Tip:
Highlight text to annotate it
X
Welcome. I'm Dr. Paul Jarris, executive associate director
of the state and territorial health officials. We'll begin with basics to get everyone to
speed. We're also joined today via the web with senior
deputies, preparedness directors and members of NACCHO's preparedness task force.
We have become familiar with events in Japan, an earthquake one of most severe in history
followed by a tsunami that caused damage far as the West Coast of the United States and
concerns of radiation leaking from Japanese nuclear power plants.
While we offer help and support to those in need, it's a reminder of the importance of
the disaster preparedness within our own country. The unthinkable continues to occur.
We have to be prepared for all hazards if we're going help our communities become more
resilient in the face of disaster. With so many new officials in our state health
departments we want to bring together the key people from federal departments who have
resources available to assist states in preparing, responding and recovering from these disasters.
These officials also reach out to you in times of emergency to learn what they can about
what is happening on the ground. It is important to develop a relationship
before disaster strikes. Today you'll gain valuable information.
But we don't want this to be one sided so please take a moment and jot down this email
addressů Studio@HHS.gov. It's on your screen now. We encourage everyone
watching to email any questions you have regarding today's discussion.
We'll ask your questions once we heard from all the guests.
If it's answered as we move through the program we won't go back and do it again.
We do ask you to keep your questions brief. Otherwise we'll have to edit for a bit of
time. Please let us know your first name and the
region or state you come from. All right, let's get to it.
Joining us on the panel today to explain the federal and state partnerships are several
heavy hitters in the field. Dr. Nicole LURIE, assistant secretary for
preparedness and response with the Department of Health and Human Services.
Her office is the lead entity for federal public health preparedness and response and
serves as the principal advisor to Secretary Sebelius on matters regarding bioterrorism
and other emergencies. Dr. GARZA, assistant secretary for health
affairs and chief medical officer of The Department of Homeland Security.
He manages the DHS medical and health security matters, over sees the health aspects of continuously
planning for chemical, biological, radio logical and nuclear hazards.
Finally, the primary DHS point of contact for state and local officials on public health
matters. Rear Admiral Ali Khan, Assistant Surgeon General
an director of emergency preparedness and response, he served as one of the main architects
of the CDC public health bioterrorism preparedness program, and responded to some of the most
devastating public health emergencies affecting numerous world wide populations.
Finally, Colonel Jay Newbauer, command surgeon for NORAD and United States northern command
or NORTHCOM. Principal medical adviser to the commander
and staff and is responsible for the integration of DOD medical assets in support of military
response to civilian disasters. Let's start with Dr. LURIE.
Assistant secretary for preparedness an response for HHS.
What exactly does it mean when you hear your office is the leading entity for medical response?
As secretary's principal adviser for preparedness and response my office is responsible for
coordinating the various components of HHS from a policy perspective and from a preparedness
and response perspective. This includes both running the secretary's
operations center, and then coordinating across CDC, FDA, SamSA, NIH, et cetera, all the agencies
involved one way or another in response. As we have seen from the events in the last
year, year and a half, every single component of HHS is involved in one way or another.
So while we all have our discrete roles to play, we all work together so that we're coordinated
and seamless when we reach the public and when we reach state and local health departments.
So if I'm a new public health official how do I request federal assistance for public
health medical emergency in my state or jurisdiction?
It depends on what kind of an event it is. If it's a small localized or regional event,
chances are good that your first contact will be with the CDC.
If it's a larger event, chances are good that either FEMA will be involved, the federal
emergency management agency or that you'll want to reach directly to one of our regional
emergency coordinators or that you'll hear from CDC or one of us.
In one of those events we'll stand up or secretary's operation center, CDC will stand up its emergency
operation center and we'll go from there.
What types of resource or assets would we turn to the Federal Government for and could
we expect to receive? Those assets come in different sizes, shape,
flavor, whatever you want to call them. So when people are catastrophically injured
one first thing we'll do is stand up and deploy our national disaster medical system, their
disaster medical assistance teams as well as mortuary teams that can be deployed and
on the ground quickly to provide direct care in a disaster.
In addition, we will then mobilize the rest of the departments assets, particularly for
example the assets expertise advice of CDC, of FDA, of SamSA and others.
In addition I should just say that we have the commission core, the U.S. public health
service of which I'm a member. And there are about 6500 strong that can be
deployed around the country to help respond to medical disasters and public health disasters
of one kind or another. The medical reserve CORps which is an asset
in the states but coordinated by the Federal Government is another asset.
We can go on and on but I should let somebody else get in here.
If we have a need you should ask.
If you have a need you can ask. Ask through our regional emergency coordinators,
you can ask for the operations center but everything is organized at the end of the
day under what's called the national response framework.
And what resources does HHS have available in the field to assist preparedness response?
So HHS is divided into ten different regions and almost all parts of the department are
represented in those regions. So we have emergency coordinators in the field
to work with your regional directors and regional health administrators to coordinate the emergency
support function or ESF-8 assets in the field. So you can go directly to the regional emergency
coordinator and they can get you the help that you need in the field.
Whether it's from the CDC programs, grant programs, whether from the hospital or healthcare
preparedness program or whether it's other kinds of assets or help that you need.
Thank you. Let's turn to Dr. GARZA, Department of Homeland
Security now. What field presence does DHS have in the states
and what is your capacity to help state health officials an states in general with preparedness
response?
Paul, you know DHS has assets deployed around the country.
In multiple ways that the public interfaces whether TSA, whether immigration and customs
or customs and border from text. But I think the point that will probably interface
with the public health and the emergency management are probably the FEMA teams that are located
in each of the ten different regions. As Dr. LURIE said.
And some other assets that are unique to our office at health affair which is is our jurisdictional
coordinators that focus primarily on biological detection of agents of concern to Homeland
Security. FEMA has unique assets and I think most have
seen those in recent days with urban search and rescue teams as well that can assist states
and locals.
Very good. Colonel Jay Neubauer, from you and DOD.
What does U.S. NORTHCOM have available to forward a state response?
Thank you, Paul. To set the framework, NORTHCOM is essentially
the commanding and control function for support from the larger Department of Defense.
State officials can usually see different uniforms, if you will, in different phases.
