equivocal responsibility measurable performance objectives and monitoring agency, with the operations planning, is essential for keeping the balance of the agencies. this does many of these things and the nursing care and you name it. there is a mass of a rate of services, and other things include population movement, this includes margaret farm -- magnet far -- migrant farms and inaccurate census data. . without realizing where the populations are without the 2010 census being in

debt. okay. pharmaceutical distribution which had five major regions we used, that was the distribution point for this act will implementation. these were the convoy routes we had through the state. because of the coordination between the army, our unit at the department of public health and several other agencies of transportation, we were able in 16 hours to distribute the 25% of the national stockpile given by the cdc to 102 counties, 95 local health departments and 356 hospitals throughout the state, 16 hours, no injuries. it was because they planned, exercise and knew exactly what they had to do. this is the case count through and i want to show you the time

frame, this is may 14th. so this is where the actual cases were occurring. this is top line call. this was on the 12th. look at all of the hot line calls and these were not even affected. it was all media driven. they were responding to what they were listening to in the media. okay. and these are the cases. we mapped out of the migrant camps because the forms we were worried about the migration and they were also trading as though they were army camps. they were not only a possibility of bringing infection in but susceptible to infection as well and could act for an explosion of local outbreaks. the things we did, as an s deployment 16 hours, three state idp each laboratory locations so we did a confirmatory test

in-house with assistance through the cdc, sample search capacity flexibility because of the locations, springfield and chicago and carbondale are separate geographical all states or about 290 miles long so we have redundancy in case something happens in one of the lab areas. cdc community mitigation strategy was also implemented, beautiful document, can indications we had the hot line. we went through the poison control center and that was with idp h because they were used to handling stress. they were able to talk to people without having to be worried, they could calmed them down, lay their fears and they know how to handle people so we actually had communication lines, spanish, english and in other languages house well. multilingual was important and the media and hospitals, local

health departments and state and emergency operation center. they were critical for making sure we had weekly if not daily meetings with some of them to bring all of the departments together to bring all of the hospital's together on calls and the private practitioners who were doing it in strategic calls making sure everyone was on the line from the agencies so everyone was listening to the same message. also the star, 21 radio system we put in a year ago that has allowed us to communicate with all hospitals at the distribution sites. it worked out very, very well. the fifth based organizations we actually had a pandemic flu ambassador programs. we have had that in existence for about two years. it encompasses 7,000 face based institutions in a database with 500 being on the main 80 or

broadcast ministers during the pandemic flu outbreak we have been putting information into their missile let's or documents to hand out in the faith based institutions. the 35 seized were always contain, cover, clean. we made sure they had a simple message and that we kept going for the community. the faith based institutions are trusted organizations with the local health department as well and our communities sectors. we do not have enough private sector interaction and that is what the leadership is about. this is a current situation, 3,002 to 59 cases in illinois. 6,762 cents were tested and 37 of 102 counties, some 37 counties are affected currently. there were 14 deaths mostly in people who had underlining medical conditions but we did

see that particular situation with asthma as being one of those that stood out in our groupings. it was also seasonal flu vaccination campaign. it is essential for us to do this. we are mounting one now. the reason is if you do push the seasonal flu vaccination program what you will do is allow us to stop potentially 36,000 deaths that occur every year as one of the things. second thing is you will decrease the prevalence of seasonal flu because if i had the flu and i am on that educated about this, with the symptoms are i'm going to my doctor, i'm going to my hospital. it could prevent a surge on hospitals, local health departments and private practice if people are immunized against the seasonal flu because once the media were john starts people are going to come in so it's important to do that. it also saves businesses and employees from getting sick from

seasonal flee when you also have people out from potentially h1n1 there's also the preparation for a mass vaccination and surges we continue to monitor these things and the last slide as to follow the cdc outlined according to age now and this is the total number of cases and the number of deaths for each of these categories and you can see it's almost a distribution as we thought with this group the 25 to 49 be more affected. at least preliminary from this data. what we needed, some things we need other than founding with a smile, more wireless access for laptops, workspace templates and emergency operations centers, pre-identify and traditional stuff to support the pheoc and

