```

[House Hearing, 113 Congress]
[From the U.S. Government Publishing Office]

 
                 ASSESSING CENTRAL INDIANA'S PREPAREDNESS 
                          FOR A MASS CASUALTY EVENT
=======================================================================

                             FIELD HEARING

                               before the

                       SUBCOMMITTEE ON EMERGENCY

                        PREPAREDNESS, RESPONSE,

                           AND COMMUNICATIONS

                                 of the

                     COMMITTEE ON HOMELAND SECURITY

                        HOUSE OF REPRESENTATIVES

                    ONE HUNDRED THIRTEENTH CONGRESS

                             FIRST SESSION

                               __________

                             AUGUST 6, 2013

                               __________

                           Serial No. 113-31

                               __________

       Printed for the use of the Committee on Homeland Security
                                     

[GRAPHIC] [TIFF OMITTED] 

                                     

      Available via the World Wide Web: http://www.gpo.gov/fdsys/

                               __________

                  U.S. GOVERNMENT PRINTING OFFICE
86-245                    WASHINGTON : 2014
-----------------------------------------------------------------------
For sale by the Superintendent of Documents, U.S. Government Printing 
Office Internet: bookstore.gpo.gov Phone: toll free (866) 512-1800; DC 
area (202) 512-1800 Fax: (202) 512-2104  Mail: Stop IDCC, Washington, DC 
20402-0001

                     COMMITTEE ON HOMELAND SECURITY

                   Michael T. McCaul, Texas, Chairman
Lamar Smith, Texas                   Bennie G. Thompson, Mississippi
Peter T. King, New York              Loretta Sanchez, California
Mike Rogers, Alabama                 Sheila Jackson Lee, Texas
Paul C. Broun, Georgia               Yvette D. Clarke, New York
Candice S. Miller, Michigan, Vice    Brian Higgins, New York
    Chair                            Cedric L. Richmond, Louisiana
Patrick Meehan, Pennsylvania         William R. Keating, Massachusetts
Jeff Duncan, South Carolina          Ron Barber, Arizona
Tom Marino, Pennsylvania             Dondald M. Payne, Jr., New Jersey
Jason Chaffetz, Utah                 Beto O'Rourke, Texas
Steven M. Palazzo, Mississippi       Tulsi Gabbard, Hawaii
Lou Barletta, Pennsylvania           Filemon Vela, Texas
Chris Stewart, Utah                  Steven A. Horsford, Nevada
Richard Hudson, North Carolina       Eric Swalwell, California
Steve Daines, Montana
Susan W. Brooks, Indiana
Scott Perry, Pennsylvania
Mark Sanford, South Carolina
                       Greg Hill, Chief of Staff
          Michael Geffroy, Deputy Chief of Staff/Chief Counsel
                    Michael S. Twinchek, Chief Clerk
                I. Lanier Avant, Minority Staff Director
                                 ------                                

  SUBCOMMITTEE ON EMERGENCY PREPAREDNESS, RESPONSE, AND COMMUNICATIONS

                  Susan W. Brooks, Indiana, Chairwoman
Peter T. King, New York              Donald M. Payne, Jr., New Jersey
Steven M. Palazzo, Mississippi,      Yvette D. Clarke, New York
    Vice Chair                       Brian Higgins, New York
Scott Perry, Pennsylvania            Bennie G. Thompson, Mississippi 
Mark Sanford, South Carolina             (ex officio)
Michael T. McCaul, Texas (ex 
    officio)
            Eric B. Heighberger, Subcommittee Staff Director
                   Deborah Jordan, Subcommittee Clerk

                            C O N T E N T S

                              ----------                              
                                                                   Page

                               STATEMENTS

The Honorable Susan W. Brooks, a Representative in Congress From 
  the State of Indiana, and Chairwoman, Subcommittee on Emergency 
  Preparedness, Response, and Communications.....................     1
The Honorable Joe Donnelly, a U.S. Senator From the State of 
  Indiana........................................................     4
The Honorable Todd Young, a Representative in Congress From the 
  State of Indiana...............................................     5
The Honorable Jackie Walorski, a Representative in Congress From 
  the State of Indiana...........................................     6

                               WITNESSES
                                Panel I

Mr. Andrew Velasquez, Regional Administrator, FEMA Region V, U.S. 
  Department of Homeland Security:
  Oral Statement.................................................     8
  Prepared Statement.............................................    10
Mr. Mark J. Bowen, Sheriff, Hamilton County, Indiana:
  Oral Statement.................................................    17
  Prepared Statement.............................................    18
Mr. Steven Orusa, Fire Chief, Fishers, Indiana:
  Oral Statement.................................................    22
  Prepared Statement.............................................    23
Mr. John H. Hill, Executive Director, Indiana Department of 
  Homeland Security:
  Oral Statement.................................................    24
  Prepared Statement.............................................    25
Ms. Diane Mack, University Director, Emergency Management and 
  Continuity, Indiana University:
  Oral Statement.................................................    31
  Prepared Statement.............................................    33

                                Panel II

Mr. Chad S. Priest, Chief Executive Officer, MESH Coalition, 
  Inc.:
  Oral Statement.................................................    47
  Prepared Statement.............................................    49
Dr. Virginia A. Caine, Director, Public Health Administration, 
  Marion County Public Health Department:
  Oral Statement.................................................    55
  Prepared Statement.............................................    56
Dr. Louis M. Profeta, Medical Director of Disaster Preparedness, 
  St. Vincent Hospital, Indianapolis, Indiana:
  Oral Statement.................................................    58
  Prepared Statement.............................................    61
Dr. H. Clifton Knight, Chief Medical Officer, Community Health 
  Network:
  Oral Statement.................................................    63
  Prepared Statement.............................................    65
Dr. R. Lawrence Reed, II, Director of Trauma Services, Indiana 
  University Health Methodist Hospital:
  Oral Statement.................................................    66
  Prepared Statement.............................................    68
Dr. Mercy Obeime, Director, Community and Global Health, 
  Franciscan St. Francis Health, Indianapolis, Indiana:
  Oral Statement.................................................    69
  Prepared Statement.............................................    71

   ASSESSING CENTRAL INDIANA'S PREPAREDNESS FOR A MASS CASUALTY EVENT

                              ----------                              

                        Tuesday, August 6, 2013

             U.S. House of Representatives,
 Subcommittee on Emergency Preparedness, Response, 
                                and Communications,
                            Committee on Homeland Security,
                                                        Carmel, IN.
