But we are really right now in a phase of piloting and demonstrating and, to a certain extent, experimenting, because this is new ground for the public health community.

Mr. MURPHY. So you are working with different places like the University of Pittsburgh and others to monitor the kinds of parts that are in place, so you can pull out of each one what's the best? Dr. FLEMING. Exactly right. And in addition, I mean, a key to these the underlying notion here is that these systems can detect problems more effectively and more rapidly in some instances than our existing reportable disease system, and can be a complement to it.

That's a concept that has not been totally proven yet, and before investing a whole lot of resources in a nationwide system, we do need to see the evidence that these systems are able to do what they, in theory, might be able to.

Mr. MURPHY. Let's walk through what happens next. Say you come up with a national system that's been working in the cities and rural areas, etc. The thing about bioterrorism, it moves slow enough that you can detect and then implement strategies to quarantine, to have public education, to immunize, whatever. But, of course, the drawback is that it also moves slow enough that it can be spread throughout the Nation in a matter of a few days before anybody has a sense that they need to take some steps.

When that happens-and we have had some other hearings here, for example, with NORTHCOM, some wonderful hearings and discussing some of the aspects taking place.

But let's go let's say there is some disease that begins to be picked up in multiple cities around the country, it's spreading by whatever mechanism, through contact, it's around. Can you walk us through what happens once you get this data, in particular, the plans in place to notify physicians and hospitals, coordinate efforts, get products to communities, notify the Defense Department, even to the level of local emergency responders, EMS people, etc?

Can you walk us through what happens once you identify that there appears to be something out there?

Dr. FLEMING. It's a complicated question. Let me try to answer it in a couple of ways.

First and most basically, the health department needs to be the nerve center for making this happen. What we are talking about is gathering the information through the surveillance systems to allow competency in making the decisions that need to occur. Then, the different arm needs to come in action. The health department, as you have said, works with providers and works with appropriate policymakers to make the right things happen.

A fair amount of the dollars that have gone out over the last year for enhancing bioterrorism preparedness have been put in place through plans and exercises, exactly the kind of thing that you're talking about. So even as we speak, health departments around the country are, in fact, making plans, drilling, making sure that they have the ability to connect with the providers that they need to connect with, testing that, making sure that they're connected with the policymakers and others.

Mr. MURPHY. Is this part-there'll continue to be drills around

nities can also apply and work with health-because you also have State health departments in some I know in Pennsylvania many counties don't have a health department. They have to rely on the State. It's a slow system. And so it will require some drills and exercise to take care of that. Is that a part of the States as well?

Dr. FLEMING. Absolutely correct. And let me point out that one of the ways that we are really focusing on using these resources is to invest them in the same systems that are used every day to detect naturally occurring outbreaks and to mount the responses that are necessary to combat those. So in addition to exercises and drills, in fact, we are, because of Mother Nature, constantly being drilled in this country and around the world through the natural everyday public health emergencies that our health departments are facing.

Mr. MURPHY. Was this 5 or 10 minutes that I have?

Mr. SHAYS. Ten minutes.

Mr. MURPHY. Ten minutes? Oh good. Let me continue to pursue this.

With this kind of data out there, the question becomes one of Big Brother and how do you protect confidentiality of records. And let me add to this, a lot of hospitals are concerned now about HIPAA regulations and problems with confidentiality. So now they can't get the information that they need to track what's happening with patients.

Let me continue to build this. As we're working on such things as other aspects of pharmaceutical care for the elderly, without some openness of sharing some records, you run the continued risk of the problems that there are with prescription and nonprescription drugs. Some estimates have been out there about 10 percentI'm sure you're aware that about 10 percent of emergency room admissions they say are related to some pharmaceutical problems; perhaps the person took the double doses they weren't supposed to. Perhaps a physician did not know what else was being prescribed. They didn't know that the patient was taking over-the-counter products. Someone forgot their medication for 2 days, they took it all at once. The list goes on. And in aspects where pharmacists have data available or where the pharmacy benefits manager may have information available of what else that person is on, it helps them prevent a lot of those accidents.