distribution sites and we need staff. my staff was at the image of being burned out. we have got to get and make sure we have a staff that is sustainable for the long haul. the national guard made a mention from the bureau one of the major generals and what his statement was is that in the army there is one of these statements that says in the day the bea weare. people who are becoming ill should be put on the cyclist so when they are recovered they can be reinterpreted in areas where you have potential risks for exposure. also better private-sector involvement and much clearer definition of the usage and when it is appropriate to use an mi5 mask orloff mask. even a coif basque can stop you from inoculation and maintain local drop site database and

restructure all of the incident action plans for partner integration. so that's all i have to say in won sohn said. -- one sunset. [applause] >> thank you, dr. arnold. now we will hear from dr. marcy from new york. >> good morning. i don't have any slides which is unusual for me and i am a new yorker so i talk fast. a lot of people have talked about the importance of planning and i am definitely a proponent of emergency response planning ahead of time and ironically we were in the midst of finalizing a revision of the 2006 pandemic plan this spring when the h1n1 outbreak of life in new york city and although overall the planning process for pandemic helped the response this spring there were definitely several assumptions that ended up not being applicable to this particular outbreak. first, we thought we would have

morning ahead of time a pandemic was occurring and that it was more likely to be recognized overseas prior to its arrival in new york city and second, we were preparing for the worse case scenario in 1918 like pandemic and we thought that we would be able to address my older for the worst-case scenario but we hadn't thought through in enough detail how we might need to modify our actions fortunately and new york city we were able to identify the introduction of the swine flu into the city early after its arrival since new york city as you heard in the last session and presented as a highly explosive outbreak at st. francis prep high school in queens which was just two days after the cdc first announced the initial cases in california and only one actively a day before the first confirmation that h1n1 was causing an outbreak of severe respiratory disease in mexico.

a challenge though of being one of the first affected sites was that there was no information yet on the viral transmission characteristics or its virulence, as we had to make our initial decisions on how to respond in the absence of the data that we had hoped would be available and though initially the new york city outbreak was primarily associated with the high school within two weeks we started to see evidence of more widespread community transmission first in the area around the high school and then eventuly all areas of the city and as of yesterday we had identified over 900 hospitalized cases and 47 deaths and we estimate the several hundred thousand new yorkers were infected. and though the miracle impact was probably no worse than the seasonal flu as other speakers diluted to is that younger age groups were more severely affected. in new york city about 43% fossilized cases occurred in children, and 96% of deaths occurred in people less than 65

psp one .. we never wanted to stop the spread of the virus in north america. our public health response included several key activities. first, and my responsibility at the health department was surveillance, to monitor the impact of the outbreak in new york city and to assess the trance misincident and severity characteristics of the virus in order to provide the type of data we needed to guide our public health decisions. our most intense staffing resources were put into surveillance for severe cases, hospitalized and fatal cases, because we really needed to know, is this a more severe epidemic or pandemic? identify the people at risk for complications were those that were affected by h1n1, and if they were any dmpt from seasonal flu. second, we wanted to track the

trajectory of the outbreak, and we did this by focusing on milder illness using our existing electronic -- excuse me -- using our existing surveillance systems. not a good sign. our existing electronic -- the outbreaks over in new york city, so i should be ok. we used our existing systems for emergency department and primary care visits, which allowed us with minimal staff resources to monitor the geographic spread in the age groups affected. and third, we did several population-based telephone surveys to provide information on the overall infection rates in the city in order to estimate both hospitalization and fatality rates and allow us to compare the seasonal flu. and lastly, we did a few modeling studies with both c.d.c. and academic partners to

assess viral transmission characteristics, such as incubation period and generation time. our response to outbreaks in institutional settings was most intense, obviously in schools, but also in the city jail system. in new york city, we have about 1,600 public schools with over a million students. our rationale for school closure was not to mitigate citywide spread. again, we realize that wasn't possible. but to prevent transmission to those at highest risk in that particular affected school community if it was experiencing a sustained or increased incidence of influenza-like ill tense school. our policy was not based on just having one or more confirmed cases n. total, we closed 55 schools for five to seven days, none of which experienced a recurrence when reopened. as far as correctional settings, our main city jail has over 13,000 inmates on average on any given day, and when the initial cases were recognized around the time we started to see community transmission, we implemented an