    The subcommittee met, pursuant to call, at 10:00 a.m., at 
Carmel City Hall, One Civic Square, Carmel, IN, Hon. Susan W. 
Brooks [Chairman of the subcommittee] presiding.
    Present: Representative Brooks.
    Also present: Senator Donnelly and Representatives Young 
and Walorski.
    Mr. Brainard. I want to welcome everybody here to the City 
of Carmel and to City Hall. I want to thank the subcommittee 
for getting out of Washington. It is a good month to get out of 
Washington. Our humidity is a little lower here, I think. But 
we certainly welcome you here for today's event. I want to 
thank the staff that put so much time into putting this all 
together.
    We all recognize that no one wants a tragedy, and we like 
to think we are immune, but we all recognize that they do 
occur, and they occur everywhere, and sometimes in the least 
expected places, and that planning and preparation are 
important so that we are prepared.
    We are proud of our public safety departments here in 
Carmel. First, I think some of you know that Carmel was ranked 
by CNN's Money magazine as the No. 1 place to live in America 
last September, and that is due in part to the safety here in 
Carmel. According to the on-line magazine Neighborhood Scout, 
an organization that compiles data about neighborhoods and 
locations, we are the 33rd-safest city in America.
    But we do recognize that no community is immune from crime 
or a wide-spread natural disaster. So it is important to 
constantly improve our ability to respond in an emergency. Our 
public safety officials, key directors, and school 
administrators recently had tabletop exercises to review 
emergency procedures to better respond to various scenarios. So 
we truly appreciate the opportunity today to learn first-hand 
from the witnesses gathered here, to share their knowledge of 
emergency preparedness.
    I don't think Carmel has ever hosted a subcommittee or a 
committee meeting of the U.S. Congress before, and once more I 
would like to thank Susan Brooks and the other representatives 
for being here, and to have arranged it here at City Hall. We 
appreciate it and I want to commend you for getting out. This 
is good, I think, for committees of Congress to get outside of 
the Beltway and be here, and so thank you and welcome.
    At this time, I am pleased to turn it over to our 
Congresswoman, Susan Brooks.
    Mrs. Brooks. Thank you. Thank you, Mayor Brainard.
    Mr. Brainard. If I could just ask everyone please to just 
make sure all phones and electronic devices are silenced, are 
powered off, and ask everyone to please turn the flashes off on 
your camera. Thank you very much.
    Mrs. Brooks. The Committee on Homeland Security, 
Subcommittee on Emergency Preparedness, Response, and 
Communications, will come to order. The subcommittee is meeting 
today to examine the state of emergency preparedness here in 
Central Indiana.
    First, I want to thank everybody, including Mayor Brainard. 
We really appreciate the effort that your staff, led by Nancy 
Heck and others, had in putting this hearing together.
    I would like to also thank the witnesses who are here today 
to testify. I would like particular thanks also to our Homeland 
Security staff who came out from Washington, DC to coordinate 
this important hearing: Natalie Nixon, Debbie Jordan, Eric 
Heighberger, and Moira Bergin. They came out to help work with 
the City of Carmel to arrange this important hearing. So I do 
appreciate all the effort that has been taken with respect to 
this hearing, including my own staff, that put a lot of time 
and energy into making sure that all of you were here to learn 
about this important topic today.
    This is not a town hall meeting. This is an official 
Congressional hearing. So unlike a town hall meeting, we abide 
by certain rules of the Committee on Homeland Security and the 
House of Representatives. I kindly wish to remind our guests 
today that demonstrations from the audience, including applause 
and verbal outbursts, as well as any use of signs or placards--
I didn't see any coming in--are a violation of the rules of the 
House of Representatives. It is important that we respect the 
decorum and rules of this committee.
    Also, so that you are aware, this hearing is being webcast 
live on the committee's website, which is homeland.house.gov.
    I now recognize myself for an opening statement.
    As Chairwoman of the Subcommittee on Emergency 
Preparedness, Response, and Communications, it is a great honor 
to be here in Carmel City Hall to discuss Central Indiana's 
preparedness for a mass casualty event. As a former deputy 
mayor of Indianapolis and a United States Attorney for the 
Southern District of Indiana, I have had the privilege of 
working with some of the finest first responders, law 
enforcement, and emergency managers in the State. I also had 
the opportunity to travel to FEMA's training academy in 
Emmetsburg, Maryland long ago and received valuable training on 
crisis communications as well. This training further 
demonstrated that those involved in preparing for, responding 
to, and recovering from a disaster are selfless professionals.
    We are fortunate to have so many dedicated individuals here 
in Central Indiana as we face our fair share of threats and 
hazards. According to Indiana's recent Threat Hazard 
Identification and Risk Assessment or, known in the emergency 
management community as THIRA, natural disasters, industrial 
emergencies, and cyber attacks ranked among our highest 
concerns. I also received a briefing just last week from the 
Department of Homeland Security regarding threats posed by 
weapons of mass destruction and what they would look like. 
Chemical, biological, nuclear, and radiological attacks are 
still very real threats. A successful attack in the 
Indianapolis or Central Indiana area could severely strain our 
medical and hospital systems and have grave consequences for 
our people and our economy.
    After the tragic events of September 11, 2001, the 9/11 
Commission, which was co-led by former Indiana Congressman Lee 
Hamilton, stated that one of the main failures that led to the 
attack was the lack of our own imagination. Although Central 
Indiana may be more susceptible to events such as flooding and 
tornadoes, for which we have all trained and prepared, we must 
not let our own failure of imagination catch us flat-footed, 
and we must be prepared for the range of threats to which we 
are vulnerable.
    For example, there are many unexpected incidents that can 
occur in any area. As we saw just recently in West, Texas, a 
fertilizer explosion just a few months ago, an industrial 
incident, whether intentional or accidental, can cause great 
damage, injury, and loss of life.