Obviously the first phase will normally be a national guard response controlled by the
the state. In addition, if the event is of significance,
local installations, Army, air force, Navy, et cetera can provide assets to local officials
through memorandums of agreement, mutual aid agreements.
Again, if the event is larger than requests come up through the state government to FEMA
which we support in a larger disaster as part of consequence management, and those specific
requests then can be turned over to the Department of Defense where we can bring in specific
capabilities from field medical capabilities to air medical evacuation o to hospital support
as needed. How would a state gain access to DOD capacity?
Typically that would be through FEMA as FEMA sets up their joint federal office or regional
office. We are represented within that facility looking
at ESF requests or requirements some of those requirements are turned over to Department
of Defense for consideration. Then we match up requirements with capabilities
and provide those through FEMA to the state.
And once you're in the state how does U.S. NORTHCOM integrate into the state response?
Typically we set up our own what you call command and control structure so there will
be a joint task force set up which we'll define our command and control but that task force
will report to state officials.
Very good. Thank you.
And admiral ALI KAHN with the CDC is often the first stop and point of contact much to
the chagrin of your trying to sleep I think. With we have quite a few questions for you.
Tell us broadly about CDC's role in national preparedness an response.
Thanks, Paul. So we provide strategic direction for the
public health component of national preparedness and response.
Including support and coordination for the agency-wide activities and the activities
with state, local, tribal territorial health departments and with international health
departments. We bring CDC expertise to bear and focus on
both natural and man-made public health emergency an disasters be they radio logic or nuclear
or biologic in nature or chemical in nature. But most importantly, our preparedness program
is not just ab these catastrophic events, it's about what goes on in public health every
day. And how are we responding to our routine public
health urgency if you want to call them the food borne outbreaks, et cetera.
Then also during an event obviously we're ready to support state and local health departments
as they need with our assets at CDC or various assets we have at state and local health departments
to save lives immediately.
Can you tell us what CDC is doing currently and in the future to strengthen public health
and emergency preparedness and response?
Glad to do so. Most know us through the emergency preparedness
grant or step grant. This is direct way we support state and local
health departments, improve preparedness related activities, in addition to that grant we also
directly provide assistance with experience epidemiologists in state and local health
departments an this is the CFOLD program, the clear epi-x office program and I would
recommend to new senior health officials watching this program, if they don't have one or two,
please reach out to us, these individuals are absolutely excellent in building the epi
capacity and preparedness capacity in the state.
In addition to this direct support there are a number of other activities and ways we support
state and local health departments. so one of them is provision of critical counter
measures. The division of strategic national stock pile
procures critical counter measures antibiotics, antivirals, other materials that at the state
and locals need them during an emergency they're available to them.
And they show the metal nicely during the H1N1 outbreak where exactly as they were supposed
to, 25% of antivirals got out immediately, as planned to state and local health departments
for their use. We also manage the emergency operation center,
this is the -- often if belly button for state and local health departments to reach into
the agency for whatever their needs maybe, it provides our situational awareness and
monitoring and is our central command center. We also manage the select agent program so
if you have labs, states have labs within their state that are dealing with things like
Anthrax or plague or TULEREMIA for example we manage the biosecurity and biosafety issues
for those labs to make sure they're safe entities. And then we also -- let me also call out the
research-related activities and training activities with the schools of public health that we
conduct to make sure we have a strong evidence base for the preparedness activities in states,
and good learning materials that are available to state and local health departments with
our state -- our schools of public health so key activities there.
So it's clear why you're so busy.
Yes.
Can you tell us more as a new health official how to access the resource?
Let me step back and talk about the SNS. The SNS is responsible for maintaining -- pro
procuring, maintaining, warehousing and shipping a large number of material, it's not just
antibiotics but antibiotics, antivirals and specific materials that include bandages,
ventilators, respirators and other components that make up the strategic national stock
pile. When we originally put the SNS together the
whole thought was we would have the 12 hour push packages to send out large amounts of
materials within 12 hours of request, this program has become a lot more sophisticated
over time and now we can surge out specific materials as requested by states within three
to four hours arrival times to them depending on what the materials are.
There's recently been a big focus, a national focus with the president's executive order
on Anthrax preparedness in the United States and we're in the process of setting up new
warehouses so that select materials within the SNS would be immediately available to
state and local health departments. Now, how do we -- the last piece of background,
how do we manage to decide what goes in the SNS and really, that is done in conjunction
with Dr. LURIE so there's the public health emergency counter measure enterprise system
and that includes your shop also Alex so o to think what are the key things we need to
put in the SNS, we'll get back to that in a minute.
Finally to your specific question how did they ask for this stuff.
So the governor has the ability to either reach out to the secretary, reach out to CDC
to ask for this stuff or during specific response to reach out through FEMA-related mechanisms
and ESF-8 to ask for these materials some numerous ways o ask for materials.
As part of having a stock pile most states have measures in place how to use the stock
pile. They get a technical advisory -- they get
a scoring process to make sure that they're able to use these materials that they show
up in one component of that score is how to request it.
So most states are actually very proficient in understanding how to use it and how to
ask for it.
If I understand, governor make it is request which mean it is health official has to be
prepared to brief the governor and get them up to speed and also the timeliness, we learned
with H1N1 it's important that state designs are moved quickly to get to mouths and arms
once delivered.
All this depends on the work of the state and local health department.
It's very important for your -- for the State health officials to understand how these assets
-- various assets from the US Government, federal family would be available to them
and how they would use them. But the key is, Anthrax is a good example
which is currently a major focus of preparedness within the United States, how would you get
these antibiotics very quickly into people's mouths if need be.
Let me take a second to say we're getting valuable information and that often leads
to more questions. So if you have a question for our panelists
email them to us the address is studio@HHS.gov. It's important to keep your questions brief,
let us know your first name and where you're coming from, your state or region, and we'll
ask those questions when they arrive. Let's pick back up again with preparedness
grants. For Nikki and Holly, can you tell us a little
bit more about the grant opportunities and how are we working to coordinate these grant
opportunities?
Let's start with you Nikki, you championed this alignment process.
Absolutely. You know, I think when all this activity got
underway with a lot of emphasis on building the state and local preparedness post 9/11,
multiple federal agencies were recognized to have a role.