aggressive screening, isolation, prophylaxis, and restriction policy to contain the outbreak, and we were very successful. we only had 100 confirmed cases. we had very little sustained transmission in any of our housing units, and no deaths in the correctional facility. as far as public communication, we did numerous press releases and press conferences. a number of fact sheets were developed to address a wide range of issues and were translated into all appropriate languages. we tried to share information as soon as it was available using multiple modalities with frequent and very detailed updates made available online. we distributed over 21,000 educational posters and brochures, and we triaged about 54,000 h1n1-related calls to our public call center. as far as medical provider education, we did a number of health alerts through our health alert network to give up-to-date information to our medical partners. medical partners and

developed new york city specific guidance documents to help providers in new york deal with triage patients presenting with nonspecific a fever and respiratory illness as well as guidance on the use of the antiviral and a proper precautions or infection control and personal protection. we tried to make ourselves available to our medical partners by doing almost daily conference calls especially at the start of the outbreak with our hospitals as well as separate calls with private providers and a committed to health clinics and mental health agencies and our provider access line or call center was opened seven days a week and a little over 5,000 calls. although our response to health care will be addressed in the afternoon session in much more detail by dr. debra. here with me today we like other affected cities experience extremely high patient visits and our emergency department and primary care centers mostly involving children. two briefly touch on some of the challenges and opportunities that we faced from is

surveillance perspective the absence of having comparable of surveillance systems for seasonal flu made it difficult to compare are dated to the regular flimsies and and our findings that data describing are in perspective and especially to quickly determine if the outbreak was more severe and more restrictive control measures and unusual for flume justified in paris second it was difficult to compare our findings to the rest of the u.s. since different types and intensity of surveillance methods and public health lab testing criteria were used and unlike as many states also reporting members of my cases and quickly determined that wasn't feasible and even if we tried it wouldn't be rep. we like other states have a public health lab capacity so in new york we prior to rest testing early on for hospitalized and pillowcases only and not overwhelm our city lab with the other cases.

we are able to successfully educate our clinicians who initially wanted to use test results for clinical management but since h1n1 was really the predominant respiratory pathogen in the city during both may and june the tremendous sessions should be based on clinical presentation of influenza like illness and not on test results and finally the surveillance that we did to determine the number of hospitalized cases was extremely labor-intensive and that money not sustainable for a more prolonged or severe pandemic especially given limited that diagnostic capacity. counting every case was never part of our pandemic plan, line to focus our resources on collecting the data we need to make a public health decisions. as far as learning from this for the fall we are planning for surveillance approach that will allow us again to monitor the course and reject three of the outbreak in a more sustainable and efficient way and allow us to identify any changes in a

characteristic of the virus. it will continue to enhance our sent from a surveillance systems which were extremely useful in allowing us to the trajectory of the african to tell where activity was most intense in this city as well as the age groups impacted. we will probably take a sentinel or sampling approach to case based surveillance for some real animus and mountainous and work with a representative sample of hospitals and primary care clinics to provide information on the types of viruses circulating since not all influenza illnesses may be due to h1n1 and allow us to assess whether the virus is clinical and characteristics are changing. i like to work with federal agencies aren't in their academic partners to plan ahead of time for the types of of this clinical studies that we should conduct at the sentinel sites to address the key knowledge gaps such as how best to manage patients who are chronically ill not getting better despite anti-viral treatment and

recognize the need for consistent surveillance approach nationwide to allow for better comparison of surveillance members. i probably our biggest challenge this spring was having to put the and consciously develop a policy on school closures as we began to see more committed to a wide transmission and increasing number of affected schools. at a time this was in a way that we didn't yet have data on how severe or contagious the virus was. we did follow the federal guidance of the time that recommended closure for even one confirmed case in a school which we thought in new york city was unrealistic and unnecessary. our experience however give some opportunities to be better prepared for the fall reflected a wealth of data on both schools were closed and those that were on our watch list but remained open to husband and determine the impact of school closures on the transmission. we are collaborating with cdc on a survey of close calls to help assess both economic impact of

