absolutely on essential roll calls on the house floor it's pretty hard to have an orderly schedule here let me simply say that we were going to have two panels this morning one focused on the center for disease control the other focused on emergency preparedness in the interest of time were compressing it into one one shot i had all kinds of interesting and profound opening comment was going to make but also in the interest of time i will forego them and and try to get to the witnesses as soon as possible and save our time for questions mr wallace you have any comments before we proceed to share and i think that shows great wisdom i will also withhold my very important remarks of people that ask questions all right dr julie gerberding director center for disease control and prevention dr gerald parker principal no thank you we really appreciate the chance to present the c d c budget and to talk about our preparedness efforts in the context of the overall h h s effort and i apologize if my opening marks are bit discombobulated because i'm trying to compress two things together so if i'm  department budget proposal for always and in his testimony he mentioned eight areas of departmental priority that also have significant overlap with c d c and those include health information technology health diplomacy emergency preparedness and pandemic preparations health research and very importantly to all of us at c d c the prevention portfolio you had asked in advance of this hearing that we not only talk about what we were doing now but what the future might have in store for public health and so i wanted to start by just mentioning a few of the highlights that c d c has accomplished in the first graphic here in this past the school year we have some things that i think we can be very proud of in terms of achieving record high immunization coverage rates improvements in the survival of down syndrome the lowest ever teen birth rates very decreasing roles  of frequency of sexual activity among high school students the lowest ever cheaper kilo's this rate in our country and a further decline in resident cervical cancer rates those are all good news things but you can see also embedded in some of these highlights that we still have a big problem with health disparities and a long way to go before we we reach the goals of healthy people two thousand and ten in some of these important areas so great progress but also more to be done i think as we look ahead into the future we're impressed that what lies ahead for public health are really big problems on the next graphic i've sort of summarized how we see some of the biggest problems we're likely to face in the next decade some of these would fall into the container of urgent threat things like climate change poverty extremism that's creating so much conflict in the world those don't at first glance seem like public health issues but in fact they kind of conspire to create the incubator for a number of very important big problems for us terrorist attacks emerging infectious diseases like pandemics cultural disasters that we've seem to be increasingly engaged in a macro scale including hurricanes and tsunamis these urgent threat really can happen anytime anywhere to anybody and a public health agency like c d c especially since two thousand and one has had to scale up and speed up our ability to be part of the overall emergency preparedness and response effort on the next graphic i've presented one of those urgent threats that is the focus of part of this hearing that has to do with the problem of h five n one is sort of an example of an emerging infectious disease that illustrates all of the ominous characteristics of these big problems this is obviously a zoonotic disease arising in birds primarily remains a bird disease but it's one that is now global has spread to several continents and is continuing to spill over on rare occasions to cause severe human human disease on the next graphic the countries that have reported some human disease are apparent and you can see that this is still focused in southeast asia but by no means limited to that part of the world and as the virus moves so will the threat to human beings most recently the small outbreak in turkey in the united kingdom not causing human disease but nevertheless moving closer and closer to the united states on the next graphic i've just presented part of our global response to the flu pandemic  h five n one pandemic in birds and just really illustrating that c d c has an agency has had to become increasingly globalized we have people in more than forty five countries and we are investing resources in global disease detection as well as supporting secretary leavitt health diplomacy agenda increasingly greater proportions of our workforce our overseas we now have about two thousand people employed in international activities overall  these urgent threat are part of our portfolio but we can't forget about the other trends that are very dominant in the other half of c d c and those are the urgent realities let me just move to the next graphic which shows one dimension of this in this is the problem of aging you can see that the demographic trends for the united states over time reveal that an increasing proportion of our population is going to be a senior citizen or over age sixty five as we move forward and of course these individuals as they age would love to and for healthy aging and being physically active ing enjoying their families and their grandchildren but increasingly the  cs are moving in the wrong direction we're seeing our seniors become less healthy as they are the chronic diseases catch up to them so the next slide we have really a depiction of the urgent realities the extreme aging the extreme lifestyles and the extreme environment that are really came together to create a very growing threat we're at an environment right now where more than ten million someone say thirteen million of our children are overweight one in three of these children will develop diabetes in their lifetime if we don't reverse this trend and we're at a knowitall point that if we don't do something about these problems the benefits that we've achieved in the last century in terms of  lifespan are threatened our children may not live longer than we do and they may not have the quality of life that we can enjoy and experience today so cardiovascular disease cancer diabetes these are problems for everybody everywhere every day across our country and c d c has a very important role to play in combat in these threats i should just mention a couple of elements of this because we're right in the middle of a rollout of a new hiv and the shows of many people have  misunderstood the fact that hiv is still a problem in the united states and it's particular problem among african americans so we are launching a very aggressive social mobilization effort to try to improve access to testing awareness and communication about hiv domestically as an urgent reality that increasingly is affecting just proportionate numbers of african american men and women so these problems that we're talking about these big problems are coming in the context of our world which is also characterized by very high expectations as you know i'm sure as members of congress people really expect flawless performance they want real time intervention they want everything to happen at the speed of the internet not the speed of government and so we're working on bigger problems in an environment where we need to be more transparent and we need to be more accountable for what we're doing and that is  adjustment for an agency for all of us i think in the context of new media and new opportunities to have information present to our public in new formats and new channels we also really are working in a situation where time matters people's lives are at stake and if c d c takes too long to do something or if we're not as fast as we can be it's not just an inconvenience it really does put life on the line so we've had to invent new ways to take advantage of new technologies and new information technology to try to speed up the village to do our work i won't focus on all of the other dimensions of the future because i want to be respectful of my colleagues at the table here but i would say that in the context of being asked to do more to do it faster to do it in the more transparent and more accountable way and to do it with the same or sometimes even less resource we have to innovate and we have to really adapt to this new environment and find better ways to make what we do have go further and that's one of the biggest challenges that i as the c d c director face and i'm sure all of my colleagues in government are facing right now there's a lot at stake but we need to be able to invest appropriately to do it better and i think some of the highlights of the zero eight budget proposal really address some of those areas of innovation that a lesson health initiative to help us use school and the school education system as a way to promote better health initiative to really accelerate access to rapid testing in nontraditional areas to find the two hundred fifty thousand americans who are not  known to be infected but in fact are at risk for transmitting the virus the investments in our preparedness effort for pandemic influenza really accelerating our ability to detect and respond i think on the next graphic i have just a quick depiction of what this all really is telling us about the nature of our world if there's one thing that i would like to leave the committee with it's this picture which really says in a world where there are these many this many health challenges we really need to step back and think about how we are investing our resources are we really investing in primary prevention are we really doing what we need to do to protect people's health before they acquire the risk factors or the diseases that require such expensive treatment down the down the road we're spending less than three percent of our health budget on prevention and i don't think that reflects an adequately balanced portfolio and we at c d c would very much like to see these prevention initiatives and others be a signpost for what needs to happen as we look forward into the future and think about the health system we would like to have in the health system we need to have if we're going to protect our children's health but also our economy and our economic competitiveness on the global scale so i'll end there and just again thank the committee and if i can go back and fill in any of the gaps that i've left out in this kind of  amalgamated presentation i'll try to do that in the q and a or for the record later thank you thank you mr chairman and members of the subcommittee i'm honored to be here today to speak to you about the continued efforts of the department of health and human services to prepare prepare for and respond to public health emergencies including if it's a terrorist attack i have submitted written statement but would like to take a few moments hodding some of our important work as establishing the pandemic and all hazards preparedness act the assistant secretary for preparedness response or asked for direction coordinates these efforts across the department on behalf of the secretary ask for also coordinates activities with other departments and agencies as leader of the emergency support function eight of the national sponsors plan so our organization is young our mission to lead the nation in preventing preparing preparing for  responding to the adverse health effects of public health emergencies and disasters is far reaching and critically important to our nation's security today i will detail you for the f y two thousand and eight budget requests for the department's emergency preparedness activities and just discuss how these active