So as a result, there are multiple fairly discrete grant programs.
CDC has its public health emergency preparedness program which ALI just talked about.
My office has HPP or the hospital preparedness program.
FEMA also has a number of grants, one that you'll know most ab for example, is the MMRS
or the metropolitan medical response system. As well as a volunteer core as we do.
The department of transportation for the EMS system also have grants.
You'll find that all these grants exist within your communities.
One of the things that we've been trying to make a big push on is to get these things
coordinated and bring them together. And we're doing that for a couple of reasons,
first of all, it's not easy to use these grants if each one of them have different grant cycles
and rules and regulations how and when you can use the money, it's also not efficient
if you have to cut an paste and put stuff into multiple different formats to apply for
grants from each of these agencies. And it's also very difficult when grants have
requirements that are -- compete with one another or conflict with one another or that
tough do things twice just to satisfy the requirements of the grants.
So we are on a really big push to sync these things up across government.
ALI's office and I are working hard to think up the grants, we're similarly working hard
with FEMA, HRSA and the department of transportation, we are about to sign a memorandum of understanding
to continue this work so that we can make substantial progress in this area.
Especially at a time when we're all under the gun budget wise, both at federal level
as well as state and local level. We have to be sure that as many dollars as
possible get out to states and locals to do their jobs.
And people at the federal level and state and local level aren't spending their time
with what I would refer to as administrateIVIA, it's not trivial, you should have to follow
the rules and regulations but it should be simple and efficient so money an resources
build the capabilities on the ground.
ALI, did you have anything?
I want to reiterate that, Nikki has taken the lead for championing this for HHS.
The way she framed it to me in the past is we want to make sure it's simpler for states,
we decreased administrative burden, potentially we save dollars by making it simpler, not
just for states but for us at HHS and how we manage the grant.
And finally how do we get more impact from these grants by working more closely or lining
these grants together. I think part of that is as we move forward
is to try to think about what is a model of preparedness at a state and local health department
and if they have a good model how can then they plug in money whether it's from CDC,
whether it's from the HVP, whether from DHS FEMA dollars, how do they plug into those
monies go into a model to eventually have the best state of preparedness and that's
what we're trying to go to. I might say one other thing about that. We
have been working hard and CDC has really led in a nice way in defining what are the
public health capabilities that need to be in place in every state, in every jurisdiction
to achieve that model of preparedness. We are close behind defining what are the
capabilities that the healthcare delivery system needs to have to be able to respond
in an emergency and where those things come together.
Working similarly now with FEMA to define a set of capabilities so that at the end of
the day we're looking at a set of capabilities that we all agree on across government, we
all work together on, that are easily understandable for states and that then are grant dollars
and our expertise are in support of states being able to achieve those capabilities.
For the State health officials the two grants that are most interested in having align redirect
examination the hospital preparedness grant and public health emergency preparedness grant.
Can you update us on where we with that.
Watch the space, our teams meet calm of time as week to get this done.
They brief us every other week. It's our goal that by FY 2012 we will have
this done. One of the quirks of how these were put together
is our two grants in the same department were on different grant timing cycles.
So we're moving to get those aligned by 2012, they will be aligned and I think you'll see
a much more streamlined seamless easy to understand program with clear capabilities that everybody
has to achieve, and a clear way for us to know if we're making progress which is also
really important.
Good. Can we switch a little bit now to talk about
information sharing. And first we'll ask HHS and then hear from
DHS. How are we working to improve the information?
It's coming in a timely fashion to the states and locals when you have the information and
vice versa, when we have it. There are times when information is known
that is critical, yet doesn't pass from partner to partner.
Maybe I'll start with that and then ask my colleagues to jump in here.
First of all at the federal level we plan and prepare all of the time and once of the
first thing that happens in a large national event is we come together.
We get on the phone with each other first of all and share information on a pretty regular
basis. We come together as the inner agency at the
situation in the white house to share information as quickly, as rapidly as we can and move
as quickly as rapidly as we can o to move it out to states and locals and tribes and
territories. Sometimes on a need to know basis but as quickly
as possible. We move as fast as we can to mobilize a phone
call so that state and local health departments can get on the phone to be able to get information
as well. I would say, however, this is a little bit
bidirectional. And if -- while we're in the process of doing
thing, state and local health departments are experiencing from their end that we might
not be aware of or they have questions they too ought to be able to trigger a phone call,
call, we have mechanisms to do this, let's get on the phone and talk this through, get
the questions out so we can be on top of answering them as quickly as possible.
I'll point one other area before turning to colleagues.
In certain situations because we're prepared for all kinds of events including those caused
by acts of terrorism. Sometimes we need to have classified or secure
communications. We all here have security clearances, we have
mechanisms to talk with all the time. It's often the case we very much want to,
need to share information with state and local health officers and sometimes we find we can't
do it because of the issues around security clearances and others.
So particularly for your new health officers out there, I really want to urge you to make
getting your secure clearance a week one or month one of your job.
Please don't wait. The world isn't getting safer and there's
information we want to share with you.
Each new state health officials have received as part of the orientation packet the paper
work to complete and we can assist in doing that.
There will be more information coming shortly for that.
So we agree with you, it's essential they get security clearance.
My office stands ready to help you fill it out, process it, put it in, it does take some
time, it's not the simplest thing to go through. We have had to go through it.
But at the end of the day it's really essential for you doing your job.
Alex from homeland security there's times when the state health official is sitting
in a cabinet neat meating and the security official released information that hadn't
come down through the health channels and this causes embarrassment to say the least
for the health official if it's's a health matter.
How to make sure HHS is streaming down to governor's staff in a timely fashion?
We're learning ab things at the same time.
Right. I believe I can say honestly we work well
together in exchanging information. Is there room for improvement?
There's always room for improvement which is why we get together every month, to talk
about these issues. So but I would like to point out a couple
of things that are somewhat unique to Homeland Security.
This goes back to something I preach and you have heard me say this before, Paul.
That is public health is part of national security and you cannot have national security
without a robust public health component in it.
