[House Hearing, 107 Congress]
[From the U.S. Government Printing Office]



 
  BATTLING BIOTERRORISM: WHY TIME INFORMATION-SHARING BETWEEN LOCAL, 
  STATE AND FEDERAL GOVERNMENTS IS THE KEY TO PROTECTING PUBLIC HEALTH
=======================================================================

                                HEARING

                               before the

           SUBCOMMITTEE ON TECHNOLOGY AND PROCUREMENT POLICY

                                 of the

                              COMMITTEE ON
                           GOVERNMENT REFORM

                        HOUSE OF REPRESENTATIVES

                      ONE HUNDRED SEVENTH CONGRESS

                             FIRST SESSION

                               __________

                           DECEMBER 14, 2001

                               __________

                           Serial No. 107-132

                               __________

       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







                           U.S. GOVERNMENT PRINTING OFFICE
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                     COMMITTEE ON GOVERNMENT REFORM

                     DAN BURTON, Indiana, Chairman
BENJAMIN A. GILMAN, New York         HENRY A. WAXMAN, California
CONSTANCE A. MORELLA, Maryland       TOM LANTOS, California
CHRISTOPHER SHAYS, Connecticut       MAJOR R. OWENS, New York
ILEANA ROS-LEHTINEN, Florida         EDOLPHUS TOWNS, New York
JOHN M. McHUGH, New York             PAUL E. KANJORSKI, Pennsylvania
STEPHEN HORN, California             PATSY T. MINK, Hawaii
JOHN L. MICA, Florida                CAROLYN B. MALONEY, New York
THOMAS M. DAVIS, Virginia            ELEANOR HOLMES NORTON, Washington, 
MARK E. SOUDER, Indiana                  DC
STEVEN C. LaTOURETTE, Ohio           ELIJAH E. CUMMINGS, Maryland
BOB BARR, Georgia                    DENNIS J. KUCINICH, Ohio
DAN MILLER, Florida                  ROD R. BLAGOJEVICH, Illinois
DOUG OSE, California                 DANNY K. DAVIS, Illinois
RON LEWIS, Kentucky                  JOHN F. TIERNEY, Massachusetts
JO ANN DAVIS, Virginia               JIM TURNER, Texas
TODD RUSSELL PLATTS, Pennsylvania    THOMAS H. ALLEN, Maine
DAVE WELDON, Florida                 JANICE D. SCHAKOWSKY, Illinois
CHRIS CANNON, Utah                   WM. LACY CLAY, Missouri
ADAM H. PUTNAM, Florida              DIANE E. WATSON, California
C.L. ``BUTCH'' OTTER, Idaho          STEPHEN F. LYNCH, Massachusetts
EDWARD L. SCHROCK, Virginia                      ------
JOHN J. DUNCAN, Jr., Tennessee       BERNARD SANDERS, Vermont 
------ ------                            (Independent)


                      Kevin Binger, Staff Director
                 Daniel R. Moll, Deputy Staff Director
                     James C. Wilson, Chief Counsel
                     Robert A. Briggs, Chief Clerk
                 Phil Schiliro, Minority Staff Director

           Subcommittee on Technology and Procurement Policy

                  THOMAS M. DAVIS, Virginia, Chairman
JO ANN DAVIS, Virginia               JIM TURNER, Texas
STEPHEN HORN, California             PAUL E. KANJORSKI, Pennsylvania
DOUG OSE, California                 PATSY T. MINK, Hawaii
EDWARD L. SCHROCK, Virginia

                               Ex Officio

DAN BURTON, Indiana                  HENRY A. WAXMAN, California
                    Melissa Wojciak, Staff Director
                Howard Denis, Professional Staff Member
                           Teddy Kidd, Clerk
                    David Rapallo, Minority Counsel






                            C O N T E N T S

                              ----------                              
                                                                   Page
Hearing held on December 14, 2001................................     1
Statement of:
    Baker, Edward, M.D., M.P.H., Director of Public Health 
      Practice Program Office, accompanied by Kevin Yeskey, M.D., 
      Acting Director, Bioterrorism Preparedness and Response 
      Program, National Center for Infectious Diseases...........     8
    Regan, Rock, National Association of State Chief Information 
      Officers, chief information officer, State of Connecticut; 
      Gianfranco Pezzino, M.D., MPH, Council for State and 
      Territorial Epidemiologists, State epidemiologist, Kansas 
      Department of Health and Environment; Paul Wiesner, M.D., 
      MPH, National Association of County and City Health 
      Officials, director, DeKalb County Board of Health; Michael 
      H. Covert, American Hospital Association, president, 
      Washington Hospital Center; Carol S. Sharrett, M.D., MPH, 
      director of health, Fairfax County Department of Health; 
      and Charles E. Saunders, M.D., president, EDS Health Care 
      Global Industry Group......................................    36
Letters, statements, etc., submitted for the record by:
    Baker, Edward, M.D., M.P.H., Director of Public Health 
      Practice Program Office, prepared statement of.............    11
    Covert, Michael H., American Hospital Association, president, 
      Washington Hospital Center, prepared statement of..........    69
    Pezzino, Gianfranco, M.D., MPH, Council for State and 
      Territorial Epidemiologists, State epidemiologist, Kansas 
      Department of Health and Environment, prepared statement of    47
    Regan, Rock, National Association of State Chief Information 
      Officers, chief information officer, State of Connecticut, 
      prepared statement of......................................    39
    Saunders, Charles E., M.D., president, EDS Health Care Global 
      Industry Group, prepared statement of......................    83
    Turner, Hon. Jim, a Representative in Congress from the State 
      of Texas, prepared statement of............................     5
    Wiesner, Paul, M.D., MPH, National Association of County and 
      City Health Officials, director, DeKalb County Board of 
      Health, prepared statement of..............................    56


  BATTLING BIOTERRORISM: WHY TIME INFORMATION-SHARING BETWEEN LOCAL, 
  STATE AND FEDERAL GOVERNMENTS IS THE KEY TO PROTECTING PUBLIC HEALTH

                              ----------                              


                       FRIDAY, DECEMBER 14, 2001

                  House of Representatives,
 Subcommittee on Technology and Procurement Policy,
                            Committee on Government Reform,
                                                    Washington, DC.
    The subcommittee met, pursuant to notice, at 10 a.m., in 
room 2247, Rayburn House Office Building, Hon. Thomas M. Davis 
(chairman of the subcommittee) presiding.
    Present: Representatives Tom Davis of Virginia, Horn, and 
Turner.
    Also present: Representative Shays.
    Staff present: Melissa Wojciak, staff director; Amy 
Heerink, chief counsel; George Rogers, counsel; Howard Denis 
and Victoria Proctor, professional staff members; Teddy Kidd, 
clerk; David Rapallo, minority counsel; and Jean Gosa, minority 
assistant clerk.
    Mr. Tom Davis of Virginia. Good morning. Welcome to today's 
hearing on the information-sharing capabilities of the Center 
for Disease Control and Prevention, hereinafter the CDC, for 
responding to a bioterrorism threat. This hearing will review 
the CDC's March 2001 report, ``Public Health's Infrastructure: 
Every Health Department Fully Prepared, Every Community Better 
Protected.''
    The best initial defense against public health threats, 
whether naturally occurring or deliberately caused, continues 
to be accurate, timely recognition and reporting of problems.
    To that end, one of our top priorities must be to ensure 
that we have a strong information-sharing network that protects 
privacy while seamlessly connecting local, State and Federal 
Governments. Moreover, timely and easy access to information is 
key to applying effective countermeasures.
    However, the CDC report noted serious deficiencies in the 
timely distribution of information between Federal, State and 
local governments in response to critical public health threat.
    The March 2001 report outlined a number of goals for 
improving communication and information technology capabilities 
at the Federal, State and local level. The hearing today will 
examine our progress to date in meeting the goals set forth in 
that report and the timeframes for reaching our, as yet, unmet 
goals.
    Additionally, it will discuss lessons learned from the 
recent events related to the anthrax incidents in October and 
November of this year as well as existing pilot programs on the 
Health Alert Network and the National Electronic Disease 
Surveillance System.
    The hearing today will also review best practices for 
information-sharing among Federal, State and local entities to 
determine our next steps for responding to future bioterrorism 
crisis. The recent anthrax attacks shows the need to improve 
information-sharing capabilities of the disparate Federal, 
State and local health authorities as well as private hospitals 
in the event of a public health emergency.
    Both basic IT infrastructure and communication protocols 
must be clarified in order to achieve the efficient system 
necessary to effectively respond to an emergency.
    There is borne out by CDC's estimate that currently only 
68.1 percent of U.S. counties have high speed-Internet access 
and can receive a broadcast message. Moreover, only 13 States 
have high-speed Internet connections with all of their 
counties.
    Originally, CDC's goal, as stated in their March 2001 
report, was to ensure by 2010 that all health departments have 
continuous high-speed access to the Internet and have 
established standard protocols for data collection, transport, 
electronic reporting, and information exchange to protect 
privacy while seamlessly connecting, local, State and Federal 
data systems; to have immediate on-line access to current 
global health recommendations, health and medical data, 
treatment guidelines and information on the effectiveness of 
public health interventions; and to have the capacity to send 
and receive sensitive health information via secure electronic 
systems and to broadcast emergency health alerts.
    In the wake of recent events, the CDC is considering ways 
to accelerate the timetable for implementation of the 
recommendations in its March report, ahead of the original 2010 
target date.
    In addition, CDC has developed tools for States to perform 
a self-assessment of information-sharing capabilities. It has 
begun to work to develop a grant program to implement these 
tools, identify gaps and develop a plan that includes a joint 
State-local strategy to fill these gaps.
    Additionally, three ongoing CDC initiatives--the Health 
Alert Network, Epi-X, and the National Electronic Disease 
Surveillance System--are being used to achieve the 
recommendations listed above.
    The Health Alert Network [HAN], is a nationwide program to 
establish the communications/information distance learning 
organizational infrastructure needed to respond to public 
health emergencies. It will link local health departments to 
one another and to other organizations critical for 
preparedness and response. Its features include providing to 
State and local health officials high-speed, secure Internet 
connections, on-line access to CDC's prevention 
recommendations, practice guidelines and disease data; the 
capacity to transmit secure surveillance, laboratory and other 
sensitive data and access to distance learning programs and 
services, and early warning and alert broadcasts.
    Moving forward, it is going to be necessary to determine 
what current Federal telecommunications development programs 
can be used in conjunction with the CDC initiatives to 
facilitate necessary improvement in the public health IT 
infrastructure nationwide.
    Finally, the subcommittee will review the effect media 
reporting played in the public health community's response to 
anthrax incidents.
    As public health professionals attempted to provide 
warnings and guidance based on traditional epidemiological 
methods, they often found themselves outpaced by constant media 
reports. Timely and accurate transmission of information to the 
general public will be a vital communication objective in 
future health emergencies.
    Recent events have shown the slim margin of error in this 
area before public mistrust begins to take hold. Thus, future 
communication plans must take into account the role the media 
will play in shaping public reaction and ensuring the correct 
message emerges immediately from those responsible for making 
health policy decisions.
    The subcommittee today is going to hear testimony from Dr. 
Edward Baker and Dr. Kevin Yeskey of the CDC. We will also hear 
from Mr. Rock Regan of the National Association of State Chief 
Information Officers; Dr. Gianfranco Pezzino, of the Council of 
State and Territorial Epidemiologists; Dr. Paul Wiesner of the 
National Association of County and City Health Officials; Mr. 
Michael Covert of the American Hospital Association; Dr. Carol 
Sharrett of the Fairfax County Department of Health; and Dr. 
Charles Saunders, EDS Health Care Global Industry Group.
    I now yield to Congressman Turner for any statement that he 
may wish to make.
    Mr. Turner. Thank you, Mr. Chairman; and thank you for 
hosting the hearing today on this very critical subject. And I 
welcome all of our witnesses who have come to share with us the 
progress that we are making in this area.
    There is no question, based on what the Centers for Disease 
Control report told us just a few months ago, that we have 
serious deficiencies in our public health system in our effort 
to deal adequately with the threat coming from biological 
agents.
    The recent experience with anthrax, I think, underscores 
the need to be very aggressive with regard to this particular 
area. I noted in the CDC report that it concluded that public 
health agencies lacked basic equipment, such as computers and 
Internet connections, as Chairman Davis mentioned. It mentioned 
that many of our public health laboratories are old, outdated 
and unsafe. It also acknowledged that many of our physicians 
and other health professionals across the country are ill-
equipped and untrained to deal with the new threats.
    Our Nation long ago understood that we had to be ready to 
respond to nuclear attack, and our early warning systems, now, 
that have been in place for a number of years, enable us as a 
nation to respond almost immediately to the threat of a nuclear 
missile attack.
    We need to have the same capability with regard to a 
biological attack. And much less is understood or known about 
those threats by the American people. And I think our purpose 
here today is to
explore the progress we are making, and to determine the 
direction that we need to go with regard to that very serious 
threat.
    So I welcome all of our witnesses today. Thank you for 
coming and we look forward to hearing from you.
    [The prepared statement of Hon. Jim Turner follows:]

    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT] 
    
    Mr. Tom Davis of Virginia. Thank you very much. We are also 
joined today by another subcommittee chairman on the Government 
Reform Committee, Mr. Horn from California. Any comments?
    Mr. Horn. I listened to your eloquence and to Mr. Turner's 
eloquence, and I am ready to listen to the witnesses. So thanks 
for putting the hearing together.
    Mr. Tom Davis of Virginia. Thank you very much.
    I call our first panel of witnesses to testify. As you 
know, it is the policy of this committee that all witnesses be 
sworn when you testify. Would you please rise with me and raise 
your right hands.
    [Witnesses sworn.]
    Mr. Tom Davis of Virginia. To afford sufficient time for 
questions of the witnesses, I would like you to try to stay at 
5 minutes. Each of you has a green light there. When it turns 
yellow, you have a minute to sum up. We have your complete 
statement, and that is included in the record.
    So we will start with Dr. Baker.