    At this time, I would like to pay my respects to some 
Zionsville residents, Jeanette and Tim White, who are here with 
us today. Jeanette's brother, Kevin Saunders, was a first 
responder in West, Texas. They are Zionsville residents, and we 
thank you for your attendance today. We also last week entered 
on your behalf a letter that Mr. White prepared to the Homeland 
Security Committee ensuring his request to make sure that we 
all work together to make sure that our first responders know 
what they are running into and what the dangers are that they 
are facing. So, thank you for being here.
    In addition, we know we must be ready for large events here 
in the State of Indiana. We host the incredible Indianapolis 
500 every year. We like to host Final Fours as often as we can; 
and the Super Bowl, which we hosted and would love to host 
again. But these all present unique situations and challenges 
for law enforcement responders and emergency managers.
    As we approach September, which is National Preparedness 
Month, we must ask ourselves: Are we doing everything we can to 
be prepared? After the Boston bombings, I asked myself once 
again: How would we have handled a similar attack? In Boston, 
we saw a coordinated response from first responders, law 
enforcement personnel, and medical personnel that no doubt 
saved many lives and mitigated damages. Are we as prepared as 
Boston was?
    Boston's success was, in part, due to their preparations 
for this type of an event. They effectively used their Federal 
grant dollars to improve their security programs. They held 
training and exercises to test their plans, and they promoted 
the use of interoperable communications across multiple 
jurisdictions and sectors.
    In fact, in November of last year, Boston took part in an 
exercise called Urban Shield. This scenario was designed to 
assess that region's overall response capabilities to a series 
of complex incidents, and the exercise tested, among other 
things, their coordination of public health and medical service 
capabilities.
    Additionally, a helicopter-borne imaging unit that the 
Massachusetts State Police used to locate and capture Djokar 
Tsarnaev was purchased with State Homeland Security Grant 
Program funds.
    Now, we have held, as well, emergency-related exercises 
here in Indiana many, many times. But right now, Indiana is 
involved in another mass training exercise. Beginning on July 
21, USNORTHCOM began an exercise called Vibrant Response 13-2 
at Muscatatuck Urban Training Center. This exercise simulates a 
nuclear detonation in an urban environment. It spans 5 weeks 
and includes 8,000 personnel from 22 States. Later this month, 
the Navy and Department of Energy will conduct an exercise 
focusing on the derailment of a train transporting spent 
nuclear fuel shipments. This exercise is designed to provide 
practical experience to emergency management personnel and 
policymakers.
    Today, I want to learn what Central Indiana is doing to 
prepare for a mass casualty event, and I hope this causes 
communities all across the country to be asking the same 
question. I would like to hear what planning, training, and 
exercises are taking place. I also want to hear of any areas 
where we may need to improve in order to be as prepared as we 
can be.
    Benjamin Franklin once said, ``By failing to prepare, we 
are preparing to fail.'' Let's use our imaginations. In doing 
so, I believe we will be better prepared for both the known and 
the unknown.
    We have two very distinguished panels of witnesses here 
today, and I look forward to their testimony.
    I am also very pleased that my Indiana colleagues who were 
able to be here with us today took the time out of their 
incredibly busy schedules back here at home in the State of 
Indiana and in their own districts to be here, and so I am very 
honored to be having with us today the Senator from Granger, 
Indiana, Senator Donnelly, for any opening statement he might 
have.
    Senator Donnelly. Thank you, Madam Chairwoman.
    I want to thank Chairwoman Brooks for organizing this field 
hearing and for allowing me to participate; and to Mayor 
Brainard, the City of Carmel, Hamilton County, and the State of 
Indiana for all the hard work you do every day to keep us safe.
    I am pleased we have the opportunity to bring this 
discussion on the security of Hoosier communities from 
Washington, DC to Indiana. To all of our first responders who 
are here with us, thank you, and around the State. You put your 
lives on the line every single day. Your family never knows 
whether you are going to be coming home at night. So to all of 
you, thank you for your dedication.
    Central Indiana has grown enormously over the last decade 
and is an economic hub for our State. We must be prepared with 
the resources and the assistance on a local, State, and Federal 
level to successfully respond to a mass casualty event. The 
timing of this hearing is excellent, as Congresswoman Brooks 
was saying. I was at the Urban Training Center in Muscatatuck 
yesterday where we observed the largest homeland security 
exercise conducted annually in our Nation, the Vibrant Response 
Northern Command exercise. We had 27 different State National 
Guards here in Indiana. We had over 6,000 people working on 
this exercise. Muscatatuck has become, across the entire 
country, the central place for training for incidents here in 
the entire United States. We are very proud of our own National 
Guard and what they have done to make Muscatatuck the center of 
choice.
    This exercise prepared the military, homeland security 
personnel, and first responders for responding to a nuclear 
attack in an urban area down at Muscatatuck yesterday. I was 
deeply impressed by what I saw, and I look forward to hearing 
your expertise today and perspective on preparing for an 
emergency event on a local level.
    Central Indiana frequently hosts world-class sporting 
events, as Congresswoman Brooks was saying: The Super Bowl, our 
own Indy 500. We are proud to host these events, and to 
continue to be considered for them, we must be fully prepared 
to respond to a major disaster. I am especially interested in 
learning more about how we communicate and coordinate our 
actions between Federal, State, and local agencies to ensure a 
seamless response to affected communities.
    I thank the witnesses for being here, and I especially want 
to thank the Chairwoman for hosting this, and to Congressman 
Young and Congresswoman Walorski for being here today as well. 
I look forward to hearing the testimony. Thank you.
    Mrs. Brooks. Thank you, Senator Donnelly.
    I would now like to recognize the gentleman from 
Bloomington, Mr. Young, for any opening statement he might 
have.
    Mr. Young. Well, thank you so much, Madam Chairwoman, and I 
thank all of you for being here today, for taking time out of 
your busy and important days to testify, for those that are 
testifying, and just to be privy to the testimony that is 
delivered, for everyone else who is here with us today.
    I want to thank the City of Carmel. As a Carmel High School 
graduate myself, I am a bit parochial and proud to be back here 
in Carmel.
    Listen, the topic that we are discussing today, the 
preparedness of Central Indiana for a mass casualty event, is 
not only an essential one that we air publicly, it is one that 
is near and dear to my heart. Each of us is sort-of shaped by 
our own personal experiences, and before coming to Congress I 
had spent 10 years in the military. In the course of that time, 
I was trained in anti-terrorism and force protection. This was 
the pre-9/11 era, and today happens to be, dictated by our 
Federal Government, a period of heightened preparedness and 
alert as a result of circumstances and intelligence we have 
collected around the world. So I think this is certainly a 
timely hearing.