In that vein we have developed certain mechanisms that are intrinsic to Homeland Security, mainly
our fusion centers. For those health officers who don't have a
fusion center understand what a fusion center is, it's bringing together different disciplines
to look at threat information, to bring different minds together to interpret the data and to
give analysis. Part of the mission of my office and DHS is
to bring the health component into fusion centers through health community information
exchange. So we have been going to different communities
trying to get more public health people involved, there's robust programs around the country
we can use as models. But our goal is to increase awareness that
public health is needed in the awareness of threat and what's going on in the community.
I imagine you have access to worldwide information that could be of use to health officials,
for example, the Japanese crisis with the tsunami and earthquake.
How is the DOD tie into information share something is there a mechanism that might
flow down to a state health official?
Absolutely. We are tied in in a number of ways.
The Department of Defense does have assets around the world which help with what we call
indications and warnings. So we can be kind of a tip of the sphere in
some cases such as the H1N1 when DOD personnel were the first to get sick.
That information is quickly fed up to create that common picture we all get to see as we
develop the situational awareness what's going on.
We also are fully engaged as again with the H1N1 in the laboratory network, we have a
common laboratory network so that information is also flowed up to everyone and everyone
sees that information. Again, when we start talking about telecommunications
et cetera, where on those same phone calls exchanging information, et cetera, there's
an ongoing discussion how to do this bear. How do we develop a common operating picture
as we call it, fusing all this information together and making it available on an as
needed basis back down to not only federal agencies but down to state and local officials.
Thank you. So audience, time to do your jobs. These people
are working hard under these hot lamps and we have not yet received an email question
from you. If you have heard something that stimulated
a question, if there's a question you want to ask in a different direction we encourage
you to submit those questions. You can email them in to us and we'll be happy
to them when we receive them. That email address is HHS -- studio@HHS.gov.
Studio@HHS.gov. Keep them brief, let us know your name and
jurisdiction where you're from, we're happy to ask our guests those questions.
Let me also in this vein take the opportunity to remind health off to sign up for BX, which
is a mechanism the CDC has to send sensitive information to state and local health officials
immediately that might not be available yet in the press.
I help set up the bioterrorism program in 1999.
There's one slide I still use from ten years ago now which is all public health preparedness
is local. So information that we have at the federal
level isn't very meaningful because public health doesn't happen in Atlanta which is
what I tell my staff, it happens at state and local level so we're committed to getting
that information to where public health happens and so we need to be always challenged by
state and local officials to say we need this information, we need it now.
How do we get that information? It's always important to have that dialogue
with us.
I might want to pick up on a question that you asked ALI before about strengthening public
health because I always say if you can't do it day to day you can't do it on game day.
I think we have seen that a lot. Again, over the last year and a half.
If public health on the ground in communities all over the countries struggles and isn't
strong, it is for sure going to struggle in a disaster.
If your surveillance systems are RichtY you're delayed in finding a new disease outbreak.
If you have trouble investigating a disease outbreak you're going have trouble doing it
in an emergency response. If your emergency departments are full to
the gills all the time, you're not going to be able to handle mass casualty event when
you have it. So much of what happens through the fete program,
through the hospital preparedness program, through others, is also related to day to
day public health. I can't stress that enough.
It also means there's all kinds of opportunities for you to practice day to day things that
you need to do in an emergency response. Getting information out to your public, working
with your public information officer is a great example, as is an example like outbreak
investigation.
There's often a misperception that we have a separate preparedness staff sitting in the
health department from the day to day work. We learn at H1N1 people do every other job
that flip to emergency mode. That's something we have to continue to educate
the policy makers about.
It's a great point. I think that that's gotten a lot better over
time but there's still room to go. So I can even recall a situation just pre-H
1N 1 where a number of health departments for example were trying to practice and get
ready for pandemic by holding annual mass vaccination campaigns which they gave flu
shots and some were struggling with how are you going to do that in a parking lot arc
big box store, whatever and we're surprised to learn they actually had a part of their
health department dedicated to emergency preparedness that practices this all the time.
That's a really important point. Everybody has got now a really robust high-quality
emergency preparedness operation within their health department.
Let's flip the biosurveillance for a second. Rigorous biosurveillance capability is critical
for us providing early awareness of health security related events and saving lives as
a result. Alex your office at DHS is charged with integrating
biosurveillance nationally. What does it mean for us at the state level,
how do we relate to the work you're doing and benefit from it?
O I think most of your audience knows, challenging work at times.
Integrate it can be even more difficult. I will say this.
It is very important. And it's very important to be integrating
different types of data and not just disease surveillance data.
I think that is one of the main crux of trying to have this integrated system where you can
bring in different data from different disciplines to look at the whole picture to get a better
evaluation of what's going on in the community. So as we have been emphasizing a lot in this
conversation here, it's a two-way street. We all know that disease surveillance is at
the local and state level and we're just lucky enough to be one of the purveyors of that
data. So the data coming in, we rely on but also
taking a look at some of those different streams including threat information and giving that
analysis for those difference details back down to the states so they can help -- so
it can help them do their jobs better. As part of this system, we're again relooking
at the way we're going about doing our business and it's very important that we get input
from our state health officers how we can improve doing this data integration since
it's you're also a supplier but also a user of product that we do.
Uh-huh. So in the event of a biological release what
assets do you bring to bear and how do you coordinate with these other federal agencies?
Specifically how will you aid the states?
So if there's one thing DHS is, it's a coordinator. We have specific program witness the department
that are unique to bioterrorism and the big one that a lot of the state health officers
know about is our biowatch program, deployed in over 30 major metropolitan areas around
the country, it's an environmental sensing equipment to look for pathogens of interest
for a threat. So we coordinate -- but the beauty of the
system though is not necessarily the equipment, I believe it's the community that surrounds
the equipment. That's really what I try and spread the word
on when I'm talking with people in the hill or talking with our state health officers.
Everyone you see sitting up here is in some way touched by biowatch, whether on our coordinating
committees or whether it's on phone calls that we hold periodically.
So we view it as an integrated program, that's solely dedicated to the biotransmission.
In addition to that, working with our partners at FEMA, we have done various exercises around
the state. As Nikki pointed out, you have to be able
to do in the routine what you can do in the extreme.
So trying to educate people on these are going to be the challenges in a biological event,
these are things you need to be thinking about, these are the things you need to be preparing
for, has really I think opened up that communication and has really helped people identify where
the gaps are, where the resources are, and how we can go about being better prepared
as a nation for a biological incident.
