put him in their spots in the administration. would be truly coordinated but absent that we're looking for other alternatives. >> in terms of leadership i think one of the things the leadership provides is i had the good fortune or the opportunity to be able to watch transition and administrations to see what happens as administrations change. i also was able to see firsthand h1n1, deepwater horizon, the haiti earthquake, fukushima. and got to see firsthand how what it feels like when a disaster unfolds. and you watch it stutter, and unfolded while it was unfolding we would have conversations some of us in biodefense and say, it's 24 hours past the point which is thing we first heard about this event. has this been a pirated event? we would've been pretty much antibiotic distribution and the

specific do you think we could've done it within 24 hours? then we look at the information that we had at the moment that we heard about the event and the first 24 hours, 48 hours and you watched how the information changed and you saw that most of the time the initial information was not 100% correct. and evolves over time. so you are dealing with this evolving situation, uncertainty ambiguity, yet you still need act. and i think the importance of leadership is in that type of an environment where the information is never going to be complete but it's going to be inexact. is going to be a lot of ambiguity. you will be looking through the fog. you are going to need to be able to give advice or someone is going to need to be able to give advice to leadership in terms of options of actions. that needs to be as informed as it can be. so i think having someone like a bobcat like who's been in

biodefense for a long time uzbek bob kadlec, or an individual like they been able to offer that kind of advice. i think it's important. >> is there anything that the person needs in regards to budgetary authority? >> it's hard to get things done without the ability to control dollars. and so i think having some influence in some way of being able to move resources to direct them towards the problem but if you identify nation which can't swing resources, it's probably not going to get done. >> can you say but what you deserved -- which observed at the department level and prepared as an particular measures, countermeasures that might be helpful? >> i would be happy to. i want to touch on the anthrax and counter bush delivered to there really are two theaters of activity taking place at the top of an anthrax attack. talk about the postal hhs

consideration. there's the issue of actual taking of individual contracted the disease. that's difficult. there's a concept which is a classically preventive medicine, the diet to the idea is that maybe exposure, you want to get countermeasure in the individual to present -- prevent the disease manifestation but you eliminate a lot of morbidity mortality. what i saw at the department level with this was that i think when we talk about, we've mentioned health care coalitions to your target everybody that applies to and supports health care systems. it's a based initiatives and folks who do logistics requirements and support all of that enterprise. that's a big animal. i think what you want to do is bring us me of the support capability to the table. carter mecher the collaboration between the united states postal service and health and human services. i want to point out that was not

something that was federally driven. it was actually identified i a local jurisdictions that this was part of not in lieu of, using pharmacies or points of dispensing radio those other initiatives. it was an adjunct to them based on the considerations of the local, general or public health director as far as their overall countermeasure delivery platform. the thought was perhaps it would be a population because of mobility issues or geography or something might want his delivery to instead of a poll out of to a location. i won't speak for them the voice of this but the jurisdictions that subscribe to this and implemented they were successful and they thought that a very good working model, and i agree. it looked very good. doctor parker mentioned idea of culture change. this is what we're talking about. that was what is getting at when i talked about the idea of pulling in some sort of training requirement or some sort of potential and element necessary

with these boards to actually provide that none could come if you will, of the biodefense as part of the other duty as the sun to what we're talking here is a 21st century civil defense construct within health care community. not a bad idea. as with all things the particulars will be the success or the into doing. and from the state department and from a local department standpoint, i think which have to do is allow in of latitude for a local to make tactical decisions that will work. chief, you can probably support me on this, but i think states can become sort of the ongoing capability it's easier for the issuance of funds and requirements to go out that way but i think at the federal it's important make sure we allow that latitude for the execution of those duties so that they are effective. because this is a very diverse

country in terms of both its requirements and frankly it's resources depending on where you are. i think keeping that in mind will probably help. >> how constraining of the scope of practice will -- one of the things which are suggesting works as long as you are not narrow scope of practice rules for what health professionals can do. >> okay. so i would distinguish just very quickly, i would dissent is what we talk about with the scope of practice. superposition are individuals who have autonomy of practice, generally speaking there's a great deal of latitude. the restrictions for those individuals are determined in the civil courts and quite frankly than by the criminal behavior, some sort of evaluation by the state board on a case-by-case basis. states that those limits, and when i mentioned the study% of the university of maryland about the advanced practitioner latitudes, they were distinct

they were very, very different. and so when i talk about autonomy practice, that's one grew. then there are what used to be classically the physician extenders, practitioners, individuals of function in much the same way but even if some sort of supervised degree or have some sort of arrangement. that's changing to some degree in the united states and it depends on the state. so it's hard to answer that question in totality. that's what i'm offering so much qualification is that you then get into sort of tactical training and that's never different kind of construct. that requires if you will protocol driven, symptom driven. the answer is how do you do that? that's why going back to the border the folks at issue licensure but if that's a piece of the required cme is for a license to renew our efforts for new graduates to that as a part of the curriculum that might be the best way to do it spent if

you look what's happening in health care that are less blessed independent practitioners, the autonomy is, they are part of larger practices or aca's or acos or they are employees. >> that's quite true. that said, even if they are employed they can do what they do unless they have their licensure. and so that's why i am saying rather than making it part of a social organization or a guild or something of that nature that i think the licensing board that allows them into of that employment is probably the most effective way to do it although there are many. >> very helpful and very provocative. i think we can keep it there for the next couple of hours but we're going to move onto the second panel. as they come forward, we thank you for your participation today and your contribution. thank you very much. thank you. [applause] >> the next that will involve the public health response, and

we are three distinguished individuals who will join us. doctor mckinney deputy commissioner of the chicago department of health. ms. melissa hearst, hearst consulted, dr. james senior partner of martin and associates, former commander surgeon of the north american aerospace defense command u.s. northern command department of defense. we invite you to come forward. will 20 minutes be all right? want to try and catch lunch hour. a lot going on. [inaudible conversations]

>> [inaudible conversations] i realize your scheduled events has been a break but we're going to try to keep this moving. we've got five very system which battles so don't want to change -- short change them. mademade we can get made we can catch them in or to an break for all of 10 minutes for lunch. but we are going to proceed with our second panel the public health response and doctor mckinney, we would like to proceed with you first. >> i would like to start with dr. bush. >> listen, we do as instructed. we can do construction up here believe it or not. >> thank you mr. secretary. and i will be continuing some of

the themes of hospital preparedness and hopefully provide a transition to public health response. since leaving government i've been fortunate enjoy teaching public health and other topics. i'm delighted to be able to speak with you today on a topic i consider to be a key importance to our nation, especially when we experience another blow event such as the ball or other significant natural or man-made disasters and the topic is resilient hospitals. if the opening chapters of the celebrated book five days of memorial the author recounts in detail the or by fax of life and death in the storm ravaged hospital, post-hurricane katrina. she describes major medical so without electricity, clean water, wastewater treated ventilation under limited communication, supplies and transmission. patients deprived of life-saving

technology lingered and then died in the heat a nightmarish scenario indeed -- >> can everybody hear in the backcourt very good. thank you. just double checking. you are good spent of the 60 grid infrastructure sectors, health and public health is important in the immediate disaster response and recovery. the population that we served, both critically ill and injured hospitalized patients are arguably the most vulnerable segment of our society. the of the reason perhaps we need to focus on resilient hospitals today is that the sector is one of increasing complexity and relies on a combination of support from the other sectors, especially the power grid and a reliance on moment to moment connectivity with information technology and the internet. i will refer to that as i.t. so resiliency for our purposes working definition is the ability to take a blow and come back.