    I would also say after I left the military, I spent my last 
day at a think tank in Washington, DC, and it happened to be 9/
11, and that was a formative experience and reminded me that we 
as a Nation had a long way to go in terms of coordinating our 
efforts between agencies and with the American people 
themselves in order to figure out what happens during a day of 
mass chaos, and such days will come again as a result of either 
terrorist attacks or natural disasters or industrial accidents 
or what-have-you.
    Within weeks after leaving that job, I worked for a United 
States Senator, Senator Lugar. I happened to be in the office 
during the time of the largest bioterrorism attack in American 
history. Remember the anthrax attacks on Senate and House 
office buildings and some other sites.
    So all of these things have reinforced my belief that we 
need to continue to do everything possible to prepare for these 
contingencies. Now, since I have been in Congress, I represent 
the Ninth District, which runs from just south of Indianapolis 
to the Ohio River. It is also tornado country, at least it has 
been in recent years, and we suffered a horrible, deadly 
tornado that went through many of our towns. I see a lot of 
familiar faces in the audience, people who helped us through 
that tragic event and came together.
    Together we learned that though much progress has been 
made, much remains to be made in terms of coordinating our 
efforts between agencies and among personnel in order to help 
people when they need it the most.
    So my expectation, my hope today is that we can tease out 
exactly what is being done to prepare for the next disaster, 
what has been done, and how we can help at the Federal level, 
help enable all of you to do your jobs in a more effective way, 
how to educate our constituents about how to prepare for a mass 
casualty event and reduce the number of casualties.
    With that, I will yield back to Madam Chairwoman and thank 
all of you again for being here today.
    Mrs. Brooks. Thank you.
    At this time, the Chairwoman now recognizes the gentlewoman 
from Jimtown, Mrs. Walorski, for any opening statements you 
might make.
    Mrs. Walorski. Thank you, Madam Chairwoman. I, too, am 
grateful to be here today, and I am grateful for your 
leadership in hosting this field hearing today.
    I serve on the Armed Services Committee. I am from the 
Second District in Indiana, which is in the South Elkhart and 
Northern Indiana area. One of my extreme, I would say, passions 
is making sure that we keep our Nation safe. My husband and I 
were living in Eastern Europe during 9/11, and when we watched 
it on TV from thousands of miles away, it changed my 
perspective forever on what National security is to this 
country. We didn't know if we would ever see our families 
again, and we didn't know if we would ever get home again and 
what home would look like. They started the evacuation process 
in Europe where we were to move all Americans to a safe place.
    In the Second District, we had our issues as well with 
Mother Nature. But I am grateful to sit here with Senator Joe 
Donnelly, Representative Todd Young, and under the leadership 
of Congresswoman Brooks so that we can figure out a way that 
Indiana can again lead the Nation. Our State is leading the 
Nation in virtually every matrix that has any kind of 
comparable grid in it, and this is also an area. I can tell 
you, to the mayor and to the resources here in Carmel, I toured 
some of the trucks outside before we came in here, and what a 
system we have, and that we have a chance to learn how to do 
better.
    So the issue that we are learning about today is certainly 
Central Indiana. I can tell you as well, Grissom Air Reserve 
Base is doing training exercises this weekend. This is a very 
appropriate time to be talking about this, as Congressman Young 
just said, when we have 21 embassies around the world that are 
continuing to be closed as we lead up to September 11 again. 
Whether it is an attack from individuals who seek to do us 
harm, or living in the Midwest where we live and the dangers 
that we face with Mother Nature, I am here to learn, take 
notes, and just ask questions on how we can do things better; 
and to, again, I know, stand and be proud of this Hoosier State 
because we do all things well.
    So to every first responder, I am the daughter of a city 
fireman, and I so much appreciate every one of you that fights 
the fight every day for us on the front lines. So I look 
forward to hearing from our panels today.
    Thank you again, Madam Chairwoman, and I yield back the 
remainder of my time.
    Mrs. Brooks. Thank you to the gentlelady from Jimtown, 
Indiana.
    We are pleased today to have two panels of very 
distinguished witnesses before us today on this important 
topic. I am now going to introduce the first panel, and they 
will then testify, and then we will switch to the second panel 
after they have given their opening statements and testify.
    To my left, Mr. Andrew Velasquez is the administrator of 
the Federal Emergency Management Agency's Region V. In this 
role, he coordinates preparedness response, recovery, and 
mitigation activities for the States of Illinois, Indiana, 
Michigan, Minnesota, Ohio, and Wisconsin. Mr. Velasquez was 
appointed to this position in April 2010 after serving as 
director of Illinois' Emergency Management Agency. So, thank 
you for coming and joining us.
    Next on the panel is Mr. Mark Bowen, who is the sheriff of 
Hamilton County, Indiana, a position to which he was elected in 
November 2010. Sheriff Bowen has been with the Hamilton County 
Sheriff's Department since 1991 and was appointed chief deputy 
sheriff in 2003. Prior to being elected sheriff, he served many 
roles in the sheriff's office, including field training 
officer, firearms instructor, accident reconstructionist, 
Special Emergency Response Team member, Tactical Tracking Team 
member, and Honor Guard member.
    Next is Mr. Steve Orusa. Chief Orusa is the fire chief of 
Fishers, Indiana. Chief Orusa is a published author and a 
frequently invited speaker on public safety leadership and 
development techniques. He has provided analysis on public 
safety response for USA Today, Fire Chief magazine, Fire 
Engineering magazine, and has also appeared on BBC, MSNBC, Fox 
News, and CNN to provide expert analysis on disaster response.
    Next to the chief is Mr. John Hill. He is the executive 
director of the Indiana Department of Homeland Security, a 
position Governor Pence appointed him to in January of this 
year. Mr. Hill is responsible for the State's emergency 
management and homeland security efforts, which include 
planning and assessment, preparedness and training, emergency 
response and recovery, fire and building safety, and field 
services. Prior to joining IDHS, Mr. Hill served as the 
administrator of the Federal Motor Carrier Safety 
Administration. He also served as a member of the Indiana State 
Police from 1974 to 2003, providing expertise as commander of 
the Commercial Vehicle Enforcement Field Enforcement and 
Logistics Division.