school closures on families as well as what children actually did it when not in school. and the rear in the process of reassessing our approach with a fall like many of you with a more aggressive closure policy likely being limited to this an area where the virus becomes material and especially in children. leslie though not we simply communication. from a risk mitigation perspective it was very talented and beyonce are reassurance regarding our finding that the go over all the illness was mild we were sometimes recommend a more restrictive and extraordinary public-health measures than we normally do for seasonal flu, most obvious thing closing schools. was also very difficult articulating our rationale for how we're approaching our school closure decisions because it wasn't a simple numerical cut off or formula and ensuring timely notification of that particular school committee when a closure decision was made.

we also found it difficult to use public message in that sense to help dampen the demands on our emergency departments especially for those less severely ill or the seeking testing for reassurance are to return to work or school especially for those who didn't have any easy access to medical care. on the other hand, we were in that some of our messages regarding persons who didn't need to seek early treatment and not being heard well, especially among persons who might not consider themselves at higher risk including pregnant women or parents and children with mild asthma. with respect to provider communication it was sometimes challenging to expand our policy differences with cdc especially with respect to respiratory protection as w along with several other states did not recommend it routinely use of a respirators and as was the need for the type of measures and committed these settings, it is unrealistic for persons at high risk in new york city to avoid

crowded places. as far as opportunities in which everything else we now have some time i think this summer and based on our experience to improve our communication tools and messages and that this especially to leverage of the tools that are available palm our federal partners. as well as working through some of our policy differences given that the knowledge we all gain from the spring and findings of the current flu season and the southern hemisphere. i just want to in the during the first two weeks of the outbreak in new york city i used to tell my staff when it was mostly limited to st. francis high school in queens that my nickname for the outbreak was swine flu 2009, the best prepared mr. l ever and though it ended up being much one than in jail or exercise because i'm still learning how we are fortunate in that in the experience we just had and the lessons we learned openness and a much better position to raise the town is we're all concerned about in the fall so thank you and soren that i couldn't talk.

[applause] >> our final speaker, the executive director of the division of health. >> thank you. greetings from the navajo land. i want to extend my greetings to secretary sebelius, secretary napalitano, secretary duncan, and the state government and also all you're distinguished ladies and gentlemen. again i am from the navajo nation and the executive director of the lahood division of health and i'm honored to be here and speak to the distinguished group here. would like to do is alan flag to a high that some of the things we have worked on it in navajo land. i want to give you a sense of where we're coming from by doing

, the nomination is only one of over 500 indian nations in this country so i wanted give you a sense of how the indian nations operate, the land base. also wanted to share with you the lessons learned from our perspective and then also with some recommendations. again in the navajo nation is only one of the over 500 indian nations in the country. and each nation is different. it has its own culture, it has its own way of looking at things, on values and a own way of dealing with the emergencies. for the nomination we are located in the four corners region. we have the land that expands to this id of arizona, new mexico, and utah. and the nomination is about the size of the state of west virginia, 26,000 square miles. the land is mostly rural, 728%

of the roads are paved. we have 9,000 miles of public roads and only 22 percent roads are paved said this means to him that in inclement weather conditions is really hard to get around. the population density is 7.1 persons per square mile so it is a very rural, over the weekend during the fourth of july i was invited to a family gathering near a place called the pine springs. i went from my home and tried to gallop on i cornyn and went west and then it turned right near hot, arizona and turned north and drove 18 miles on dirt roads, washboard, if you know what i'm talking about. it took me one important -- it took me one an hour and 30 minutes to travel 18 miles -- and that is the conditions we

have in our communities and on navajo land have 300 people registered, about 200 reside on the nomination. in addition to the three states region we are also located in three different federal regions under region six in dallas, also have to work with the region eight office in denver, colorado, and also have a third place which is region nine in san francisco so any time that we have to do with different federal programs we have to be aware of a stiff and settings. the health care delivery system is such that the indian health service is the primary health care provider of the navajo people. vesicant organization that is very active and health care delivery system is in the navajo division of health which is where i'm coming from and then also we have when we, that contract writers.