resilient hospitals are able to prepare for and adapt to changing conditions and withstand and recover rapidly from disruptions. not just hospitals of course should be considered but health care facilities, all types are vulnerable. nations receive care in a variety of different facility include a long-term care, nursing homes, clinics, and increasingly at home. it is not just the physical structure which must withstand table and come back but we need resilient staff, resilient management resilient plans and planning. and naval aviator friend told me once that truly superior pilots plan ahead to avoid those situations where they might have to use their superior skills. hospitals and their staffs have repeatedly shown superior skills in disasters, but we would prefer to have less the roads and more routine activity carried out according to the plan. of course, this is an all hazards approach to referring to

a variety of different threats against hospitals. hospitals have unique vulnerabilities. patients are more sensitive to changes in nevada, temperature humidity, noise, et cetera. the very young, the very old and, of course, the very sick have very different requirements requirements. some patients have to be isolated from others ended separate ventilation system changing rooms as we saw in cases of ebola. some patients rely on other specialist technology with a limited a battery supply of perhaps several hours. so when the power goes off if -- its backup generators eventually run down as well. another vulnerability, to devices connected to the internet is that some medical devices to include some life-sustaining medical devices can be hacked remotely either turned off or the setting changed.

when the power goes completely off, hospitals quickly become dark and dangerous places. most backup electrical generators are designed for no more than orgy-72 hours of continuous operations after that they probably need -- 48-72. another unique issue of hospitals is the evacuation of critically ill patients connected to life support. when only one or two facilities are no longer able to care for patients, the option remains to evacuate. when health care facilities across an entire region are affected, we have to be able to continue to provide care in place but one example where we saw this was the hospitals admittedly were able to discharge those of lesser iq but held back because of the difficulty of evacuation those patients were on life support until basically we reached the

limit for aeromedical evacuation to electronic medical records stored in a cloud can be both a help and interest. when i.t. systems and access to the internet stop, modern medicine as we know it ceases to exist. although valuable patient records and other data makes it somewhere out there on a server inability to access the retrieved data stops are this is usual. the ability to record and store nation demographic and clinical information on a secure handheld device, especially in mass casualty, is essential. the data can be downloaded later or sent to another device with internet con activity is restored. tracking of patients and their accounting family members is particularly important when facilities are being evacuated. otherwise we may have to revert back to paper records and clipboards which were both used in the shooting incident in a roar colorado a couple of years ago. less effective perhaps that

ability to revert back to another legacy system is also an indicator of resiliency. i might go on to say that it's this integration of information from the hospital to ems to public health responders needs to be shared across the board and that's really the key to success. and a point made earlier just in time supply chain public hates disaster health care delivery. and the need for cost effectiveness complicates resiliency. because it is more cost effective to have vendors deliver supplies just in time there is less waste and less wasted shelf space. the days of large stocks of iv fluids pharmaceuticals disposables are gone. and said vendors may obtain supplies from multiple sources both domestic and overseas, and those vendors in turn have a supply chain from even more

obscure sources. and i.t. systems connected them all. as systems become increasingly complex, they are also increasingly fragile. and for now failed missions such as disaster health care communications, intensive care units, life support emergency rooms, we need redundancy and additional capability. this capability could include more trained staff commitment supplies and house, functions within the hospital are then prioritized as mission-critical or non-mission-critical such as we do in the military. and function of lower priority may need to be turned off in an orderly manner, as in the phrase failing gracefully which is already practice. all this of course adds to business costs staff hours overhead liability can represent an additional risk to the hospital but very briefly i

just attend a risk management meeting reserve it was conducted among ceos, cfos and a new term, crl, chief risk officer number one were costs associated with regulation to number two interesting, were cyber threats and number three, for these business leaders were infectious diseases. alternate technologies can be useful in a disaster if they are baked in. ppd 21 promotes research and development to enable the secure and resilient design and construction of critical infrastructure and more secure a company cyber technology. now as an example an architectural firm based in boston is assigning hospitals from the ground up which have more natural ventilation and lighting are more spending in the water, and have reduced

requirement for wastewater treatment. some of these hospitals include a thermal tower which polls it to the facility without the use of lectures at the have large fans in common areas in case this doesn't work. the day-to-day electricity requirements for these hospitals are much less more the hospitals on ground level. patients can be moved more easily without the use of elevators. why is this technology that is more commonly? because these hospitals are being designed for third world applications and locations situations in africa and elsewhere. these countries that experienced disaster loss of life more frequently than we do here benefit from this technology. certain at that patients of this type of technology are needed here to make our hospitals more resilient. these technologies are appropriate and resource saving all of the time and do not have to be turned on in a disaster.

micro grids, another example of technology useful all of the time is a backup electrical generation system incorporating conventional diesel generators, renewables, batteries and the ability to push power back into the grid with possible associated cost savings. these micro grids are less susceptible to hacker attacks and electromagnetic pulse emp as well. i've seen one of these systems seamlessly transition from providing power for a large portion of the military base to putting power back into the grid and then stored energy in batteries. they also have the ability for portions of the system to go off-line for a. of time so that they can be maintained and refueled. remember that was a problem in superstorm sandy. currently department of defense has such a joint capability

technology demonstration rjc td, which could be adapted for use in a large medical campus. for example and i could discuss that subject further if you're interested. system of systems approach is needed a for the site i like to use when giving summer talks is one showing that there is a critical infrastructure sector stacked on top of each other with lines of interconnectedness. so, for example, power grid relies upon transportation transportation is connected to water, the water sector meet electricity and i.t. connects all of them. health care may not directly affect all the other sectors but it's fair to say that all the other sectors affect health care. especially vulnerable in a disaster our patients at home or in a long-term care facility which must have an electrical outlet for life-sustaining

technology such as ventilators oxygen generators, and real dialysis. >> if i could ask you to summarize. we will submit your entire record for the -- test me for the record. there's a lot of questionable to the direct of this bill so if you would be kind enough to do that for me i would appreciate it good i just want to speak in favor as other speakers of coalitions, not only in the agency but public-private partnerships and coalitions of hospitals, special as was spoken about on the previous panel. grant funding from the government will never be enough. colleague told me you can never graduate to preparedness. but specific funding dedicated toward a specific vulnerability such as hospital cybersecurity or emergency power supplies can however, help. so i think with that of ago had been close and --

>> thank you very much. >> good morning and thank you very much again for the opportunity to be here. i was asked to discuss the public health response will and some of the challenges that we face in public health with regard to real-time epidemiology and other tools for characterization of the spread of disease. so i will highlight a few public health roles and then talk briefly about some of the challenges that we still face. so the public health response to biological events is multifaceted. it requires skill staff resources and wherewithal to complete the mission and relationships with key partners across all levels of government nonprofits, the private sector and community leaders and advocates as well. in a biological event, public health officials responsible for characterizing the thread utilizing epidemiological tools and investigative procedures. robust surveillance systems and mechanisms for information

sharing helps to facilitate and maintain situational awareness across public health, health care and other public safety partners. up on characterization of the third, public health officials must coordinate with the health care system providing treatment recommendations including the use of medical countermeasure recommendations for laboratory testing and other diagnostic procedures, and recommendations for personal protective equipment to ensure proper protection of health care workers as well as continuous communication with health care partners to ensure the maintenance of surveillance activities and bidirectional communication flow between public health and health care. on the operations side public health must ensure that medical countermeasures are distributed participants travel to affected populations to protect against the threat particularly anti-potential expos were not hospitalized. this is done i ensuring that

operationally sound plans and procedures are in place pre-event that they can not only for the actual medication distribution, that all of the logistical components that operate in the background and ensure a successful mission. i empathize operationally sound because over the years we have learned that it isn't sufficient to just have a plan but the staff needs to be continuously trained on those plans and functional at full scale exercising are necessary to evaluate the viability of those plans, and how well the response can be carried out. in other words, there needs to be proof that the plan can do what it says it can do. and i'm happy to say that in my jurisdiction, our public health responders are fully integrated into our unified command structure so we don't have the turf wars and resource pulling that can occur when it's time to respond. overlaid across all areas of

public health response are the need for quick, efficient, and comprehensive risk communication messages to the public continuous information sharing with response partners, and engagement of those who are most vulnerable, putting those with access and functional needs and, therefore, may not be able to get the medication distribution points. the elderly and the chronically ill residing at home and those were socially isolated and maybe distrusting of information sources that most of us depend upon daily. finally, there's the need for relationships and partnerships. we often say that at the time of the disaster is not the time to be distributing business cards. however, we underestimate the power and the strength of relationships with key partners who have resources and tools that can be brought to bear to support the public health mission in response to biological event.