    Finally, I would like to have the opportunity to see if 
Senator Donnelly would like to introduce a witness on behalf of 
the Democrats.
    Senator Donnelly. Thank you very much, Madam Chairwoman.
    I would like to introduce Ms. Diane Mack. Ms. Mack is the 
IU Director of Emergency Management and Continuity. She is 
responsible for ensuring that all IU campuses have viable and 
adequately-tested emergency response plans, and that each IU 
department has plans in place to ensure critical functions can 
be recovered quickly if they are interrupted by emergencies 
such as a building fire or tornado damage.
    I know that is a location of great fondness to Congressman 
Young as well, and if you would like to say a word, go right 
ahead, sir.
    Mr. Young. Thanks for your service. Thank you for 
affiliating yourself with such a fine university, and just if 
you ever need anything, please do call. We are all here to 
help.
    Mrs. Brooks. Thank you.
    At this time I would like to inform everybody that the 
witnesses all have submitted full written statements and 
testimony, and that will appear in the record.
    I just also would like for everyone to realize that we are 
on a timer system, and there is a timer here up at the podium, 
and everyone has 5 minutes to testify. When the light turns to 
yellow, that means you have 1 minute remaining. When the light 
turns to red, that means that your 5 minutes are up.
    We are going to begin now with Mr. Velasquez. Thank you, 
and we will now recognize you for your testimony.

  STATEMENT OF ANDREW VELASQUEZ, REGIONAL ADMINISTRATOR, FEMA 
         REGION V, U.S. DEPARTMENT OF HOMELAND SECURITY

    Mr. Velasquez. Good morning, Chairman Brooks, Senator 
Donnelly, Congresswoman Walorski, and Congressman Young. Thank 
you for the opportunity to appear before you to discuss what 
FEMA Region V is doing to support the States in our region, 
including the great State of Indiana, to prepare for all 
hazards and how those efforts could support our response to a 
mass casualty event.
    As stated before, I am Andrew Velasquez, the Region V 
administrator, and in addition to serving the State of Indiana, 
Region V is also responsible for serving the States of 
Illinois, Michigan, Minnesota, Ohio, and Wisconsin, and 34 
Federally-recognized Tribes. Region V enjoys a very close 
working relationship with each of our six States, partnering 
with our State directors, our homeland security advisers, as 
well as our adjutant generals, as we work together to enhance 
safety and security for our region and the residents that live 
within our region. I hope that you will learn from our 
testimony today that we have been continuing that partnership 
with Director Hill since his recent appointment.
    FEMA operates on the principle that all disasters, 
regardless of scale, are inherently local. As such, county and 
local first responders play a vital role during the initial 
response to any emergency. As we all know, if a local 
jurisdiction or a county jurisdiction becomes overwhelmed, then 
the Governor can request assistance from the Federal Government 
through FEMA. This is the tiered response philosophy that we 
employ. It is how the emergency management system and process 
operates in this country for most incidents. If the Federal 
support becomes necessary, FEMA will help coordinate response 
activities, including leveraging support from our volunteer, 
faith-based, and private-sector partners.
    This does not mean that the Federal Government is passive 
in its support to our States. We are in regular contact with 
our State partners so that when severe weather threatens or 
there are reports of any unusual activity, we can begin 
preparations such as prepositioning commodities, activation of 
response personnel, and the activation of our Regional Response 
Coordination Center.
    With that basis, please allow me to explain the various 
efforts that are currently undertaken to increase preparedness 
throughout the region for any hazard that may present itself, 
including those that could result in significant levels of 
damage or destruction.
    Our frameworks. Consistent with the principles and 
directives established by the National Preparedness System, 
FEMA is developing a series of National frameworks which 
describe the roles and responsibilities of all stakeholders. 
These frameworks include the NRF, the National Response 
Framework, which has been in place since 2008 and updated this 
year. This framework aligns roles and responsibilities across 
Government and the private sector in a unified approach.
    The National Disaster Recovery Framework, which was 
recently rolled out across the country, focuses on how to 
restore, redevelop, and revitalize the health, social, 
economic, natural, and environmental fabric of the community, 
as well as build a more resilient Nation.
    The foundation of these frameworks rests on the 
understanding of the potential threats and risks that affect 
the State. A process known as THIRA, which was recently 
mentioned, and risk assessments are used to determine what can 
happen, where it can happen, when it can happen, and how bad it 
could be.
    With regard to funding, FEMA works to increase State and 
local preparedness by supporting a variety of grant programs 
and working to ensure that they are managed effectively. As a 
Nation, we have made significant investments in National 
preparedness capabilities throughout our various grant programs 
during the past decade. Through our various grant programs 
during the past decade, we have seen preparedness in the area 
of building capabilities, equipment purchases. We have also--
due to certain reductions in overall preparedness grants, 
grantees are currently required to focus their funding on the 
maintenance and sustainment of current capabilities and closing 
gaps in core capabilities.
    Given today's topic of the hearing, I would also like to 
note the increased emphasis on mass casualty events represented 
in the grant guidance for fiscal year 2013. The Homeland 
Security Grant Program guidance specifically prioritizes on 
improving immediate emergency victim care at mass casualty 
events. Within this priority, there are two key objectives: 
Improving emergency care to victims of mass casualty events, 
including mass shootings; and improving community first aid 
training.
    FEMA has provided more than $547 million to the State of 
Indiana through 23 different preparedness grant programs since 
fiscal year 2002. In 2012, the total amount of grant funding 
was just over $24 million. These dollars have come from a wide 
variety of programs to support different initiatives in the 
State of Indiana. They have supported building capacity and 
capability through the State level, through planning grants, 
safety of key infrastructure such as ports, chemical 
facilities, and transit, promoting preparedness of individuals 
through Citizen Corps programs, increased capability of local 
first responders through the fire grant, and staffing for 
adequate fire and emergency SAFER Grant programs.
    In closing, FEMA Region V is continuously working to evolve 
our approach to preparing America's citizens and responding to 
events that threaten their lives and livelihoods, and to better 
fulfill FEMA's mission. To that end, we are actively working 
with our Government partners at the State, Tribal, and local 
levels, as well as our non-Governmental partners, to prepare 
for whatever may impact the region, and we look forward to 
continuing that great work.
