Your time and considering on my diatribe here and wanted to share some reflections from somebody who worked both within the World Health Organization on Communicable Diseases at the United Nations on the biological and tox sick Weapons Convention and looking at addressing multiple nontraditional ways of mitigating the effects of naturally occurring deliberate or accidental diseases as well as somebody whos been looking at this from the private sector so thank you. We thank you very much. We start with the department of health in chicago you have quite an Operations Center out there, i visited many times years ago, and its very sophisticated, its its own Fusion Center. And that community and there are a few others, very few like that in the country. Our Public Health community, 24 7 in that center. Yes, sir, we are. And that is because we have utilized our Grant Funding to be creative in our standing, we have a Public Health person who was embedded 100 in our office of Emergency Management and communications. While he works on Public Health issues, he works on Emergency Management implications and support needs for those Public Health issues and he is on call 24 7 for that emergency Operations Center within our Emergency Management structure. You have tabletop or actually on site training exercises that include a bio or chemical attack. Yes tabletop and functional exercises, its very expensive to conduct very, very large scale functional exercises on the magnitude that would efficiently support our population on an annual basis. One of the things that we have done is, we do smaller functional exercises each year, building up to a larger more full scale exercise. We exercise our Health Care System partners on a modular basis, so we are focusing on our areas of weakness and not continuously applauding them for our areas of strength. Public health is the lead Emergency Management serves as the coordinating body they work closely with us and ensure that we have all the resources we need. Your the Incident Commander in Public Health . Thats correct. Youre the trained person that handles the Public Health part of the response . Yes, maam. With regard to surveillance and detection. The move toward Electronic Health records trying to protect the privacy of individuals Public Health records, is there a digital station where Public Health officials can see trends developing in the Broader Health community can respond. Is it an anecdotal effort where that position uniquely trained, identifies something that is ab other an the and based on that anecdotal incident is it a coordinated effort or zhou rely on that trained physician. There is a system that has been implemented across the state of illinois for diseases that are reportable by physicians to Public Health, we then report into that electronic system. Also, specifically, within the city of chicago, we have developed protocols for identification of febrile rash illnesses as well as acute respiratory illnesses whereby clinicians can identify unusual trends of what they are seeing coming into their ers and they report those to us specifically at the local health department, so we can activate our ep deem yo logical teams to do further investigation. Your career both in the private sector and a great career in the public sector. Do you find that that illinois mod sell replicated around the country or unique to a few states. Have you had an opportunity to observe and comment . Yes, sir. And i would say its hit and miss, i think that the type of Fusion Center that you mentioned is particularly more likely to be in the larger cities. Its not just state by state its almost city by city. Resource driven, but also the depth of the ems and Public Health infrastructure i think that Critical Mass is what drives these Fusion Centers i think we need more regionalization. I think we need more linking of the existing Fusion Centers and better opportunities for smaller communities also to participate in that process. Would you comment on you talked about nontraditional partners having a particular role in respond inging to a biological event. Who are we underutilizing based on your experience. Who should be part of the integrated system of response and recovery that we have failed to utilize as effectively and frequently as we should. I believe since we havent had a lot of mass casualty event notice United States, and we havent had a lot of problems we have to look overseas a little more but i do think that we domestically we should be using the National Guard a bit more i do think the private sector, folks were talking about using the private sector for logistics, i agree i do believe that you can have teams of people who have already been used to working together and theres been reference to postal workers and teachers unions or even construction workers who Work Together who can be trained to do particular things like decontamination or possibly even do things related to burial if need be. The military has a role to play. I was a strong proponent of having the military involved early on in ebola. Something else on a Previous Panel had discussed that. Dr. Alexander . Thank you very much for your insight. I have a question related to International Corporation in combating terrorism. And as we know, obviously you connect locally think globally as we say. My question to you is from your experience on the governmental level as what is nongovernmental agencies what works and what doesnt work specifically to the threats of Infectious Diseases. We have seen with ebola. Using h1n1 as an example in april 2009. Of course Infectious Diseases knows no border and that the first indications of this new pandemic virus was actually at a u. S. Military, u. S. Navy lab at the mexican u. S. Border where they were able to pick it up one of the Stronger Network of labs is the one that dod uses in coordination with others, i think this idea of a Network System of systems of various labs, both government sponsored and other include the ngo. It needs to be better coordinated, but i think that the sooner we can pick it up, while from a u. S. Perspective, while its further away, obviously, the more time well have to prepare and well be able to provide more assistance that way overseas. I think networks of labs, system of systems, early notification transparency and coordination. Just to echo that, there are already collaborating centers in labs at the International Level that are networked so the World Health Organization has them in different regions as well as in Different Countries that are potentially pathogen specific for some. Some are just certain levels of biosafety in which to test pathogens. Additionally, they do the same thing for the World Health Organization and food and agricultureal organization. While theres a lot of capability out there, a lot is duplicated and the coordination is rather ineffective in my personal opinion. The issues that weve seen even with ebola, theres an expectation that these International Organizations should be at the helm of the response. That may not necessarily be the case, they may be able to provide subject matter expertise, theyre not involved in terrorist activities or count er counter terrorism. Since 2008, we all know theres been a pretty substantial decline in support for state and local Health Programs i think its on the order of 45,000 jobs over the last five years. Can you all say what the impact of that has been in your observations to Public Health preparedness and can you give us one particular thing that rises to the top of the list that you think this panel could do to represent improve the Public Health awareness. Weve seen a continuous decline in Public Health budgets from a