on.
Our first--you know, E-coli operated--the first five cases
came from five suburbs. Fortunately, they all report to one
location. We could put it together and act immediately. Our use
of this regional emergency medical Internet, it simply fell
into our hands.
With more resources, we can do great things. However, my
local tax base, as the support for my department has gone from
45 percent down to--it's starting to approach--I'm sorry--55
percent, starting to approach 40. The State is cutting back. We
are really looking at hard times and sustaining these systems
can't go on indefinitely.
Mr. Shays. My time has run out. But, Dr. Hall, what would
you like to say?
Dr. Hall. Just to say that certainly, from our point of
view at Global Alert and Response, we spend far too much time
being reactive and not enough time being proactive; and that is
simply because of a lack of investment in the system. It means
we have enough money to buy the brakes, but we haven't got
enough money or time to get the motor to stick it all together.
And what you see--that systems I'm sure all around the world
building up, building on experience like we have built on the
experience of ebola and meningitis outbreaks and other things
but never quite enough time to glue that together so that you
actually have a system that is stream--that means that
information can flow very quickly and very rapidly.
Ms. Ignagni. Mr. Chairman, can I make a quick comment?
One of the things that I think has probably been implicit
in the discussion, particularly from the previous panel, but
wasn't said very specifically is that in the last couple of
years there has been a dramatic progress in the ability to
unite the systems and create a system of systems. What now we
have the capacity to do, like we do in defense where we have
command centers tracking what's going on around the country,
the Secretary has created a command center in terms of getting
the information in, looking and arraying the information. If
you go into that command center, what you see are different
geographic locations and the ability just to put up on the wall
where blips are coming up.
And I think perhaps what you have been hearing this
afternoon is a reflection on how far that has gone and come
from where we were. But I think, just as we have learned in
this country that we need to take a new approach to thinking
about defense as well, I think that the consensus in the public
health community is that we need to think more like that in
public health. So I think that there has been a dramatic
progress over the last couple of years and now it's the
question of how we get to where you are suggesting we need to
go, and I believe that there is tremendous consensus about that
objective, and I think we can do it. There is probably more
interest in achieving that now post SARS and some other
experiences than there was a year or so ago throughout the
country.
Mr. Shays. Thank you very much.
I appreciate the patience of my colleagues. I don't always
do this, but Dr. Kelley, Colonel Kelley, do you have any
observation you would want to put on the record? I would have
to swear you in, but if you would like to, I would be happy to
have you come up. So the answer first has to be yes or no.
Colonel Kelley. Yes.
Mr. Shays. OK. And with the indulgence of the committee, I
would just swear you in. If you would raise your right hand,
please.
[Witness sworn.]
Mr. Shays. I appreciate you, Dr. Kelley, staying for this
hearing. I know your superior was here. I mean--but what
observation would you like to make?
STATEMENT OF PATRICK W. KELLEY, M.D., DR PH, COLONEL, MEDICAL
CORPS, DIRECTOR, DEPARTMENT OF DEFENSE, GLOBAL EMERGING
INFECTIONS SURVEILLANCE AND RESPONSE SYSTEM
Colonel Kelley. I think I would like to make several
observations.
You know, money can go only so far. But what we really need
is leadership to make it clear that these are our priorities
that need to be followed. In our various organizations,
civilian and military, there are many, many issues that we are
trying to balance back and forth and prioritize. We have to
prioritize not only budgets but time, and it's very critical I
think that our leaders understand that this needs to be a
priority.
I think one thing we have to realize, too, is that
surveillance implies a response. I can't put a precise figure
on this, but I would guess for every dollar you spend on
surveillance you need several available to fund the response
that is implied by the generation of this new information, and
I know various health departments outside the military that
find that a particular challenge. Now that their surveillance
systems are getting better, they have to--they find themselves
constrained in reacting to the wonderful data that they are
generating.
Mr. Shays. We will note for the record that Ms. Selecky and
Dr. Foldy were nodding their heads continuously as you were
talking about that.
OK, anything else?
Colonel Kelley. No, sir. Thank you for the opportunity.
Mr. Shays. Well, you are welcome. But thank you for
staying, and thank you for your good work as well.
Is there anything? Mr. Janklow, any other comments you want
to make again?
Mr. Janklow. Could I ask a couple quick questions, Mr.