    I appreciate the opportunity to appear before you today, 
and I look forward to answering any questions you may have. 
Thank you very much.
    [The prepared statement of Mr. Velasquez follows:]
                 Prepared Statement of Andrew Velasquez
                             August 6, 2013
                              introduction
    Good morning Chairman Brooks, Ranking Member Payne, and Members of 
the subcommittee, I am Andrew Velasquez, Region V administrator for the 
Federal Emergency Management Agency (FEMA).
    Thank you for the opportunity to appear before you to discuss what 
FEMA's Region V is doing to support the six States in its Region: 
Illinois, Indiana, Michigan, Minnesota, Ohio, and Wisconsin, in 
addition to assisting 34 Tribal governments in their efforts to prepare 
for all hazards.
    FEMA's mission is to support our citizens and first responders to 
ensure that as a Nation we work together to build, sustain, and improve 
our capability to prepare for, protect against, respond to, recover 
from, and mitigate all hazards. We accomplish this through grants, 
training, exercises, and other support, and work with our State, 
Tribal, territorial, and local partners to lessen the impact of future 
disasters through mitigation efforts.
    FEMA is committed to getting resources into the hands of State, 
local, Tribal, and territorial governments and their first responders, 
who are often best-positioned to prepare for and respond to acts of 
terrorism, natural disasters, and other threats. Here, in Region V, it 
is my job to coordinate preparedness activities among our State and 
Tribal partners.
    FEMA operates on the principle that all disasters, regardless of 
scale, are inherently local. Local fire, police, and emergency 
management agencies will always be the first to respond and the first 
to begin the process of recovery. As such, local and county first 
responders play a vital role during the initial response to any 
emergency. If a local jurisdiction becomes overwhelmed, the community 
can request the assistance of their county, which can provide immediate 
assistance and if necessary request additional assistance from the 
State.
    If the response is beyond the State's or Tribe's capability, then 
the Governor or Tribal official is able to request assistance from the 
Federal Government through FEMA to the President. This tiered response 
philosophy is how the emergency management system operates to support 
an impacted community for most incidents. If the President determines 
that Federal support is necessary, FEMA will help coordinate response 
activities, including leveraging support from its volunteer, faith-
based, and private-sector partners.
    This does not mean that the Federal Government is passive in its 
support to States and Tribes. FEMA, through its 10 regional offices and 
headquarters, is actively monitoring open-source media and reports from 
Federal partners, such as the National Weather Service and the U.S. 
Geological Survey. FEMA is also in regular contact with its partners so 
that when severe weather threatens, or there are reports of any unusual 
activity, the Region can begin preparations, such as the prepositioning 
of commodities, activation of response personnel (e.g., Incident 
Management Assistance Teams, collocation of FEMA staff with State 
Emergency Operations Centers, Urban Search and Rescue teams), and 
activation of the Regional Response Coordination Center (RRCC) for any 
potential response that may be warranted.
                                doctrine
    The emergency management field has evolved significantly since the 
terrorist attacks of September 11, 2001. The attacks that day exposed a 
reality that we must now not only consider, but also plan for. One of 
the outgrowths of those attacks was Homeland Security Presidential 
Directive 8. This Directive was updated to reflect the evolution of our 
understanding of these types of events and of lessons learned.
    In March 2011, the President signed Presidential Policy Directive 8 
(PPD-8), which focused on preparing for the threats that pose the 
greatest risk to the security of the Nation, including: Acts of 
terrorism, cyber incidents, pandemics, and catastrophic natural 
disasters. PPD-8 establishes, among other things:
   A National Preparedness Goal, which contains our collective 
        focus for success and provides a basic definition of the core 
        capabilities;
   A National Preparedness Report, which enables us to report 
        on our progress toward building capacity;
   A series of National Planning Frameworks, which set the 
        strategy and doctrine for building, sustaining, and delivering 
        the core capabilities across the five mission areas--
        prevention, protection, mitigation, response, and recovery.
    FEMA has worked with representatives from across the whole 
emergency management community to develop these products. PPD-8 
emphasizes creating a robust capability based on cross-jurisdictional 
and readily-deployable State and local assets. This would mean that 
Federally-funded capabilities, such as equipment and teams, can be 
deployed across the Nation in response to a catastrophic event. Second, 
planning focuses on those events that severely stress the Nation's 
resources and lead to major impacts on our communities. This does not 
mean that we will abandon our planning related to reoccurring hazards 
and those events that are most likely to happen. However, it does mean 
that we need to step outside of our comfort zone and think about those 
threats and hazards that could overwhelm us and stress the Nation's 
emergency management system.
    PPD-8 focuses on a shared responsibility approach to all phases of 
emergency management, not just response. In this approach, the whole 
community is engaged before, during, and after a disaster.
                               frameworks
    Four of the five frameworks have been published. The National 
Disaster Recovery Framework (NDRF) which was released in September 2011 
and recently rolled out across the country, focuses on how to restore, 
redevelop, and revitalize the health, social, economic, natural, and 
environmental fabric of the community and build a more resilient 
Nation. The updated National Response Framework (NRF), as well as the 
new National Prevention and National Mitigation Frameworks, were rolled 
out on May 6, 2013. Each of these frameworks addresses the unique 
expectations and challenges for each mission area.
    The NRF aligns roles and responsibilities across Government and the 
private sector in a unified approach in responding to any threat or 
hazard.
    Prevention-related activities are covered in the first edition of 
the National Prevention Framework. This framework focuses on addressing 
the challenges stemming from an imminent terrorist threat.
    Fostering a culture of preparedness--centered on risk and 
resilience to natural, technological, and human-caused events--is what 
the first edition of the National Mitigation Framework is all about. 
The document provides context for how the whole community works 
together and how mitigation efforts relate to all other parts of 
National preparedness.
    The Protection Framework is under development. We are working 
closely with our partners in DHS and across the emergency management 
community to ensure that the development of the Protection Framework is 
closely aligned with the implementation of Presidential Policy 
Directive 21 and Executive Order (EO) 13636, which address 
infrastructure protection and cybersecurity respectively. This 
alignment will ensure that the efforts undertaken under PPD-21 and 
EO13636 will be linked to the larger protection mission space.