again, these include relationships across all levels of government, the private sector, nonprofits, elf care and health care coalitions but also immunity leaders and advocates. and i often tell the story the personal story of an elderly man with whom i was quite familiar who was living in the lower ninth ward as hurricane katrina approached new orleans, refused to evacuate his so because in his mind this was just another storm. and he didn't trust the messages that were being delivered through the mainstream media or even by the government. however, if those same messages have been delivered by the leader of this local masonic lodge or perhaps the pastor of his church, he perhaps would've trusted of those messages and the outcome would have been quite different than what it actually was. so again i stress that relationships are key. we won't always know how we may need to leverage those relationships until the situation is upon us. in times of challenges, there

are many particularly with regards to epidemiology and surveillance in the effort to characterize the threat. what we know is the public health official blurb about the threat any number of ways. one, perhaps could be to the bio watch system which would put a several hours behind the time of the agent released. another could be the bbs system which is present in many postal facilities across the country in the jurisdictions that actually have bbs system. or most likely through an astute position on duty when a symptomatic patient presents in the er. but my point here is that there's no single detection mechanism that is consistent across all jurisdictions and no standard competency level that is required for any of the three mechanisms that i mentioned. for those reasons there is great need for bio surveillance that integrates multiple approaches or multiple mechanisms for bio

surveillance to improve ordination across jurisdictions and increase competency for quick detection of a biological release. we have many tools in our toolbox but we need to figure out how to best integrate those tools and move forward with resolving some of the outstanding issues that still remain for those of us in public health. and briefly and in conclusion some of the outstanding issues continue to be remediation your in other words, how clean is clean after a biological event. ..

>> thank you for this opportunity to share some reflection. while i apologize in it and i am actually going to speak about the politics of the response a little bit more than the epidemiological challenges we face or some of the successive. >> that is inherent to the challenge we face. you don't have to apologize for that. you are on topic. >> i personally don't have any funding to defend, nor do i have a portfolio to protect. so consummate lady i will speak in my personal capacity as a risk analyst and consultant who has worked inside and on the periphery of health security for around 20 years. so while we are here to talk about the public health response

to a biological or chemical incident and i realize we are toward a shopping chemical incident today an incident of any origin against humans in ag but they focus on livestock, the point i want to focus on his there are many passive assumptions surrounding the act of responding and not all of my comments will remain within the purview of health. some things may be anathema to clinical professionals in this room. i was going to use the three examples. one of those with ebola in west africa in the united states, but since it has been discussed so much, i think i will not talk about that appeared in several talk about polio in pakistan nigeria and afghanistan in the western united states. obviously we can talk about burst in the middle east hemorrhagic fever in south america and we can talk about a lot of other pathogens that cause diseases that are of high

consequence. in general the passive assumption that we are looking at are really rather basic and it is who should respond to what should the response speed where does the response begin and when and how should response be handled by its should to be health care professionals, law enforcement, military's or other cadres of teams of people or all of the a? i also went to caveat with a few assumptions of my own. one leadership is too fragmented and lack even that is one of the issues that have come up repeatedly. also, in my personal opinion responding to a kinetic biological or personal attack is somewhat less challenging than responding to a non-kinetic incident because you have no forewarning and no other laps out or disaster space that you can survey all. i would also say the majority of u.s. policies prioritize a duty to treat her care over a duty to contain the threat essentially

we engaged triage and consequently a standard of care as opposed to population health and sufficient care. also, decontamination is seen as inferior to therapeutic countermeasures. also, there's still a lot of reluctance from what i can tell for nontraditional partners in the response arena in the response generally and that would include the private sector we heard a bit about in the military. these folks have a lot of cool toys at their hands in their convenience whether it is geospatial data uavs trucks beyond communication equipment, things we don't normally associate with people in clinical and public health environments. we are also reluctant to communicate with the public about mass fatality management for both humans and livestock and we saw that a lot with ebola. we address the aerial practices and actually talk about cultural

differences. and they need to actually potentially put aside some of those differences rather than appeal to each and every individual preference. solana dusters like ebola in west africa, polio in pakistan, nigeria and afghanistan are generally responded to make rapid onset disasters and by that i mean you often get duplicated in disparate versus and coordination mechanisms thrown together in an ad hoc manner by signaling the need for better management and managers. and health care professional should focus on the health aspects of a disaster and should not be in charge of managing the response of a large-scale incident. i wanted to talk about polio in pakistan and afghanistan and nigeria. while currently the u.s. doesn't have a problem with polio, when there is an infectious disease

of high consequence in the world it has the possibility of becoming a problem in the united states. in the polio virus and the aftermath of world war ii with second nuclear wars that americans care most today remains endemic in three dairy terrorist race countries. afghanistan, pakistan and nigeria. many of these al qaeda, taliban and al qaeda rom are proponents of anti-vaccine, specifically antipolio. moreover and 24 teams are also outbreaks in somalia with al-shabaab cameroon, ethiopia, south sudan and madagascar. the likelihood for for cross-border infections particularly in contiguous nations that border anti-vaccine controlled areas consequently into regions and affiliations with known anti-vaccine

terrorist organizations poses a risk made over the last 40 years. if polio is not effectively managed him in the cdc resurgence of polio could paralyze more than 200,000 children worldwide every year within a decade. while there is no such thing as a microbial manifesto, terrorists and extremists reject in polio vaccination on behalf of their children are functionally turning children into my co-braille mujahedeen. -- microbial mujahedeen. perhaps it can be labeled as passive bioterrorism. terrorists are deliberately disrupting disease prevention systems in place i.e. vaccines incentivizing obstructionist behavior including committing violence against health care workers as well as sacrificing children to did these. and they are murder should they succumbed to illness or death.

the insidious form of bioterrorism does not require the need for manipulating pathogens or even mimic the effects of an endemic to these were successfully westernized the first polio rather deliberately denying prevention measures for diseases permitted to run its course unfettered. additionally, finds an obstructionist acts taking place we seen a 2014 nearly 90 related killings of health care workers that when not to vaccinate children. 80 of those health care workers targeted and killed were in pakistan or 10 in nigeria. in short the effects of preventing access to health care or is to immunize children due to violent extremism into nine children with a life even in her bench and are actively exposing children to polio as a weapon. so on the point i would like to make is a recommendation until there's recognition whether it's

law-enforcement or military, polio is a threat to national security were security forces are actively engaged in threat reduction efforts and will continue its resurgence. that also raises the concern for the united states and the rest of the world. i wasn't going to talk about this and i'm not a veterinarian, but i looked at a lot of the economic impacts of the diseases. last friday i was sitting in my friend and i began speaking to the people next to us and it's going to sound a little folksy, but brian marcia will operate a family-run cattle ranch were visiting washington d.c. from montana to meet with their congressman about the problems they face. while brucellosis is the air is the error not to conceive, meaning one can infect animals their concerns about domesticated livestock in and

around their farm. they are westernized aged and other countries that had they have as well. the disease has been previously controlled and eradicated in humans however rest of our remains in wild rice and in yellowstone park and has spread through montana. they migrated again spreading the disease into cattle in the state. the consequences revenue lost as well as operational disruption of these ranges in one of the things i found interesting was the cattle were being sent to montana in drought ridden states like california and texas. they fear was that states would not do that in montana would lose revenue from that as well as not been able to sell the cattle back or any of the beef

byproducts. one of their concerns was they wanted to ensure political issues are managed to eradicate the disease and bison while the bison population continues to grow and spread to wild elk into ohio and wyoming. they have had concern and with a state official wildlife parks and the montana department of livestock and we see on a smaller scale disparate coordination leadership of an issue that has been highly politicized about who believes what is necessary and who gets the right resources to allocate towards whichever. what they really wanted and i am not here as a plug to them, but they were quite illustrative in terms of identifying the fact there's still a lot of need for addressing infectious diseases as we saw in foot and mouth disease, bse related to sars and

the billions and billions of dollars that came out of that. my work in the private sector in a lot of pandemic planning includes supply chain security. this can't be understated. this is billions of dollars. some of the state-funded. some of the private sector some of the public-private partnerships. there's a lot of money at stake which means a lot of livelihood affected. said the exports are waning and the disease remains unmitigated and potentially the effects that can reach our national livestock industry, which in another doll presents a try. the issues about who responds when do we respond. do we respond before something becomes a disaster quite with ebola we responded in a rural ireland and it would not have actually become a disaster. just having an outbreak or an epidemic of a pandemic

pro-disease doesn't make it a disaster. it is a disaster when everything in all the people and resources are overloaded and the management falls to pieces. so, ultimately i just really wanted to thank you for your time and consideration on my diatribe here and wanted to share some reflections from somebody who worked within the world health organization on communicable to use as and the united nation on the biological toxin -- biological weapons convention looking at addressing multiple nontraditional ways of mitigating the effects of naturally occurring deliberative or accidental but these as a fellow somebody looking at this from the private spectrum. thank you. >> we thank you very much. we'll start with the department of health and chicago appeared you got quite an operation center out there i visited many times years ago.