  STATEMENT OF EDWARD BAKER, M.D., M.P.H., DIRECTOR OF PUBLIC 
 HEALTH PRACTICE PROGRAM OFFICE, ACCOMPANIED BY KEVIN YESKEY, 
 M.D., ACTING DIRECTOR, BIOTERRORISM PREPAREDNESS AND RESPONSE 
        PROGRAM, NATIONAL CENTER FOR INFECTIOUS DISEASES

    Dr. Baker. Good morning, Mr. Chairman and members of the 
subcommittee. I am Dr. Edward Baker. I serve as Director of 
CDC's Public Health Practice Program Office. With me today is 
Dr. Kevin Yeskey, who currently serves as Director of our 
Bioterrorism Preparedness and Response Program. Thank you for 
this invitation.
    And, as you know, increased vigilance and preparedness for 
unexplained illnesses and injuries are an essential part of the 
public health effort to protect our citizens against terrorism 
and other public health threats. The terrorist events on and 
since September 11th have been defining moments for all of us, 
and they have greatly sharpened our Nation's focus on public 
health.
    Even before the September 11th attack, CDC was making 
substantial progress to define, develop, and implement 
nationwide a set of strategies and capacities required at the 
local, State and Federal level to prepare for and to respond to 
deliberate attacks on the health of our citizens. Since 
September 11th, we have worked very closely with our public 
health partners to accelerate these efforts, to share critical 
lessons learned, and to identify seven specific high-priority 
areas for immediate strengthening. We are committed to working 
with you and others to increase our efforts even further in the 
months ahead.
    As you know, CDC serves as a trusted source of scientific 
information on emerging infectious diseases and many other 
public health threats. Since September 11th, CDC has issued 175 
updates in response to the terrorist attacks and anthrax 
investigations through a variety of communications channels 
reaching an estimated 7 million health professionals in the 
public.
    These have included our rapid communications systems, the 
bioterrorism Web site, which is www.bt.cdc.gov, nationwide 
satellite broadcasts through our public health training 
network, and special telephone hot lines. This level of 
communication and collaboration with our partners has been 
crucial to the investigation and response to these events.
    But improvements can be made as called for in CDC's report, 
which you, Mr. Chairman, referred to a moment ago, the report 
entitled Public Health's Infrastructure: A Status Report.
    The specific recommendations regarding information systems 
are being achieved through three major initiatives that you 
referred to a moment ago--the Health Alert Network, the 
National Electronic Disease Surveillance System and 
Epidemiologic Information Exchange, or as we call it Epi-X. I 
would like to describe each of these briefly.
    The Health Alert Network, as you mentioned earlier, is 
designed to be the Nation's rapid on-line system for health 
communications information and training. When fully deployed, 
the Health Alert Network will link all local, State, and 
Federal public health agencies to each other and to their 
community partners, private health care providers, and will 
serve as an electronic platform for the applications that I 
have mentioned.
    On the morning of September 11th, the Health Alert Network 
was fully activated within 4 hours of the attack on the World 
Trade Center. We issued an alert to top public health officials 
across the country, and in the ensuing 12 weeks, some 60 
alerts, advisories and updates have been distributed through 
the network.
    To date, as you mentioned a moment ago, 13 States have 
directly connected all of their counties electronically to the 
Health Alert Network via high-speed, continuous Internet 
communications; and 68 percent of all U.S. counties are now 
connected.
    The Epidemiologic Information Exchange, or Epi-X, is CDC's 
secure, Web-based communications system, which serves as a 
portal for private electronic exchange of epidemiologic 
information. In response to the attacks of September 11th and 
subsequent events, the Epi-X system has immediately provided 
secure communications among State and large city 
epidemiologists and CDC programs, including our Epidemiologic 
Intelligence Service.
    The National Electronic Disease Surveillance System is a 
visionary system which will be built on the platform of the 
Health Alert Network. It is targeted toward electronic, real-
time reporting of information for public health action. It is 
designed to provide an integrated, coherent national system for 
public health surveillance that will have the flexibility and 
capacity to support a wide range of public health efforts, 
including our emergency response.
    So what have we learned from these recent events? We have 
learned many lessons. First of all, that these unprecedented 
events have given us a chance to work and prepare for the next 
challenge with a deeper understanding of bioterrorism and how 
we share information.
    We have learned that linkages that we have forged between 
clinical and public health communities are strong, and that 
these linkages have saved lives by detecting disease early.
    We have learned how to shorten the time lag between 
acquiring new knowledge, communication and action; and we have 
confirmed that close collaboration between local, State and 
Federal officials builds confidence in our local response.
    And finally we have learned more about what information is 
valuable to the public and to our partners, and that will help 
us craft messages and materials in the future.
    In conclusion, we have made substantial progress to date in 
enhancing the Nation's capability to prepare for and to respond 
to a bioterrorist event, but there is much more to be done. The 
best public health strategy to protect citizens against 
terrorism is the development, organization, enhancement of 
public health prevention systems and tools, including enhanced 
communications systems and messages.
    Not only will this approach ensure that we are better 
prepared for a bioterrorism event, but it will also enable us 
to do our jobs better every day. A strong and flexible public 
health infrastructure is the best defense against any disease 
threat.
    Thank you very much for your attention and for your 
leadership in bringing this issue to national attention.
    Dr. Yeskey and I are happy to address any of your 
questions. Thank you.
    [The prepared statement of Dr. Baker follows:]
    