programs that and on minister that federal programs that used to be administered by federal agencies and we have indian health services that provide services to over 200,000 active users and one year we have served about 1.2 patient visits. let me also say that navajo traditional healing practice is still part of the health care delivery system. we have navajo people that get sick and they do not hesitate to utilize the native practitioners and we still hold them very dearly. over the years the navajo nation had to do with a number of public health emergencies, such as tuberculosis, hunter virus, hiv, and other diseases such as salmonella and e. coli and then also sometimes we have to get involved with what we call operation mott left, we also had

to help people we had to deal with forest fires and now we also have to get involved with the h1n1. then they give you a sense of how we dealt with the h1n1 outbreak this past spring. we first got the information in april and right away we set up a meeting with the navajo area indian health services and then initiated the whole alert face for team and then set up an incident management team and then also said of the emergency command center that was manned by the navajo bioterrorism program and then we also resorted to that epidemiology's center and then these programs have the daily contact with the navajo area indian health services, also had to contact with the states of arizona and mexico and it worked very

closely with the surrounding 13 counties. and then very fortunate that we were able to respond quickly according to the information that we got from the navajo-area indian health services. there were all together 71 suspected cases that were reported, 13 cases were confirmed, and nine individuals were hospitalized. and very fortunate that all these individuals recovered. now, let me turn to some of the things that want to share with you in terms of the lessons learned in working with the various entities. some of the challenges and then some of the gaps that we saw, there were several. one has to do with there are issues related to multijurisdictional issues. there's also a lack of a

sprenssive public health policy plan. because when you work with the various entities, like the counties and the states, you have to understand them, you have to understand the rules and regulations. there is a definite need to develop formal agreements between various entities within the navajo nation. nomination and when you don't have a very comprehensive plan, this may contribute to delay as services and also long the delay of distribution of drugs so sometimes we do need medical supplies that need to be delivered quickly which you have to get into checking with someone and that someone is to check with someone else again so that is what we go through, but in spite of all that i think we have a good working relationship with most of the entities that have to work with.

secondly there issues related to the lack of infrastructure and information technology. there is a definite need for one definite strategic national stockpile facility in navajo area, there is also a need for adequate information technology that would allow us to process data collection and also to analysis including disease recording and reporting systems. right now we have to wait and look for one entity for a certain report and didn't and then at the end try to bring in altogether. there are issues related two culturally specific information communication system. for example, one-third of the navajo population speaks navajo language. this means that someone has to

take the time to translate information. once the information is translated then we have to disseminate the information and the available mass media that we have is local radio station, it is very useful. we have a radio station, very use all and other produce stations in border towns and then we also had to resort to some of the staff within it now home bioterrorism program and we have one individual, a lady that was very good and translating information. she has her own way of translation and coming up with good messages and she was saying something like -- [speaking in native tongue]

-- what does that mean cranks' she was saying you are out there listening to me and i take this time to do your own prevention. while you are washing your hands, perhaps you can sing happy birthday. [laughter] that is very effective and so i say whenever i get questions about h1n1 i say and this young lady's name is ileana, i say, well, this into a lean man, she says everything is okay then everything will be o.k. so that is the kind of individuals that we have in the communities and these of the kind of individuals that are very rare and they can help us to communicate directly with our constituents and our customers. the other thing that i wanted to mention is due to the remoteness and the mountainous terrain, than that of a pot -- the

nomination -- uses mobile telephones and seller of phones and a lot of times to get into remote areas and you may have a cellphone but it doesn't always work. just as i describe to you over the weekend i went 18 miles north of up by 40. once i got 10 miles away from interstate 40 my cell phone was useless. no communication. i also wanted to know there are issues related to lack of out of quote technical resources and may need to adequately prepare for an emergency, and the outbreaks of any infectious diseases. a lot of times we don't he the real sources. have indian health services as a primary health care provider put in as well documented in his only son and a half the amount that is needed so a lot of times in these cases is indian home services within the have the