it is very sophisticated. it is its own fusion center and that community and a few others and there are very few like that in the country. the public health community 24/7 and center quack >> yes, sir. we are. what we have done is utilized the grant funding to be very creative in our staffing. we actually have a public health staff person who is embedded 100% in our office of emergency management and medication. so while he works on public health issues, he works on emergency management implications and report means for those public health issues and he is on call 24/7 for the emergency operations center and the operations within our management structure. >> have you had tabletop or on-site training exercises that

include a bio or chemical attack like >> yes, sir. tabletop exercises as well as functional exercises. as you might imagine, it is very expensive to conduct large scale functional exercises on the magnitude that would efficiently support our population on an annual basis. one of the things that we have done is we do smaller functional exercises each year building up to a larger, more full scale exercise and we also exercise all health care system, particularly hospital so we focus on areas of weakness and not continuously applauding them for areas of struggle. one way to exercises related to bio event and other public health infectious diseases public health is the lead. however emergency management serves as the coordinating body so they work closely with us and ensure we have the resources we need in order to execute the

response mission. >> so you are the incident commander and public health clinics >> that is correct. >> you with a trained person that handles the public health part of the response? >> with regard to surveillance and detection but the move towards electronic health record and at the same time protecting the privacy of individuals of that health records is there a digital fusion center that positions around the state of illinois if they see an anomaly or unique systems of public health officials in your fusion center can see trends developing more of the broader health community can respond, or is it still in and it total effort for this position uniquely trained identify something aberrant and based on the anecdotal incident, the public health community gears. is it a court rated r. for to

rely on the superb position click >> there are actually both. there is an electronic disease program implemented across the state of illinois that all local health departments reported to for disease is reportable by physicians to public health and we've been reporting to the electronic system. specifically within the city of chicago we have developed protocols for identification of rash illnesses as well as acute respiratory illnesses whereby clinicians can utilize protocols to identify unusual trends of what they see in the er is in a is in the report goes to a specifically at the local health department so we can activate our epidemiological dreams. >> are they in the private sector and the public there? do you find the model is replicated around the country or

is it unique to a few states when we really be part of the infrastructure of all 50. do you have an opportunity to observe and comment click >> yes, sir. i would say it is hit and miss. the type of fusion center that you mention is particularly more likely to be in the larger cities. it is not just state-by-state. it is almost city by city. resource driven but also the death of the ems and public health infrastructure. i think that critical mass is often what drives these fusion centers. i think we need more regionalization. i think we need more linking to the existing fusion centers and better opportunities for smaller communities to participate in this process. >> would you comment -- you talk about nontraditional part or is having a particular role in responding to a biological event. could you give us a frame of

reference for that notion speenine who are we utilizing speenine who out there should be part of the response and recovery that is utilized effectively infrequently as we should have nine >> i believe since we've not have a lot of mass casualty events in the united states and we haven't had a lot of problems, we have to look overseas more. i do think that we should be using the national guard quite a bit more. i do think that the private sector and some folks using it for logistic purposes and i absolutely agree i do believe you can have teams of people who authority been used to working together in this reference to post the workers and teacher union or even construction workers who work together who can be trained to do particular things like decontamination or possibly things related to burial if need be.

i think the military has a role to play. i was a strong proponent of having a military be involved early on and ebola. i also think sometimes we can learn from their command structure that somebody else on a previous panel had discussed. >> advisory board. dr. alexander. >> thank you very much for your insight. i have a question related to international cooperation in combating terrorism and as we know, obviously you connect and think globally as they say. my question to you is from your experience on the governmental level as well as nongovernmental agencies what works and what doesn't work related specifically to the scratch of

the infectious diseases we have seen with ebola. >> you want me to take a stab at that? in april of 2009, of course infectious diseases knows no border in the first indications of this new pandemic virus was actually at a u.s. military coming u.s. navy lab at the mexican u.s. border where they were able to pick it up. one of the stronger labs is the one that dod uses in coordination with others. so i think this idea of a nap work, system of systems, of

various labs government-sponsored and others to include the ngo volunteer community needs to be better coordinated, but the sooner that we can pick it up from a u.s. dave while it is further away obviously the more time will have to prepare we will be able to provide more assistance that way overseas. networks of labs, system of systems early notification of transparent b. in coordination. >> just to echo back they are already collaborating centers in mind that the international level that our network. the world health organization has them in different regions as well as different countries that are potentially pathogen specific. some just have certain levels of biosafety in which two to test.

so while there is a lot of capability out there a lot is duplicated in the coordination is still rather ineffective in my personal opinion. the issues that we have seen even with ebola there is an expectation that should be at the home of the response. that may not necessarily be the case. they may be able to provide subject matter expertise. they are certainly not involved in terrorist activities or counterterrorism. >> please. >> in 2008 we all know there is been a pretty substantial decline in support for state and local public health programs. i think the number i've seen a summer in the order of 45,000 jobs lost in public health over the last five years. can you all say what the impact of that has been in your

observations to public health preparedness and can you give us one particular thing that rises to the top of the list do you think this panel could do to help improve the public health component of bio preparedness? >> so i would agree that since 2008 we have seen a continuous decline of public health budgets from a funding standpoint which has obviously adversely affected the staffing complement within public health agencies. i have seen from my personal experience a drastic decrease in the number of staff available to simply carry out basic core public health functions. what i can say is utilizing public health emergency preparedness funding from the cdc as well as from the hhs office of the assistant secretary for preparedness and was on at least in my situation

we have been able to relatively maintain emergency preparedness staff or by a response. however, that capability is getting in recently difficult to continue to maintain because those funds albeit grant funds come are continuously declining as well. i think we have had great success in our city for leveraging those financial resources that have been available through the screens. again as they continue to decline, even the levels of creativity we have been able to enact are becoming more and more difficult to maintain. from the panel's give, i would say that the advocacy for maintenance of those funding dollars would really go a long way in helping us maintain bio preparedness. when i look specifically at the funding we are able to provide and utilize for preparedness of our help your system, it is

grossly insufficient. within my own jurisdiction, i have 28 acute care facilities at the hospitals in over 120 long-term care facilities that i am trying to keep prepared with a very small number of $3 million per year. >> debbie troy. >> i was fascinated by the microbial mujahedeen than the bioterrorism. it seems there are two aspects to this problem. one is the active efforts of nefarious folks who want to weaken our disease systems another are people on the grounds you don't trust western medicine and the agents and the western public health workers. what steps do you think we could take to alleviate both aspects of the problem? >> thank you.

i think one, the u.s. security apparatus needs to work with the input of the public health community about the best way to prevent and control polio, which is actually something we know because it happens to be polio when it's not a newly emerging these. we know how to contain it and stamp it out. but there has to be a decision by the u.s. national security apparatus to work in a bilateral fashion with the pakistani national security apparatus. maybe we do it through the indian surprisingly because the indians have offered bilateral support to pakistan for polio and nothing has been happening since the offer has been made. or merrily, my perception is primarily that have been because pakistan has made the decision and how they will go about doing things. an example, and maybe a year ago were the last six months, a

local administrator in the northwest had actually decided he was going to co-op some of his goons with guns to go around and enforce that children are vaccinated. they were in the children were vaccinated. nobody was harmed. nobody was killed, but there was an enforcement mechanism in place. one of the things we need to discuss uncomfortable things related to whether or not security we talk about health security, if you elevate the label, that you have to be willing to enforce that as a security concern. i do think there're things to to be done, but obviously you have to have the acceptance of the internal pakistani and also in nigeria and afghanistan, you have to have their input as well. [inaudible] >> thank you.