Chairman?
Mr. Shays. You sure can.
Mr. Janklow. With respect to the--Dr. Foldy, if I could ask
you--and let me ask you, Ms. Selecky, first. In the State of
Washington, are you satisfied that you are where you want to be
in the State with respect to the reporting system for State
purposes?
Ms. Selecky. No, and the reason I say no is because we all
can do better; and I think that last comment is part of that.
You not only need the way you do the reporting, you need to
have the foot soldiers to do the work at both the State and
local level. The communications system's in place to work to
make sure that the public and private people across the State
are getting the information to take the action. Can we do it
better? Absolutely. We need to upgrade electronic capability
across the State. We have already reviewed our reportable
diseases in Washington State. We updated them just 2 years ago.
We updated our quarantine and isolation rules just in December.
We have those kinds of tools. But we have to continue to work
on the common data, elements that all of us will agree on come
together in Washington State. We are doing better than we were.
Mr. Janklow. Are there a set--do you have common data
elements in place?
Ms. Selecky. We have common reporting from all our private
providers as well as public providers in and around the list of
communicable diseases that includes emerging diseases like
SARS, and in real-time in Washington State we have those kinds
of reports to know what we have going on with that. Whether
it's E-coli from spouts--we have that from this summer--E-coli
from lettuce--it was multi-state. We had it this summer. It's
about getting that information to move into action.
When I hear you all talk about and when we talk about a
common system, I get concerned that we are waiting for the
perfect system when what we really need to have are the
foundations to be able to use whatever system exists.
Mr. Janklow. When I talk about electronics, ma'am--I
understand an earthquake can be disruptive. But I don't see a
national earthquake coming. I mean, if anything, it would be
very regional in terms of its scope; and so I don't know of
another effective means other than electronics in war. If we
have to go to paper, we can. But to the extent we go to paper,
we've lost. Once we have to take the war dealing with someone
deliberately injuring our people with bacteria or a toxin or a
virus, at that point we have lost.
So what I'm wondering is, putting a system in place, what
does it take to do it? Because electronically the world is
there. It's there. The kids know it. Napster knows it. The only
people that don't know it most of the time are the governments
and the adults, but the kids have figured it out, whether it's
with their chatrooms or whatever.
Second of all, I don't think it's that difficult. I realize
there could be arguments, but I don't think it's that difficult
to come up with a list of sicknesses, diseases, symptoms,
differential diagnosis, whatever you want to call it, that are
reportable events.
The third thing is, there has been a huge amount of Federal
money, of national money, our money, that has gone in in the
previous couple of years. All the States received very sizable
grants, one for their laboratories and two for their planning
for this type of thing. And so I understand it's not enough,
but it's a huge amount of money if it was somehow coordinated
better than we all coordinate it.
So I realize our time is up on this stuff, but I just--the
point that I'm trying to raise is, is there--and I realize we
need more trained people and we need more money. But, absent
those things, is it OK the way the States and local governments
are doing it? Or is there something that all of us can do in a
national wartime scope that would make this more effective and
more efficient in terms of the wartime side of this issue?
Ms. Selecky. One of the things we clearly do have to work
on, and are working on, are secure ways of getting this
information sent between State and local; and that is using the
common standards you heard Dr. Fleming talk about. So we are
working on that.
You are saying, speed it up. You are saying, get it done
because we are in a wartime kind of thing. It's not about
laissez-faire. And I would absolutely agree with you, your
point about it makes sense to come up with a common list of
diseases. States have those. States work with State and local.
We are based on that. So that one you rest assured on.
Your point about the earthquake is well made. What we have
to do is not falsely rely on it as the exclusive way of doing
things. The investments made by Congress over 2 years have
moved us along, but I want to have a digital signature in every
clinician's office at some point, that clinician can have
someone enter the data from their office, from their outlying
remote clinic or from their ER room so that the local health
department and the State health department have access to that
immediately and we transmit it to the Feds.
Mr. Shays. We can keep going on and on and on, but I think
this is probably a good time to stop. You have been a wonderful
panel. You have helped put the whole thing together for us, and
we appreciate your participation. Thank you very much.
With that, we will adjourn the hearing. Thank you.
[Whereupon, at 4:59 p.m., the subcommittee was adjourned.]
[Additional information submitted for the hearing record
follows:]
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