activities are coordinated across the department we have initiated we have achieved important successes as of today the national disaster medical system transferred to h h s from the department of homeland security and we have deployed to the m d m s successfully as recently as a state of the union address aspers also working to complete the transfer of the hospital to parents programs from the health resources and services agency administration we have shown great progress in improving our nation's ability to respond to an infant influenza pandemic since december two thousand  development of cell culture and an engine sparing influenza vaccines we have initiated new efforts to promote collaboration including the development of the public health emergency medical countermeasures in apprise the enterprise coordinated inner agency effort and is responsible for defining and prioritizing requirements for public health emergency account of measures coordinating research and of product development effort chairman to meet these requirements and establishing deployment strategies for the medical counter measures included in the strategic national stockpile we have achieved successes but we have also learned by the lessons the discovery and development of new medical countermeasures is complex and an inherently risky endeavor we have learned from the research and development increase the maturity of the candidate pool potential project bioshield projects bridging the gap from the n i to research and development programs and project bioshield across the valley of death this funding is essential to support the full spectrum of emergency preparedness response activities across the department in closing a request of twenty two million in direct funding for project bioshield management support fifty five million for the national disaster medical system and increased six million and an increase of thirty six million across asked for to improve all hazards regional for fairness in response to pass city asper looks forward to promoting continued progress in integrating preparedness and response efforts across the department including the implementation of the pandemic and all hazards preparedness fact the implementation effort includes the participation of over two hundred representatives of the department two senior level bodies and eight work groups each of which is co chaired by not only in the successful implementation of the statute but also the continued integration of our preparedness and response efforts department wide i thank you and i look forward to answering your questions th chairman mr walsh members of the committee i appreciate the opportunity to discuss with you for a few more minutes this morning the and i each research component of the complex issue for which the department is responsible for namely reemerging and emerging public health threats i'm going to focus on the research component there are several components you've heard from dr gerberding about the public health components you've heard about the development programs we're going to talk a bit about the research for a couple of minutes as shown on this first visual here as with all of the n i h s endeavors what we do is based on a solid foundation of fundamental basic research when one deals with emerging and reemerging threats we have over the past several years substantially built not only our intellectual capital but also our physical infrastructure to perform some of the experiments that are necessary in addition we do the clinical trials that are ultimately aimed at providing the scientific basis for the development of countermeasures in the forms of diagnostics the reputed and vaccines for decades now d n a has had experience in addressing the issues of emerging and reemerging threats and i've discussed this with this committee over several years including for example h i v aids sars west nile virus multiple drug resistant microbes particularly malaria tuberculosis and s apparatus was already in place to look at the biological threats we've had to push the envelope because we had a gap there there with regard to chemical and radiologic for obvious reasons that that was fundamentally military responsibility in the time of the cold war and we've had to play catch up on that but the naturally occurring capability that we have for these diseases has aided us greatly to respond rapidly to at least the biological components of that for example following nine eleven and the anthrax attacks of the fall of two thousand of september the eleventh several years ago we put together a strategic plan that i presented to this committee on previous appropriations hearings followed by research agenda we have rapidly first in two thousand and three and then subsequently two that put together a progress report the most recent of which we will distribute to your staff that just came out a month ago which is the latest progress report on what we've done it is obviously time constraints to go over all of the details but i do want to point out just a couple of issues that we feel very important one is in the arena of smallpox protection you know we do have and we rapidly gear that up to have enough smallpox vaccine for the entire nation to vaccinate but even though there uncommonly if not rare the toxicities can be substantial so we've work now on a much safer component what we call modified vax any anchor and studies over the past year have shown very clearly that animals in an animal model of smallpox can be adequately protected with a product that has very very few toxicities in addition the first really encouraging antiviral against smallpox s t two forty six has been shown to be safe in humans and effective in an animal model the other arena that i want to bring to your attention is the hemorrhagic fevers particularly ebola and la just recently i present to this committee at a hearing a couple of years ago about the first a bowl a vaccine that was actually produced and tested at the end i h we've gone to the second generation which is a single dose and becomes effective within weeks instead of months and also utilizing the technology of what we call interfering r n a or inhibitory r n a a technology whereby you can molecularly interfere we have now a promising therapeutic against the ball that this is an extrapolation of the technique for which andrew fire and craig mellow to and i grant these just this year won the nobel prize for that technique i think it's a good example of how rapidly you can extrapolate and apply fundamental basic research findings into things that can be protecting the country i want to spend a minute or two on the issue that dr gerberding introduced and that is the situation with seasonal flu and its relationship to pandemic influenza as i get i've told twenty first century type vaccines and drugs getting more people vaccinated the c d c has been an extraordinarily good job of pushing that to get more people vaccinated we need better vaccines if you do it for seasonal you'd get out of the crisis mode for doing it with pandemic next visual i just want to highlight just very briefly some of the accomplishments over the past year since i spoke to this committee i mentioned the genomic sequencing component which we do in collaboration with other agencies including the c d c we now have over two thousand isolates of influenza that make those genomic sequences available to our pool of invest the gate is so that we can get the brightest and the best working on influenza in addition we are studying the molecular interface of the evolution of the virus between animals particularly birds and humans with regard to diagnostics the c d c has taken the lead role in that we've collaborated with them and i want to bring one to your attention a particularly encouraging new molecular technique called an m chip which we are now have down to about seven hours to get it if we can get down to less than an hour thirty minutes we'll have what's called a point of care diagnostic which you can actually make available very rapidly we don't think that this is going to be available next week or next month but within a reasonable period of time it'll be parts available therapeutics we maximizing the use of existing drugs i spoke to you about tamiflu last year the possibility of resistance we know there is already resistance to the  antivirals two of which are very encouraging one that blocks the binding of the virus to the cell the target cell and another which interferes with a plimmer raised component or the enzyme required for viral replication and then finally with regard to vaccines you might be called i spoke to this committee last year about the fact that we had developed a pandemic a preplanned amec vaccine against the h five n one that was the good news the sobering news was that it was available only t induce an immune response that you would predict to be protected at a rather high dose and unattainable dose for practical purposes in addition it was only effective in doing that in about fifty percent of the people now utilizing  compound which amplifies or expands the immune response the results are encouraging from several companies as well as and i and other funded namely you give an h five n one and with a significantly less dose you can get the degree of protection and a greater percentage of people a higher degree of protection and it even spreads across different variants of the h five n one so this is the kind of thing that we're pushing and i think are going to have an important impact on our strategies and finally the ultimate goal which i think is attainable but not easy is to develop a universal vaccine for flu whereby you don't necessarily have to be changing it each year for the drift that you see from year to year and perhaps even the goal that we'd like to get at is have one that would even be effective against the emergence of pandemic strains so on this last slide i want to reiterate really the fundamental principle that drives us there is a delicate balance that is also a perpetual challenge when you talk about public health emerging threats they will be with us forever be they naturally currying or a hopefully never deliberately propagated microbes have the ability to persist to emerge and re emerge what we do want to r n to maintain that delicate balance in our favor is the public health measures that dr gerberding has mentioned to you the countermeasure development that dr parker has mentioned to you as well as the b market with that one but it's good to hear dr gerberding you talked about i think you said three percent of our budget is spent on prevention obviously will congress tends to establish priorities by the way it spends money i don't think that's how you do it because i think prevention obviously would be a priority you have fires to put out basically but there's two two points that i wanted to raise on this issue of prevention staff advises me that a majority of chronic health conditions health diseases are preventable by modifying lifestyle factors yet only fourteen proposed for a forty percent reduction so it looks like we're actually going in the opposite direction of where we probably should go in terms of prevention would you care to comment any view on that thank you your staff  informs you we estimate that about seventy percent of chronic disease is preventable through lifestyle changes that address the main risk factors which include tobacco poor nutrition lack of physical exercise and excessive alcohol use if we could deal with those risk factors we really could attenuate the majority of the chronic diseases that our citizens are facing there are many important program activities going on that do in fact target those behaviors a part of our recent investment in something called the national center for health marketing is a recognition that we don't have the science