    Mr. Tom Davis of Virginia. Dr. Yeskey, you are just here to 
help answer questions; is that right?
    Mr. Yeskey. That is right.
    Mr. Tom Davis of Virginia. Before I go to Mr. Horn, Steve, 
I will start with you. But I want to ask one question.
    A specific concern raised by local health departments was, 
it was unclear exactly who was in charge at the Federal level.
    Before we embark on an in-depth examination of information-
sharing capabilities, has CDC moved to address this fundamental 
point: Who is in charge?
    Dr. Baker. This is a challenging issue, as you know. And 
what we do at CDC is to work with our local and State partners 
in any investigation of a disease outbreak. And so we work to 
defer to the local authorities as they relate to the media and 
relate to their communities to provide information.
    As far as within the Federal system, CDC is designated as 
the lead public health agency in events of this type.
    Mr. Tom Davis of Virginia. Getting the word out is very, 
very important. We will hear some of the later testimony in 
terms of some of the confusion.
    I am going to recognize the gentleman from California.
    Mr. Horn. Thank you, Mr. Chairman. I have got one interest, 
and that is the laboratory interest.
    Are they spread accurately across the counties that you 
mentioned, that had this network in computing?
    One of our problems in the last 30 years has been where 
doctors had their own laboratory that was separated because it 
was felt they would--to get just their labs, and they were told 
to go get separate labs. And hospitals have certain labs.
    So if you have some of this type of either flu that--some 
biological or chemical, how do we deal with that and get that 
done in a very rapid time so people aren't panicking? What is 
your feeling on that? And what should we do to link all of 
those labs up?
    Dr. Baker. Two thoughts, Congressman. One is that there is 
an activity under way called the Laboratory Response Network. 
This was created under the bioterrorism program, and this 
network has been used extensively throughout the anthrax 
situation to handle samples. It was used extensively in Florida 
to process materials there. And expansion and strengthening of 
that network is one specific way to address part of what you 
are asking about.
    A second major initiative is one that we refer to as the 
National Laboratory System. You mentioned private hospitals. We 
believe there needs to be a concerted national effort to link 
the public health laboratories, that are typically run by 
governmental agencies, and private hospital laboratories in a 
much more seamless way to move information back and forth 
between them, to share information, to have standard protocols, 
standard ways of transmitting samples back and forth so we can 
track them more efficiently.
    So those are the two initiatives that are under way to 
address the laboratory issue.
    Mr. Horn. What about the smallest towns? Do we separate 
them at certain things and get a different chain or what?
    Dr. Baker. Within the Laboratory Response Network, there 
are levels of activity. And the smallest level, the lowest 
level, has the least complexity. A small local hospital 
laboratory, for example, would have that capacity in most 
situations. As you move up the level of complexity, there are 
more centralized laboratories that address this.
    Our commitment is that every community, regardless of how 
remote or how rural, have access to those laboratory services.
    Mr. Horn. Thank you.
    Mr. Tom Davis of Virginia. Thank you very much.
    Mr. Turner.
    Mr. Turner. Thank you, Mr. Chairman.
    With regard to increased coordination, tell us a little bit 
about the degree of coordination between our Federal agencies. 
In particular, I have on my mind, as many of us do, the recent 
reports about the Department of the Army's research on anthrax 
and the fact that, apparently, that may not have been known by 
other agencies of government.
    Is that a problem? And should there be greater coordination 
and knowledge exchanged there?
    Dr. Baker. I am going to defer to Dr. Yeskey a bit on the 
specifics. He is more directly involved with the anthrax 
activities than I am. But just a general thought on that.
    There have been very close collaborations with various 
parts of the Army, USAMRIID, the laboratory that does the work, 
as you know, on infectious disease research and has worked very 
closely with CDC throughout the course of the anthrax 
situation.
    Again, it is always good to have more collaboration and 
more communication. We never can do that too much. But I would 
like Dr. Yeskey to elaborate a bit on your question.
    Dr. Yeskey. I would agree with Dr. Baker that increased and 
improved coordination and integration is a desired goal. CDC 
worked hard, and continues to work hard, to integrate our 
activities with other Federal agencies, both within DHHS, such 
as the FDA or the Office of Emergency Preparedness, as well as 
outside the Department, with the Department of Justice, with 
the Environmental Protection Agency and others.
    We try and coordinate--during the anthrax incident, we had 
close collaborations with all of those organizations, had a 
full-time liaison established at the FBI headquarters. I had a 
full-time liaison at the U.S. Postal Service office to help 
coordinate our activities with theirs.
    So we attempted to make our best efforts at coordinating 
our activities both within DHHS, as well as outside the 
Department.
    Mr. Turner. Is there full disclosure between those agencies 
and those laboratories; or does each of them just sort of go 
their own way, share what they want to when they want to?
    Dr. Yeskey. I can speak for CDC's laboratories. We tried to 
coordinate and had daily telephone conferences with both the 
FBI laboratory personnel, as well as Department of Defense 
personnel, to help coordinate lab result reporting during the 
anthrax incident.
    Mr. Turner. What kind of tracking is there of dangerous 
biological agents when they are transferred from one lab to 
another? And are those protocols common throughout government 
agencies, or do they vary from one to the other?
    Dr. Yeskey. The transport of hazardous agents falls under 
the Select Agent Rule where organizations or institutions that 
manage or that are involved in the interstate transport of 
hazardous biological agents must register and then coordinate 
those transfers with the CDC and the Federal Government.
    Mr. Turner. By what method are those agents transmitted? Is 
it by ordinary private carrier? U.S. mail? How do those things 
travel?
    Dr. Yeskey. There are established protocols for the 
transport of those materials to ensure that the integrity of 
the packages remains during the transfer of those. CDC has 
written protocols that govern that.
    Mr. Turner. And what method of transport is used for those 
kind of materials?
    Dr. Yeskey. Depending on distance, it can be air courier, 
it can be ground transportation; but it is usually regular 
courier, private service.
    Mr. Turner. So the private service transmitting the package 
would know it is dangerous, but may not know exactly what they 
are transmitting from one locale to the other?
    Dr. Yeskey. That is correct.
    Mr. Turner. Is that an appropriate way to handle this type 
of material, or should it be handled by the agencies and its 
employees by personal delivery rather than by using private 
carriers?
    Dr. Yeskey. I will have to provide that information for the 
record at a later time.
    Mr. Turner. Does that answer mean you don't have an opinion 
or you are not familiar enough with the process to have an 
opinion?
    Dr. Yeskey. My opinion is that it is appropriate, it is an 
appropriate mechanism for the transport of the materials.
    Mr. Turner. If we were going to suggest improvement in the 
handling of that material, what kinds of things would you 
suggest that we look at?
    Dr. Yeskey. I think we need to examine to see if there are 
methodologies to improve the packaging, integrity, the 
notification of how the material is sent from one organization 
to the other, receipt times, anticipated delivery times, things 
like that, ensuring the security of that package as it goes 
through the transport system.
    Mr. Turner. Should we be reevaluating who we share this 
material with? In other words, I understand that some private 
labs can have access to some materials. I believe that is 
correct; isn't it, Dr. Baker?
    Dr. Baker. What we might want to do, just on this line of 
questioning, if this would be responsive, Congressman, is--if I 
understand your question, you are asking us about the transport 
of hazardous materials for which CDC does have responsibility 
under the Select Agent Rules, as Dr. Yeskey mentioned.
    Each of us does not deal directly with that particular area 
of activity. Inevitably, in light of recent events, we are 
rethinking a lot of things we are doing, and this may be one of 
them; I can't tell you that today.
    We would be happy to provide to you and work with you on 
specific areas that may need improvement, including how these 
get transported and some of the issues that you are raising for 
us today, if that would be helpful to you.
    Mr. Turner. It would be helpful.
    As I understood your answer there, you are already 
beginning to look at those protocols?
    Dr. Baker. What I said was that in light of recent events, 
we in public health are rethinking a lot of things. This has 
been an extraordinary experience for all of us, and CDC has 
been having a number of expert meetings over the last several 
weeks, bringing in experts from around the country to reflect 
on what has been happening and to then learn from each of these 
groups of people that come in.
    And we can share with you both that sort of thing and on 
the specific issue that you raised in terms of the transport of 
hazardous materials. We are undoubtedly rethinking that. But 
neither of us is directly involved in those discussions. So we 
would be happy to share that with you.
    Mr. Turner. Thank you.
    Mr. Tom Davis of Virginia. Thank you. I have a few 
questions.
    Today, on the second panel, Dr. Sherratt, who is from my 
home county of Fairfax, is going to testify that the lack of 
CDC guidelines on anthrax initially created both anxiety and 
inconsistency in patient care. We also know the example of the 
post office reacting differently to this, looking at what I 
think might have been best-available-information differently 
than Congress did, as the information became available.
    I guess my question is, how would you characterize CDC's 
actions in this? And what are we doing to ensure that we get a 
better response in the future?
    I recognize we are on new ground. This came out of nowhere. 
So we are just looking back here, not looking for people to 
jump on, but to understand what happened and how we can better 
it the next time.
    Dr. Baker. The first thing I was going to say, Congressman 
Davis, was exactly what you just said. This is clearly an 
unprecedented event, and we all recognize that. And the 
response, both at CDC and at the State and local levels, has 
been unprecedented. We have had folks flying into various parts 
of the country, we have been issuing alert notices over the 
Internet, we have been doing nationwide satellite broadcasts. 
All of those are unprecedented responses.
    We have learned from each of those particular activities. 
And, again, it is important we think to go back and look at 
what did happen, as you are doing here today, and learn from 
those lessons and, therefore, do better next time.
    This was a bit of a shakedown cruise for all of us in terms 
of the whole public health system, and our information systems 
in particular. We are very proud of the way in which CDC and 
our partners were able to get information out through these 
mechanisms that we have talked with you about today.
    As I mentioned, we issued an alert 4 hours after the World 
Trade Center event, around 1:30 on that afternoon. And issued 
alerts that went out now to as many as a million people on 
various aspects of the anthrax investigation. We have done a 
series of nationwide teleconferences. We did one just yesterday 
on smallpox. That whole series has reached over a million 
people. This is the Distance Learning Network that we utilize 
to educate our public health work force around the country.
    Unquestionably, we will be better off next time. Why will 
we be better off? First of all, the networks are in place and 
they are working and they are being expanded. So through all of 
this, through that experience, we have improved our 
relationships, we know better how to work the system.
    Second, we have developed a very large amount of question-
and-answer, very specific information, on a lot of aspects here 
that come up in the course of this investigation.
    Mr. Tom Davis of Virginia. Let me ask you this. Does your 
distance learning reach the private health providers as well?
    Dr. Baker. Yes, sir. We have done programs in cooperation 
with the American Medical Association, the American Hospital 
Association, National Medical Association, a range of partners, 
public health, private. And again, as I said, these 
broadcasts--the first one we did on anthrax, I think reached 
about 500,000 people. It is on the Internet. You can go there 
and pick it up later on. It is actually being picked up 
overseas, as well, we are told, on the Internet.
    Mr. Tom Davis of Virginia. OK. Another panelist in the next 
panel notes in his prepared statement that the NEDSS, HAN and 
the Epi-X projects are not always as well coordinated, and 
sometimes appear to have a little competition between them. Do 
you think that is accurate? And competition is not always bad, 
but in terms of when you want to disseminate information, you 
just have to take a team approach to get it out there and not 
try to play territorial. Do you feel that there is some of 
that? Are we still trying to get bugs out of that system? These 
are three new systems.
    Dr. Baker. Several thoughts. These are three new systems. 
That is the first and most important point. This is an 
ambitious enterprise overall to create an integrated public 
health information and communications system.
    It is best to think of these three elements as three 
initiatives that ultimately flow together into an integrated 
approach to improving the way in which we share information. 
The Epi-X program is a confidential private way in which 
epidemiologists are sharing information back and forth. So the 
members of this network, there are over 700 participants now, 
can log onto a secure Web site and can talk back and forth 
about epidemiologic issues.
    The NEDSS program, or the National Electronic Disease 
Surveillance System, is quite complex and quite challenging. 
Ultimately when it is in place, it will be a marvelous tool for 
public health, but it is the one that is really the least far 
along in terms of its actual implementation, and the reason for 
that has to do with the complexity.
    The basic answer to your question is that these are three 
complementary approaches. The Health Alert Network provides the 
platform, it connects everyone to the Internet. The Epi-X 
program and the National Electronic Disease Surveillance 
Systems are supported by that platform.
    Mr. Tom Davis of Virginia. OK. What steps are you taking to 
help ensure uniformity in control system architecture once 
systems like the NEDSS are implemented by individual States? Is 
there or will there be an oversight or central control board to 
regulate how the systems are used or modified?
    Dr. Baker. First of all, for the Health Alert Network 
system, we have technological standards that were put in place 
a couple of years ago, and we are just in the process of 
updating them. So there will be then, from CDC, a set of 
technology standards that grantees under that grant program are 
provided with so that, therefore, they can buy the right kind 
of computers. They will have the right way to connect to the 
Internet and those kinds of things.
    As far as the National Electronic Disease Surveillance 
System, there are a very extensive and complex set of standards 
that NEDSS participants will be asked to adhere to. So its a 
standards-based approach. Again, ultimately you won't be able 
to participate in these systems if you do not adhere to the 
standards.
    Mr. Tom Davis of Virginia. OK. Can HAN be expanded to 
include private health care providers?
    Dr. Baker. We are expanding it now to include private 
health care providers. Since September 11th we have increased 
the distribution. We worked, as I mentioned earlier, with the 
American Medical Association, American Hospital Association. 
The way this works is that we send a Health Alert Network 
notice to professional organizations like the ones I mentioned, 
and they send it out to their members.
    Mr. Tom Davis of Virginia. One of the problems with 
anthrax, and you can take a look at it, whether it is smallpox, 
or plague or whatever, is insufficient vaccines on hand, 
available, and ready to go.
    Obviously we were caught off guard. This is the first time 
we have faced this. How are we preparing in the future on this? 
Do you have guidelines? We are looking ahead now to possibly 
expanded germ warfare, biological warfare?
    Dr. Baker. I would like to begin the answer, but ask Dr. 
Yeskey to elaborate.
    On the smallpox issue, Congressman, we did a nationwide 
satellite teleconference just yesterday to inform the public 
and private health care communities about smallpox. It included 
experts from around the country. Secretary Thompson kicked that 
program off. Dr. Koplan, who is our Director at CDC, 
participated. Dr. Henderson, who is now working in the 
Department, was also part of that program.
    It was designed to educate people about smallpox and 
familiarize them with a major new plan that has just been sent 
out to our partners to look at as far as smallpox is concerned. 
As you know, the Department and CDC are committed to getting 
increased amounts of smallpox vaccine so that those will be 
available to people if the need should arise.
    Dr. Yeskey. I would agree. Our contingency planning and our 
preparations for additional agents that might be used as a 
biological weapon continue. We recently released a smallpox 
emergency response plan to State health officers. We continue 
to look at other agents and preparing response plans for those 
particular agents and ways of enhancing the public health 
infrastructure so we can respond more appropriately for another 
event with a different agent.
    Mr. Tom Davis of Virginia. Let me ask another question. 
This really goes throughout information, expanding to all of 
us, whether it is congressional briefings on what is happening 
in Afghanistan or whatever. I learn more from television than I 
get from all of the darn briefings. I don't know how my 
colleagues feel about it, but I sometimes get more than that. 
Same here in your case.
    It seems that CDC might be able to communicate to the 
general public. I am not talking about other health officials 
and providers, but directly to the public using the news media. 
Are there any plans to aggressively make use of the media in 
future events so that the CDC message, not the message of 
endless consultants hired by the media, can get out to the 
public? Because at the end of the day, you, the umpire, are 
calling the balls and strikes on some of this, and are closest 
to the problem and have, I think for the most part, the most 
up-to-date research and information. I think that is fair.
    Dr. Baker. I have a couple of thoughts on that. First of 
all, I personally think many of us at CDC were very proud of 
the role that our Director Dr. Koplan played in communicating 
through the media directly to the public and did exactly what 
you are talking about, Congressman, of trying to work with the 
media to get the message out. And other experts at CDC were 
involved in doing this as well. There was a daily briefing of 
our Public Affairs Office with the media folks to give them the 
information that they need to do their job. And so working 
closely in partnership with the media is a very important part 
of this.
    Also, some of the things that we do directly, like the 
teleconference series that I mentioned, actually are picked up 
by the media and are utilized in various ways. And, again, we 
have learned a lot. I think one of the areas that we will now 
do better on is this whole area of working with the media in a 
complementary, coordinated way and do a better job next time.
    Again, we are proud of what we have done, but we have 
always--we always have opportunities to learn from this 
experience.
    Mr. Tom Davis of Virginia. OK. Finally, in the testimony of 
the next panel, we are going to hear concerns that certain 
aspects of the privacy provisions in HIPAA will hinder efforts 
to improve surveillance. Have you considered these concerns, 
and do you think it might be necessary to revise the privacy 
regulations, and are you comfortable? It is always a tough 
balance over what should be private and what should be public 
in those issues.
    Dr. Baker. This is an area which I believe we would best be 
advised to give you an answer back. HIPAA is a very complex 
area. Others at CDC work on that, and perhaps we would be best 
advised just to answer that one for the record.
    I would like, if I could, to just mention one final point 
since I believe we are drawing to a close here. We particularly 
appreciate the support of the Congress in passing legislation, 
the Public Health Threats and Emergencies Act, last year. The 
act was, as you know, initiated in the Senate, and the House 
activities are very important.
    And this provides us with an unprecedented opportunity to 
strengthen the public health infrastructure through a new grant 
program that we will be developing with our partners. So, 
again, we appreciate the leadership here in the House and the 
Senate on that legislation. And we are committed to working as 
quickly as we can to get those resources out and to implement 
that piece of legislation.
    Mr. Tom Davis of Virginia. Thank you.
    I am going to recognize Mr. Turner.
    Mr. Turner. Dr. Baker, is there a national registry of all 
dangerous biological agents identifying their location and who 
is responsible for those agents?
    Dr. Baker. I understand your question. I will begin an 
answer, and I think probably best to elaborate for the record.
    Dr. Yeskey mentioned earlier, and, Kevin, you may want to 
say more about this, the select agent rule is part of what we 
are talking about. There is a list of specific agents that are 
listed there. These are biological agents. There are also 
chemical agents where inventories are done. I am not sure if 
your question really related specifically to biological or more 
broadly than that.
    There are also ways in which these are inventoried, and 
where people understand, for example, where a particular 
chemical is located in terms of the plant and how it is 
handled, that sort of thing.
    Mr. Turner. With regard to biological agents, is there a 
master list kept somewhere that would tell us where all of the 
dangerous biological agents would be in this country and who is 
responsible for them at those locations?
    Dr. Baker. We are not aware of that. I understand the 
nature of your question, and what we will do is come up with 
our best answer to that in terms of what is actually done in 
terms of tracking these hazardous agents. I think that is what 
you are asking about.
    Mr. Turner. Is there even a list of what we would call 
dangerous biological agents? Is there an agreed list?
    Dr. Baker. There is an agreed list of what we consider the 
important agents as far as terrorism is concerned. Those have 
been identified. And then there are the select agents which are 
comparable to those. We can provide that list to the committee.
    Mr. Turner. Would it not be appropriate, if we have not 
already done so, to have a law that requires a national 
registry so that we would know where all of those dangerous 
biological agents are at any given moment in this country; who 
has possession of them and who is responsible for them at those 
locations?
    Dr. Baker. I understand your question. I understand the 
logic of your suggestion. I am not in a position to say yes or 
no to your question today, but we will be happy to do so for 
the record. I understand your question.
    Mr. Turner. Dr. Yeskey, do you have an opinion on that?
    Dr. Yeskey. Again, I agree with Dr. Baker. We will be happy 
to provide a list of the agents and how they are managed.
    Mr. Turner. It seems to me in this age of biological 
terrorist threats that it would be wise if we at least had some 
requirement that dangerous agents and their locations be known, 
perhaps even to go so far as to have some notification system 
in place for the transfer of those agents. I assume by your 
answers to the previous questions there must be no control 
whatsoever on the import or export of dangerous biological 
agents into this country?
    Dr. Baker. I would go so far as to say I don't believe that 
is true. Again, I am sorry that we don't have the information 
at our fingertips to answer your question, as far as the 
importation piece is concerned.
    Mr. Turner. I would appreciate if you could give us some 
response to that, because I would like to know if there is a 
list somewhere of all of those agents, where they are, who is 
responsible for them, and if there is any control whatsoever on 
the transport of those, any notification requirements when they 
are transported within our country, or when they are imported 
or exported. Thank you very much.
    Dr. Baker. I would be happy to work with you on that.
    Mr. Tom Davis of Virginia. Mr. Horn, any other questions?
    Mr. Horn. Fine.
    Mr. Tom Davis of Virginia. All right. Well, I thank you 
very much. And what I think we will do, you will have 10 days 
to supplement any remarks that you would like to make.
    We will take a 3-minute break as we change panels and allow 
the next panel to come forward. We appreciate very much your 
being here today.
    [Recess.]
    Mr. Tom Davis of Virginia. As you know, it is the policy of 
the committee to swear in witnesses. If you would rise with me 
and raise your right hands.
    [Witnesses sworn.]
    Mr. Tom Davis of Virginia. Thank you very much. Please be 
seated.
    You see that we have our indicator box in the front. It 
will turn green. What we would like you to try to do is stay 
within 5 minutes, because your total testimony is part of the 
official record. We will start with Rock Regan over here.
    Rock, we are going to start with you. Gregory; is that your 
actual name?
    Mr. Regan. Greg.
    Mr. Tom Davis of Virginia. I remember that.
    But we appreciate all of your being here, and we will start 
with the Rock over here and move straight down. Try to keep it 
within 5 minutes, then we will go with questions. Again, we 
appreciate everyone being here.