resources are not that have to become part of our partner so that we also have some existing emergency response structures that may have to be activated but most of the time there are not properly funded so we have to resort to the existing resources and honor to make it functional let me mention some of the strategy is that help us prepare for the response to h1n1. fortunately the nomination in partnership with the navajo area indian health services in 2006 we did what we call vaccination exercise. the exercise we brought together various governmental agencies including the state, county, law enforcement, a childhood resources and in one day we were able to vaccinate 24,000 people

in the span of a hours and this is through the use of 15 distribution sites so with one day of vaccinating 24,000 that in total lead to vaccinating 80,000 people in one year so that was a very helpful exercise that we did and we repeated the exercise of on. by the timing to the exercise people were vaccinated and able in that one day mack's fascination or able to pick up additional 6,000 but in the end in a given year 2007. able to exceed 80,000 individuals. another thing that we learned was that establish -- we also have begun to use the national incident management system and than by using them for able to

utilize this cdc how emergency response and led to the stage, the local government and childhood health directors so in that process while we have these existing protocols and policies, we are able to do less to these policies and protocols and in the process i think we always learn new things and always trying to make our system is better. so also in the process we are fortunate to have also opening up new doors to other new resources and other technical support. than some of the of opportunities that we seem it again and we hope that h1n1 does not come here again but we have to has has been said by previous speakers, we have to be prepared. the nomination again i am sure this is true for all indian

nations, we want to be partners with the states and burners with the counties and also want to make sure that we try to take care of those issues related to a jurisdictions because a lot of times people do get hung up on jurisdictional issues and i think that needs to be dealt with. also need to deal with what can pertain to cost sharing plans and also need to warm or with plans that can be cornyn in and also have a good public information system. so it's that that we close by saying i do appreciate again for being invited and i think the navajo nation is certainly here along with other indian nations coming here to work with different agencies and the department of health and human services. in particular cdc i think we need to make sure that cdc

cannot make sure that all the state agencies contact with all respect of indian nations throughout the country. and then in summary, i think we are prepared if it does occur and then that we have to do the work involved i hope that we'll get enough resources to augment the health care delivery system and that we know -- now have and be able to work on things. i think it is important and it has been said before we do a proper planning and preparation and certainly this does mean establishing that close working relationship and partnership with all entities in the nation's and it's a barn to work on cost-sharing plans. data and information sharing. of cdc in indian health services, they do have a data warehouse is but a lot of times i think it is very trying to get information out so that is

information that needs to be available to all indian nations and then there is definitely a need for technical assistance and training. i think the last thing is public information is very important. and many times in a country that one size does not for all hands is very important that every state work with respect to indian tribes and nt -- every in the nation has their own resources and individuals who have the resources that we can be able to mobilize and be able to be a part of the work team. then finally again i applaud the the the problem of health and human services for working on preparing for any possible h1n1 outbreak again but in the process i again want to say keep emphasizing that indian tribes

need to be involved and indian tribes are ready to work with you. thank you very much. [applause] >> thank you very much. it is clear that there is a breath of experience and learning and i'm going to open the floor up for questions to the panelists, but let me start off with the question of my own and that is that the epidemic after this point has affected all of our institutions and i would like to just to think about where the legacy of this response is likely to be when it eventually is over. >> [inaudible] i think the legacy for the initial responses to the public health system has really responded in a tremendous way with all the associated organizations in national governance council has been a

really instrumental. we also have a national process that is going on so it is going to require that because we are is a emergency start on the local level. and all the state, local and federal and always in the process of developing any kind of incident action planning so are the association's like w.h.o. and all the others need to be part of the process of developing any kind of planning that goes and the federal so they can make the good of mind with the local levels because the local house apartments called me and many of them we were able to assuage them from that moving out on us and making sure that they stayed engage with us so it is very important that the federal doctrines translate into common languages that people can understand and appreciate and also comply with.