around how to influence lifestyles and behaviors that we need to know what it is that we should invest in to make a bigger difference at c d c we believe that science is the source of our credibility and there is a science around influencing and marking and promoting better health but we i have a only a small investment there right now in terms of the steps to health care u s program that was always intended to be a starter program with a five year grant cycle and the seventeen million dollars that are not in that budget line this year represent programs who have come to the end of their funding cycle but those that are still in play will continue to complete their overall funding cycle and we are using those dollars to support the new initiative to try to reach our adolescents in schools through a program that will reach into about thirty six hundred schools around the country and try to deal with nutrition lifestyle and exercise for students and even from the research standpoint is trying to get to the point so that we could be complementing from a research standpoint the goals that dr gerberding has said we heard some interesting testimony from some of the scientists that i regarding drug use alcohol abuse and ways of affecting the usage patterns in individuals by utilizing other means of chemical means and otherwise one other question and that is since september eleventh two thousand and one two hundred million dollars of c d c s budget was there before two thousand and one one two hundred million dollars of c d c s budget was dedicated to terrorism preparedness and emergency response double that amount was spent on chronic disease prevention since that time it's flipped so we're spending much more money on terrorism related concerns and less on chronic diseases that the right balance you know i lived through nine one one i've been on the job ten days as part of the senior leadership team at c d c when the attacks occurred and i think all of us  got a big wake up call at that point i don't think is the situation is that we have over invested in terrorism i think that we had under invested in it prior to that point in time and we are still working very hard across our nation and around the world to bring our preparedness up to a level that we have uniform confidence in but that doesn't mean that the urgent realities go away and i think the struggle that we have is how do you balance that portfolio these are both very important aspects of public health and we need to be able to do them both well and both with with the appropriate amount of federal and state and local support to be successful film and some of these because we've got started so late and we have so many members here during my tenure on the subcommittee i made it my goal to help eliminate health disparities we know chronic diseases disproportionately affect minority populations for various reasons from access to health care to education and prevention strategies any effort we make to increase chronic disease prevention programs will help all americans but i am particularly interested in one program that targets minority populations the reach program from what i've seen the reach program has been an effective tool in the federal government's efforts to the to develop strategies to eliminate health disparities or reach grantees or community coalitions from every region of the country designed to meet the needs of local populations in fact a group in my district access community health network is a reach recipient grantees are focused on eliminating pervasive disparities in six priority areas cardiovascular disease immunizations breast and cervical cancer screening and management diabetes h i v an aids and infant mortality new evidence from the c d c has demonstrated that undeniably these programs have improved health outcomes for the targeted populations often dramatically dr gerberding your budget level risk for the spawn but to fund this program is presently at thirty four million there's a letter going around the house now asking for a fifty million dollars appropriation i'm wondering how many more grants to help and in health disparities could be made from that increase and would you support or oppose that effort and i do recognize that your budget is going to be balancing a number of critical question thank you you have made the point well that the reach effort is successful the most recent data i've seen from my reach project has indicated that there is able to really they were able to eliminate the disparity in blood sugars among diabetics that were engaged in a program i believe in south carolina so it is a very successful targeted program but it is not a very highly scaled program so it is reaching people effectively but it's not reaching a lot of people because of the scale and scope of it and you know i think that this is one of those areas where we need to be looking at where are we getting the biggest value foreign investment i think most of us at c d c have looked at the data to understand that reaches successful and that we ought to be looking at whether or not redirection or investment in this program is the idea whose time has come of course we always say as operating division heads that if you invest we will get results and so i'm not going to deny that if we had more money and reach we would be able to expand the program but we all recognize the competing priorities that we face one final question my that my time nearly expiring david how much time do i but two minutes are think in this year for this year the president has proposed an increase of ninety three million dollars for testing programs in h i b and eight with sixty three million of the targeted for ten cities with the highest infection rates injection drug users and prisoners since we haven't seen an increase in c d c s h i b prevention budget in five years it's obviously long overdue because african american and other minority populations are disproportionately impacted by the unaids the recommendation include an act and emphasis on these americans and i note that the budget proposal promotes rapid testing in localities which have demonstrated the highest prevalence rates will the c d c provide grantees with rapid response testing kits for their use in this effort thank you i think the  can say yes to all of the above the proposed initiative in zero eight is disaffiliate targeting people at highest risk and very strong focus on african american men and women since that is the highest risk group in the united states right now the initiative does promote access to rap and testing and it does attempt to reach people in the environments where they are most likely to seek care but it also puts a strong emphasis as part of our overall context and universal testing  on a voluntary basis of people between the ages of thirteen and sixty four and that initiative was in the president's budget for zero seven but because of the jr it would have representative increase so it's not currently funded but we are looking at options for finding some resources even though seven to jumpstart that effort will have to see how that goes and get back to the committee as as we as we move through the spin plan for the zero seven budget it's very important to us that we had a hundred leaders of the african american community in atlanta yesterday to try to launch this mobilization effort so we're building a network of commitment around the country as a regular thank you mr chairman a couple questions mr gerber dean sleep and sleep disorders have been recognized as critical factors in major diseases such as cardiovascular and sun is c d c collecting data on the impact of sleep disorders i don't know the answer to that question mr chairman i will have to find out i know the previous testimony that secretary leavitt provided about sleep apnea and sleep disorders as an emerging area of concern in a co factor number of other issues as a lead us to start to examine but i'm not aware that we have a specific program secondly and maybe for the record you could put something in dr gerberding i met with some people yesterday who are suffering from various other conditions we have a program at c d c that is specifically focusing on blood disorders and i will have to check to see if their work is honing in on this particular problem or no but what you're mentioning are a number of very important health problems to small numbers of individuals and those are the kinds of health issues that we have the hardest time with and they didn't last in the shuffle of some of the bigger issues and i helpful to have someone draw attention to them so we'll check on that if you're one of the victims in fact very important thirdly i noticed that dr frank she mentioned in your in his testimony the recent reemergence of west nile virus so i'm a little confused why the funding for west nile is being eliminated in the c d c but the funding for west nile not being eliminated there is a reduction proposed in the budget level for that and the reason is when the money first appeared it was in the context of the urgent situation of the virus moving very quickly across the united states and our state laboratories did not have testing capability or the ability to do surveillance of mosquitoes and so forth those capacities have been developed in state health departments and i think we're looking now to see what other important gaps exist that we can redirect those resources to address the last question are we getting the health care system seamless and i'm talking and system that i was specifically thinking you might appreciate seeing that really maybe in your hand out it shows the connectivity that we're working toward the secretary as you know has a very important health information technology initiative and this is just one small piece of it but this is the piece that helps link the information technology from the health care setting into the local state and federal public health departments and the red dots here are hospitals that have  specifically entered the system now but we also have the d o d facilities in the v a hospitals already providing information and you'll see this map get increasingly red this year because we are going to be working with the regional health initiatives and other means to accelerate food safety dr gerberding and we've talked about this before she d c has made progress in food net pulse net i'm no question about that my view is that we need to go beyond investigating and at c d c does on reporting beyond investigating i don't know that our science and the mechanisms to deal with them are evolving at the same speed quickly i think that is just something that we can do with the c d c you've  got you've got laboratory capacity you asked for increased funding for special pathogen labs i asked the question about our capacity discover pathogens in our food supply how can we do it in the most rapid and most effective way how can c d c be a part of dealing with performance standards and how do we in fact increase the number of states that are involved in food that today thank you you know the food safety problem is a example detection and most importantly try to use that information to feed back and close the loop and take the handle up the pump so to speak but the problem is enlarging faster than our capability to keep up with it is made very good progress in the minds of some food items but the one problem area remains produce an area where the trend is going in the wrong direction more outbreaks larger outbreaks will affect it and dealing effectively with produce safety is going to require that intersection of u s d a f d a and c d c really putting our heads together and figuring out what can we do to prevent these problems but also what can we do to improve the speed of detection that we have the science now to deal with performance standards in these