 STATEMENTS OF ROCK REGAN, NATIONAL ASSOCIATION OF STATE CHIEF 
   INFORMATION OFFICERS, CHIEF INFORMATION OFFICER, STATE OF 
 CONNECTICUT; GIANFRANCO PEZZINO, M.D., MPH, COUNCIL FOR STATE 
 AND TERRITORIAL EPIDEMIOLOGISTS, STATE EPIDEMIOLOGIST, KANSAS 
DEPARTMENT OF HEALTH AND ENVIRONMENT; PAUL WIESNER, M.D., MPH, 
   NATIONAL ASSOCIATION OF COUNTY AND CITY HEALTH OFFICIALS, 
  DIRECTOR, DEKALB COUNTY BOARD OF HEALTH; MICHAEL H. COVERT, 
 AMERICAN HOSPITAL ASSOCIATION, PRESIDENT, WASHINGTON HOSPITAL 
   CENTER; CAROL S. SHARRETT, M.D., MPH, DIRECTOR OF HEALTH, 
 FAIRFAX COUNTY DEPARTMENT OF HEALTH; AND CHARLES E. SAUNDERS, 
     M.D., PRESIDENT, EDS HEALTH CARE GLOBAL INDUSTRY GROUP

    Mr. Regan. Good morning, Mr. Chairman and members of the 
committee. My name is Rock Regan. I am the chief information 
officer with the State of Connecticut, and the president of the 
National Association of State Chief Information Officers. 
Again, it is a pleasure to be here to talk about such an 
important issue.
    The events of the last 3 months have galvanized government 
at all levels to increase our emergency preparedness 
capabilities for a range of threats. The threat of bioterrorism 
is among one of the most challenging and terrifying among them.
    The current anthrax crisis which has hit so close to home 
in Connecticut, the U.S. Capitol, as well as recent outbreaks 
of Ebola virus in Africa illustrate just how important our 
bioemergency preparedness is. It has been observed by many that 
our first line of defense in preparing for bioterror is our 
ability to communicate and coordinate.
    Our information and communications systems lie at the very 
heart of our response. The State chief information officers sit 
at the nexus of these communication and coordination systems, 
and we appreciate again you calling this hearing on these 
important issues of today.
    I think, as mentioned earlier, the March 2000 report by the 
CDC outlined a couple of specific goals: the skilled work 
force, robust information and data systems, effective health 
departments and laboratories. Certainly our focus is on the 
second one, robust information and data systems.
    NASCIO agrees with the CDC's March assessment in terms of 
the HAN initiative as well as the National Electronic Disease 
Surveillance System. HAN and NEDSS is a great first start.
    In Connecticut, if I can personalize this, the National 
Electronic Disease Surveillance System will replace 18 stove-
pipe systems with an integrated data repository for the sharing 
of this information. So I think, as Dr. Baker said, it is a 
very complex process to put that together, but I think the 
benefit will be great.
    These goals which again are critically important for all 
health departments in the Nation to have continuous high-speed 
access to the Internet is going to require substantial 
investment for States and local governments, which, again, they 
cannot bear alone. I think, you know, as we go forward and look 
at the deployment of those systems, the one fact that has to be 
considered is the current networks that are available in the 
State and local governments.
    Beyond HAN, really the way to do that is a coordinated 
integrated State information architecture, and if I could talk 
specifically about a couple of issues that NASCIO is involved 
with, there is currently one with the criminal justice 
community, a global justice initiative, to create a national 
natural integrated architecture for justice systems. It doesn't 
appear, by my knowledge, those of the CIOs that I have talked 
to, that this effort is under way for the public health 
infrastructure.
    While the initiatives going forward, again, are very 
critical, it is unclear, I think, from many of our perspectives 
of how they plug into the overall architecture. Standards are 
great, but certainly local governments and State governments 
would like to have a say in how those standards are put 
together and how they fit onto the overall overriding 
architecture.
    The justice integration architecture to me would be a 
blueprint to follow for the public health systems. Again, as we 
look at those initiatives such as anthrax, the ability to 
cross-communicate information in a very timely basis across 
multi jurisdictions, not just health agencies, public safety, 
Governors, other departmental agencies within States and local 
governments, particularly first responders, the State CIOs and 
Federal homeland defense officials in conjunction with Justice 
and CDC again may do well in considering using the justice 
integrated architectural process here for creating a public 
health information architecture that, again, fits in with an 
overall State architecture and a homeland defense scenario. 
This integration will allow for access as appropriate to vital 
alert and response information by all affected State agencies.
    Again, getting back to Connecticut, Connecticut, we had an 
anthrax issue, a 94-year-old woman who passed away as a result 
of the anthrax. We had a very excellent response by CDC, over 
20 people responded; FBI, over 20 people responded. To think in 
context of what advantage to the 1 event, 10 events, 1,000 
events across the country, our ability to communicate was not 
in place.
    And I think that the infrastructure and architecture that 
we are talking about in these networks will be the vehicle to 
do it. We are just not going to have enough trained people to 
respond to these situations. So the communication 
infrastructures will be vital in any response, particularly if 
it is a national response.
    State CIOs again want to be involved in the planning 
process. And to sum up, I think, as we talk about 
communicating, it is not just one way from the Federal 
Government down to the State and local jurisdictions, it is 
multiway processing, down from the Fed, up from the local, 
State to the Feds, again the sharing of information.
    And summarizing, I have been asked by my Governor to ensure 
an effective information communications infrastructure for 
responding to the bioterror threat. As the Nation's governments 
gear up to prepare for the threat of bioterrorism, NASCIO 
believes the path to efficient implementation of preparedness 
initiatives lies with open coordination between all levels of 
government and views toward information systems that emphasize 
open architectures rather than closed, stove-pipe systems. To 
this end NASCIO has opened up communications with Director 
Ridge's Office of Homeland Security and would be pleased to 
coordinate and initiate coordinating relationships with CDC and 
others to more effectively implement our public health 
infrastructure improvements effort.
    These efforts, we believe, are necessary to safeguard the 
American public in every part of the Nation, in every State and 
every county, and in every city.
    Again, I appreciate the opportunity to speak before you 
today.
    Mr. Tom Davis of Virginia. Thank you very much, Mr. Regan.
    [The prepared statement of Mr. Regan follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT] 
        
    Mr. Tom Davis of Virginia. Dr. Pezzino.
    Dr. Pezzino. Mr. Chairman, members of the subcommittee, I 
am Dr. Gianfranco Pezzino, State epidemiologist with the Kansas 
Department of Health and Environment. I am very pleased to be 
here today in my capacity as president-elect of the Council of 
State and Territorial Epidemiologists [CSTE].
    I was asked to address questions today revolving around how 
the use of appropriate information technologies has helped 
public health officials in the management of the anthrax crisis 
of the past months. For more than a decade CSTE has urged CDC 
to move away from a model of separated, self-contained 
surveillance systems and to work toward the flexible integrated 
solution.
    Three initiatives have been developed in the past few years 
by the CDC with substantial input from local and State public 
health partners. These initiatives are NEDSS, the Health 
Network, and Epi-X. NEDSS is an important effort. One important 
function of NEDSS is the establishments of standard 
architecture based on current industry standards for public 
health electronic information systems. The use of those 
standards will allow agencies to achieve a more effective use 
of information technology and to share data.
    The second initiative is the Health Alert Network. This is 
primarily an infrastructure project to improve the information 
technology infrastructure in local and State health departments 
by helping public health agencies to obtain Internet and e-mail 
access.
    And the third project, Epi-X, is an Internet application 
developed by the CDC. Through its secure Web site, Epi-X allows 
public health officials to exchange communication about 
outbreaks and other emergency health events. This electronic 
forum has been extensively used during the anthrax-related 
emergency to share information, experience and intervention 
protocols. Another unique feature of Epi-X is emergency 
notification by telephone or pager to defined groups of public 
health officials.
    So how do these projects interact with each other? Epi-X 
uses the standards defined by NEDSS and exploits the network 
built through the Health Alert Network. All these three 
projects provided some essential functions during the response 
to the anthrax threat of the past month.
    The pager that I am carrying here today is a Health Alert 
Network pager. This pager received multiple messages from the 
Epi-X project in the past few months and mailed these messages 
directing me to go to the Epi-X secure Web site that was set up 
using NEDSS standards.
    So, in summary, each project gains strength from the 
presence of the others, and none of them can be successful 
alone. While these are positive developments, much work remains 
to believe done. We have identified three priority areas that 
need immediate attention.
    First, the process of integration envisioned by NEDSS is 
far from being completed. Even the three projects that I 
mentioned, NEDSS, Health Alert and Epi-X, have not always built 
on each others' strengths. And at times they have appeared to 
compete for the same scare resources or to attempt to establish 
one project as the only one worth expansion. Funding for all of 
these three projects must be assured. The three projects must 
work together to achieve their common goals.
    The second area of priority is the link between public 
health departments and private health care providers. Virtually 
all public health emergencies will be detected through 
information available from some private providers. Currently 
the most common communications methods between private 
providers and public health departments remain mail, fax or 
telephone. It takes about 3 days for my office to prepare 
mailing labels, duplicate a letter, and put it in the mail so 
that we can reach our thousands of providers throughout the 
State with some public health notification.
    Private health care providers also play a key role in the 
response to public health emergencies. And the Health Alert 
Network needs to expand to include private providers so that 
they can be quickly notified of the existence of public health 
threats and how to contain them.
    And finally, it should never be forgotten that the 
functioning of even the best computer network remains based on 
the presence of trained, skilled, qualified public health 
workers. The most timely alert will be of little use when it 
reaches a health department running 3 half days a week and 
staffed with one part-time nurse, as it happens in some rural 
areas of my State and other parts of the country.
    Funding for the support of a basic public health 
infrastructure must increase dramatically, and it must 
represent a sustained effort over time.
    In conclusion, CSTE supports and appreciates the efforts 
made by the CDC in the past few years to improve and integrate 
public health information systems, but many barriers remain. 
Nevertheless, projects such as NEDSS, Health Alert and Epi-X 
have contributed enormously toward achieving better integration 
of information, more timely detection of public health 
emergencies, and more prompt and effective dissemination of 
health alert messages.
    These initiatives are all complementary to each other, and 
funding and support for all of them must grow considerably so 
that the expected results can be achieved in a short time as 
possible. We cannot afford to wait.
    I want to thank you, Mr. Chairman, for the opportunity to 
testify here this morning on this important topic.
    Mr. Tom Davis of Virginia. Thank you very much.
    [The prepared statement of Dr. Pezzino follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    
    Mr. Tom Davis of Virginia. Dr. Wiesner.
    Dr. Wiesner. Good morning, Mr. Chairman, and members of the 
subcommittee. I am Dr. Paul Wiesner. I'm the director of the 
Board of Health in DeKalb County, GA. I'm pleased to present 
testimony here today on behalf of the National Association of 
County and City Health Officials. That's the organization that 
represents the nearly 3,000 local health departments in the 
United States.
    CDC had the foresight to establish three local Centers for 
Public Health Preparedness in late 1999, and we're fortunate to 
direct one of those centers. This morning I'm going to focus 
only on two of the lessons that NACCHO has learned about 
dissemination of information and building public health 
infrastructure through the Health Alert Network.
    The timetable for achieving the goals stated in CDC's 
report that the chairman mentioned earlier must be rapidly 
accelerated. Early detection and a timely response to a 
bioterrorist attack depends upon a solid local and State public 
health infrastructure. This infrastructure requires a crucial 
array of capacities: a trained work force under top-notch 
organizational management; partnership building; systems 
readiness; epidemiological laboratory and surveillance 
expertise; information and communication systems; and the 
ability to develop local programs and local policies.
    Without the fundamental capacity which we call 
infrastructure, the local health department is unable to 
address the regular community health problems that exist in the 
community, the threats that come from either infectious disease 
or environmental hazards, and certainly counter the threats 
from potential bioterrorism.
    That same infrastructure that's used for all of the other 
practices of public health in our local community are the 
framework and foundation for preparation for bioterrorism. The 
local public health department in many ways is the linchpin of 
bioterrorism preparedness.
    Now, today, the general population has an unprecedented 
understanding of the importance of public health but they have 
little grasp of the magnitude of transformation that is needed 
in public health practice nationwide. For all health 
departments in the country, capacities have not kept pace with 
the challenges. We must have a long-term initiative to 
restructure and rebuild the Nation's public health 
infrastructure at the State and local level as well as the 
Federal level, because only in that case will we have everyone 
in our communities protected.
    Now, I'm going to talk about a second point that is a 
little bit more subtle and less direct than the infrastructure 
question, but it's no less critical. No one doubts the need for 
rapidly and accurately transmitting information vertically in 
the public health system, up and down between the Federal, 
State, and local public health agencies. That's absolutely 
vital. But what is just as important is what might be called 
the horizontal communication and transmission of information in 
all levels of government, and building those systems that 
communicate horizontally within our communities.
    Substantial investments in technology and systems building 
are needed. The needs at this local level where I work, what I 
might call the retail level of public health, are substantial. 
We need real-time surveillance systems on the ground, rapid 
secure and redundant communication at this level throughout the 
country, educational and training resources for us and our 
partners. And there are many within the local community beyond 
simply the hospital and the medical practitioner, well-trained 
public health investigative teams, local plans for 
pharmaceutical assessment and acquisition and distribution, and 
periodic testing of communication protocols technology in our 
overall local plan for bioterrorism response.
    NACCHO's experience with the CDC-supported centers has 
demonstrated that there's one core element as far as that 
horizontal development, and that is partnership development. 
Improvements in technology must be linked to a horizontal 
system of solid, local relationships between public and private 
agencies.
    Now, in conclusion, significant investments of people and 
money will achieve this new level of public health 
preparedness. Restoring the local public health infrastructure 
creates the sustaining foundation for preparedness. Threats to 
the public health do not respect jurisdictional boundaries, so 
if we're all going to be protected, every health department 
must be able to contribute to this. Sustaining this effort 
requires a commitment from all levels of government.
    Thank you, Mr. Chairman.
    Mr. Tom Davis of Virginia. Thank you very much.
    [The prepared statement of Dr. Wiesner follows:]
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    Mr. Tom Davis of Virginia. Mr. Covert.
    Mr. Covert. Thank you, Mr. Chairman, members of the 
committee, staff members. I'm pleased to appear before you 
today. I'm Michael H. Covert, president of the Washington 
Hospital Center here in Washington, DC. I'm here today 
representing the American Hospital Association and its nearly 
5,000 hospitals, health systems, networks and other providers 
of care.
    One of our key readiness challenges is to foster stronger 
ties between the public health system and hospitals. Hospitals 
are a public safety asset. We need to better integrate 
hospitals into the public health and safety infrastructure to 
enhance our community's ability to respond to disaster. This 
will require a Federal recognition of the important role that 
hospitals and health systems need to play in coordinating 
community-wide efforts to deal with disasters, including 
potential agents of bioterrorism. And it will take a commitment 
of Federal resources to support efforts by hospitals and public 
health departments to access and distribute information and 
emergency alerts, monitor the health of communities, and help 
detect emerging health problems.
    Let me share with you some of the lessons that we've 
learned from our experience in dealing with the recent 
outbreaks of anthrax in the Nation's Capital area. We learned 
that a lack of effective integration and communication between 
the Federal Government and our local health department early on 
stymied our ability to effectively plan the screening and 
monitoring of a large number of anthrax patients. By the way, 
we saw over 500. There was no regional tracking mechanism to 
capture information that could have been used for monitoring 
epidemiological trends. Each institution in the first days was 
left to its own devices to gather information on how best to 
treat patients and then in turn share it with the health 
department.
    Many questions arose as to how to maintain the privacy and 
confidentiality of this data. These concerns will only be 
exacerbated by the new Health Insurance Portability and 
Accountability Act's medical privacy regulations.
    Our experience in responding to anthrax cases also 
underscores the need for public health departments to be able 
to update hospitals continually on key developments, but the 
health department was often unable to do so, which affected our 
ability to plan for care and staffing.
    Another potential problem is the jurisdictional issue. Who 
coordinates surveillance efforts to avoid duplication? In rural 
areas of the country, hospitals will need to play a larger role 
in performing many of the duties that a health department would 
normally perform. As a former health director, I know there 
were many communities that lacked resources and personnel to 
track and manage a mass casualty incident. There also needs to 
be better and more sophisticated gathering of data and 
operations of artificial intelligence capabilities to help 
evaluate patients who may be victims of a terrorist attack. 
Ideally, these systems should also tie into hospitals' 
electronic medical records.
    Over and over again, the points of failure in a disaster 
response are the information and communications systems. Cell 
phones don't work. Land line telephone systems are overloaded. 
There are no systems for tracking patient data on a regional 
basis. We need to invest a large amount of money to build an 
information and communications infrastructure that has 
capacity, redundancy, and robustness and includes all public 
safety agencies--police, fire, EMS, and hospitals.
    Mr. Chairman, September 11th and the aftermath changed the 
way hospitals must think of disaster readiness. Hospitals must 
now prepare for what once was unimaginable. For example, the 
Washington Hospital Center will need to invest over $40 million 
to deal with current readiness needs today. One fourth of those 
dollars, between $8 and $10 million, are needed to be spent on 
information systems, communications, and technology. When you 
hear the request for significant funding by the AHA, they are 
very much on track, at least with what I believe what we are 
finding at the individual hospital level.
    To strengthen community readiness, the AHA is pleased to be 
a part of a new coalition, the Partnership for Community 
Safety. The partnership includes public health officials, 
hospitals, fire chiefs, emergency physicians, emergency medical 
personnel, and nurse leaders: the heart of any community's 
front line emergency response efforts. I know that you 
recognize that.
    In conclusion, hospitals are upgrading existing disaster 
plans and continue to tailor their disaster plans to suit 
individual needs of the community in the face of new threats. 
America's caregivers perform heroic life-saving acts every day, 
and in the face of the unexpected they can be depended upon to 
rise to the needs of their respective communities.
    I appreciate the opportunity and look forward to answering 
questions.
    Mr. Tom Davis of Virginia. Thank you very much.
    [The prepared statement of Mr. Covert follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    
    