>> having been involved in emergency response planning for several years i think it is always time to engage some key sectors in really coming to terms with what the issues will be of the experience of a real event so i think the real legacy of what happened in new york city is that we have been able to leverage this experience to bring together other key partners including our emergency management partners and public safety partners as well as critical infrastructure to really think through the issues are begin to rethink the the issues with us hopefully in a more operational and realistic way in the event that we have immersive year pandemic in the fall and island and into that our health care planners who we have been able to engage must then some of the other sectors but there are some key lessons learned that we haven't expected with a surge on our emergency

departments and clinics so we expected that, we thought we could minimize it with some public communication and it was more challenging. we learned a lot that will hopefully give us opportunity to engage more broader spectrum of partners especially to deal with continuity of operations that will help with other emergencies as well. >> good morning again. again as i emphasize i think local involvement is very key and then i think it is very easy for indian tribes to be left out and i think it is very important and also in every indian community there are oil some resources that are unique and then i think they need to be involved, the tribal leaders need to be part of the discussion and again we have always said from the indian

community that one size does not that all and have done a number of public campaign such as the work with cms on medicaid and medicare. we have said over and over that indian tribes need to be involved and how you get the message across and then how you do your national campaign. we are being asked to do something and in the process of disseminating information we have to take that responsibility to break down, to inside information and then tried to get someone that can be able to convey the good information and the right information to all our customers so i think we can be able to establish that partnership early and then be able to be at the table. i think we can go a long ways. thank you. >> thanks, and there are questions from the floor, if you could go to the microphone and

introduce yourself that would be great. >> association of territorial. we talk about some populations but not in a poor and vulnerable population and out like to have them comment on that -- with this outbreak we have many undocumented individuals who feared coming forth for health care because they were afraid of it legal action being taken in based on the active seeking health care. in addition we have many people who work in the service sector and other industries for the have no set time and no benefits and that they don't worth and don't make money and don't eat so we're going to have to deal of that issue if they're going to be able to stay home with

their children are they themselves ought to work so the two things i asked you to comment on, one is can you comment on what to the to do to deal with folks who are undocumented so they are not afraid to see care for themselves or their children. every new legal action. secondly how are we going to assist the people who don't have the benefits which is a large part of the population so they can stay home other children or not go to work themselves? >> both of those are very insightful questions. the undocumented question was very important to us in illinois state because we had 50 migrant camps, people were coming into the area and we had no idea of who was coming into the area. and they are usually followed by a mobile units to provide their medical care so we actually identified their infrastructure

for health services and made a link with them but i think you're absolutely right, until that the stigma is removed warren had the ability for us in the federal level to say you are able to treat people without repercussions for their status, we will have trouble with those populations people wanted to come forward voluntarily so i think it had to be a policy change and within our legal structure that we make the change but also how we deliver services and the community level, on the local level. the second part was i think we also need to talk about how to assist families that are coming in against the healthcare system and i can't afford to participate. when they are taking off from work i think the business community and that is where the leadership comes up and talking to businesses about how to take care of your workers that are

valuable to you but are at a disadvantage because they don't have access to health care, how you change your policies and creative ws of dealing with that as far as scheduling and also providing health care of services and house support for children who are ill the future they are treated in a proper environment so i think those resources and money to the school system and through the health care system needs to come to address that issue really for front and in a short time. we don't have a very long time to have this national model in place. does it require the right paper in requires action really. >> how will briefly comment on the last question because i agree, is a critical issue and when we did a survey is of the closed schools to get a sense of

what people who were supposed to be staying home, there is a percentage of even high school kids who end knowledge that was schools are closing and a rail there were still going to work so getting that message about staying home if you are ill is a critical johns especially for in more severe pandemic and facilitating that we need to ensure that all workplaces have policies that our billing to loosen up in the event of a pandemic to allow their workers to stay at home and provide the opportunity for them to work at home so that are not coming to the workplace and i think that responsibility needs to start with government policies of the federal, state and local levels some it is part of our pandemic discussions in the past and appear on an accelerated pandemic planning schedule as well specifically dealing with this issue within government as a month as are private business