                                funding
    In addition to doctrinal changes, FEMA works to increase State and 
local preparedness by supporting a variety of grant programs and 
working to ensure that they are managed effectively.
    These grants are grouped into three broad categories, including:
   Overarching homeland security grant programs in support of 
        State, local, and Tribal governments;
   Targeted infrastructure protection grants which support 
        specific critical infrastructure protection initiatives within 
        identified jurisdictions; and
   Firefighter grants programs, which provides funding for 
        staffing and equipment directly to fire service agencies based 
        on a competitive process.
    As a Nation, we have made significant investments in National 
preparedness during the past decade. Due to reductions in overall 
preparedness grants, grantees are currently required to focus their 
funding on the maintenance and sustainment of current capabilities 
along with closing gaps in core capabilities as identified in the 
THIRAs and State Preparedness Reports.
    Given the topic of today's hearing, I would also like to note the 
increased emphasis on mass casualty events represented in the grant 
guidance for the Fiscal Year 2013 Homeland Security Grant Program. The 
guidance specifically prioritizes on improving immediate emergency 
victim care at mass casualty events. Within this priority there are two 
key objectives: Improving emergency care to victims of mass casualty 
events, including mass shootings; and improving community first aid 
training.
    The DHS/FEMA Regional Catastrophic Preparedness Grant Program 
(RCPGP), which started in 2008, identified 10 High-Threat Urban Areas 
to receive funding to develop regional catastrophic incident plans. One 
of the 10, the Illinois-Indiana-Wisconsin Combined Statistical Area 
(Il-In-Wi CSA) encompasses 16 counties and the City of Chicago. Since 
the program began, the area has received more than $14 million. The 
RCPGP focuses on three primary goals: (1) Fixing shortcomings in 
existing plans; (2) building regional planning processes and 
relationships; and (3) linking operational and capabilities-based 
planning to resource allocation. The four primary core capability areas 
are Transportation/Evacuation; Mass Care and Sheltering; Public 
Information and Warning; and Logistics and Resource Management. With 
this funding, the Regional Catastrophic Planning Team, consisting of 
representatives from the 16 counties, has coordinated planning efforts 
with county and local representatives to develop and integrate the 
county and local emergency management plans, as well as evacuation 
plans for the combined statistical area. In addition, they have 
developed the Gear Up Get Ready campaign, which focuses on preparing 
citizens to become more resilient during emergencies and disasters.
    FEMA has provided more than $547 million to the State of Indiana 
through 23 different preparedness grant programs since fiscal year 
2002. In 2012, the total amount of grant funding was just over $24 
million. These dollars have come from a wide variety of programs to 
support initiatives in the State of Indiana. They have supported 
building capacity at the State level through planning grants, the 
safety of key infrastructure sectors like ports, chemical facilities, 
and transit, promoted preparedness of individuals through the Citizen 
Corps program, and increased capacity of local first responders through 
the Fire Grant and Staffing for Adequate Fire & Emergency Response 
(SAFER) Grant programs.
    We also work to increase resilience by reducing the impact of 
future disasters, whether they are floods, tornadoes, severe storms, or 
terrorist attacks. The agency's mitigation grant programs are available 
to State, Tribal, territorial, and local governments. These programs 
support cost-effective projects that will lessen the impact of future 
disasters by encouraging the development of local mitigation plans; 
acquisition and removal of flood-prone properties; and construction of 
storm water detention basins.
    FEMA has provided Indiana approximately $46 million in mitigation 
funding since fiscal year 2008. This funding has improved resilience 
through the removal of flood-prone properties, which is a priority for 
the State of Indiana. When all of the existing projects are completed, 
nearly 950 flood-prone homes will have been permanently removed from 
danger and their owners compensated to move. Indiana has also 
undertaken projects to promote the development and adoption of local 
hazard mitigation plans, public awareness campaigns, and tornado alert 
sirens.
    As we look to further strengthen our ability to prepare for events, 
the President's fiscal year 2014 budget proposes to reform the grant 
programs and establish a National Preparedness Grant Program. Creating 
this program would create a robust National network of capabilities, 
eliminate redundancies, and make the most of our limited resources, 
while strengthening our ability to respond to evolving threats across 
America.
                            risk assessment
    As a condition of grant funding, DHS/FEMA requires a Threat and 
Hazard Identification and Risk Assessment (THIRA) for States and Urban 
Area Security Initiative (UASI) cities and recommends county and 
municipal emergency management programs also conduct a THIRA.
    The THIRA process helps communities identify capability targets and 
resource requirements necessary to address its anticipated and 
unanticipated risks.
    THIRAs also help the Federal Government understand regional trends 
and gaps where Federal resources may be needed to support State and 
local governments. FEMA Region V has actively engaged its States to 
cooperatively undertake this assignment. Working together to identify 
capability requirements, FEMA is able to more quickly ensure that 
should Federal support be needed, it will be in the best position to 
deliver what States and Tribes need, when they need it.
                                planning
    Region V, in coordination with its Federal, State, and Tribal 
partners, collaborates on catastrophic planning initiatives for events 
that stretch the capabilities of local and State governments beyond 
their typical response efforts. For example, our planning includes 
projects, such as All-Hazards Response Planning, Catastrophic 
Earthquake Planning, and planning for an Improvised Nuclear Device. Our 
plans are built around both the Response Core Capabilities found in the 
National Preparedness Goal and on the administrator's intent to include 
whole community concepts in planning efforts.
    One way that we are ensuring we incorporate the views of our key 
operational partners is through quarterly Regional Interagency Steering 
Committee meetings, held at our Regional offices in Chicago and around 
the region. These meetings give us the opportunity to discuss various 
emergency management planning and preparedness issues with our 
partners.
    Having a wide variety of stakeholders involved in the development 
of our plans helps ensure that responders at all levels know what their 
respective roles are and how they interrelate, which leads to a more 
coordinated response.
Region V All-Hazards Plan
    The notion of all-hazards planning has been a driving force in 
emergency management for many years. Region V developed its All-Hazards 
plan utilizing a combination of planning factors such as, Metropolitan 
Statistical Area (MSA) information, potential infrastructure 
vulnerabilities, State capabilities, historical disaster information, 
modeling, and the unique characteristics of Region V.