    Mr. Tom Davis of Virginia. Dr. Carol Sharrett. Dr. 
Sharrett, thank you for being with us.
    Dr. Sharrett. Good morning, Mr. Chairman and committee 
members.
    It's an honor to be here this morning to participate in the 
discussion on the response and information dissemination 
capabilities of our Nation's public health system to 
bioterrorism threat or incident. I'm Dr. Carol, Sharrett, a 
preventive medicine public health physician and the health 
director for the Fairfax County Health Department.
    As the threats of bioterrorism a became reality, our 
Nation's public health system had to take the lead in 
protecting the population from disease. The recent rapidly 
evolving anthrax crisis challenged our ability to respond to 
new threats and to communicate quickly and effectively. By 
virtue of the size and capabilities of the Fairfax Health 
Department, we assumed the leadership role among the health 
departments in the northern Virginia region.
    In collaboration with the Virginia Department of Health 
[VDH], and the Arlington and Alexandria health districts, we 
operated a health assessment and treatment clinic for residents 
of Fairfax, Arlington, and Alexandria who were potentially 
exposed to anthrax at their work site.
    The Fairfax County Health Department routinely collects 
information on reportable communicable diseases. Other time-
sensitive public health data including health alerts, 
guidelines, and protocols are received through e-mail, fax, and 
the Internet. During the anthrax crisis, communication between 
our health department and the State was hampered by temporarily 
inoperable e-mail systems at both the State and county level. 
As you recall, this was about the time of the Nimda virus, and 
Fairfax was hit hard by that. We therefore had to rely on an 
already overtaxed fax system to collect and disseminate 
information. The Inova Health System's disease--excuse me, 
Disaster Support Center gave invaluable assistance to the 
health department by cooperatively preparing anthrax-related 
information to blast-fax to all medical care providers 
including hospitals in the northern Virginia region.
    We also provided anthrax information through the Fairfax 
County Web site with linkage to the Inova Health System, VDH, 
and the CDC.
    On October 12th, the Fairfax Health Department, through 
partnerships with the medical community, State health 
departments, and the CDC put in an enhanced disease 
surveillance system and operation. This has been explained 
before so I won't go into that. Real-time information sharing 
occurred by the health department participating in daily 
conference calls with VDH and the northern Virginia health 
departments. Another call was with the District of Columbia 
Hospital Association, which had representatives from all of the 
metropolitan area hospitals, Council of Governments, the local 
and State health departments in Maryland, Virginia, and D.C., 
and we also had a daily conference call with the Fairfax County 
Emergency Management Coordinating Committee, which consists of 
25 county agencies that have responsibility for emergency 
preparedness.
    The anthrax crisis, as has been said before, was uncharted 
territory. Few health care providers had ever seen anthrax and, 
with its high fatality rate, they grew increasingly concerned 
about potentially missing a diagnosis. We received urgent 
requests from doctors asking what to do with the growing number 
of people who were demanding testing for potential exposures 
and what we would recommend for diagnostic procedures and post-
exposure prophylaxis.
    Initially the lack of CDC guidelines created both anxiety 
and inconsistency in patient care. Local medical providers and 
laboratory and hospital emergency staff were all clamoring for 
information. Although CDC staff were working at D.C. General 
and the other area hospitals which were treating anthrax 
patients, their focus was primarily an epidemiological 
investigation. As a result, the release of information to the 
State and local health departments was slow, often with 
relevant information being first reported on Fox Channel 5 or 
CNN.
    We quickly set up a telephone information line to respond 
to the community's concerns. Calls from the public began right 
after the anthrax case in Florida was diagnosed, and the 
numbers increased dramatically after the Daschle letter on 
October 15th. Our public health nurses were trained to answer 
citizens' calls regarding anthrax, smallpox, suspicious 
packages and bioterrorism in general. They operated our health 
department anthrax information line from 7 a.m. to 11 p.m. This 
was 7 days a week. Between October 20th and November 16th, we 
received over 200 calls per day, with 400 at the height of the 
crisis. Some of these calls came from as far away as England 
and Germany.
    We communicated with the public using anthrax and 
bioterrorism updates on the Fairfax County Web site and cable 
television station, anthrax fact sheets, town meetings on 
emergency preparedness, news releases, press conferences, and 
local media interviews. The media helped in publicizing the 
anthrax information line number as well as getting the word out 
on the regional health assessment and treatment clinic status.
    The media reported much information before State or local 
health departments were made aware of it by the CDC. An example 
was the change from Cipro to Doxycycline for post-exposure 
prophylaxis. It became necessary for our communicable disease 
program staff to listen to NPR, CNN and read the Washington 
Post prior to reporting to work. Our anthrax information line 
was affected by the story of the day, requiring additional 
nurses on the phones to handle the flood of calls after evening 
news broadcasts.
    The media occasionally reported inappropriate advice from 
television medical consultants as to which individuals needed 
treatment and testing based on potential exposure at work 
sites. The CDC formal guidelines arrived later, with the public 
near panic levels in the interim. Once again, the local 
emergency rooms, health care providers, and health departments 
were faced with citizens demanding unwarranted treatment, 
utilizing scarce resources which should have been conserved for 
those who were indeed at risk.
    An example of media reporting that hampered the ability of 
the health department to adequately respond to the public 
involved nasal swab testing. The media reported that the nasal 
swab was the test for anthrax when, in fact, CDC was using it 
as an environmental epidemiological tool. Individuals flooded 
local emergency rooms, urgent care centers, and other care 
providers. However, the nasal swab was of no use in determining 
whether an individual required prophylaxis or treatment. Nasal 
swab testing only overtaxed medical and laboratory resources, 
diverting them from medical care that was required during the 
anthrax crisis.
    I notice I'm out of time. I'll just jump ahead since you 
all have----
    Mr. Tom Davis of Virginia. Your entire statement is in the 
record.
    Dr. Sharrett. I'll go on to the conclusion. In conclusion, 
the CDC is to be complimented on their prompt epidemiological 
response to the anthrax crisis. And once medical information 
was released, it was excellent and extremely useful. Not having 
a clear understanding of who ultimately was in charge of the 
unfolding crisis, I believe, was the major reason communication 
was delayed.
    The health of the public can be preserved optimally in the 
event of a biological attack only with a strong, clear, 
communication leadership role by the CDC. Controlling the panic 
that naturally occurs in such a crisis is a primary role of 
public health. I believe the public would have been better 
served had the CDC given daily updates on national television 
to the public and to the medical care providers.
    Despite our perceptions, the anthrax crisis unfolded 
relatively slowly, but had this been smallpox instead of 
anthrax, our slow transmission of information would have been 
devastating, with rapid spread of the disease and increased 
mortality.
    The cooperation and collaboration on the local level was 
extraordinary, with everyone involved providing service to the 
point of exhaustion, as I'm sure was true throughout the region 
and also for VDH and CDC employees. To effectively respond to 
future crises, it is evident that local, State and national 
public health agencies need additional funding for personnel, 
training, equipment, supplies, and systems development. Our 
current capabilities will not adequately protect the public.
    Thank you, Mr. Chairman.
    Mr. Tom Davis of Virginia. Thank you very much.
    Dr. Saunders.
    Dr. Saunders. Mr. Chairman, members of the committee, thank 
you very much for the opportunity to address this group. I 
would like to speak to you today from a couple of perspectives. 
The first is as a businessman and president of EDS Health Care 
Global Industry Group, a company involved with large-scale 
information technology services. The second, though, is as a 
physician with a long career in disaster management; having 
served, for example, for many years as a medical director of 
the city and county of San Francisco's Department of Public 
Health Paramedic Division 911 Medical Response. I have been 
involved in many disasters and multi-casualty events, including 
managing the medical response to the Loma Prieta earthquake.
    Also on September 11th I was at the World Trade Center when 
the first plane hit, and I spent the duration of that event 
participating in that incident, including providing emergency 
medical care to victims at the scene. So I do have some unique 
perspectives, I think, both from a practical standpoint and 
also from an IT perspective.
    First of all, a couple of lessons learned. No. 1--and the 
first thing I'd have to say is I'm always in awe of the 
American spirit and the resilience and the courage and the 
compassion and the initiative that individuals undertake these 
times, and I'm proud to be an American. And that needs to--
can't go without saying. But the second thing is that 
disaster--organized disaster plans are nothing more than 
educated guesses at the hand you'll be dealt. Oftentimes 
reality is different. The key to success is fluidity and 
adaptability of the response, and the key to success there is 
information and communications. This is exactly where our 
public health system falls down.
    Emergency care workers have no method for providing 
information in real-time about what's happening from minute to 
minute in their health care environment. So, the surveillance 
information that's real-time is lacking. There's no method for 
rapid dissemination of that information--not only about 
bioterrorism, but hazmat incidents. In fact, at 2 a.m., if I 
have a child bit by a dog, I don't know if there's rabies in my 
community because there's no easy way to access that 
information at the point of care. There is no effective and 
reliable way to keep your pulse on the status of our health 
care capacity, bed capacity, ambulance distributions, the 
availability of health care personnel and materiel.
    And, finally, health care workers are unprepared to deal 
with rare, but critical events: bioterrorism, hazmat materials, 
things that they see rarely and perhaps hear about once in 
medical school, but aren't prepared for.
    EDS supports the recommendations of the CDC and the E-
health initiative. In fact, I'm on the leadership council of 
that group. We support the recommendations for a Web-based 
system for real-time surveillance, including linkage to 
relevant information systems at the point of care. We also 
support a mechanism for rapid dissemination of information 
outbound to health care workers. But I would further add that 
we can build on that with some additional things to keep in 
mind that would be of benefit.
    No. 1 is a very effective method for Web-based distance 
learning at the point of care, at the time that it's relevant, 
when care is being delivered, so the health care workers can 
understand how to treat these victims. Another is a mechanism 
for event tracking of both victims and the impact.
    At the Loma Prieta earthquake, my colleagues and I 
published a study of the impact of that, and it took months of 
research, combing through ER log records to find out, in fact, 
how many casualties there were and what the distribution was. 
That's too late to be effective for decisionmaking.
    Capabilities for monitoring and allocating health care 
resources are needed so we don't have 200 physicians showing up 
at a hospital to take care of victims who all happen to be 
across town.
    And finally, security hardening of our information 
infrastructure for health care information is also needed. That 
means redundant systems, hot backups, hardened facilities.
    There will be challenges in the implementation of this. 
First of all, development and maintenance of the applications 
and the content. Second, integration to the relevant systems in 
the care environment, whether it's lab systems, the hospital 
information systems or registration logs and so forth will be 
difficult. It will be time-consuming and it will be complex. 
There will be maintenance required on the interfaces.
    The education and training of health care workers so we 
understand how to interface with these systems and how to 
extract value from them will be a challenge. The policies 
around privacy and security and access to that information: 
who's appropriate, who's authorized, and when. And then the 
business process changes. We have to learn that instead of 
mailing in a 3-by-5 card to report a reportable event, now we 
go online to provide information.
    So success, in conclusion, will be based on an effective 
partnership between the public private sectors of health care, 
as well as the information technology business community. I 
think that when these occur--and it will be a journey--it will 
be of great benefit to us all.
    I thank you again for the opportunity to be here.
    Mr. Tom Davis of Virginia. Thank you very much.
    [The prepared statement of Dr. Saunders follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT] 
    