partners. >> the first american native people, there is always a mention of the treaty rights and also the right to receive services in this country and oftentimes i think it has been raised again at one point they wanted to use december 2005 there was a model past and had to work on to deal with the need to have a citizenship and identity and. any time that anyone called for assistance from medicaid there was a requirement for the citizenship documentation and and what we learned in the process we hope this doesn't happen again. and is with navajo 17,500 navajo were over 60 years old and over 90% and not have a printer certificates and and even those under 60 including myself did

have a birth certificates and we had a challenge to work on which was two really come up with some documentation that would show that we have the right to receive services if we applied for medicaid, for example, so in these kind of discussion and think the hope that we work hard to fully understand it with indian tribes are at and then fully understand the counties in the states also need to work with us in terms of getting the information corrected. thank you. >> we're going to take these final two questions but i ask for very short questions and answers as well. >> thank you very much, when i heard the panel say this was a dress rehearsal and folks were still tired i was wondering about discussions about strategies for the marathon for public health and our other

sectors of the local level, the federal level one thing that could help would be relieved of the state employees that are on federal funds. use 5% of their time for emergencies and may be expanding that for the marathon and the strategy but i was wondering about local and state strategies of. >> , okay, for the state's strategy of one of the things we are looking at is merely one of the lessons learned from the spring and was how to rotate your staff and ensure that you're appropriately covering times and that your focus is in the right place as far as testing. a lot of the energy went into doing a lot of testing initially and that filicide because we started telling people not to come in for testing. it to stay home. also the cdc been a very good statement about air travel here it is already here so why are we comply with our airports. those things helped us to refocus our energies and move

our staffing in the correct direction and is jim it correctly, but all the states are facing cutbacks right now, all the states are facing layoffs and and think that those things cannot happen in the public health sector and education sector especially with this happening now and homeland security sector. this is the time it is critical, we don't know what will happen in the fall, these areas cannot afford to have cuts. if anything we should try to increase because in of the staffing shortage which pre-existing me actual pandemic itself. >> i will make a very brief comment which is something we instituted in new york city was a flame out or burn out policy and i want to emphasize how born in is to take care of ourselves during these things in the town for people working too many days in a row and to many hours and there's actually a limit on how many days to give work without taking a break. we had our mental health, part

of the department of health and york city, actively doing outreach to make people taking breaks they needed. and having those plans in place ahead of time as well as a rotating staff mike knightley -- and there was and as many people who rotate through. >> i just wanted to make a few comments. in these to the navajo nation and i think this is probably too for and that indian nations, we have what is, a navajo nation pandemic influenza plan that we're working o every time that we deal with certain incident it does get updated and i think in some committees there is always a need to get some technical assistance to do that capacity so that is very important. and then the there is always a need of technical assistance. thank you. >> just a final question.

really quick with dancers. >> out of my 27 questions, for the people of wisconsin, we know that we don't have the surge capacity of skills, infectious disease, epidemiologist are emergencies like this one. we also have a chronically unaddressed massive epidemic that is ongoing in this country of sexually transmitted diseases. could we perhaps look at cdc level and the state level and beyond a hiring more communicable disease epidemiologist to work on the as to the epidemic and keep in reserve part massive emergencies like this fall? >> yes,, yes, yes. [laughter] but i also wanted to thank the the federal government and the speed and in the amount of interest, secretary sebelius and secretary napalitano come mcginnis bunning but there was a

reinstitution of immunization of our public trust i think in the spring as well and i think we need to stay on that pathway. doing things like that making sure we have is that for epidemiology and those things are moving in that direction. >> i am actually going to let that be the final comment. i would say that as cdc people from all over the agency were working on a response. are limited and i think that managing wish to have and the short-term to the highest priority areas is keen a matter what the response. i want to thank our panelists and the audience for their participation. [applause] >> how is c-span funded? >> the u.s. government. >> private benefactors. >> i don't know. i think some of it's government-raised. >> it's not public financeding.

>> probably donations. >> i want to say from me, from my tax dollars. >> how is c-span funded? 30 years ago, america's cable companies created c-span as a public service, a private business initiative, no government mandate, no government money. .