>> please. >> i would like to follow one that just a little and then maybe dr. mckinney said that that -- something intriguing. we were talking about the need for leadership and also strong partnerships and my colleague at the end i think would agree about how can we put the public backing to help and empower people. one is i think there is something to be sad. we need some strong leadership to bring all of the partners together and i think you captured him of that. i feel a little uncomfortable gleaming pakistanis were not vaccinating their kids when we can't seem to do a very good job of that in parts of the united states and i hate to call people on the west coast terrorists because they are not vaccinating their children from measles. i want to put some context to

bear. there is a lesson learned about communicating. mckinney brought that up about communicating upwards because we seem to have a problem with communication. what if some of your experiences? i do believe you have to have a strong leadership nationally to encourage that. and also kind of authorizing and make that an acceptable approach. >> we have done a significant amount of that type of work in my city, primarily engaging and educating faith-based leaders and developing mechanisms whereby we can distribute messages to fake-based leaders and in turn request that they distribute those messages to their congregation. we have done the same as social service work in the nation and human service work in nations that work with specific honorable populations groups and

one great example that i always like to share is a collaboration with the organization formerly known as the chicago lighthouse for the blind. they have a low-frequency radio station that reaches over 40,000 visually impaired people in the chicago metro area and parts of indiana. you need a special receiver to pick up the radio station. but we distribute our risk communication messages to the agents the end they then read those messages over this low-frequency radio station and reach over 40,000 people we otherwise would have no way of reaching. so that is one example. we have also begun an effort about a year and a half ago where we are now educating and training and exercising head start and daycare providers to do business continuity planning and keep their operations

running and keep the children entrusted to their care save until the parents of those children can be reunited with them. for us, it is a multifaceted approach across multiple disciplines because government cannot be everywhere at once and we must involve community members community leaders and community organizations to help us do what we need to do to protect our citizens. >> can i just -- >> please. >> i definitely agree. i don't want to make a blanket statement that pakistan is doing this. if this is about terrorist and extremist organizations including al qaeda affiliates, talent and affiliates, boko haram, al-shabaab in somalia and others using an ideology to ensure that people die or become

chronically injured for the rest of their lives and help them as orders. so while you may be in california ideologically opting out, in my opinion for the totally wrong reason because there's no actual scientific linkages about that nation, it is not a too nuanced difference. it is not an ideology of hate and extermination. it is an ideology over one cells. what is going on in nigeria pakistan and afghanistan is truly a security threat. measles was a concern in the measles out rate is what had me start looking at what is going on in these areas. >> one final question. dr. terbush, because of your work with dod with the work with countermeasures and in that area, as we go forward in the 21st century to build a better

relationship between dod, public health community and agencies to buy a defense there still seems to be from time to time and this is a great respect it is still a silo pretty difficult to permeate and based on your experience, is there any recommendations he would make in terms of the kind of collaboration or improvements between dod and the private sector as you address a public health and bio defense emergency. >> dod does a pretty good job of research, but i think the strength is in the private sector. as several speakers have previously mentioned that are to was the mechanism by which a lot of these orphan drugs and countermeasures guide to the so-called valley of death. there is a guaranteed customer and that still needs to be done. we are getting back to leadership, but i think the

string over what isa 85%, 90% of the health care site juries in the air. it is not in government. that goes for r&d as well. we have brilliant minds in dod research, but the cutting-edge stuff with regard to development to relate new technology vaccines, countermeasures and coordination with dod. i would speak in favor also the intelligence community and say that we need the good and tell us you will too help us to know in which direction to develop these new countermeasures. >> i appreciate that. very helpful to us because we have had different people testified with regard to return having a role in offensive than unifying and integrating mutual capabilities for an outcome that is very helpful. we thank you. we thank all the families. ladies and gentlemen, we are

going to take a 10 minute break. maybe nine and a half. lunches are outside. dr. irwin will be her luncheon speaker. if you've been in the military you understand what i'm about to say. you've got 10 minutes, so swallow it down into it later. food is outside of the door. we will reconvene at a quarter to 1:00. thank you very much to the panelists. [applause] [inaudible conversations] [inaudible conversations] [inaudible conversations]

[inaudible conversations] [inaudible conversations] >> so, a brief break in this daylong discussion of bio defense. up next, dr. irwin by letter professor of health policy and management at columbia university. also director of the national center for disaster preparedness. this is about a 10 minute break and we will return with live coverage here on c-span2. while we wait for it to resume them all attendees gather lunch, congress is away for a two week holiday break. during the times numbers and a constituent in their traveling

domestically and overs each. house speaker john boehner is in the middle east and today he met with the prime minister benjamin that yahoo!. they make marks to reporters just under five minutes. [inaudible conversations] >> mr. speaker, it is great to see you again. your visitors an opportunity for me to thank you and your colleagues from both houses of congress and for both sides of the aisle. with the warm welcome he gave me at the u.s. capitol. today, it is my great pleasure to welcome you and your delegation to jerusalem, the capital of the state of israel and the capital of the jewish people for 3000 years. john your visit here is a testament to the historic and

enduring bond that unites our two nations, are two democracies. this is a bond founded on our common values, shared commitment to liberty and equal rights for all. and if the wind of values is amended by our common interest. i believe it is plain to see that those common values and interests are clearer than ever. the middle east is plagued by anti-western antidemocratic and anti-american extremism. terrorists brutally beheaded their shackled captives or video camera. that's it lead their people and chance to death to america while visiting intercontinental ballistic missiles to reach america. this violent and unstable region, states are imploding and fanaticism is exploding. one thing remains rocksolid, our

friendship, our alliance our partners. it makes both of our country stronger. it makes both of our country safer and it is the anchor for our shared those for peace and ability in this region. so that means this opportunity to reiterate something that i have said before that needs to be said again and again. the people of israel know that we have no better friend in the world that the united states of america and the american people should know that they have no better friend in the world than the state of israel. john, you are one of 12 children. you came to the right place. we are the descendents of the 12 children of jacob also known as israel. john, welcome to israel. welcome to jerusalem.

>> well, mr. prime minister let me just say how happy i get to be in israel. our delegation spent the last five days throughout the middle east and regardless of where in the middle east we have then the message has been the same. you can't continue to turn your eye away from the thread of all of us. as you said bonds between the united states and israel are as strong as ever. our two countries operate on many different levels. while we may have political disagreements from time to time, the bonds between our two nations are strong and they will continue to be strong. it has been an historic trip in an historic opportunity to be here in israel at this time.