        
    Mr. Tom Davis of Virginia. Thank all of you for your 
testimony. We have a number of questions. I'm going to begin 
with Mr. Shays, who has belatedly joined our panel from 
Occoquan. I guess you're coming down in traffic. Thank you for 
being here. Of course, you've worked a lot of this in your 
other subcommittees. We appreciate you being here today.
    Mr. Shays. Mr. Chairman, I am very grateful that you're 
holding this hearing and I thank you for putting together such 
an excellent panel. I have an opening statement which I would 
like included in the record. I would just ask my--I would 
first----
    Mr. Tom Davis of Virginia. Without objection.
    Mr. Shays. In regards to the public health's 
infrastructure, the status report that we're discussing today, 
I want to read one paragraph that just think says a lot to me. 
It's on page 8. It says: ``work force demands on our Nation's 
public health information infrastructure has never been 
greater. Today, global travel, immigration, and commerce can 
move microbes and disease vectors around the world at jet 
speed; yet our public health surveillance systems still rely, 
in many cases, on time-consuming resource-intense pony express 
system of paper-based reporting and telephone calls.''
    I think that our world is under tremendous threat. Our 
country is. We basically have to protect ourselves from a lot 
of pathogens, just as we would protect ourselves from 
individuals or armies that might invade us. And the first issue 
I'm going to focus in on is the whole issue of monitoring. I'm 
led to believe, but I don't know if this is true, that we are 
in our--because I'm told it isn't, and I find when people 
respond to any questions that they're not doing it. Are we 
monitoring every major urban area's hospital, every day 
requiring them to give us the potential outbreaks that they 
might be encountering? So are we getting a handle on a 
potential outbreak? Because, obviously, if we do, then we have 
an easier time to respond. I throw it out to the panel and 
whoever would like to respond to it first would be welcome to. 
Could we perhaps, Doctor--with you, Dr. Sharrett.
    Dr. Sharrett. We do that daily with all of the hospitals.
    Mr. Shays. You want to use your mic.
    Dr. Sharrett. We do that daily. And you're right, it is 
labor-intensive. But all hospital emergency room visits and the 
intensive care units, all of that is monitored. We do it not 
only for diseases, but for disease syndromes, so anytime 
there's any indication of something that would cause you to 
suspect that there is a potential for any bioterrorism agent, 
then----
    Mr. Shays. Define to me ``we.'' Is it we, every hospital, 
through their public health director or--who is ``we''?
    Dr. Sharrett. We, the health department, in cooperation 
with the hospitals.
    Mr. Shays. You call them up every day. Do you say, what's 
your count? Do they call you if you don't get----
    Dr. Sharrett. We physically have a nurse that is in every 
hospital every morning, or else in touch with the hospital 
every morning. But if there's something that we think needs 
specifically going over, we will go to the hospital and go to 
the record. But we get that information every day.
    Mr. Shays. Mr. Regan--do I say it correctly, Regan? Among 
this panel I hope you realize you are first among equals. Hats 
off to you and the State for how you dealt with the West Nile 
Virus. Do you get involved in this issue of being aware of 
reporting, or do you only hear about it if there may be a 
particular problem?
    Mr. Regan. I get involved with it, particularly with 
working with our commissioner at the Department of Public 
Health, who again has outreach to the local hospitals and local 
communities, again, as the provider of the information 
technology infrastructure. Anytime there's a requirement for 
disseminating information through that infrastructure, I am 
hand in hand with the public health commissioner.
    Mr. Shays. We did a table-top exercise in Connecticut, and 
they do it in other areas, where we--in this case, we had a 
practice where all the communities were involved, the State and 
the Federal Government, and it was a chemical outbreak in an 
Amtrak train. The thing that amazed me most was the--when we 
got all done, the firemen knew what they intuitively should do; 
the policemen, we learned that they were the canary in the coal 
mine. That was a shock to them, too, to realize the hit. But 
the one thing that stood out the most to me was the health 
people, the hospitals, our health directors, they were the ones 
who were just kind of in left field, not because--in other 
words, they knew how to treat, but they were treated like the 
stepchild, with no disrespect to stepchildren, but in other 
words, they were not given the kind of respect and attention 
they should get. Communication was by one, you know, phone that 
might not work. Their systems didn't coordinate with the fire 
and police.
    Are we finding that is the case in other places besides 
Connecticut? Could someone speak to that?
    Dr. Wiesner. From NACCHO's perspective, Congressman, there 
is an enormous need to improve the uniformity of capability and 
capacity throughout the country for doing the kinds of things 
that you're talking about. For instance, in our three Centers 
for Public Health Preparedness--one in DeKalb County; 
Rochester, NY; and in Denver--even in those places that have 
been working at this for a couple years, there are needs for 
improving just exactly what you talk about.
    So there's an infrastructure improvement that is absolutely 
necessary. And the kind of description that you provide for it 
is, in the context, absolutely correct. I want to emphasize one 
piece, at least from our experience in DeKalb County, is that 
we take a view to this that we ought to be better prepared 
every day. I'm sure that's true in each health department. And 
so we build on past successes. We actually prepared for the 
Olympics and we had syndromic surveillance within our hospitals 
in 1996 around heat-related illness and working with the State 
on food-borne illness possibilities.
    Then almost all of the local health departments in the 
country, to one degree or another, worked on the Y2K problem. 
And we have--and then, of course, when the East Coast in 
particular experienced the West Nile Virus presence, we worked 
with our hospitals to set up syndromic surveillance related to 
that particular effort. But it must be much more uniform, and 
the investment in both the technology and in the work force is 
absolutely critical.
    Mr. Shays. Thank you. Thank you, Mr. Chairman.
    Mr. Tom Davis of Virginia. Thank you very much. Mr. Turner.
    Mr. Turner. Thank you, Mr. Chairman. Mr. Covert, give us 
your assessment of the preparedness of America's hospitals to 
deal with infectious contagious diseases that come to the 
emergency rooms of those hospitals. I've often had the fear 
that a lot of hospitals would just be closed down if we had 
somebody walk in with smallpox, and that would be the end of 
health care for that community. Are they better prepared than I 
understand them to be?
    Mr. Covert. To answer your question directly, I think we're 
getting better prepared. I would tell you that I had some of 
the same issues myself in the past, and in looking at gearing 
up. I think we are today, not only from infection control 
standpoint, but also in caring for patients. However, let me 
also say that in terms of the actual infrastructure that might 
be required, let's say if a smallpox--an individual presented 
themselves smallpox, the ability to isolate that patient and 
then care for them, I think that's going to be a challenge for 
many hospitals. And it's one of the issues that we say 
ourselves that we're going to have to do a better job of 
physically gearing up for. Do we have medical capabilities and 
strong infection control programs? The answer is absolutely 
yes. I'm confident in that regard. But the key is putting these 
other pieces in place to be able to isolate and then support in 
care of those patients.
    Mr. Turner. I gather that the larger, more urban hospitals 
would be better prepared to deal with that than many of our 
rural hospitals?
    Mr. Covert. I think that would be a fair statement only 
because of the resources that are generally made available in 
those kinds of settings. It does not mean that there are not 
some strong--and as you know from Texas, some strong regional 
rural institutions, but I would answer your question by saying 
yes, those institutions that normally would deal with these 
kind of issues every day are going to be significantly better 
prepared in responding to the unusual kinds of biological 
agents that we might be seeing. A lot of the traditional 
infection, the flu, the other things that we would see, 
hospitals are prepared and do respond every day in that regard.
    Mr. Turner. Mr. Regan, I think--Mr. Shays is not with us, 
but I was curious; you made reference to the 90-year-old lady 
who contracted anthrax and died, and it was suspected that that 
she contracted it because of cross-contamination of the mail. 
Was that ever verified and was the path of that--of her mail--
traced to the extent that it could have been determined whether 
it crossed the path of the letters that were sent here from New 
Jersey to Washington, or was that just speculation?
    Mr. Regan. It was not confirmed 100 percent, but there was 
a high probability that there was cross-contamination in that 
case, but could not be by the facts derived at the home--I 
don't think they could actually prove that they found any 
anthrax at her home.
    Mr. Turner. Was there an effort actually to track the path 
of that--of the mail that goes to her residence, to see if it 
went through locations where the letters that arrived here in 
Washington also may have traveled?
    Mr. Regan. Absolutely. In fact they were able to establish 
there was some cross-contamination through one of the 
processing centers in Connecticut from some of the mail from 
New Jersey. I think that's where they suspect that there may 
have been the cross-contamination that ended up at her house. 
But they were never able to substantially find enough evidence 
at the house to make that case.
    Mr. Turner. Thank you. Thank you, Mr. Chairman.
    Mr. Tom Davis of Virginia. Thank you very much. Mr. Horn.
    Mr. Horn. Thank you, Mr. Chairman. I think we're all 
talking in somewhat the same manner, because it's an 
involvement of information and getting involvement of the 
bureaucracies that you face in counties and States. We have an 
excellent FEMA operation at the Federal level, in my judgment, 
and most of the Governors are very good at the Office of 
Emergency Management. And certainly there's been a major role 
for chief information officers that we didn't have 10 years 
ago.
    I'd be curious with the following situation: I come from 
Los Angeles County, 10 million people, 83 cities; and the 
sheriff there, and the surrounding suburbs, which is another 10 
million from San Diego to Santa Barbara, and that has been done 
with pacts, compacts, and information in terms of telephone 
use, radio, all the rest. Sometimes when they have exercises, 
we find that, say, a few years ago, the communications were all 
on the East Coast in terms of their radio frequency. And that 
sort of gave the West a very difficult situation.
    So I'm curious in terms of the following: We do have a law 
that trucks that go across the country have what chemicals are 
in that so that if something happens, a fire department knows 
what they're dealing with. The same with facilities in most 
jurisdictions; everybody sort of knows. And in our case with 
the earthquakes, you never know when that's going to come. And 
it isn't easy.
    So I'm curious what the CIOs feel and the epidemiologists 
do with finding the information and spreading it to the right 
people at the right time. How do you feel about that, since 
you're all association leaders that are looking at it from a 
United States 50-State situation, not just your home situation, 
but you represent both. So I'm curious, Mr. Regan, do you feel 
that the CIO situation is well represented, or are there places 
still in the country where they can't seem to get their 
computing going?
    Mr. Regan. I think, again representing the CIOs, certainly 
it is a relatively new position in States over the last 5 to 6 
years. I think what our Association has found out and, as is 
the case in Connecticut, those CIOs that are at Cabinet level, 
that report directly to the Governor, that have enterprise 
responsibility for infrastructures across many governmental 
functions--again, I'm not a doctor, I don't necessarily have a 
stake in public health, but I provide services to public 
health, I provide services to public safety, transportation, 
labor, department of banking, all spectrums of government. So I 
think that, again, if CIOs--and it's more predominant now than 
it has been ever--have again a seat at the table with the 
Governors, with the other Cabinet officials that can look from 
a broad perspective to deal with these--the multitude of issues 
and look for, again, effective and efficient solutions across 
that spectrum that again looks across the horizontal, is where 
State CIOs have been very effective.
    The issue that you brought up in the frequency spectrum, 
I'm surprised because we have the situation in Connecticut--I 
thought it was the West Coast that had all the frequencies, 
because it certainly has been a challenge. When September 11th 
happened, there was some issues in terms of communication on 
the wireless systems across the local and State police systems, 
particularly in Fairfield County, which was, again, the doorway 
to New York City from Connecticut.
    Mr. Horn. Have the CIOs looked at the September 11th 
situation nationwide and, if so, what are they; and should we 
and you be looking at the FCC to see what can be done?
    Mr. Regan. We certainly have. In fact, a month ago at this 
time, the CIOs met in Washington to essentially focus on 
security and critical infrastructure protection. One of the 
components of that, again, is the ability to communicate the 
wireless. It was not, again, the focal point, but we looked at 
all the considerations of how States need to coordinate our 
activities better; who do we coordinate with the Federal 
Government?
    It has been unclear, I think, with the appointment of 
Richard Clarke, who works in the Office of Homeland Security 
and cybersecurity and terrorism, it's starting to become more 
clear, but it still is sometimes very frustrating to find an 
answer when you're dealing with our Federal counterparts. The 
States seem to have it together. We seem to be able to 
communicate very effectively. We're putting processes and plans 
in place to do just that. And, again, I think what our hope is 
is to be able to come provide some recommendations to the 
Congress, to help structure the way, again, we communicate with 
some of the Federal jurisdictions in this area.
    Mr. Horn. Now, your information can go pretty rapidly to 