areas and so that we could quickly move to performance standards i believe that c d c has that if we do not how do we get there what kind of resources necessary to do the scientific research to get their performance standards from our standpoint meantime from  problem to time getting the product off the shelf but i think you're probably also referring to performance standards at the source and that would have to exactly that's exactly what i'm talking about there's another issue here with where you do your investigating where we get questions about how long it takes and how we can do with that but i'll ask those for the record but this is about developing the science in order to deal at the source with performance standards and with produce and with then with it with other products i would need to confer with dr von eschenbach and you'll be happy to know that and i have created a leadership forum between f d a and c d c so that we have a mechanism to bring these kinds of questions where the two agencies have to be putting our science together to solve problems so you'll be able to see i think some real acceleration of progress from our two agencies on this front ok thank you do i have any more time left mr chairman i just wanted to make a comment because your testimony said which i think addresses the issue of chronic illness the annual burden of cardiovascular disease in this country seventy nine million you know is the same order of magnitude as a projected impact of an isolated influenza pandemic ninety million and yet the increase for c d c is that marginally close to what   would you join me in the meantime i don't know that any questions have been asked relative to malaria in africa progress being made there and otherwise i'd like to hear about that if you would thank you larry as everyone knows is one of the three most important and demick diseases around the world and one that we can do a lot on without a very complicated investment  we are pleased to be part of the new president's men malaria initiative which over the next three years will have malaria comprehensive programs in fifteen countries so usa id is the lead agency for that but resources are coming to c for us to provide our science and our technical support we for example helped lead the science that proves that insect embed insecticide imbedded bed nets really did save lives of children and we are very  pleased to say that already in the three countries where the program's been initiated that we're beginning to see reductions in the rate of mortality among children and the true impact from the malaria program in some of these focus areas but it is a big problem and it's one that could unpredictably change in the context of climate change so we've got to stay right on top of emerging areas of malaria as well conduct such sluice against a compliment as we do between the c d c and the n h that the research that has taken place over the last couple of years has really been very encouraging from a from a standpoint of understanding several things including the molecular basis for resistance of malaria has really given us a quantum leap in understanding some of the intricacies of the malaria cycle and the vulnerabilities for drugs in addition a vaccine trial that has taken place has been the best we've seen so far namely there's been about thirty percent protection against death and fifty percent excuse me against infection and fifty percent protection against serious disease now that may not seem great by standards of vaccine but that's the best that we've seen thus far with malaria and there are a couple of companies that we're working with for example using a radiated circum spores so it's the company in rockville that we're dealing with has results that are now looking good and have gotten support not only from the n h but also from the gates foundation so things are moving along with trying to bring it into the twenty first century another one of those diseases that have been neglected from a scientific standpoint we're trying to correct that for the record your judgment on c d c s total budget needs to adequately carry out its mission on the other core programs that that you have to deal with such as a chronic disease prevention infectious disease management and so on c plays a very critical role in maintaining the health of this of this nation therefore i was was concerned to read a report that there are a number of scientists and management positions that are vacant at c d c can you tell us if we are having difficulty hiring the staff that you need to fill these positions and if so can you elaborate on why this is happening thank you we have been successful in feeling all of our senior scientist physicians physicians with extraordinary people but the challenge we're having now is in part because of the pandemic preparedness requirement for new people and in part because we're trying to move people off our strategic national stockpile contracts into full time government positions as well as a number of other needs that the agency has for new kinds of technical experts we have more than eight hundred people in the queue to be hired at the agency that represents about ten percent of our workforce and we are not able to move quickly enough to identify the talented people get through the hiring process which is unbelievable in government as you probably know but very difficult in an environment where the workforce and our own the people who are responsible for this through hiring in planned consolidation has been reduced by about fifty percent so there's not an area that is directly within my responsibility but it is certainly an area that affects our ability to hire quickly and get people on board at c d c and that coupled with the known fact that government as a whole is facing a tremendous issue with retirement has really created a very difficult bottleneck for the agency in appreciate your question because it's a great concern to me and i think my colleagues experience similar similar issues could you provide for the committee your views on actions to gerberding hurricane katrina titus many painful lessons about emergency preparedness and when the hurricane hit new orleans and the levees were breached the state's newborn screening laboratory was decimated and the normal operations for newborn screening diagnosis and follow up were interrupted for several weeks does this indicate that we need to have a national or centralized newborn screening laboratory to serve as a backup in the event of a catastrophic event such as katrina and what other essential laboratory services might face a similar interruption in a large scale natural or terrorist disaster thank you for asking that and in fact that situation did reveal two things one is that there was not a plan to accomplish that and second that other states do have the capacity to search there empacher agreements to pick up where one state can't fill the bill but if we were to have a situation where there was broad impact on multiple laboratories then we need additional search capability and c d c laboratory is planning to support that one of our responsibilities under dr partners  parker's mandate is that we identify what are the critical public health functions that we must be prepared to support federally in the context of something like a pandemic or a national catastrophe that would severely attenuate state's ability to search amongst themselves and newborn screening is definitely one of the items on that list do i have time for one more question mr chairman is my time up just out of that regional planning regional africa are african american the issue i think you're already covered that except i just want to get at the issue in florida where our state health department  has pursued a pretty aggressive effort to try to address the problem in the in the black community and the m m w are recently reported some success in that arena a significant drop in incident it's one of the components was the rapid test and are you looking at that as a tool to be used in this problem what i'm being told from people in the field that it's  informative for fees people can find out very early and it helps check spread essential if they know and if their loved ones know that they have a if they can find out quickly and cheaply you know we have been working on improving access to rapid testing aggressively for just a very short period of time and already for example the city of new york has been able to almost double the number of people diagnosed with hiv infection in their emergency department so with the current program that we have projected in the support that we hope to be able to provide we expect we would find about thirty one thousand cases of hiv that would otherwise have gone undetected so it is a remarkably important component of finding the unknown persons we also know that people who don't know they're infected account for about sixty five percent of the transmission so when they learn they're positive they change their behavior and transmission rates drop back down this is a very important effort not only for the infected person so they can get lifesaving treatment but also because the fuel of hiv infection the united states are the undiagnosed people and the more we can do is to find them the rapid test is critical to that because we lose people when they don't come back for their test result in two weeks but we also lose people because it's inconvenient to test them in the clinicians aren't providing it so the whole point of universal testing on a voluntary basis is to find those people who don't recognize their risk or haven't been able to access the test in the traditional context dr felt she did you want to add to that and i think the c d c should really be commended for their recent guidelines  testing a part of routine care there's no doubt and we've seen that in studies completely unrelated to that the point that dr gerberding made is very accurate that of the twenty five percent or so of the people who don't know that they're infected those are the ones that drive the epidemic and we also know that when you are at a point where you are have a high viral load and that's usually early on in the very early part of the infection or later on that that's the time when you are more likely to spread it to your partner so you can get people early on who don't know they're infected get them counseling get them into treatment bring the viral load down you're going to have again a secondary positive effect on decreasing one of the driving engines of infection so the idea about getting people tested getting the results rapidly is already shown positive impact and i think the positive impact is going to be even greater than than we're imagi g so it's a very very important move that was made thank you dr gerberding in the labor h b o last year senator lieberman and i supported over here put in some language  calling for the and i h to look at the the s d specifically the value of the vaccine safety data link and looking at mercury mercury content in childhood vaccines and  the conclusion of that that panel one of the conclusions was the panel identified i'm quoting from their report several serious problems that were charged to reduce the usefulness of an ecological study designed database they were picked up by the media it was published all over the country no link now we have a group of professionals and i each telling us that the data link is not u seful for this very purpose well i'll just i'll just give her an opportunity to respond that i would say very quickly that the v s e is exactly what you described it's an ecological tool and it's been affected at finding most recently cases for a syndrome that may or may not be associated with meningitis vaccine and within to subsume that may or may not be attributable to or the new rotavirus