Can you talk more specifically how you assist the states in developing that preparedness
and capacity to respond?
Part of it is built on the exercising -- those exercises that we hold.
We hell one in each of the ten FEMA region this is last year and we're in the process
now of looking at better refining those to get to specific points.
So that is one aspect of helping them prepare. Through the biowatch program of course it
is bringing them together to talk ab consequence management.
If there were a detection of a biological event.
These are teams that are not just Federal Government, this is states, FBI, fire department,
emergency management, that are all really dedicated to that mission.
In addition we have the regular disaster framework things with FEMA becoming involved and at
the more strategic level we're involved in helping with the threat and risk information
which feeds a lot into programs that Nikki and Ali run vis-a-vis the SES and all these
difference programs. Ly mention and colonel Neubauer mentioned
this earlier in the conversation, maybe it was ALI, that mentioned the excellent work
we're doing with the executive order the past year, and I think it was a really good example
of how the federal suite of families come together to focus on a particular mission
and it's extraordinary some of the solutions that we came up with and better ways to work
together. In order to help the state officers and the
locals get better prepared to respond to a biological event.
So you talk about the information you share with the governors and Homeland Security advisers,
state emergency managers. Tell us how that information is shared and
in what ways can the state health officials gain access to that information and provide
information of that system?
There's a couple of different mechanisms. So DHS has multiple avenues to reach down
into the state government whether through threat information on criminal activity or
for health issues. So our department of intergovernmental affairs
interacts with the state and local government on various different issues.
As part of the incoming process for the new governors as well as the Homeland Security
agents and the state health officers, DHS put together a briefing book on governor,
this is what you need to know about Homeland Security.
Inside of that the office of health affairs develop, this is what your state health officers
need to know about the issues with health and homeland security.
So I would urge the state health officers if they haven't seen that document yet to
see if they can find it and if they can't to get in touch with us and we'd be happy
to provide it for them.
Your office has provided us with a copy and we'll be putting it on the secure part of
our website for the State health officials when they log in.
Thank you for that helpful document, thank you for sharing it with us.
Colonel, is it similar in the military, the law enforcement guys in the military and the
medical guys in the military or do you share this information seamlessly across medical
and the other responders?
Certainly there's an attempt to share information across, there are lines of authority along
law enforcement and medical, certainly there are different functions but we work at again
the overarching umbrella function to make sure information shifts back and forth.
We certainly pay great attention to security issues as we look at medical issues.
Because as Alex said very critical connection between health security and overall security.
Can we touch on fusion centers? And the -- there's been some jurisdictions
that have been successful having help sit in the fusion centers and others not so successful.
There's practical aspects to how that works out.
Could you touch upon that and if you have experience in DOD with fusion centers if that's
what you call them we'd learn to hear from you also.
DOD has more experience bringing the medical and health threat information into their planning
for whatever operations they're going to be doing.
The fusion centers for all the talk is still a relatively new concept that's been developed
around the country. So some centers where they have been fairly
well established have been able to thoroughly describe what health brings to the fusion
center, what capacity and capabilities an skills they bring.
Fusion centers still are mostly surrounded by law enforcement agencies.
But I think as more people understand the complexity of threat that's going around in
the world today more people do understand that you do need to have -- somebody public
health expertise within the fusion centers. Whether that is just evaluating information
that comes through from your street cop that brings information in?
Or being able to discern national threat information that comes down through those threat streams,
and this is what it means to you as a community provider.
So we're trying to develop this discipline of the person that can bridge that gap between
the security apparatus and law enforcement capabilities and people that understand the
public health world and where those two interact. There are -- there's a lot of discussion about
how we can get these positions funded, what sort of capabilities should they have and
other issues like that. Which we're trying to develop the best practices,
this is the type of person you should have as well as advising FEMA about really we should
be able to fund some of these people through system of our grant programs.
A couple of things certainly within the military we have operation centers which are becoming
more and more common throughout the federal interagency partners and at each level then
the challenge is to fuse the information that's available, pass it up, fuse the information
gained, pass it up, and continue passing it up and sharing with the interagency.
I will say that we've done a few things that I think are fairly novel with interagency.
One is the biowatch biological indications and warning assessment consortium, which is
a group of essentially experts within the interagency that gather and share information
so it's more a communication function but we for example hear something we can go directly
to an expert in another agency and say what does this mean and get that analysis function
before that information gets passed up. I think that is a harbinger of the way we're
heading and I think a very valuable tool.
Very good. In a minute I'm going to ask if you have questions
for each other. Let me ask one more, once more I'll talk to
the folks at home and if you want to email a question us to, that would be great.
Dr. GARZA, what is DHS doing for emergency management, in some ways public safety but
in many states these are within the health departments and responsibility of the public
health official.
DHS has a somewhat unique relationship with EMS as well, partially because we for all
intents and purposes we have EMS that's organic to our agency so we have EMTs and paramedics
that work with our customs an border protection and with our immigration and cuss tops enforcement
coast guard secret service we're familiar with the challenges that go with that.
Part of what our office does, in addition to working internally to DHS, to train, equip,
make sure they're up to standard, is to work with the community of EMS providers as well
to develop guidance, to assist them with whatever issues there are in working with the Federal
Government, through our FEMA partners in the USFA, the United States fire administration,
helping with the EMS issues that are unique to the fire departments as well.
We also sit in I think most of us here or each of our departments here sit on the federal
interagency committee; it's a rotating chair, not popularity.
So that committee is really charged I think with bringing that federal look at what can
we be doing to bolster EMS for the country? As you know Paul, we're engaged now on producing
a white paper for the white house looking at what the future of EMS going to look like.
So there's a lot of different ways we reach out and touch the EMS community.
I think you hit it on the head, they done really sit in just one particular discipline,
they span a lot of different disciplines between public health, emergency medicine an emergency
management.
Very good. We do have a question from Idaho.
Wonderful state, from Bob. And I guess I'll direct this to you, Dr. KAHN.
Incident command structure is integral to the job of first responders.
Do you think training in ICS is part of public health duty?
Absolutely. Without a doubt.
Not only should it be training of public health duties, it already is part of public health
duties. We increasingly see that routine responses
are managed at state and local health departments using the UCS structure, nice to see.