Now, we're looking, too, here at collecting data on symptoms. If it is just looking at sales, numbers for what's happened with antihistamines and pharmacists, that's one thing, but ultimately you have to get down to the level of who has this? That's been part of the elegance of tracking SARS around the world, that you were able to track it down to a hotel in Hong Kong, ninth floor, who was there, and tracking them around the world. Clearly you're going to need some sort of records like this, too, but it has to be looming over people's minds of-on the one hand they want to know if there are symptoms in a town, they want action to be taken to identify that, but also protect confidentiality. How do you walk that line? Dr. FLEMING. OK. An excellent question. Let me say first that I think most people in public health would not see it as public health

this information to be made available, and so we're on the same side of this.

There's a couple of strategies that are used. First there are some kinds of surveillance where you don't need identifying information, and so the first question that we always ask in any of these surveillance systems is can we get what we need without having identifying information there, and if so, let's not get it.

But as you pointed out, there are some places where, in fact, identifying information is needed so you can track back to the individual or the individual's provider to get more information to assure that the right things are happening to that person and to take the appropriate actions in the community.

This is an issue that public health has been dealing with, you know, for 100 years. And, in fact, on a day-to-day basis, personal identifying information is routinely relayed from the medical community to the public health system, and that information is guarded very carefully both from a legal standpoint and from a security standpoint so that there have been few, if any, breaches in the history of public health where an individual's confidentiality has been compromised, and that's by maintaining attention to the sanctity of privacy and, when information that is identified is obtained, making sure that it's used wisely. That's the answer.

One last thing about HIPAA is that there is a lot of confusion out there, obviously, and we're working in the health care sector, but HIPAA, in fact, does give an exemption to public health, so providing information from the clinical sector to the public health sector for public health purposes and says in that situation it is OK to transfer identifying information.

Mr. MURPHY. Well, I certainly hope as all this is gathered a great deal of training information is available to physicians, hospitals, emergency responders, police, etc., because a lot of them still don't know what to do.

And let me ask one final quick question. Who is ultimately in charge when a disease outbreak is determined? Who is the top of the chain of command?

Dr. FLEMING. Well, the President, obviously.

Mr. MURPHY. I mean, is it where the thing occurs first? Oftentimes first responders, whoever's first on the scene in that community, is now in charge either nationwide, or it begins in some State

Dr. FLEMING. I'm sorry. I misunderstood your question. Health is a State's right, and so it will be the State health department at which there is legal jurisdiction for the health events going on in the State. If an event crosses_State boundaries, then it becomes also from a legal perspective a Federal jurisdiction issue.

Mr. MURPHY. And so such actions as quarantining, other information then becomes through-Health and Human Services, HHS and CDC begin to take control and begin to tell States what they should do in communities and travel, etc?

Dr. FLEMING. The short answer is yes. The more accurate answer is that we really do have a good partnership in public health, and so CDC and State and local health departments routinely, every day, in the absence of who is in charge, make critically important

Mr. MURPHY. Thank you.
Thank you, Mr. Chairman.

Mr. SHAYS. I thank the gentleman.

In our two panels we have the national looking at the civilian and the military, and then we have basically State and local and international, and we're also looking at the private in our second panel.

I was just curious, Dr. Tornberg, as you're hearing the questions being asked to Dr. Fleming, besides thinking what you're going to do this evening or tomorrow or on the weekend as it related to this hearing, what kinds of things go through your thoughts? I'm just trying to figure out how you interface with CDC.

Dr. TORNBERG. Well, we interact extensively with CDC and I have with Dr. Fleming on issues. The collaboration extends not only to CDC, but to a host of other Federal agencies and the World Health Organization. As I indicated in my earlier statement, we have representatives assigned to CDC, military epidemiologists. We are currently assigning an individual to represent-Dr. Winkenwerder-at the-to Dr. Gerberding's office as we speak.