vaccine but it was never designed to answer questions about long term or delayed health effects from a vaccine it doesn't mean there's no value in it as a clue or a potential pro but you cannot develop a definitive answer from an ecological system that has good you shared my outrage that this generation of children may face a lower life expectancy than our generation due to increases in obesity and decreased physical activity this disgrace is happening on our watch and the president's proposed adolescent house school promotion initiative to combat obesity seems to be funded through cuts in other physical activity promotion programs with no new funds for other obesity prevention programs so i have a few questions about that and then if you can respond first of all i'd be interested in knowing if we're doing such a great job fighting obesity that we can cut funds for this effort and whether the administration believes that obesity prevention doesn't deserve more funding from the federal government and if you can tell me and i want to focus on the schools for a moment and i happen to have the bill as you know stop obesity in schools act stop number one how is the c working with the department of education to assess the wellness policies that have been developed by school districts number two how many school districts have submitted these policies and how many were required to and how will schools that were required to and did not be encouraged to comply with existing laws will c d c report back to congress on the effectiveness of these policies and i think we should consider what could be done to strengthen and improve these policies and what more can the federal government do to make obesity prevention a prayer r d so if you could respond i'll try to brief and what i can't say here we can we can discuss another time a summit for the record we have an evidence based tool called the school health index has systematically looked at the science around what programs work what's the most effective way to make a difference in the health status of students in various grade levels throughout school and that school health and is the foundation that most schools are using when planning for their wellness requirement my understanding is that schools who receive federal funds through u s d a or the department of education have to have a wellness plan in order to continue their qualification about check on that and i do not know how many have complied so that's another piece of information but the purpose of the adolescent initiative that we've have opposed is to try  proposes to try to get some resources into as many schools of possible to connect them with the scientists at c d c who are experts in the evidence base for what works to give these schools the technical support an access to our expertise working with the department of education to make sure that the money goes from c d c to the state department of education and from there to the thirty six hundred grant schools that we hope will benefit from this in the first go around but the important thing is education department doesn't have the kind of health expertise that we have we have easily don't have the understanding of how to embed this in the overall curriculum or the realities of school financing today so by bringing this  together in these demonstration projects will be able to document those schools are doing the things that the health index recommends and then begin to create some kind of an evaluation platform for seeing if it actually makes a difference i mean ultimately it's not what are you doing it's are the children healthier than they were before you started the program will take some time to figure that out have we gotten any feedback at all on the effectiveness of these programs it's just too early to really to be able to answer that question you know there are some examples for example mr peterson's alma mater in titusville pennsylvania has a comprehensive program of exercise and i think they're beginning to see some results in terms of the health status of students in that school where it's from preschool all the way through graduation but you have to follow a cord of kids over time and kind of compare them to kids in the constable school that didn't have the intervention that's expensive and we don't have that resource right now but i'd like to continue the discussion because it seems i've been on this committee for a long time and we've been talking about this issue a long time and we've been talking about the impact of obesity on health and the costs not never mind the pain and suffering so i hope we can continue that and hopefully there'll be some measurements that can affect the delivery of our services probably time for one more  thank you very muchan hopefully we can continue this discussion thank where we are in bioshield what this budget will do in terms of making the maxime's available that we are supposed to stockpile where we are with the anthrax vaccine as well as other vaccines and how this budget will affect that capability well the the advance development budget request is absolutely critical i think we have learned a great deal about the early phase of project bioshield and what is just absolutely critical is to be able to have an advanced development component that will bridge that gap between tony's programs and get across that valley of death so it can be developed and then go into a project bioshield procurement type contract and then ultimately in strategic national stockpile for distribution and use so as far as the what's in the budget request it supporting project bioshield if that's development is just absolutely essential so we can begin that that approach on the anthrax vaccine but i also want to state that antibiotics are still our first line of defense for an anthrax attack and we have forty million doses of anthrax of fill that work for fulfilling that requirement if i could just add very quickly there is a research project going on with the existing anthrax vaccine that's led to some very promising opportunities to essentially double the value of the product that we do have because  will likely be able to have fewer doses and we can use the route of administration that does not result in as many side effects so until we have the new products we are also trying to make sure that what we do have goes further and is safer is anybody looked at  or do we know once we have the stockpiles bioshield stockpile of vaccines and so forth what's it going to cost or what are we going to have to plan on for budgetary purposes to keep it current because a lot of people think you're going to be able to just buy these and put them on the shelf they'll chairman type contracts the total lifecycle cost is something that's you'll be seeing from us and the future and that is something that the enterprise that i mentioned in my oral comments that  we have the responsibility for managing the stockpile at c d c i think it's very important that people understand this in simple terms that things will expire we will never use them we will have to repurchase them that's a lot of money but it is an important aspect of the stockpile which is basically an insurance policy against a catastrophic situation where we need it and i'm fearful that people will think that we're not prepared for that or that that's a waste when in fact that's the very heart of what the stockpile is  renewable and resource that that does take an ongoing investment putting thing for or members of congress you know because there are people who think that once you buy them you just put him on the shelf and they'll be there forever and we do it's going to be an ongoing cost that we're going to have to anticipate but i appreciate what you're doing in that area and i know that you're working on new vaccines and second generation third generation whatever vaccines to make them more effective and more user friendly if you will and i appreciate the research and the dollars that you're putting into that i think it's money well oral health the oral health grants to the twelve states that are receiving them now i think the programs have been successful and oral health is an area that has not been part of the mainstream public health effort in too many areas and so those grants really sent a that oral health is key to overall child health and child development as well as adult health particularly for children so i am hopeful that we will be able to continue that program it is fascinating whether finding out the legal means i'm a tween or a health and some other some other diseases in the first currents of those so i hope that's a program that we continue after over first th for the rapid test kids want to ask you a couple of questions about that it's estimated now that about three hundred thousand people who are infected are not aware of their status and also that once these tests are conducted we may find thirty one thousand or so new infections which of course is very scary i want to find out first of all how this is is moving forward secondly with regard to the pretest counseling and one of the issues that we've been working on many of us in the congressional black caucus and a variety of caucuses here as well as in our own districts trying to help leadership understand the need to get tested so that others will follow sixteen members of the congressional black caucus were tested using the rapid test kit and also back in my district and i was tested again twice and what i learned through that process was very instructive one was that  there is a lack of pretest counselling at least many people don't know for an example that the results of the tests will not be made public and so i want to find out from you in terms of pretest counselling where are we on that first of all and how are people prepared to accept whatever news they receive as a result of the tests are there provisions man or do we have the type of care and treatment that's required for follow up if in fact the tests are positive are people now being included from the latino hispanic asian pacific american black community and terms of  how perspectives patients will be incorporated into these regulations and just how it's going as a relates to prisons i know part of the sixty three million as is to identify and i don't know if it's they prison federal prison but inmates to be tested i guess it's with the opt out provision and how do you see that evolving because i have legislation of course that would require all federal prisons to conduct opt out testing and then provide the condoms and the counseling and treatment that's required in prison because ninety five of inmate percent of inmates of course the coming out and so we have to put this on the top of our agenda so i was glad to sleep this but it's not enough money but i want to see how you're going to implement that thank you thank you know i may not be able to get all of this answered in detail in brief way but i wanted to try to focus on a couple things first of all thank you for the leadership that's exactly what we did in atlanta yesterday was to get african american leaders from all sectors media entertainment sports eccentric to do exactly what you're talking about the act campaign is awareness it's communication and it's testing and we're trying to roll that out throughout all of the communities that at greatest risk the resources that are proposed in the budget and that we hope we will might be able to find a way to get from the jr would allow us to test two million people and that's where the two million fairly high risk people and that's where the tomato thirty one thousand unsuspected or on diagnose cases would come from that is an estimate right now we would want to target those grants to the areas that had the highest problem and where we believe we would have the highest rate of undiagnosed infections this