rural parts of our States. But in terms of epidemiologists, Dr. 
Pezzino is not so easy. And the question would be, if they 
don't have laboratories in the part of the State--let's say 
Wyoming, even California, part of it is rural, and Utah, 
Arizona, so forth--are there kits or something that can be put 
together where, either using a high school chemistry lab or 
biological lab, and see if certain cases with the local 
hospital, or they--if they have a local hospital, and sometimes 
they are 200 miles away--even though some of them are veterans' 
hospitals and State hospitals, how do you feel about that in 
terms of what we could do on the spot to do it with a kit?
    Dr. Pezzino. Obviously, Congressman, we all wish that we 
had the magic test that could be used on the spot and give us 
within a few seconds the answer that we all want: Is this a 
real threat or what? I am firmly convinced that ruling out 
false threats is as important as recognizing true threats. 
Unfortunately, that's not available. And there are a lot of 
people at work doing research at an advanced stage, and some 
kits look very promising. But right now there is really nothing 
that can assure us that something found on the spot is or is 
not a threat.
    I think when you're talking about laboratories, things look 
a little better, because one of the purposes of the 
bioterrorism initiative that was funded through CDC and other 
sources is to create a laboratory network that reaches down to 
the local hospital level and can assure that is happening and 
has happened. It has been tested in the last months and is 
working. So most laboratory tests can be done in local 
hospitals. And then if they're not fully negative, then it 
would have to be sent to a reference hospital, which is usually 
the State health department or public health laboratory. But at 
least they are able to rule out what is not a threat.
    I also totally agree with Mr. Regan's assessment. I think 
communication within the State and within the State government 
is actually not as problematic as communication among States 
and other Federal partners, and also communication with private 
partners. That's really one of the weak points that I recognize 
in my testimony. I think that's where we have to put a lot of 
efforts, because I have no problem at this point in reaching 
out to my hospitals in my State, or my local health 
departments, and my challenge is how to reach out to the 
physicians who are in the front line of this work.
    Mr. Horn. Mr. Wiesner, you represent the county and city 
health officials, and, Mr. Covert, you represent the American 
Hospital Association. As I recall, there's accreditation 
standards for various hospitals. Is that most hospitals have 
that, or are there some that aren't up to the accreditation?
    Mr. Covert. In response to your question, Congressman, most 
hospitals almost all have accreditations. And you're referring 
to the acute care, but also in terms of a number of other 
specialty hospitals as well. It is very few that are not 
accredited or do not choose to go through that. Remember, all 
of them are required through our HHS to have some level of 
accreditation in order to be able to receive Medicare funding.
    Mr. Horn. Well, some of the things we've all talked about, 
would it be right that the next go-around, we have certain 
questions for accreditation and, if so, what have you learned 
to put in?
    Mr. Covert. Let me share with you, that is actually an 
issue right now that I know that the American Hospital 
Association and the Joint Commission is actually looking at, 
and to establish a task force that will look through to ask 
those questions as you go through that accreditation process in 
order to be able to respond to the issues that you're raising. 
And I think that hospitals will do well as they're gearing up 
and moving forward. But in answer to your question, yes, that 
is happening right now.
    Mr. Horn. My subcommittee has jurisdiction over the 
federalism of the country. One of the things we're having the 
General Accounting Office do is look at some of the radiation 
situation that could be breaking loose--the biological, the 
chemical, and the water supply. That's all over the United 
States. And if we have these nuts running loose, we need to do 
something besides just a fence around the reservoir. And what 
happens when something happens to the water supply? Are there 
any of your committees within your associations that are 
looking at that?
    Mr. Covert. In terms of each of these respective areas, I 
think they're now beginning that process of gearing up. There 
have always been accreditation standards and licensure 
requirements for us to meet and to respond to. So that first 
basic level, let me give you a level of comfort that it's 
there. However, in terms of taking those additional steps and 
how we prepare and then secure, and how would you deal with the 
effects of contaminated water supply, as an example as you've 
brought up, or changes in power supply, that we'd have to 
respond to. I think hospitals now, as part of their disaster 
planning, are actually doing that on an individual basis, not 
just simply what's happening at the national level.
    I think that you will see in the next year, as we're going 
through this process, either accreditation requirements or 
standards expected of respected institutions and how you 
respond to those issues, and how you tie that into the entire, 
obviously, public health setting that we look to.
    Mr. Horn. Does every hospital in the United States have a 
temporary energy supply based on diesel or whatever to keep the 
lights going and all the rest of the things?
    Mr. Covert. All hospitals are required--you'll see this at 
the State level as well as from the accreditation requirements, 
about having emergency backup and supplies to be able to 
support your OR and emergency room, and to have a certain level 
or extent of supply, whether that is appropriate backup 
generators or whether that's oil or gas, inclusions associated 
with water, to be able to respond if you needed to for a period 
of time.
    I think the challenges coming for us is when it becomes an 
extended period of time then, that you might see from some kind 
of biological attack or situation that you have to respond to, 
that I think is going to be a challenge that we need to plan 
for. And that I think is one of the areas that the Hospital 
Association has commented on. Part of the costs associated with 
this is building that infrastructure, which doesn't exist 
today, beyond that very short-term capacity. And that's why you 
see, then, requests for significant number of dollars for 
individual hospitals to be able to respond to that question.
    Mr. Horn. Thank you, Mr. Chairman.
    Mr. Tom Davis of Virginia. Mr. Horn, thank you very much.
    Mr. Horn. Thank you. We appreciate the witnesses here. 
Great group.
    Mr. Tom Davis of Virginia. I have a technical question, 
probably everybody understands in the room but me, but I'm 
going to ask it. Rock, I'm asking you just because you're CIO. 
CDC initiatives like HAN or NEDS are Web-based. So if you use 
the existing infrastructure for these initiatives, what's the 
chance that a typical spike in Web usage at a time of an 
emergency would render these systems unusable just because 
you'd have a capacity issue?
    Mr. Regan. As we look at architecting these systems, that 
certainly is a critical element of how do you look at the 
spikes, particularly when you need it the most. We as 
information technology professionals do this every day. It's 
the same requirements for public safety. Again, if you have a 
public safety event, you want to make sure that you have the 
capacity, the ability to have capacity.
    Mr. Tom Davis of Virginia. We've seen how cell phones fail 
at that time.
    Mr. Regan. Yes, absolutely. That's a primary example. I 
think from an architectural standpoint, some of the things we 
look at is shutting down traffic that is not important traffic 
on a network so that, for instance, if you were to have other 
requests from other agencies like regulatory agencies in the 
event of a disaster, we would actually shut those parts of the 
network down to essentially guarantee network availability and 
system availability for those that need the information and 
need it now.
    Mr. Tom Davis of Virginia. I see. Rock, while I've got you 
a couple of other questions. I was under the impression CDC had 
sought substantial input from States and localities when they 
were developing HAN and the NEDS standards. Is it your point 
that the outreach might have extended to health officials but 
not the CIOs?
    Mr. Regan. I think that's exactly our point, is that a lot 
of the information that we're talking about here doesn't 
necessarily go directly to health officials. That, again, there 
are other elements in government that have to have the 
information available to them at the right point in time. 
Again, as CIOs, we provide services to a cross-spectrum of 
government. So when we look at creating these standards, while 
they're, I'm sure--in fact, I know they're very good 
standards--they are, in fact, to some degree stovepipe 
standards in this element. We certainly would like to look 
across the spectrum in other instances where we have standards 
in terms of how they fit.
    Mr. Tom Davis of Virginia. OK. Dr. Pezzino, several States 
have not yet signed onto implementing NEDS. How widespread is 
acceptance in the public health care community of the NEDs 
architecture, and do you suggest to CDC anything they can do to 
obtain more widespread acceptance?
    Dr. Pezzino. I think actually most States have accepted the 
NEDs architecture as an important step toward standardization. 
Certainly I would say all States recognize the need for 
standardization. The main issue when it comes to implementation 
is, obviously, funding. Unfortunately, there were only a few 
States that were funded when their application for funds was 
turned into the CDC, and there were at least 25 States that 
applied for NEDS money last year and didn't get any funding 
because of lack of money. So I think what you are seeing is not 
so much a result of a lack of motivation, but more a lack of 
funding.
    Mr. Tom Davis of Virginia. Let me ask you this. How 
extensively are the Epi-X updates available through mobile 
communication devices? The CDC indicated that Epi-X experienced 
significant challenges on September 11th because many State, 
you know, health officials were forced to evacuate their 
offices and they didn't have plans in place for offsite access.
    Dr. Pezzino. That is true. That is certainly one limitation 
of the system. At present, there is absolutely no capability to 
make Epi-X available for mobile devices. Another weakness of 
the Epi-X project is that it doesn't allow any communication 
between States and their local health departments. That's why 
we are really strongly supporting an expansion of the Epi-X 
project to include local health departments, to have State 
levels of Epi-X that can act almost as independent parts of one 
bigger picture.
    Again, I'm afraid I have to go back to the previous issue 
of funding. The Epi-X project has had little or no funding at 
all. It was never, to my knowledge----
    Mr. Tom Davis of Virginia. Just ask you to do the same 
thing--ask you to do more with the same amounts of money.
    Dr. Pezzino. There was not indicated funding for Epi-X. It 
was internal money that CDC was able to mobilize.
    Mr. Tom Davis of Virginia. Dr. Wiesner, let me ask this: 
What's the status of the core capacities for bioterrorism 
preparedness for local public health systems?
    Dr. Wiesner. That's an important question because the 
capacity measures are actually part of a broader effort of 
measuring the performance of infrastructure. And it actually is 
linked to the earlier question of being able to move health 
departments to some form of voluntary or formal accreditation.
    The situation, as far as the specific performance 
indicators for bioterrorism, is that a continuing assessment is 
occurring and there are just large areas for improvement, some 
of which we've incorporated into the testimony that you've 
heard earlier, or the written testimony.
    Mr. Tom Davis of Virginia. OK. HIPAA has mandated certain 
information sharing and security standards for health care. Do 
you feel there's a need for a similar regulation within public 
health that not only mandates standardization across public 
health but also ties back to uniform standards with health 
care?
    Dr. Wiesner. Well, I think to the degree that local health 
departments are engaged in the provision of personal services, 
we are already subjected to the HIPAA regulation. Our 
experience with the current threats that we're talking about 
really does beg for at least a reexamination or looking 
carefully at the HIPAA regulation.
    With regard to the importance of being able to receive 
real-time syndromic surveillance for the protection of the 
community for bioterrorism threats, we believe that we have the 
current authority to receive those with the HIPAA regulations 
as they are presently stated.
    Mr. Tom Davis of Virginia. OK. Mr. Covert, would you agree 
with that?
    Mr. Covert. Mr. Chairman, I would. And I would also add 
that I think it's going to be a tremendous challenge for us. 
We're not just dealing with issues of consent forms, we're also 
talking about that transmission of that information oftentimes 
is literally to an individual patient as you then aggregate 
that data to use it. If you look at the regulations today, 
there's some question about our abilities to be able to do 
that.
    I guess I should make one other comment. It's not that we 
have a problem with issues of privacy or confidentiality 
whatsoever, but when the regulations themselves and then the 
paperwork and the bureaucracy that goes with it actually, truly 
get in the way of caring for patients, real time, then that's a 
challenge for us to address.
    So I think that--and as I've shared with the regulatory 
task force staff folks--Christine Schmidt, who is going to 
chair Secretary Thompson's task force--is we need better 
guidance, better clarification on those guidelines, so that we 
can apply them appropriately, not just in the event of an 
attack as a result of bioterrorism, but every day.
    The dollars that we're talking about spending, even at the 
Hospital Center alone just to comply with regulations--several 
millions of dollars not even related to the issues that we are 
here talking about today from an infrastructure standpoint, 
from an information systems standpoint--is going to be 
significantly greater. So I think it's going to be a challenge. 
And I would agree with Dr. Wiesner.
    Mr. Tom Davis of Virginia. Thank you very much. Dr. 
Sharrett, in your statement you noted that the county health 
department in Fairfax lacks the ability to seamlessly connect 
the local, State, and Federal data systems as well as the 
capacity to send and receive confidential health information 
and to broadcast health alerts. What initiatives do you see the 
Commonwealth of Virginia doing to improve that situation? Do 