let me take a moment to say congratulations on your reelection. >> the hard part begins now. >> i was the easy part. the election is the easy part. we are glad to have you. >> thank you very much. a pleasure to see each and every one of you. you know, i would like to offer you some lunch. >> good. i am hungry. [laughter] >> and again we are back live at the hudson institute for this daylong forum on biodiversity. attendees are gathering their lunch to hear from luncheon speaker dr. irwin red letter, director of health and policy management at columbia university. a few minutes or not we will have live coverage when that gets started. while we wait, we will take you back to the beginning to hear from former congressman, mike

rogers. [inaudible conversations] >> that is funny, really it is. you know it is different being on this side. [laughter] i discovered that a secretary. thank you very much. >> exactly. i do appreciate the opportunity to be here and i appreciate the work of the panel. i have been with hudson now a couple of months and the intellectual firepower there is both inspiring and i have learned -- you think you come in fairly well schooled and you realize you have a long way to go when you hang out with my fellow colleagues at the hudson is it too. they doing really powerful work. i just thought i would tell you our journey is little bit on how we in a bipartisan way back to the bar to bill on issues that we saw coming up to we didn't believe are going to be addressed because it is really

hard to get people's attention about hunting you can't be for you can't touch necessarily, but you know the devastating consequences. many nights chairman of the house intelligence committee you don't speak for things you don't know. often, centered around our threat matrix of bioterror attacks and our ability to respond in a way that i think would be completely approved rio. so in a shoe and i started in 2006 after a series of investigative is too strong, the least he carries into the status of terrorists at least attempting in their interest in obtaining bio weapons. what we found was there was a high degree of interest in obtaining weapons, but we are in the middle of a conflict in iraq. we are artists in the middle of a conflict in afghanistan at that point in the focus is not necessarily where it needed to

be. working back with the white house at the time the bush administration collectively with anna eshoo mike rogers republican working with the white house, we agreed that we needed to have a special fund or absurd to try to produce countermeasures in a mark where there was no market place for it that was the biggest problem. there is only one single customer in reality for these countermeasures. i don't care if it is radiological exposure. i don't care if it is smallpox on a large scale. bubonic plague which we have seen strong interest in terrorist argument nations and try to find delivery systems for them. we realized that we needed to have some rain on a larger magnet to to have both stop piles and push it up to the first responders were first responders can first access.

this is how the spurs started. you can imagine what other challenges facing the united states it was hard to get people's attention on it. so i credit anna eshoo again, my partner in this comment and the white house were saying as good this is something we have to deal with given the levels of threat and given all the other things we have. the one challenge we had subsequent to its passage was full funding. we got plenty of authorization money set aside or these countermeasures and it was very, very tempting as you know governor ridge. that money was just too tempting to be moved somewhere else for what they would perceive bigger priorities. the enemy was not knocking on our door with the bubonic plague or smallpox or fill in the blank. we know they were interested. we knew they had aspirations to use it in aspirations to put it together. we didn't have enough to say within 30 days or 60 days or 180

days something that will happen with ideological weapons. it always became a backseat issue. we have had successes along the way with medical countermeasures . hhs just signed a contract of about $31 million for the new and improved anthrax countermeasure. a lot of attention paid to it, but there is the reason there was a lot of attention because we watched terrorists a lot of attention to it. we wanted to make sure that we have stockpiles of countermeasures to run the country that could address a problem if it happened. survivability rate in those cases would go astronomical. the money will oust be used to test the capability of anthrax countermeasure is. we think there can be both a prophylactic treatment, which you see now in a a response treatment of anthrax. if someone gets exposed, there is an opportunity that we can

have a vaccine that could save the person's life. so while it back to me has been a slog. it has been a work in progress, but i think we have made some progress. i know and i eshoo, with susan burks, and a republican from indiana signed a letter to the chairman recently requesting 400 some million dollars in additional money to the fund. if they can get anywhere near it, that would be a success dory. we are going to have to continue to keep everything on schedule. >> we have quite a bit of ground to cover and i'm grateful for your willingness to help us keep to the schedule. our luncheon speaker is dr. erwin redletter. he is a professor of health policy and management at columbia university. he is also director of the national center for disaster preparedness. we will invite erwin to share

his thoughts with us. a pleasure of working with erwin since my days in the white house. dr. redletter please get us the benefit of your thinking. if you would, please. i expect you can be prepared to get quite a few questions from the panel. >> looking forward to it. thank you very much. i appreciate the opportunity to be here. i have known many people in this room for quite some time. we have been through a lot of issues and struggles to gather and it is i feel a privilege to speak to all of you on the blue ribbon studies panel. i am going to try to keep my remarks pointed and specific as i can. part of the introduction babies should then i am a person with a half cent to class. i just want to forewarn. half-empty glass as opposed to a

full glass. full disclosure. i want to say there are many issues to explore as we think about disaster readiness in the united states. not that most americans thought much about this issue before that beautiful sunny day in 2001 when america was attacked by terrorists on the very day as it turns out, was new york city mayoral primary election that did not have been. clearly mostly but not entirely unexpected attacks with great loss of life and dramatic infrastructure discussion was shocking enough or all of us. and why wouldn't we be shocked quiet weary country isolated from a certain level of turmoil and threats are more prevalent than other continent and other nations other than around. we were observers from afar. yes, we had the oklahoma city bombing by a home-grown

terrorists, but this kind of extremist violence by evildoers from other countries just didn't happen here. to me there was another aspect of the 9/11 attacks that i can consciously or not to our corrective disbelief and shock ended his days. the actual complexity, logistics, the coordination the precision of the unimaginable scenario three simultaneous jumbo jet hijackings was very much in the realm of a pretty mediocre bruce willis movie. but it wasn't of course. it was a real, honest to god wildly imaginative terrorist attack that shook the nation and the world. we could have learned and applied a lot of lessons from that attack and the anthrax that soon followed. in my view unfortunately, we had experienced this they did not turn into real lessons and lessons that did not change policies or the way we prepared for subsequent events. sadly enough that is true for most of the disasters we have

experienced in the 14 years since 9/11. experiences without lessons lessons about applications. we have made progress and some of it okay. and we are nowhere near where it should be. we should know for certain will be protectively referred to as wake-up calls have been far more suggestive of alarm clocks with very accessible snooze buttons. the catastrophe happens. there is intense drama and media coverage followed by promises to prepare or respond better the next time. we hit the snooze button and drift back into complacency not changing as much as we should have. that is human nature on some level. not learned since the years of 9/11 from how to respond for a major anthrax attack, prepare for a super storm or breakdown the most important thing we fail

to do was to learn to think about disaster readiness with sufficient imagination and an appropriate scale. it's not that improvements haven't been made. some important progress has been made, like making airplane caught its impenetrable. despite of the horrible german wings tragedy last month, in balance i think we did the right rain and we did it pretty well. but have we learned how to accelerate recovery from a major storm like katrina and the golf which 10 years later is still ongoing. what about this no-space of recovery from the 2012th superstore and sandy in the northeast still far from completed. articles in today's paper about delays in funding and how people get out of the jam they have been in since that storm. radio and communication technology challenges contribute to the deaths of hundreds of responders in the world trade center attack in 2001.

in 2015 14 years later responders including firefighters rushing to a serious smoke condition in the d.c. metro system couldn't communiqué from the tunnel the units on the surface. it really couldn't communiqué. and while some might disagree, i am telling you we are hardly better, in my opinion, if at all to respond to a major pandemic than in 2006 and 2007 when worries peaked about a possible avian flu that could replicate a global disaster like the spanish flu of 1918. even though we spoke volumes of planning binders in terms of what we needed to do i don't take you could show me a large american city that has prepared and sustained a public health systems such a calamity. not a single city in the united states. even worse if you could find the article he prepared health systems, no plans for that scratch the surface about how we could assure the pipelines and

supply chains for food and water needs in a massive epidemic or how we get the vaccines or antibiotics made a trio and distributed properly and in a timely way. or have the analyzed, what do we know about the enormous impact of pandemic of this size would have on the economy locally and nationally, maybe globally? what are those impacts? how are we going to cope with those cliques who was planning to deal with them. here these are the things i worry about, which is one of the reasons i have a limited social life and why my wife doesn't let me talk about my work at home. that said i do want to talk about the things i would consider among the more important barriers to the united states being better prepared than we currently are. not in any particular order, but all in my mind important fact yours. the list for the purpose of my remarks this afternoon does not

include the gross underfunding of the public-health system and other essential systems to improve resilience and i think he discussed this at some length already today. about funding i want to make one point which is we can't really we mean by prepared. how can we expect to find something that we can't define? after all what do we mean by a prepared city or a prepared state or even a prepared hospital if we simply don't know the answer to that. if you could attend hospitals, you'll get 10 answers. 10 cities will give you 12 answers. i would daresay i do this when i speak about this topic. i will not do it here because we just are going to do it. normally i would ask you to raise your hand in this room if you feel with respect to yourself, your family, your pets your community how many

of you actually, raise your hand visibly -- how many of you actually feel prepared for a major disaster in your community? how many? i've spoken to all kinds of audiences. if i get more than two or three hands that i test them. who is taking care of your mom in the nursing home? who picks up the kids from school of? what do you do about important payors? what is happening as we get into the details, it is abundantly clear to me that we don't even know what we mean by prepared individuals. we can call the red cross perfume of guidelines. that is hardly enough to deal. >> we are glad you didn't answer the question -- ask the question here. good job. >> out of kindness and respect. i am just saying that if you can't define it how can you find it.