is really the first year in the twenty five years of age that we've been able to have the kind of information that c d c needs to determine the incidence of hiv from the person this is a historic moment because i've been involved in this disease since my early training at san francisco general hospital so when we have this incident information we'll know more about where we should be focusing these resources and try to put the money where the problem is the greatest you're bringing up the issue of pretest information pretest counselling and culturally competent counseling and testing which is a big challenge and that's exactly why these programs need to be developed and administered at the local level where people in the community can weigh in and help design and format the approach that's going to make the most sense prison's a very special case published  recently a situation where incarcerated persons were tested for hiv multiple occasions and at least eighty eight prisoners acquired hiv while in prison so there is a hazard in some of our prisons and we do need to do more both to diagnose and treat people but also to intervene and protect people during that vulnerable time of their of their histories and there is a disproportionate health disparity in the in who's in prison but also among prisoners in the persons who are hiv infected so this is an area where we are going to begin with this investment and hopefully our results will show that it's worthwhile continuing and even expanding in that on has physical exercise every day and i'm not what grade they start but i know middle school and up are tested and to pass gym they don't have to be good at a sport that to get the heart rate up their heart monitors i have to get the heart rate up three days a week until there's nothing i mean most adults learn about the necessity of getting your heart rate up and midlife when you have a crisis that's what most americans realize that's important and if we had that across america we would we would change the health of america in my view you i think you know what the problem is i think you know what we need to do but how do you do it when you're an agency that does not have state offices you do not have community offices don't know your own national identity that that has a program how do you connect with the population what what is your means of getting people how do you how do you to change behavior and we have a wholesale approach and a retail approach and our our wholesale approach is to try to provide our best science and to create programs and evaluate them and then disseminate them throughout the backbone of public health the state and local health departments that are closest to people but increasingly because of the internet and because of our global communication capability we also can reach directly to people and increasingly we're doing that through the internet through web based tools through new media like second life and i pod casts and so on so the if there's a channel out there we want to use that and tried to deliver a segmented part of the market the message in the way that they're most likely to receive it we use to t v p s a as we have had targeted campaigns like the verb campaign so we would like to do as much of that as we possibly can from a retail sense the person we need to meet with the most doctor mom women make eighty three percent of the health decisions in our country they broker their children's health often their spouse's health their parents health that's the person that we need to have in our mind when we're thinking about how to formulate our health advice and what really matters to the hearts and minds of the people who are using the information resources that c d c has so we can't do one without the other we must have a solid network of governmental public health agencies throughout our country but increasingly at every level people are also reaching directly to citizens and engaging the broad network it's not just about health so you know what we what was so wonderful about the flu summit was how the governor of every state brought  the the secretary of health and human services our leaders from homeland security c d c and i age together with the business leaders education leaders the health leaders the faith faith leaders the community leaders and the health care organization leaders the leaders in all of these different sectors came together and said flu pandemic planning is a local problem and we need to roll up our sleeves get to know each other prepare plans that make sense across our community and then exercise them and that is really a metaphor i think for that network is a metaphor for what really is the solution to problems like obesity like aids like a number of other really big problems that we're going to face we've got to build a solid network that is has to be pretty good to public health some very weak public health and i won't name any names today but so your whole message then depends on the effectiveness of the state to deliver that message to the moms you're talking about and to the kids and the families i'm going to urge you again rate the states rate them on what they do let them compete for a good rating because that's that will make a difference nobody wants to be below the fifty percent off and i know the state i come from will up their health budget for the first time in thirty years probably because it's never had a so had a governor since i've been around that has made health an important issue in pennsylvania and i said it publicly all said from anybody because i can debate it and  i'm sorry i can win that argument but i was thinking we were talking as we were coming over here you know there are other groups community action agencies deal with the poor of our country i was having dinner with a couple of last night they're interested in how they can help they realize the health problem they agree with we've got to figure out a way to relate with our wise and our youth clubs and so forth so a direct more direct connect dr weldon was talking about connecting our wise in rural areas maybe with our middle schools to where that's the same facility with it because make it affordable you talk about public health offices rural america doesn't have them in pennsylvania we had seven besides the state that was our seven largest cities so i guess steps to a healthier u s team seems like a fantastic program why you know all what you were just saying about tying these communities together and you know getting people talking the steps to a healthier us seems like it was a great step in that direction and it's being cut by seventeen million you explain why you know we're all in a situation where we're trying to make what we have go as far as possible and you know there is no perfect solution in a time when our budget is constrained we designed the steps program not to be a funding program in perpetuity we designed them specifically to how communities build a network and get started in how they would leverage you know their own community success so that communities that are not going to continue beyond their five year never were expected to continue beyond the five year period and we made a really tough choice that we might be able to get more impact on our children by redirecting those resources into the school system you know in an ideal world we would make that choice we'd be able to do both but since we do have to make a choice it was our judgment that we would be able to reach more kids and more schools through the adolescent initiative and that was flat funded correct lesson the adolescent initiative is new it is a plus up of seventeen million dollars that was not previously in the budget one of the  i'm reading through the secretary's five hundred day plan comments you know how c d c and his five hundred day plan kind of come together and one of the one of the items you mentioned is comprehensive and novel early prevention can you share with us some of the novel preventive ideas are going on one of the things that's happening at c d c is the development of some overarching health goals by life stage because what we're struggling with is that our money comes as a diabetes money heart disease money autism money at this money but people are more than the sum of their diseases and their body parts and so when one of the innovations that we're working on inside the c how can we bring people from these different categorical perspectives to build programs that are more integrated for the first time have senior management officials in the in the set of states that are there to look at all of c d c s investments and say why do we have thirty four grants what would it be like if we could integrate r t b r h r s t d money into programs that made more sense to the people that were serving rather than this arbitrary compartmentalization and that innovation really means let's just take immunizations for example children be between the ages of birth and two years have multiple visits to their pediatrician for a shot or what would it be like if at those same visits we could talk to mom about fire safety or injury prevention or good nutrition or you know physical fitness in the home there are a number of other health interventions that moms are interested in we have a target audience but we've never bundled our programs together in a way that allows that kind of curriculum approach pre conception care there are a whole set of very important things that women need to know before they're pregnant whether it's spinal bifida and folic acid repletion or hiv testing or s t d screening or hepatitis b vaccination there's a set of things that need to come together in the integrated way a more holistic approach and that's been really tough on us because our budget is categorized but we're trying to learn within c d c and across the state health system how can we build those comprehensive prep wrench and programs in a more synergistic and holistic way we're just starting on this we may eventually have to come back and ask congress for some flexibility and how our money is amalgamated but we really believe that this is one of the ways that we can get more impact from the dollars and science that we do have to look forward to working with you on that real quick because i know  he issue timely enough the issue of stress that seems to touch and one way or another all of these issues are you are you studying the effects of stress in our society it seems to me that this is kind of the underlying problem of a lot of chronic health issues is there any attention being paid to the issue of stress and how as for our young people through some of these programs and as adults to deal with this there's no question that stress is a co factor for almost everything that we deal with and the lead that samhsa has as an agency for mental health is very important part of our department but we also have an interagency process and dr marc safran is a scientist at c d c who coordinates all of our work in this area so i have a three page summary of the various things that c d c is doing relevant to mental health that i could share with you if you're interested but that's in perfect example of things kind of in a compartmentalized way that we need to build into a more logical public health model and dimension and make sure that when we're doing surveys about health that we consistently include stress or mental health and axes in the evaluation one of our most important tools the behavioral risk factor surveillance system does address people's satisfaction with the quality of their lives and ask questions about their overall a mental health status but i think we need more detail and a more holistic approach to that area as well appreciate the gentleman's times ten seconds no i got a fast three seconds i just want to say is you're trying to integrate integrate a