As part of the new guidance coming out shortly with the new grant -- the new capabilities,
the new national standards are already out and the states will be using them as par of
the new guidance at the end of this fiscal year but the IMS is very much called out in
that as they think about incident management and how they manage incidents within their
state so I think it's critical component. That's how they then link back in to what's
going on at the national level, when we think about the national incident management systems,
it's absolutely critical. We learn from many of these incidents that
we need everybody possible trained and up to speed.
Great example of doing business day to day. There's many day to day week to week year-to-year
uses of the incident command system. And the more you use it and integrate into
your normal operations the easier it will be to stand it up and use it in a major event.
It has wide applicability with anything unexpected. Best example I had is chronic disease where
people are investigating this chronic disease cluster that had various pieces, wait, why
are we doing it to ole way, why not use the incident command structure to organize our
information how to get it done so it's nice how that's becoming organic, your word how
that's becoming organic and how local and state health departments are thinking about
responding.
Right. We use the modified ICS to track the reform
legislation. So much was coming from o so many places.
Absolutely.
Perhaps this follows on to the ICS question but can you tell us or about the EOC, the
directors EOC as well as secretary's EOC and how they interact with each other and if you
can get to it, how a state EOC plugs into that system.
Sure. Actually that's -- that brings up something
I wanted to jump within a little bit ago. So the secretary's operation center here in
the Humphrey building and that coordinates the various aspects of the federal response
again using ICF, at least once a day if not more depending on the intensity of the event,
they pull together all of the parties that are involved again for shared situational
awareness for reporting in, for tasking out, different things that need to get done.
We coordinate closely for example with emergency operation center at CDC which stands up again
to do the internal CDC functions as well as a lot of outreach to state health departments
in particular. And similarly work closely with Alex and DHS
and with the white house in that regard. One of the things that's happened I think
over the last couple of events, there are two things that happen actually that I wanted
to call out. One is, I think this really started with H1N1,
CDC did a terrific thing in bringing in representatives from state and local health departments to
their emergency operations center. We often swap, have liaison officers between
CDC and my office or between DHS, and my office. USAID but we haven't integrated state and
local health officers into those before. I think one of the things that that did was
both facilitate the flow of information out to state and local health departments and
bring us much faster recognition of the kinds of issues that people were facing in their
local environments on the ground. So it's I think been innovation so to speak
in terms of how we do this and how we work toward better information sharing really across
both the federal family and different levels of government federal to state and local because
at the end of the day as ALI said, all events all response is really local.
So that's been a terrific innovation in terms of how we move forward in addition to much
better work I think whether liaison and others.
For us the EOC serves as our command center for international situational awareness all
the time but more even -- during emergencies than it serves as our hub for sort of assessment
coordination, response recovery, related activities, we link up nicely with the secretary operations
center and individually with the NOC and -- components as need be.
The nice innovation and Nikki said, we actually now when we set up for a response have a dedicated
unit that's about state and local preparedness so it's a team about state and local preparedness,
most state and local health officers will be aware of that team led by Chris COSMOS
who runs the division of state and local readiness, it's her and her team's responsibility to
reach out to states immediately to have full awareness of what they're doing and what their
needs are to make sure we're meeting their needs.
We appreciate having a spot there and being there in the EOC that helps us communicate
with members.
Another piece of this that's worth talking about a might be because I think one of the
things that we have learned, I know state and local health officers feel it when you
have a large national or international event, even if there is not immediate harm to human
health, where we have to send the national disaster medical system or whatever, people
have lots of health questions and concerns and even though the health and public health
impacts may not be immediate, there are a few days, a few weeks or a few months away.
So thinking about the fact that health and public health is always at the table, it's
a component. You always have to address people's health
at public health concern, the sooner we do that the better I think it's something important
to keep in mind so we all Stan up our operations centers much earlier if for no other reason
than to be on top of what those concerns are. Often those concerns last longer than the
even.
They sure do.
If I could ask you a little bit more about the budget for PHPR and how you prioritize
and what your focus is over the next year or two.
Glad to. As you know, these are challenging fiscal
times, not just for the health and human services but across the Federal Government so for next
year the president's published budget for next year the expectation is approximately
10% cut for the public health emergency preparedness grant to state and local health departments.
We're also aware of approximately $20 million cut for internal CDC-related activities and
concomitantly there's complete elimination of dollars that go to support the schools
of public health that support the research and training and activities, the evidence-base
for preparedness. The president has recognized the critical
importance of strategic national stock pile and what that value is to state and local
health departments and there was an increase in dollars for the State -- for the strategic
national stock pile to have adequate materials on hand for the needs of population.
So given that it's an important challenge to think about how we best use the dollars
available to us to get the most possible impact within state and local health departments
and we have done a couple of things in terms of thinking about priorities and strategic
planning. In the midst of strategic planning for public
health prepared -- at least the public health component, preparedness, and that includes
looking at the gaps, looking back over the last not just looking back over the last ten
years to influence what we're thinking about the future, ten years, based on where we are
fiscally and what are the things we need to do most, some of those things are already
visible. Should be visible to state and local health
departments. The new national standards for purr lick health
preparedness is an example of saying here is a nice roadmap of the key capabilities,
do an assessment to understand what your needs are and go back to these capabilities, figure
out which capabilities you need to build and here are some measures to test yourself either
from a real event or an exercise whether or not you have built those capabilities.
So with those roadmaps and clear performance measures and task and functions you can make
better use of your dollars as you move forward. So there's ongoing activities to say even
in this resource restricted environment how do we make best use of those dollars to get
the most impact for public health preparedness.
Okay. From your own point of view looking at the
preparedness of the states and across the country where do you see the areas that you
would like focused to go toward? And your priority?
There's a couple of things. We have done I think a good job preparedness
at the state level, not that there more can't be done but at the end of the day we need
to think about what this community preparedness look like and have prepared communities.
CDC does haven't the bandwidth to prepare every community in the nation.