in a sense we're definitionally challenged and that is a big problem. let's put that aside and say that is lingering out there and something that at some level we have to deal with. i will give you the five top concerns are five of my top concerns. first is unfortunately the federalist system that we live under in the united states. in many ways the system serves our country and its people very well. the point is that decisions affect the lives of city in search of the extent possible decentralized and by design, government decisions are made by levels of government as close as possible to the people being served. that is the point. if a fundamental tenet of our society and on the whole it is good. the problem is it doesn't work for disaster planning. federalism and disaster planning are essentially incompatible. because federalism doesn't allow us to create an enforceable coordinated master plan to

revamp the ability to ensure specific regions are prepared for disasters which are particularly likely and specific to their own communities. why does the state of alabama require every school to have a safe shelter for the kids and staff in oklahoma doesn't? why? is a tornado less likely to kill school true to in oklahoma and alabama? howard why is that tolerable? what about terrorists that nation of an improvised nuclear device? not a dirty bomb but an ind. why is no city in the united states, no city prepare for such an event even though people in the federal government say that new york city, chicago, washington, houston san francisco l.a. are all potential terrorist ind targets. it is improbable but something that is on somebody's book of business to think about. why does the mayor get to decide that it isn't a priority?

.. at every level of government. when you hear a report from an official at the local health

department, here is what we are doing to prepare for this disaster. the mayor should be saying but what do we need on the path to get where we need to be what more is that going to take? we cannot be satisfied within a numerator answer to a denominator question. it's their problem -- the third problem is what i refer to as the authority conundrum and managing disaster decision-making from the disaster communication plans to implementation of any effective. five years ago the bp gulf oil spill became one of the greatest disasters in history. so who was in charge of the response? and the capping of the deep water while? the care of the affected communities. the president assigned to the coast guard commander and the federal agency of the united states under the president. is that who was in charge? was the governor of louisiana and georgia and have about the bp itself and all of the above?

how about the parish president at the time? a lot of people have a lot to say. if there was somebody fully in charge of that response i would be glad to know it but it wasn't actually a parent to me and that is the problem. a year later after the disaster and catastrophic failure of the nuclear power plant, who was in charge? again, impossible to determine who was in charge. that is the problem. from the message into the strategies to stop the damage this is a question and these are questions never properly answered. and if it were answered or some entity was in charge, it was a closely held secret. if it required all health and public hands on deck in new york city, who would call the shots? command center but who makes the final decision?

the mayor, the governor, the health department of the city? some years ago there was the ceo of one of the largest systems in new york city said to me that in terms i will not use here because i don't know all of you but let me paraphrase what he said it was i don't care who tells me to evacuate the hospital, i'm in charge and responsible for the life and safety and i report to the board of directors of my private voluntary health system. i do not report to the mayor or governor or the president for that matter so unless it was a major national emergency declared, i will decide what i'm going to evacuate my patients and which hospitals i will send them into when and how i will send them. so he perceived himself as being the sole independent responsible party. and he says you are right.

we don't control that. when we do planning on the health system readiness in new york city we have people getting together with a meeting specifically to plan for the disaster. either they come as we saw after the ebola, they are going to want reimbursement from expenses they incurred getting ready for the disaster as a result of the disaster. the bills that came into the nearly $5 billion fund that was appropriated by congress were just out of control. there were millions of dollars for hospitals that said since we have to get ready we should spend this amount of money and not only have we lost revenue because we didn't admit patients so things are out of

control. for problem, the category on the disconnect. i'm going to give you three quick examples. then i will worry about the disconnect between the silos of public health and personal health services. so, between the disasters, the dalia function of state and local public departments are fairly routine most of the time to provide all kinds that provide all kinds of community services and surveillance creating policies for the special programs in the childhood vaccinations to restaurant inspections and the like. many have disaster planning as well but therefore the health department they are there for the health department. in new york city, the health department does not plan for the 75 private-sector hospitals. its talks if talks with them and interacts with them but doesn't plan with them truly. on the other silo is the massive

direct health services system from the doctor's offices and clinics to enormous academic medical systems carrying for patients into teaching new generations of health professionals into supporting medical research and all that's fine. it's fine except when it comes to planning for war responding to disasters. in health and public health and the circumstances it must function as an integrated coordinate a single system of assessment direct care public safety and prevention. decisions about hospital allocation of scarce resources and a myriad of functions blur the line between the public's well being and the health of individual patients. right now we lack the resources and in most places the planning authority to integrate these two systems when it counts and in a big disaster that is a major problem. second disconnect, military and civil and civilian assets. take the example of an evacuation.

let's say a hypothetical elected mayor of a town of 65,000 people comes previously a prominent business leader can he committee became ineffective aldermen and with great personality he's elected mayor. he appoints a number of commissioners with a wide range of experiences, some relevant others not so much. maybe federal disasters state resources but now the city was caught in the publishing of 60 to 70,000 people need to evacuate quickly. the emergency plan is put together and here we go greenlight. wait how is this going to work? who has the food supply, the water cut the medical care not only because they have chronic medical conditions but somebody will have a heart attack were seizure en route. who is dealing with that in organizing the traffic patterns and making sure there are diapers because the babies to

construct it will be slow, where is the fuel coming from and who will deal with motor vehicle accident and where are these people going by the way? is the national guard being deployed and who decides what they are doing and how they are coordinating with local resources flex shouldn't they be coordinating with local resources? we didn't see that after sandy. shouldn't the regular military forces of the united states be in charge of large operations like this? who or what goes logistics and people moving better than the u.s. military and why exactly are they running the show on the circumstances i just described? where were they in the planning process so they were known and fully toward made assets while we are planning and not ad hoc wireless happening? we need to fix this. that is a big barrier but it

needs to be rethought in the age of the mega disasters, completely rethought. the final example is the private sector which is deeply unsettling for people. it's owned by companies and individuals in the private sector but the government is in control of the regional planning disasters and i talk about a couple of examples where confusion in the gulf and japan was very apparent. when the state commission was convened by the governor in the aftermath were charged to examine what happened and more specifically asked to recommend what should happen in future disasters to avoid or mitigate some of the problems created such as the gas shortage crisis.

the governor wanted to know what the state should do to avoid similar crisis in the next storm. we concluded their first up steps could be taken for instance the fuel reserve stockpile in the strategic locations around the state. millions and millions of gallons are used so there is a limit to what that can do. it's the private sector that owns the refineries and the delivery trucks and those are the key factors in making the supply chain during the disaster. like it or not coming at you should like it they are a part of the solution. it's not just because they own the asset, they also have the experience and expertise in a lot of brainpower not just lipservice but we need them at

the planning tables every single time that we are doing serious disaster planning. we need wal-mart and ups and fedex helping us in the distribution systems. there is much more we could talk about about this but i want to wrap this up and i do want to say i could have talked to you now and at some point i would like to about other issues for example the issues of the vulnerable populations which have been marginalized in essence the most disaster planning. the administrator actually is in the camp that i applaud which he understands all understands full rubble populations have to be part of the central planning as we are going if we are going to have an effective plan. it's necessary. i don't think people understand how many people there are. let's say we have 310 million people, 75 million are children, 45 million are senior citizens, an hundred 20 million have some kind of product elements