lot of your programs you know we here have hearings on s chip and medicaid and school based you know health centers how do we pool all this together not just with you but also we have schools that have eighty or ninety percent of the kids are qualified for s chip medicaid how do we use that program to tie it with you guys and to really streamline this and make it work and get it down to the school level thank you mr chairman dr let me simply say if you want to study stress i would suggest you send a team to study o carcasses we try to read as we try to reach consensus on iraq will come over what your turn is next  i'd like to talk about tuberculosis something kind of an usual happened today there was an editorial actually in one of our major newspapers in minnesota the new the new tb apparel worth of concerns and i've been doing some research and talking to some researchers and physicians and people involved in global health as well as people concerned with health care here in the global epidemic goes on to say a fresh flock of u s soldiers will soon head to africa to open the pentagon's newly announced african command designed to strengthen u s ties with this continent and the reason why am i i antibiotic resistant tuberculosis is a problem in latin america as well now just in case people think this is a problem here round home it's it's continue to to spread in other parts of the world but in january tenth two thousand and three in minnesota doctor who had been traveling a doctor in duluth exposed his patients to tuberculosis that was antibiotic resistant and they detected early on in there they monitored people and got a and human services the c d c prevention the green book i don't see anything about antibiotic resistant tuberculosis in there and i looked under global aids program on page one seventy six and one seventy seven i didn't see anything there now i know you're aware of this and i know the c d c and i want to get on top of this because it's of significant concern to us as a population and i realize that this budget was but pared by the administration i want to know what the c d c as our lead public health agency needs congress to do because i i believe we need to take action on this what your going to need in order to deal with x this really serious problem especially as we have more and more people traveling more and more people going if you could maybe share with the committee the death rate from this disease thank you we are very concerned about x d r t v and it is a highly resistant form of t v it's the price we pay for using our first line drugs and then needing second line drugs for multi drug resistant and then developing resistance of those drugs to engines that fuels the problem our number one h i v infection and number two tuberculosis treatment programs that are in adequate and don't completely deal with directly observed poor quality treatment so people are exposed to the drugs but not enough concentration to cure the disease only enough to allow the resistant bacteria to emerge there are three issues one is outbreak that's going on in south africa right now which has a almost one hundred percent fatality rate among the hiv infected people the second issue are the scattering of cases particularly in russia the balkans korea and other areas where poverty and lack of access to public health infrastructure is allowing this problem to emerge and then thirdly in places like the united states where we either have the introduction through people who are foreign born or foreign infected or  refugees who could be arriving with the problem in our country we've had very few cases since two thousand about nine cases none of them few of them were a child the infected prior to two thousand our cases the multi drug resistance were highly related to hiv and involved an outbreak in the new york city area where twenty health care workers and prison guards got the infection and with very high mortality rate this is a very serious health issue i'm pleased to say that  because congress in the joint resolution increased the pepfar funding we aren't going to be able to use about one hundred twenty million dollars of pepfar money for the aids hiv related component of x t r tb and we're now looking in conjunction with the world health organization something called the green light coalition to understand where is the problem right now so some survey data some a laboratory testing data will become available that will help us more precisely pinpoint where the problem is a growing what do we need to be doing we want to be out in front of this so i would be very happy to have someone briefed in with more technical expertise on exactly what we think we do need but we also need a little bit more information yeah absolutely thank you  question thank you mr chairman your budget justification states that spending on chronic disease accounts for more than eighty three percent of the one point four trillion spent on medical care in this country it states further that if this pattern holds the cost to our system by two thousand and thirty will be an additional three to four hundred billion dollars per year excluding inflation these are actually astonishing numbers and i must admit i've seen them a number of times though for the past few the years these statistics have been cited in the newspapers on t v and in other sources however ten pages deeper and the justification you can find a functional table which lists the funding amounts committed to various chronic diseases with the exception with the exception exception of steps to a healthier us program which is a laminated and the adolescent health initiative which is increased they are all flat funded and have been for the past three years you sound the alarm but there is a little in this budget that shows an increase commitment to prevention given the aging of our population in the current trends i believe this is extremely short sided can you please explain to me the disconnect between the recognition of the problem and the commitment to providing the resources necessary to solve it i have to say that you are correctly pointing out the straight line aspect of our overall chronic disease budget the same is true of our environmental health budget influenza emerging infectious disease budget and of course the reason for that is not because we don't recognize that these are important and serious health threats it's because we are in a very tight budget environment and really really hard choices have had to be made you know i'm learning firsthand how unpopular it is to try to move money from one budget line to another even in really small amounts and it is a very very difficult situation we're making choices between critical programs that are very compelling all of us who recognize and value health protection health promotion and and prevention as well as preparedness but it is you know the reality  not just about the competing priorities of homeland security in the war it's also about the discretionary resources that are becoming less and less available as the resources for medicare social security in the cost of health care delivery services are increasing in part because of our population demographics so people need and deserve those benefits but those mandatory expenses mean that all of us are working on the string king discretionary pot and  and i'm not a person who has a solution to that but i respect that's the reality and that's why we are trying to make some really tough management decisions and trying to do more with less at c d c across the board the  bring up the homeland security saw i do and then and then we also talk about health and i'm wondering and it may be a blog paygrade here of the panel but but when we talk about overall risk and you look at i think i saw somebody the publisher number the other day that there's a one in eighty thousand chance of a person dying by a terrorist incident in terms of worldwide and they were saying the risk is very small in terms of figuring it out the numbers the die and yet your health numbers are enormous and terms with things like pandemic and and chronic diseases and things like that is there anybody that's looking at comparing these risk and then asking the question are we committing resources in the areas that really matter in terms of overall risk and you know the calculus you're defining is really hard and in part it has to do with the statistical probability of something occurring it has to do with the actual quantifiable objective impact but it also has to do with the subjective value that we place on different kinds of health threats and emergencies and events and when people ask me what  concerned about i usually say complacency because things like chronic diseases because they are everybody every day all around us they've lost their impact on our psychology we take them for granted we accept that it's ok we accept it's ok for people to have a hiv and transmit it we accept that it's ok for kids to be obese well it's not ok but how do we make that passion that we feel as leaders in this public health officials a parent to the person who's making the decision about whether to drive through the fast food or you know walk from the rear of the parking lot or not we've got to somehow aggressively engage our public in knowing that there are alternatives we don't have to be unhealthy we don't have to be on safe homes or i'm not going to have time for my questions of for myself but let me so if you just make some random observations heard discussion here about prevention this morning in fact and preventive medicine in fact that's a pretty meaningless concept for forty four million people have no health insurance their chances of ha  consistent preventive medicine practiced in their behalf is between slim and none secondly i can't help but obs are observe that when i first joined this committee in the sevent general feeling was that we had virtually wiped out to come close to wiping out infectious diseases and we're not going to be turning to other challenges in the field and it seems to me that some of our biggest challenges the last few years have been the road one of the reasons we ask people to do that is because we have this argument made in washington that if a program is level funded in nominal terms that somehow you're standing still it's a status quo budget in fact if that's the case you're dropping backwards because by the time you factor in inflation population growth if you look at these funding levels in terms of real prick capita expenditures that means that funding for c d c has dropped fourteen percent in real in those real terms since two thousand and five on that me and that is at the same time that we've had no increase for heart disease and stroke gra program chronic disease programs are flat funded in the president's request discretionary immunization programs cut by seven percent and the military says request the request for a way to cut state local emergency preparedness capacity funding by fifteen percent so seems to me that if we're going to keep doing this if this were a car we'd have a rear view mirror that was bigger than the windshield so i am  more than a little concerned about the priorities expressed in the budget i i'm going to ask you a couple questions at this point about about your own professional judgment with respect to this budget will give you the question exactly as we wanted stated and we would like to have you answer it without benefit of the views of all and be interfering  of monetary bonuses ordered to c d c administrative managers rather than scientists i'd like you to respond to each of those concerns and tell us what specifically are doing to address the problems  cities i would be very happy to take just a moment ago and i really look forward to setting the record straight first of all one of the most important points