We work through the states. And pick local health departments to get that
done but really focusing on the issue of community preparedness and resilience which is such
a big piece when we think about the national health strategy, how do we get communities
prepared. The second gap that I have noticed looking
back is how we make sure we have good integration between public health, medical care and emergency
management and you ask emergency management questions a couple of minutes ago, you asked
the healthcare questions. I think we need to do a lot better than we
have currently done. A vulnerable population, any of your health
officers mean as couple of weeks in the job they'll realize quickly that during any disaster
what's going on with the population comes up almost like the first or second question.
And that also includes the broader issue of mental and behavioral health issues, we need
to do better preparedness around those issues. And then another thing that comes up is biosurveillance.
We have a long way to go in biosurvey lens, that's a major gap that remains for us nationally,
Alex touched on those issues already but they're even broader than that.
Electronic laboratory reporting, how do we get ELR up an running at every state and local
health department, the meaningful use issues that many of your state health officers will
now start dealing with the information fusion there's -- so biosurveillance is something
that really needs to get markedly improved because detection is so critical for us when
we think about response, timely response really hinges on timely detection.
So I want to second for a moment what ALI had to say about this much more seamless integration
of emergency management public health and personal delivery system.
This is absolutely critical. It can really only happen at the community
level. One of the things that I hope is going to
happen as a result of this grant alignment process is that that's really a big part of
it so that we identify where the overlaps and hand offs are and can build a system and
help support through federal guidance and dollars to build a system that is much more
seamless in that regard. I want to call out one other issue, it's something
I know you and I have talked about. ALI and I have talked a lot about that we're
working on in the federal level and it's something called budget preparedness that when an event
happens, we take very serious we have to move money really quickly from congressional appropriation
through the whole federal system and out to states.
I think you'll see in the current guidance and others ways in which we can do that better
but at the same times need to do the same thing moving out to local health departments.
I urge you now to start thinking about what are the kinds of things you need to put in
place so that as we move from the state level to the local level we don't have long delays
in hiccups and contracting processes and the other in getting that done.
We're happy to engage on that as well. Particularly in these economic time, very
difficult period. Certain assets are done at scale in the state
whether the alert network or laboratory capacity and high level epidemiology so the State has
to go through a contracting process at the time when states are slow in contracting down.
Hiring is being slowed down. And then contracting and granting is slowed
down and the same at the local level so this economic crisis has affected government's
ability to move money quickly. We've got to figure it out.
Great.
I had a couple of questions come in. June in Virginia.
Other than the opportunity to provide input on revisions to CDC capabilities which is
much appreciated, what other feedback opportunities exist within your program?
I imagine if other programs in your office at late States an locals might not be aware
of but may impact or assist state and local public health activities.
And second component to that question, in addition, what information do you wish you
knew about the state level and how can state level activity help inform your thinking an
decision making?
I think all of us can answer. Did you want me to start?
Why done you start.
Every state has a public -- has the theft grant, all states territories and major cities
have -- so 62 have the public health emergency preparedness grant and they have a grant officer.
So that is their direct link back to us to tell us what they're doing and to learn from
us what we're doing and how to get input and provide us input into those set of activities.
We welcome that. One of the things I have been trying to do
is get out to as many states and cities as I can to try to understand the programs and
how to improve those programs but there's on ground people to help provide and share
information in addition to those theft officers. We have the states an another way to interact
with us. The strategic national stock pile has people
based in states that's another way to interact with us.
So many ways to directly interact with the agency around preparedness issues and provide
us guidance an input and ask questions.
I'll maybe ask a couple of things to that, as I think as any time we go through any major
programatic reviews and changes that's what we have been doing with a hospital preparedness
program, what CDC suggested with this program, we try to develop process where is we actually
explicitly seek the input of state and local health departments.
So those opportunities will be upcoming and will continue.
In addition we have regional emergency coordinators and hospital preparedness field people in
every region specifically again for the purpose of getting that kind of feedback and bringing
it back up. But in addition, there are a couple of other
things that I might want to call people's attention to.
For example, we used a lot in the last couple of years, the institutes of medicine, preparedness
forum to surface ideas, get feedback about things like how should counter measures be
distributed as an example. Home stock piling those kinds of things.
So state health officers are preparedness directors might want to join that forum, it's
free and you can participate, most meetings are webcast.
Other kinds of non-governmental structures through which you could also surface ideas
provide feedback, itself, as we ooh Ohio et cetera, as we're working through the national
health security strategy. There are there's been a lot of stakeholder
and public outreach and there's also the usual bureaucratic mechanisms you can use to provide
feedback. The chapters and plans get published in the
federal register and there's a comment period specifically for that.
I know ASTHO and others push that and make those opportunities for comment available
to states so there are lots of them, and if you done find ones that you need reach out
to us.
We're in the process of expand our project officer, the number of the project officers
expanding the training, and their training, I mean, these are real experts in public health
preparedness and we would really like your state health officers to reach out.
Colonel, wondering how you gain an awareness of what the assets of a state are, local areas
so that if you were asked to come in you know what's going on the ground?
You rely on the national guard or -- Actually, we have a number of sources of information
and I will mention at this point we have joint regional medical planners.
So I have 12 of those at four offices throughout the country who interact directly with regional
emergency coordinators, with HHS, amend go as partnership in the states and start helping
them and listening to them about what they have informing them about what we have have
so they can incorporate those assets into their planning.
Let me take an opportunity just to say what would really be helpful for each of the state
and local officials is to go meet with the DOD installations within your state and understand
the capabilities they bring to bear and include them in local programming so when an event
happens there you have got additional assets right at your fingertips.
They're not here today, I would say the same thing about VA.
Absolutely.
Perhaps we'll follow-up with you and find out context so they can follow up there.
We have a question from rod in Idaho. So Idaho, we know you're working today.
The new platform for community recovery and responses community resiliency and the 15
public health capabilities. Is there a way or method to evaluate this
initiative and how are federal resources going to leverage to facilitate this?
I think one of the things we have been working on through the capabilities is also a measurement
system so that in fact we are able and states are able to look at their progress toward
meeting those capabilities. In a pretty objective and reply cash balance
way. And that is the major focus going forward.
A lot of work is being done on measurement metrics valuation.