funding standpoint which has obviously adversely affected the staffing compliment within Public Health agencies. Ive seen from my personal experience a drastic decrease in the number of staff that we have available to simply carry out basic core Public Health functions. What i can say is that utilizing Public HealthEmergency Preparedness funding from the cdc as well as for from the hhs office of the assistant secretary for preparedness and response, at least in my situation we have been able to relatively maintain our Emergency Preparedness staff for bioresponse. However, that capability is getting increasingly difficult to continue to maintain, those funds, albeit grant funds are continuously declining as well. I think weve had Great Success in our city for leveraging those Financial Resources that have been available through those grants. As they continue to decline even the levels of creativity are becoming more and more difficult to maintain. So from the panels perspective i would say that the at vow kasi more maintenance of those fund ing dollars would go a long way to maintain our biopreparedness, when i look specifically at the funding that we are able to provide to and utilize for the preparedness of our Health Care System, it is grossly insufficient. Within my own jurisdiction, i have 28 acute care facilities at the hospitals, that is, and over 120 Long Term Care facilities i am trying to keep prepared with a very small number of about 3 million per year. I was frightened and fascinated by theres two aspects to this problem one is the active efforts of nefarious folks who want to weaken our disease systems, there are people on the ground who dont trust western medicine and people who are the agents who are going the western Public Health workers. What steps do you think we could take to alleviate both aspects of this problem. Thank you. I think that the u. S. Security apparatus needs to work with the input of the Public Health community about the best ways to prevent and control polio, which is actually something that we already know because this happens to be polio and its a disease, not a nulg emerging disease, we know how to contain it, and how to stamp it out. But there has to be a decision by the u. S. National Security Apparatus to also work in a bilateral fashion with the Pakistani NationalSecurity Apparatus. Maybe we do it through the indians surprisingly, the indians have offered bilateral support to pakistan for polio, nothing has happened since that offers been made but primarily my perception that primarily thats happened because pakistan hasnt made up their decision about how theyre going to go about doing things. An example was, in maybe a year ago or the last six months a local administrator in the northwest had actually decided he was going to co opt some of his goons with guns to go around and enforce that children were vaccinated. And you know what, it worked. And the children were vaccinated. Nobody was harmed, nobody was killed, there was an enforcement mechanism put in place one of the things we need to discuss are those uncomfortable things related to whether or not security if we talk about security, if you elevate it to security you have to be willing to enforce that, as a security concern. I do think there are things that can be done, obviously you have to have the acceptance of the internal pakistani and in this case in nigeria also in afghanistan. Have you to have their input as well. Weve been talking earlier today about leadership and the need for strong leadership also partnerships. My colleague at the end would agree about weve been talking about how can we put the public back into Public Health. One is, i think we theres something to be said, theres strong leadership to bring all the partners together i feel a little uncomfortable for the pakistanis not vaccinating themselves. We dont seem to do a good job of that in the United States, i hate to call people on the west coast terrorists, because theyre not vaccinating their children for measles. I think dr. Kinney brought that up, with utilizing experts of trust, we seem to have a problem with Risk Communication. I do believe it has to you have to have a strong leadership here nationally to encourage that. And also to kind of authorize it, and open it up and make that an acceptable approach. Weve actually done a significant amount of that type of work in my city primarily engaging and educating faith based leaders, and developing mechanisms whereby we can distribute messages to those faith based leaders and in turn request that they distribute those messages to their congregations, weve done the same they work with specific vulnerable populations groups, one great example i always like to share is a collaboration with the Organization Formerly known as the chicago lighthouse for the blind. They have a very low frequency Radio Station that reaches over 40,000 visually impaired people in the chicago metro area and parts of indiana you need a special receiver to pick up the Radio Station. But we distribute our Risk Communication messages to the agency. And they then read those messages over this low frequency Radio Station, and we reach over 40,000 people that we otherwise would have no way of reaching. So that is one example. Weve also begun an efforts about a year and a half ago, where we are now educating and training and exercising head start and day care providers to do Business Continuity planning and keep their operations running. And keep the children that are entrusted into their care safe until the parents of those children can be reunited with them. For us its a multifaceted approach across multiple disciplines because government cannot be everywhere at once. And we must involve community members, community leaders, and Community Organizations to help us do what we need to do to protect our citizens. Can i just i definitely agree. I dont i dont want to i dont want to make a blanket statement that pakistan is doing this, this is about terrorists an extremist organizations, including al qaeda affiliates taliban affiliates in nigeria. And others who are actively using an ideology to ensure that people die or become chronically injured for the rest of their lives, and hail them as martyrs, while you may be in californian id yo logically opting out, in my opinion for the totally wrong reason, theres no actual scientific linkages about vaccination, its a not too new answered difference. Its not an ideology of hate and extermination, its an ideology over ones self. Whats going on in nigeria pakistan and afghanistan is truly a security threat. And measles was a concern the measles outbreaks is what had me start looking at what was going on in these areas. I have one final question. Because of your work in dod, i mean obviously they were constantly working with Counter Measure s measures as we go forward in the 21st century and try to build a better relationship between dod, do you have any recommendations . There still seems to be from time to time i say this with Great Respect for the organization, theres still a silo. And based on your experience are there any recommendations you would make in terms of the kind of collaboration improvements between dod and the private sector. Dod does a pretty good job of research. I think the strength is in the private sector, as several speakers had previously mentioned, that barta was the mechanism by which a lot of these orphan drugs and Counter Measures got through the socalled valley of death. There was a guaranteed customer and that still needs to be done. Were getting back to leadership, i think private sector iks the strength over 85 90 of the Health Care Sector is in the private sector, its not in govern