i'd like to make is that we have an extraordinary group of senior leaders at c d c and i think some of the staff members of this committee were present at the public health caucus and had a chance to meet and greet them the leaders of our science domains have collectively between the leaders and managers who are the most senior but more than a thousand person years of public health experience and is really an extraordinary group so i think c d c has a deep and strong bench of science at the helm and some young people have moved up to fill ranks and we've had i think a real healthy and robust renewal there i think the issues around performance bonuses were mischaracterized in the press of the five hundred top paid people at c d c including bonuses and wards ninety seven percent of them are scientists you know we have to compete with an ever difficult challenge i'm sure and i was experiencing this as well with academia and the private sector to get top scientists in the agency but we can compete we have the flexibility to bring them on board and that characterization of using bonuses unfairly to support management over science was simply completely inaccurate and i can assure you i am not the top aide person at c d c the last thing that i would like to say here and then maybe i can follow on with some more information for the record is that i'm deeply concerned about morale at our agency and really in most of the other places that were included in recent o p m surveys as we've looked deeper into the c d c aspect of that survey we've learned that there's not a uniform problem across the board there are some parts of our agency that are having more problems than others and the part of the agency that probably is experiencing the deepest problem is the part of the agency that's been the most affected by some of the reorganization challenges but we will go and sit with people and say you know what can we do how could we help what do we need to be doing better differently the things that our most on people's minds day to day are we can't hire our travel system doesn't support us we don't have the money we need to do the good work that we think we need to be doing so budget travel in the hiring f t s is a really big piece of the kinds of thing that affect people on a day to day basis and i want to do more about those problems but i also know that this is an agency that is a can do organization and people are working very hard they're doing incredibly wonderful public health work but i'm worried about their ability to sustain that when ten percent of our workforce is missing and our budget isn't keeping up with the responsibilities that we feel in our hearts so let me i've got a series of seventeen questions on ask you with respect to  bucks got a series of questions again which i would like you to answer with respect to contracting practices in your agency again without benefit of interference from will it be  pandemic the administration strategy hinges on the ability of manufacturers to produce in a short window of vaccines enough to cover the entire population we're told that you will have sufficient productive capacity until two thousand and eleven or two thousand and twelve i'd like to know what you think we can do to cut that time and i'd appreciate if you answered within the next two weeks for the record because we have to shut down here today i do want you to answer one question here not however as i understand the current situation the federal government has thirty eight million courses on hand and additional twelve million courses would be purchased with two hundred forty eight million dollars requested in the always budget i'm told that eighty percent of these purchases will be for tema flu which is produced by roche pharmaceutical but i understand has indicated it may have to either shut down production lines or put the u s order for twelve million courses behind behind large incoming orders from the united kingdom and other countries if the two hundred forty eight million dollars is not available until october first of all seven or later if the bill is delayed passing is that in fact the case i've heard the same thing you have you've heard in that regard and i've heard that if if the money were provided earlier course it would be utilized but if that were the case i have to ask that an offset also be provided but i have heard the same thing you've heard mr chairman let me simply say that earlier we heard references to concerns about complacency i'm concerned about that with respect to this program and that's why we're going to be adding money in the supplemental request  position like and it seems to me if if the president could ask for one hundred billion dollars to fight an incredibly stupid war in iraq that we can and suggested we meet some other priorities that are certainly as it will be concerning in terms of their threat to the country then one other question with respect to hospitals we've surge in iraq but my concern is about the ability of the hospitals to provide the surge capacity in fact if we didn't get hit with penn demick flu and from everything that i know about it it appears that our hospital system would be overwhelmed in short order and it would make what's happening at walter reed look minor by comparison to the incredible god awful mess we would have on our hands nationwide if this hits what what what syria what's your response to that and why is the administration proposing to cut hospital preparedness grants by eighty one million or sixteen percent in the in the new budget well hospital to parents is very important to us and as you know the hospital preparedness program to parse those is is moving from so to my office in the office of secretary preparedness and response and our plan for the house for parents program is to promote and encourage and do more so we can develop regional partnerships regional collaboratives in and sent devise those type of relationships so we can develop those partners better at the regional level and the new law in fact even encourages  e partnerships that may not go directly to states and so we're working through that and one thing i want to say those we will not and do not intend to disrupt any the very well functioning partnerships that are already led by the states so what our goals and purposes is to be able to increase some of our presence at the regional level so we can better leverage the investment that's already occurred in the hospital parents programs and help help develop those partnerships and actually even more importantly we need to be able to better take advantage of the innovation and the innovative ideas that are happening to the local and the state levels and be able to get those innovative ideas transmitted to other areas of the country as well there is a lot of innovation going on there and we can't do that from washington we need to be able to better do a do a better job of enhancing those regional collaboration's my time is more than expired and i have a series of other questions that i need to respond to for the record but let me just close with this we have invested a lot of money in veterans hospitals in the past few years even before the war started but even though we did that there are now being overwhelmed and certainly the military hospitals are now being overwhelmed by people returning from the battlefield in iraq and afghanistan i don't pretend to certainly are not doing nearly what we need to do know to prepare the system and i would like you to simply tell us if we had if we had no budget constraints what of the things this committee could help you and the states do and the localities to do to greatly enhance our ability to deal with that kind of a huge surge in usage that we would have  well if you have a thirty second thought right now and appreciate hearing it well as you know we have invested over two billion in hospital preparedness and and we want to be able to do more to  thank you we have not finished our buildings and facilities master plan as you know we have a plan to rehabilitate and reinvent the lab the dated campus that we were operating under but we did open very important building this year including our state of the art infectious disease laboratory which allows us to finally be able to work on more than one special pathogen at a time under the highest level bio containment facilities we also opened our global communication center which has turned out to be an unbelievable resource for us we can literally communicate around the world now that a push of a button so our communication is getting stronger and our laboratories are coming up we have another large laboratory building that is just coming out of the ground now we'll have a new animal care facility which we desperately need at c d c and some other resources and i'm also pleased this year that we've completed the second environmental health lab so we now have state of the art laboratories to measure the presence of more than four hundred fifty chemicals in people's blood and urine it was that laboratory that found the cough syrup was the culprit of the deaths in panama we got the answers just very quickly with regard to the care and treatment as a result of those who test positive from the rapid test with regard to be in aids the twenty five million for aids drug assistance program how does that factor into your budget request and do you foresee our health care system being in strips if in fact find thirty one thousand new infections the care and treatment budget is not part of the d c s budget but we recognize if we diagnose more people there'll be more care and treatment and our response to that is you know we better we know that we need to have people who can't get their needs met then we don't know it at all so i think that the  changes in the care and treatment are designed to keep up with new diagnoses and if we do this right we'll have fewer new cases and ultimately we'll end up with fewer people needing care and treatment but it is a relationship that we have with her and across the department we obviously want to make sure that anybody we diagnose has access to care and treatment and those linkages are part of the grant program dr fauci i'm not sure i saw but i on that statistical analysis question did you want to talk about that at all i thought you want might want to say someone our time run out and mr parker very briefly when you're dealing with emerging threats the threat of something that is not killing anybody now but that very well might have a very high impact that really complicates the metrics of our trying to with proportionality invest money for things that are important and ongoing and not have to take away from that to have an emerging threat it's  f particular importance in the arena of infectious disease is something that dr gerberding and i deal with not exclusively but a large proportion of what we do that has to do with influenza emerging threats i always joke with my fellow institute directors that for example dr collins who's our director of the genome is that when he goes to bed at night he doesn't have to wake up in the morning to you know make emergency whereas when i go to bed at night or dr gerberding goes to bed at night you never know what you're going to see the next day that's ok i just i'm sure you're familiar with with this this book ready or not the america trust for america's help and it has to stay preparedness course and one of the courses has two weeks hospital surgeon they had a lot of moderate pandemic only twenty five states score that they're able to do that and i'm sure has worked for shortage with nursing we only have ten states that are ready to look like that could meet the needs and i'm i'll prepare a question honest i like to hear back what we need to do this is this is the fifth you've heard this report and we haven't moved very far so i