22 million nokia anand model between 21 and 64 have a disability, 44 million are in airport, 2,000,001.5 million are in nursing homes. they are not just out there ready to be taken onto a post-it domain disaster plan that is produced. if we can't take care of those people, the plan is useless. it's dysfunctional. we have to focus on this and we haven't been today. i want to end with a thought and i would say i guess the fact as wealthy as the united states is in the past 20 years compared to other countries in the world obviously, the resources are not unlimited. and the possibilities for the devastating disasters that could

affect us are literally staggering to the imagination. and we have many of the priorities. so i am not saying spend a bank. we have all kinds of disparities in the country. we have $3.5 trillion in infrastructure repairs that needed to get done. we have cancer and alzheimer's disease and many of the schools are in big trouble. this is while the claim was canceled we got to read the entire usa today, 61,000 bridges in the united states called in bad shape. 61,000 bridges. it's not the tunnels or the levy. it's just the bridges, ladies and gentlemen. so, here's the final point i'm making here that i understand we have to make decisions and establish priorities. but what really troubles me is how those decisions are made. they are made passively, and

actively they are made by default. we don't have the grown up the grown-up dialogue that we need to conduct a mature society should have examined the need to, assesses the, assesses the assets and make the decisions about how and where we will spend our treasure. because if we did that and went through that process and then we all decided that we simply are not going to prepare for every capacity that we are going to spend the next decade fixing the schools and education systems or fix the infrastructure to make sure every kid has appropriate access to quality healthcare fine we've made a decision in the best interest of the country by everybody joining in and arriving at that decision. the problem is that the process for the decision-making is a mess. it's not proactive, it's chaotic. it's an effective come at the decision by the default and that politics and as such it has predictable outcomes.

it's literally random-access preparedness as we have across the united states. and in my opinion the mathematics situation any of us should tolerate or be proud of. that's all i have to say. >> next time that you appear you could be more provocative, okay. [laughter] >> i wouldn't expect any less of you. for the first time i will turn to the advisory panel to see if he will start. i would like to ask you to reflect on the population and i know that you have a lot of work about the last decade.

[inaudible] >> could you talk a little bit about the special populations the vulnerable populations in particular children in consideration. hispanic children represent a particular poignant challenge for us to the i'm a pediatrician by background. i'm very tuned into children and have been for my whole career. it was immediately apparent that no thought whatsoever had been given to the special needs of children and this came up two weeks after 9/11 i was at a briefing of all of the hospitals in new york city with federal state and local officials talking about the two weeks later.

it's in the public health of columbia and i said what is being done around the planning for children who might get caught up in the disaster and literally they looked at each other and one of them said nothing, which is when i went back to my own institution to make some calls in the american pediatrics etc. and a process was begun by probably 20 or 30 pediatricians from different places and different places for children that began to look at this and eventually the national commission on children was born and from that, a bunch of recommendations have been. and i would say that most of the relevant federal agencies have been really looking at harvard was the needs of children are. the problem is we don't know a lot of the answers. we don't know that those are for kids three months old exposed to anthrax, we do not know it.

so are the years we have pretty consensus conferences where we bring in the experts to say i note you don't know and i know there is no research but what is your consensus getting a call in the middle of the night. so there are things happening that we are far from a place that i'm comfortable with. new york city schools with a schoolchildren i am very worried about the level of preparedness in the schools very worried. and we are going to try to look into that and i would dare say that would be a problem in any city. we have a lot of work to do but i would say in this case that the process is started. >> we deferred to the thing

you're ready around here. >> with all of the questions that you have raised and many of them are legitimate, my question is an academic trying to look at the lessons of history with work and what worked and what didn't work. for example the experience of noah and the ark in other words in the face of the coming flood, but did he do with no time to time for the decision and that is the story. and what is the moral of the story, and i can learn from that kind of experience. >> the big point, doctor alexander, is that i'm going to

go from noaa to buying disability insurance. it's a mindset that i think adults generally come to that if we can just kind of weight around and not do anything or investing in retirement or buy by insurance we can just keep rolling along. in and the real economic decisions to be made to have to come through some way of the process that will allow us to say we are going to build an ark and prepare the success of these for the event of a nuclear detonation.

and that is a decision that we get to buy the discussion where we want to take the risk around. i get what you're coming from. >> you have galvanized the preparedness community and officials to seriously consider the vulnerable populations particularly children to thank you for that and your leadership to that. the question or comment is along the lines of the unique challenges with the defense and particularly the medical countermeasures antibiotics in the stockpile vaccines that are licensed or in development. and you would note that the community has taken a serious grappling with the challenge is how do we really make progress now and how do we collect the data that is needed and are

there other communities that might help us or how do we really begin to make progress that we have the right antibiotics in the stockpile and the dosages for children, how do we get the vaccines that can be available for children? >> this is an expert merely important question and i'm glad you brought this up. what we are dealing with specifically is around the pharma industry and public health needs of the united states and the various mechanisms for researching coming up in the right answers that we are a little bit of drift because farmers are operating under the business model that isn't necessarily compatible with what the country needs from the public health point of view. the country is missing a public

health bar. i think you could you get appointed to the secretary of the hhs or the surgeon general surgeon general, it is somebody or something that can lead to development of ideas that will be able to take the realities of trying to have a functional business, where again the ceo does not report to the secretary [laughter] were any time actually. [laughter] dot the problem is we have different worldviews of what needs to happen and unless somebody is going to put up the money and a substantial waste of that there is an understood business model we are dealing with incompatible systems right

now and we do need some way of finding a common table that smart people from the industry and the public health committee can say listen we've tried different things but now we really do have to solve this. the policy for example who is going to develop those antibiotics and at what cost? and we can't use those because we are saving them but when there is a resistant bug that appears, then what is the model exactly? it is a really important point talking about the denominator problem i think that you have one. you said that it's nowhere near.

>> seriously though to questions, how do you prepare for the improvised nuclear device attack, to what extent it at all is washington, d.c. and its environment have there been any planning? >> this is an interesting question. because really it is an extraordinarily improbable events with extraordinary consequences that happens. but other researchers have shown us is it is a very interesting reality that if the public knew some very simple things about sheltering in place 34 to 48 hours and then leaving upon getting the right distraction from the public officials hundreds of thousands actually would be saved in a place like new york city. that's.

there are could go issues and communications issues but what is frustrating is. it could be better at saving lives is a lot of mythology there could be horrible destruction but not everybody would. they would be organized and take care of the people being taken care of. if we put our heads in the sand and do not talk about it at all then we are guaranteed if it did happen we would have the worst possible outcome as opposed to a better outcome.

>> of any such plan or occurred in the environment? >> maybe. there's a lot of things i am saying -- i'm not in the national security council and i'm not a secretary. there are things that are being discussed on a very high level that are important and complex and very top-secret. behind washington, d.c. and behind closed doors if it doesn't get to give to the cities and to the citizens, we have a problem because nobody -- where does the message get connected from the people that are interested in the continuity for example i visited the white house. he's on the seventh floor. he was in his attic in the old executive office building and i said what are you doing and he said i'm responsible for the

continuity of government. she's out to lunch. so there are things happening. there are people in the highest reaches of government discussing these things but if you don't let us know in the cities and states and counties i will tell you something else that is unbelievable to me which is that if you hold the patterns out of a large city where people are going to go, let's say we had a meltdown in the the powerplant, 18.7 million people that live within 50 miles so millions of people are going to go where are they going and when are they coming back? we have 90000 people in the communities that are not coming back in their lifetimes. there is a single town, village county of united states of america that has been appropriately planning for

receiving because it isn't just tends and bottles of water comedy when he jobs healthcare, schools, etc.. we have done as far as i know made the correct income on from this but i'm not aware of any plan whatsoever for the destination communities for large-scale evacuations persistent. so they require a lot of work and big issues. >> so what are you doing in the homeland security? [laughter] >> if you had trouble going into new york city or washington, d.c. on a beautiful sunny day how can you get out with eight or 10 million people on a bad day it isn't going to happen and you have to accept that notion and say okay i am concerned and improvised but you have huge

panic and anxiety. it's rare you would be able to see a massive evacuation and you can get off the outer banks when it's coming your way. to see three or four days coming if it is that event i don't think that you are evacuating big cities and you have to accept that as a part of your planning procedure. so the answer is nothing about evacuation is