you know what I'm talking about?
    Dr. Sharrett. Yes, I do know what you're talking about. I 
think that's a difficult question because it goes into 
confidentiality issues. And again, I think we need new systems 
that are secure, and funding to acquire those new systems. And 
I don't know, in relation to privacy, when you have a national 
emergency that perhaps some of that would----
    Mr. Tom Davis of Virginia. Get compromised. OK. I think in 
your testimony you noted that an important communication was 
delayed because there wasn't a clear understanding of who was 
in charge. To your knowledge, if you see any changes that have 
been made to address the problem from where you sit?
    Dr. Sharrett. I guess I'm not aware of that. From----
    Mr. Tom Davis of Virginia. It will almost take another 
emergency to find out.
    Dr. Sharrett. Well, other people may know. I must say I do 
not know that. One of the problems that we had was, related to 
communicating with the post office. And, how you cross from CDC 
recommendations to implementation within the post office and 
having someone directly in charge of all of that was an issue. 
And I don't know if that is--I can't say that has been 
resolved.
    Mr. Tom Davis of Virginia. OK. Thank you.
    Let me turn to Dr. Saunders for a minute. EDS's 
recommendations for mitigating terrorism seem really far-
reaching and, I would say, forward-thinking. But fully 
implementing those recommendations would likely be costly and, 
from a governmental perspective, probably not feasible in the 
short term.
    Has EDS researched the cost and time required to implement 
these solutions and, if you've given any thought, what would be 
your highest priority?
    Dr. Saunders. I view where we need to go is a journey 
rather than something that's going to be accomplished next 
year. It is important to have a vision in mind as we overhaul 
our public health infrastructure. You know, the challenge is to 
think about what the goals and vision are for the system that 
we want in the United States next year, 5 years, 10 years, so 
that all of these are part of some logical plan. So I wouldn't 
say that the costs and the time-lines are fully scoped out, but 
it's probably, a 5 to 10 year journey for a lot of these 
different components.
    Probably the highest priority would be the kinds of things 
that the health initiative is focusing on, which gets to real-
time surveillance of critical reportable events. But it needs 
to be a two-way street for returning that information to care 
workers so that they can actually make use of that information 
and make some impact in the care environment. That would be the 
highest priority.
    Mr. Tom Davis of Virginia. Thank you very much. Mr. Turner.
    Mr. Turner. Mr. Saunders, there is one other item you 
mention in your statement, the biometric human identification 
system. Give us a little insight on the state-of-the-art in 
biometric human identification.
    Dr. Saunders. EDS has been involved in implementing 
biometric systems. For example, the system--the biometric 
system in use at Ben Gurion Airport in Tel Aviv, for example, 
is implemented by EDS. That involves hand recognition. There 
are other elements that we've done in a couple of other places 
as well, including the face identification.
    I mentioned that which you're referring to because I think 
the technology is evolving very rapidly, and there are 
ultimately some limitations to biometrics that we know of.
    The thumb and face are not always capturable in some 
circumstances, based on the conditions in which those are 
captured. Oftentimes, we have people that need identifications 
who can't communicate soft data elements, or maybe that body 
parts have been damaged so that they can't really provide a 
biometric source.
    So I think at some point we are going to have to look at--
not this year, next year or so in the future--how we 
incorporate elements that are 100 percent gold standard like 
DNA information in selected circumstances--whether it is 
identification of body parts at the scene of the World Trade 
Center or other types of things, and the ability to link that 
to law enforcement and terrorist data bases.
    I mentioned that because I think the opportunity to start 
thinking down the road of things like DNA data banking--as a 
part of our biometric human identification system--is something 
that we ought to look at.
    Mr. Turner. You, of course, are familiar with the efforts 
of the CDC. And testimony today talked about three of their 
major initiatives. Do you see anything about those initiatives 
that you could offer suggestions for improvement, and are they 
consistent with moving to the next step, which seems to be what 
you are talking about in your testimony? Is there anything that 
would be conflicting or inconsistent with that move?
    Mr. Saunders. I think that there is nothing inconsistent. 
These are good first steps, but the focus of this has been 
around bioterrorism. And as an emergency physician, I can tell 
you that is a tiny, tiny slice of the kinds of problems that we 
deal with every day that have a critical public health impact.
    There are also hazmat circumstances. There are 
multicasualty incidents. There is tuberculosis and all of those 
sorts of the things that would benefit from the same kind of 
infrastructure, not just around bioterrorism. So how can the 
scope of this be appropriately broadened to serve a greater 
public health need if we are laying down this infrastructure? I 
think that would be an important issue.
    The other issue I think is going to be that the devil is in 
the details on those things. When we get into the actual 
challenge of integration into care systems: we are going to 
find a lot of very challenging issues, dealing with master 
person indexes and the multiple different ways that the same 
person is represented in different systems and resolving those 
challenges; and maintaining interfaces to those systems. Who is 
going to pay for it is going to be very difficult. So the devil 
is in the details.
    Mr. Turner. Thank you.
    Thank you, Mr. Chairman.
    Mr. Tom Davis of Virginia. Thank you very much.
    Mr. Shays. Thank you again, Mr. Chairman, for holding this 
hearing. I--I would like to--we wrestled shortly after 
September 11th as to what to tell people, and it is amazing the 
quantum leap we have come. Shortly after, some of us were 
saying what we felt to be the truth, which was it is not a 
matter of if there will be a chemical or biological attack, it 
is a question of when, where and of what magnitude, and our 
view was you tell the American people the truth, and, like 
adults, they will tell you to do the right thing.
    And our view was that people aren't going to realize this 
is a war unless you tell them why it is a war. It is a war 
because we are in a race with the terrorists to shut them down 
before they develop the delivery system for chemical or 
biological agents or, heaven forbid, get radioactive material 
in a dirty bomb or nuclear weapon. So that is why we are 
fighting this.
    What I want to ask you all is, how--besides this 
infrastructure that we want to develop, what kind of debates 
did you start to find as we--as to who should disseminate this 
information and who should have it and so on.
    Maybe, Mr. Regan, I could ask you first. I mean--for 
instance, with anthrax, was it viewed that it was important 
that the Governor be the one to talk about the woman who was 
afflicted in Oxford?
    Mr. Regan. The Governor certainly made that decision to be 
the focal point of disseminating the information. And, again, 
as part of that he clearly made it understood as to who was 
going to deal with the communication at the local level. So it 
was the public health commissioner and the Governor who made 
that decision based on the information that came to them.
    Mr. Shays. The local health director in the Oxford area?
    Mr. Regan. Oxford as well as the commissioner of public 
health for the State of Connecticut.
    Mr. Shays. Do you all get involved in any of these debates 
as to who should be providing this information, or can you tell 
us any anecdotes about how you are trying to resolve those 
issues?
    Mr. Wiesner. From NACCHO's perspective, the most important 
piece there is to actually have a plan for doing that ahead of 
time, and that is one of the things that has occurred as a 
result of our starting in 1999 in DeKalb County with a plan.
    Mr. Shays. Intuitively I could be able to tell you why I 
think you do that, but I would like you to put it in your own 
words. Why was it important to be prepared to do that and know 
who would do it before the crisis occurred?
    Mr. Wiesner. Because the public needs a credible 
spokesperson that has timely and accurate information. And one 
other related factor to that----
    Mr. Shays. I just want to emphasize your point about not 
just being accurate, but it being timely as well.
    Mr. Wiesner. One other factor about that. At the local 
health department level throughout the country, we have to 
increase our capacity of working with the media and 
establishing those relationships at the local level.
    I was surprised during the anthrax things where we didn't 
have anthrax in our area. The nearest case was 300 miles away, 
and we had significant media interaction around this. I had 
complete strangers that I didn't even know coming up to me and 
saying, Dr. Wiesner, I am happy that you are on the television 
because I have seen you before, and I recognize that what you 
were saying was useful and in the interest of the health. That 
is what we call the local presence for public health in the 
community.
    And we really need to be sure that is uniform. Now, that is 
a different level when you are speaking at the State and 
national level. I remember very clearly a discussion with our 
public safety director on one of these roundtable--tabletop 
exercises where we had public safety people, hospital people, 
private physicians, and somebody said, well, who is going to 
speak to the press? And--you know, as part of that exercise. 
And they looked to the local health director in that particular 
scenario that we were dealing with.
    But the most important piece is that you have a plan 
beforehand, and that you have incident command that includes 
communication and media relationships in your plan.
    Mr. Shays. May the record note that Mr. Covert has been 
nodding his head the whole time that you have been speaking. I 
don't know if you want to add anything.
    Mr. Covert. Congressman, I would agree with Dr. Wiesner. 
Thank you. I know, even from your own experiences internally, 
and obviously being in the middle of D.C. and having the press 
right there, the pressures that the institution faces to 
respond to the community.
    On the other hand, when you only have a piece of the larger 
information as to what is going on, you really need to look--
you need to be able to look to the--to your public health 
leadership to be able to provide--not only to calm fears, but 
to provide good information and accurate information as to what 
is happening.
    I think that is one of the things why I tried to emphasize 
in the testimony of incorporating hospitals literally into that 
infrastructure so that you have that group together and plan 
together in how you effectively communicate, because you should 
be able to look to your public health leadership. My bias is, 
having been a former health director, you want to be able to 
respond in an accurate and, if I can only reinforce exactly 
what you said, in a timely way, and I think that was part of 
our frustration here during those early days was that ability 
to be able to put out information in a timely way.
    I would also make one other comment to you that I think 
becomes a challenge for this body as we walk through this is 
the issue of jurisdiction. I know you heard from Dr. Sharrett 
and the issues in northern Virginia. We had those exact same 
issues in Maryland. We have those exact issues in D.C., and who 
was going to then represent exactly what was happening, again, 
using the term Nation's Capital area.
    I can take and apply that same situation, Congressman, to 
an area far away from here in--let's say in the heartland. What 
would I do if I was the Quad Cities or some other area along 
the way in terms of who would be in charge, for example, of 
trying to share that kind of information, particularly if it 
would be dealing with the kind of threat that would expand over 
the boundaries that Dr. Wiesner had talked about.
    So I would concur with you that there needs to be better 
direction in that regard. I think we should be able to look to 
our public health leadership, and that it does need to be 
planned in advance.
    I think we can take a lesson also, to some extent, from 
what we have learned from those entities, those settings where 
you see major disasters in the past, let's recall them, 
weather-related kinds of disasters where they have learned to 
kind of have to come together to be able to then respond. This 
is a different issue, but the same principles would apply.
    Mr. Shays. Let me quickly--I am not sure if I have a second 
more, but--maybe I will get no answer here, but is there anyone 
on this panel that would argue that not telling the--I will say 
it in the positive--that telling the truth in the long run ends 
up to be essential, and that the attempt to gloss it over, 
understate it and so on doesn't end up to result in some 
problems in the future? In other words, is truth the best 
policy when it comes to disclosing the public health care 
threat?
    Dr. Sharrett. Absolutely.
    Mr. Shays. Absolutely. Yes. A lot of nodding of the heads.
    Thank you, Mr. Chairman.
    Mr. Tom Davis of Virginia. Mr. Horn.
    Mr. Horn. Thank you, Mr. Chairman.
    I just want to say that I watched very closely what was 
done in the Washington area. The Mayor, I thought, did an 
excellent job, and when people were sort of ducking some of the 
questions, he had the health authorities right there. And I 
think since the Mayor is well known, through--by his citizens, 
that is one good way, because he is very articulate.
    Mr. Tom Davis of Virginia. Well, thank you very much. This 
has been a lively discussion, and I appreciate all of the 
testimony in your followup answers to the questions that were 
posed to you.
    Before we close, I want to again thank everybody for 
attending the oversight hearing today. I want to thank the 
witnesses. I want to think my counterpart, ranking member, 
Congressman Turner, and the other Members for staying here 
through the hearing and participating.
    I want to thank my staff again for organizing this. It has 
been very productive. And, again, you will have up to 10 days, 
if you want to supplement anything you said, anything occurs to 
you you want to get in the record, we will be happy to do that.
    These proceedings are closed.
    [Whereupon, at 12:10 p.m., the subcommittee was adjourned.]
    [Additional information submitted for the hearing record 
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