It's critical and all of us in public health take the set of issues about having an evidence
base going forward. Also I think it's important to recognize that
evaluation has to take place all the time. You don't want to build something, let it
run a while and evaluate and decide how it's working or not but you continuously want to
do something, check it, evaluate it, doing it more, more than just about anything else
and measurement is essential to that as well. Kudos to the Idaho folks out there clearly
reading the new national capabilities, national standards which is what we want people to
do. That's how they -- that's how thigh do their
assessment for what their needs are, within their state and what people will o notice
quick Lisa number of those 15 capabilities they have existing measures to them and a
number do not. By the time the theft guidance comes out in
August or September we will add a couple more additional measures and by 2012 we'll be done
with all measures. However, since these capabilities were just
developed you need to develop the capability before developing the measures.
That's what the capabilities and measures are developed, there are people working in
con -- conjunction with them, to pilot these measures and make sure the final measures
are good measures so by 2013 we'll have a full suite of measures for each capable -- capability.
Did you have questions for each other, something to ask somebody sitting next to you?
That's a loaded question.
[LAUGHTER]
I did want to touch briefly on that last answer which is, I think what we're discussing here
is this what administrator of FEMA is going to the whole of the community effort which
is it's not just about the individual agencies within the state, whether it's health, whether
public works but it takes a whole community to be able to respond to a disaster.
That's been the engaging thought going forward, how can we build that resilience in the communities,
what does that look like, how can we achieve it.
So it's really even beyond the sphere of public health.
It involves the entire community. Certainly public health plays as large role
in that.
Uh-huh. So your turn.
What is it that you want or wish the state health officials knew from your different
areas, what -- give you each a chance to answer that.
What is it you wish they knew, what you wish they asked you that you could have answered?
I think really just establishing an ASTHO has been a very good partner with this is
having that opportunity to communicate much more frequently with our state and locals.
I think I can speak for most of us, our days get jammed with a lot of stuff, usually at
federal level which is why it's refreshing whenever we have meetings with community groups
or with state and local groups to -- or what we get out of DC and go to the communities
because then you get a really good appreciation on what's happening at the community level,
what works, what doesn't work, what things can we affect at a policy level for the nation
that can help the state and local person that's really doing hard work on the ground.
So if there are maybe more or different mechanisms that we could communicate back and forth what's
working for them, what isn't -- what do they need, recognizing that these are economically
constrained times but what ways can we make their lives better.
Let me jump in and say one of the key components at least from my perspective is planning.
Making sure that we start thinking about not only issues but magnitude of issues as I look
at disaster from my perch, our challenge is to figure out what folk also need.
So if they have got an idea of certain events, certain magnitude where they're going to run
out I can start then planning what to bring in and help.
Very good.
I think those are both great points. I guess I would maybe add a couple of others.
I hope now and certainly by the end of the webcast that you take that we all have no
question about the fact that preparedness is central to public health.
And I'm not sure that everybody needs to that understanding.
I think that understanding is more widely shared but not universally shared.
And as you talked about before, it's not just that it's off to the side but something that
operates and needs to operate and be integrated day to day with the rest of public health
and the health department needs to do and the functions that need to go on.
Being able to articulate that and articulating clearly embracing is something that I hope
everybody needs to know. Other things I would add to that are the fact
that it's usually the case that if I have an issue or problem or you in the health department
has an issue or problem that's not the first time the issue or problem came up.
And we tend to try to keep it to ourselves to try to solve it ourselves and end up with
stove pipes reinventing the wheel when other people worked on it, there's good practices
out there you might want to look at and adopt and having a better system for surfacing those
issues, sharing those promising practices, I hesitate to call them best but sharing those
promising practice and experiences, one of those things that I think can short circuit
an awful lot of time and effort and frustration that people feel there's a lot of document
and experience at CDC, a lot in my office arc lot and a better system of surfacing those
issues and no question is silly, it's not a shortcoming that you have a question or
need but to do that is really important. And the corollary to that is don't wait to
be asked by us. If there's an issue that surfaced in your
community, again, chances are others need to know about it or maybe we don't know about
it so having bidirectional communication is something else I hope everybody takes from
this.
Pointing out what you just said we work with so many states and territories.
We can say it's an interesting problem they have dealt with that, let's get you plugged
in and the health official contact is so helpful. So --
I will invite the state health officers to meet with the public health emergency coordinator
in in their state to try to get a better understanding what the program looks like, often that person
at the same time there's significant public health resources out there combined between
the two programs for the State department for preparedness.
the more the state official is used the more the resources are used across the health department
to make sure we're getting the most impact for day to day activities in addition to the
planning, requisite planning for the major catastrophic disasters down the also please
have the opportunity to immediate meat with project -- if they have to meet with the emergency
coordinator, meet with the CDC project officer or the HPP project officer, these are technical
experts we're spending time an energy making sure they're experts in preparedness and can
answer their questions and give the best possible advice.
You mentioned challenging times. Challenging times is a good reason for CFOS
again, make another plug for career epi field officers.
They can be hired off the ground via assistants these are great people that can help you ratchet
up the quality of preparedness in your state and they're used for all sorts of broad activities
within the states to help for response activities and direct two way as Nikki said, directly
always available during one weekend in March, around the Japan earthquake tsunami and radiation
event with Josh an John had to trouble calling me Saturday morning saying we're hearing about
raid year ago in the air, what does that mean. So --
We have no trouble calling one another, linking in and late Saturday afternoon.
An hour -- Please, reach out to us.
The other thing that's safe to say, the first time you learn emergency preparedness response
capabilities shouldn't be during a crisis. That's not when you're in front of the camera
in front of the governor saying how does this system work.
Good. Well, I want to thank you all, thank our panel
members for participating in this in depth discussion.
Dr. Nikki LURIE, Dr. Alex GARZA assistant secretary for health affairs and chief medical
officer department of homeland, admiral AliKAHN, CDC and Jay Neubauer, for NORAD and NORTHCOM.
Thank you for joining us today. If we didn't answer your question or if you
have more, you can send this to infocenter@ASCO.org. And you find the new HHS public health emergency
website, we'll have a lot of information covered here as well as extensive information around
public health and medical disasters. Visit www.PHE.gov for more information from
HHS. We hope this program, we'll have this program
archived on this website we gave you in a few days.
I'm Paul Jarris, we hope this program provided you with valuable information and the opportunity
to meet with our federal leaders and we'll talk more with our federal officials and decide
whether to do more of these timely topics. Thank you all.
Thank you.