So the collaboration is very close, and there's an ongoing active discussion. Particularly with the SARS outbreak, there's been really intense collaboration between CDC and the World Health Organization and our assets, the assets of DOD-GEIS, in addressing this issue, and I think we have a really fine working relationship. Mr. SHAYS. Now, if there wasn't the terrorist threat, you'd still be in business, and why would that be true? In other words, if you never had to worry or-not just the terrorist threat, but a sanctioned military effort on the part of an adversary to use biological agents, if you didn't have that concern, whether it was sanctioned by a government or individual terrorist attack, one used against the military or one used against civilians, would you still be in business, and why?

Dr. TORNBERG. Yes, sir, we would be. In fact, our ongoing efforts and our fight to preserve the health and safety of our personnel demands that we be very active and proactive in this arena, as we have been from the earliest days of the Department of Defense. Our forces are expeditionary in nature and exposed to a host of

Mr. SHAYS. I get the gist of that. Thank you. That's clear to me. Let me ask you, Dr. Fleming, though, so you have Dr. Tornberg, who's focused on a national and international, tell me how your focus becomes international in terms of the fear-in other words, we have representatives from our military all around the world. Is your focus international as well as national?

Dr. FLEMING. Absolutely. And it is for several reasons. The spector of infectious disease is perhaps the most obvious threat. A case of drug-resistant tuberculosis or SARS is simply a plane ride away in today's world. And one of the best ways to prevent the emergence of both known and unknown diseases in this country is to make sure that we have a strong global network and a U.S. presence, a CDC presence, overseas fighting those diseases in the countries that they're occurring, minimizing the chance that they will come here.

Dr. FLEMING. CDC's primary expertise is in people and epidemiologists, so we have a handful of field stations, but in my opinion, the real international resource, the resource that CDC provides for the world, is in the trained epidemiologists, and we currently have approximately 60 CDC medical epidemiologist in various countries working with local ministries of health on critically important issues, be it polio eradication, or HIV prevention, or surveillance for infectious diseases.

Mr. SHAYS. Dr. Tornberg, how many-is that classified information?

Dr. TORNBERG. No, sir, it's not. We have five overseas laboratories.

Mr. SHAYS. And where are they located?

Dr. TORNBERG. We have a laboratory in Thailand, in Jakarta, Indonesia. We have one in Peru, Kenya and Cairo.

Mr. SHAYS. OK. Now, getting to where Mr. Bell is, in Congress, we have to wrestle with a constituent who will say we need to do this, and they want a State law because they don't like what their-they want a Federal law because they don't like what their State is doing, and we get into this issue of, you know, do we overrule State law and have a uniform law. And I try explain that you sometimes can end up with a common denominator, and you might want a stronger law in one State versus another.

But when you get into health care and you get into this issue of collecting data, I'm really unclear as to what restraints there are. I mean, is there an untold story here that Republicans don't want to get into this because there is the States rights issue, and Democrats may not want to get into this because of the personal privacy? I mean, is party ideology, conservative or liberal, getting into play here besides the issue of resources and people-dependent and money, because I'm thinking, good grief, we're not going to have a vaccine for every potential pathogen, every potential illness inflicted on us. So one of the ways that we are going to deal-and we wouldn't want to necessarily even if we could, because there's always some side effects with that.

So we want to it seems to me our strategy is identify quickly, isolate it, contain it, and deal with that as we find it. And I'm unclear from you, Dr. Fleming, as to, you know, are we going here and there, or are we just trying to say, well, given this disparate kind of system we have, we'll make the best of it? Or should we say this is absurd, this is ridiculous, we want to have unified information, we want to have every local community send it up to the State on real time, we want it available to the Federal Government on real time, just like K-Mart might know what they have in their inventory and what they sold in the last 15 minutes? In my mind, that's kind of the way I'm thinking, but I'm not sensing that's the way the Federal Government's thinking.

Dr. FLEMING. First off, I think-just so that you'll know, I have about 20 years experience. Most of that is actually working at the State level. I have been at CDC for about 3 years, and so I have a little bit of history here. And I think if you'd asked me this question 20 years ago, I would have said you're absolutely right, be