    While Region V faces a wide range of hazards, we have identified 
nine National Planning Scenarios that guide our planning efforts. These 
include an Improvised Nuclear Device, Pandemic, Catastrophic Dam or 
Levee Failure, Nuclear Release, Major Winter Storm, New Madrid/Wabash 
Valley Seismic Zone Earthquake, Chemical/Biological Incident, Major 
Summer Storm and Multi-State Flooding.
    Using MSA information based on demographic data pulled from the 
2010 Census provides us with an immediate snapshot of potential 
resource needs that may arise in the event of an overwhelming disaster 
in any of our States. We analyze the population of an area, the number 
of households, the number of children, as well as percentages of 
households that are below the poverty line, in assisted living, have 
persons with disabilities or other people with access and functional 
needs, have transportation needs, and those with Limited English 
Proficiency.
    Using the expertise of other Federal agencies and our own resources 
within DHS, we are also looking at potential infrastructure 
vulnerabilities that could negatively affect survivor outcomes and 
response capabilities. Each State also has identified critical 
infrastructure that they believe to be vulnerable in the event of a 
catastrophic incident.
    As I mentioned earlier, information pulled from State Preparedness 
Reports and THIRAs is a critical element of our Regional All-hazards 
planning. This information allows the Region to survey each State and 
determine potential resources the Federal Government may need to 
provide in the event of a catastrophic incident.
    As you know, Region V, which is centered in the middle of the 
United States, has a number of characteristics that make our All-
Hazards planning unique. We are home to 17 percent of the National 
population, including Chicago, the third-largest U.S. city; 10 cities 
within Region V are designated under the Urban Area Securities 
Initiative; we are a major transportation shipping point with 15 
percent of all U.S. freight shipments (by weight) originating within 
Region V and 25 percent of all U.S. rail traffic traveling through 
Chicago to reach other points within the United States. In addition, 
Chicago is a major hub for telecommunications, natural gas, and air 
travel.
Region V Earthquake Plan
    The FEMA Region V earthquake plan provides guidance on how the 
Region will coordinate and execute its responsibilities and mission to 
effectively respond to and provide immediate Federal resource support 
following a catastrophic earthquake, aftershock, or cascading impacts 
from such events. Region V has two notable potential earthquake 
threats, the Wabash Valley Seismic Zone and the New Madrid Seismic 
Zone. Region V States, including Indiana, have established a history of 
successful planning efforts in preparation for a catastrophic 
earthquake, particularly within the New Madrid Seismic Zone, though the 
lessons learned and processes used also have value for a Wabash Valley 
incident. The earthquake plan was developed around a 7.7 magnitude New 
Madrid Seismic Zone scenario, which was based on seismic modeling 
conducted by the Mid-American Earthquake Center.
    This planning effort included workshops, exercises, and on-going 
planning with Federal, State, and local partners. These workshops, held 
in each of the potentially impacted New Madrid States between 2006 and 
2010, focused on the Response Core Capabilities outlined in PPD-8, as 
well as on resource allocation. These workshops culminated in National-
Level Exercise 2011, which focused on a catastrophic earthquake event 
in the zone.
    Following this large-scale exercise, we are continuing to work with 
our partners to expand our planning efforts, focusing on logistics, 
operations, and planning. These workshops placed a heavy emphasis on 
commodities, staging, and logistical needs in disaster response. The 
next milestone for this plan will be a CAPSTONE exercise, driven by the 
Central United States Earthquake Consortium and its member States, to 
examine the private-sector resources in a New Madrid event.
Improvised Nuclear Device Planning
    The third planning effort that has helped us tremendously to expand 
our preparedness for all hazards, and in particular for large-scale 
disasters, is our planning for an Improvised Nuclear Device (IND). Our 
IND planning effort focuses on identifying effective response tasks 
that could save and sustain lives. While such an incident would have 
specific impacts, the process that we used to develop the plan is one 
that we could use to expand our preparedness for other catastrophic 
events.
    With this in mind, Region V is developing a contingency plan for a 
10-kiloton explosion. The plan is being developed collaboratively with 
more than 300 partners at the Federal, State, and local levels, as well 
as from private-sector and voluntary agency representatives.
    The resulting document is a blueprint for common understanding that 
outlines how partners need to respond to an event from hour 1 to hour 
96.
                    new innovations/lessons learned
    As we move forward, it is important to note that we are constantly 
working to improve our operations. We are learning lessons not just 
from past disasters, but also from disasters to which we are currently 
responding. We are implementing new force structures to improve the way 
we deliver services, new technologies to improve our situational 
awareness and coordination, new logistical models to improve the way we 
deliver commodities, and new partnerships to expand the notion of whole 
community in preparedness and response.
New Force Structures
    To ensure that we are consistently delivering a high level of 
service to disaster survivors and to our State, local, and Tribal 
partners, while at the same time ensuring we continue to complete our 
non-disaster response functions, FEMA is moving toward a new force 
structure that maximizes our staff and capabilities. To this end, the 
agency recently stood up new, full-time Incident Management Assistance 
Teams (IMATs), and is hiring disaster response staff that can deploy 
for longer periods of time.
    FEMA has also established members of the DHS Surge Capacity Force, 
made up of employees from other DHS components and Federal agencies. 
During Hurricane Sandy, we deployed more than 1,100 of our co-workers 
from the various DHS component agencies in support of the response 
operations. We have also adopted a new model for serving disaster 
survivors by standing up Disaster Survivor Assistance Teams (DSATs) to 
replace the former Community Relations function. These new DSATs are 
deploying to the field fully trained and equipped not only to share 
information about the help available after a disaster, but also to go 
into neighborhoods and register survivors, answer case-specific 
questions, and facilitate survivor access to our full range of post-
disaster services.
    Any incident that would generate mass casualties would involve the 
deployment of large numbers of FEMA and DHS staff. These new force 
structures and programs ensure a more nimble and robust response and a 
higher level of service to disaster survivors. Region V was the first 
region to utilize the DSAT model in response to severe flooding in 
Illinois, allowing it to be more survivor-centric by bringing services 
to survivors, rather than asking them to come to FEMA.
New Technologies
    FEMA is implementing new technologies to improve our preparedness 
and response capabilities, using satellite imaging and flood modeling 
to improve disaster response, engaging with the public through social 
media, and adopting new technologies to improve interactions with our 
response partners.
    We have adopted, and actively use WebEOC, which is an emergency 
management information-sharing tool that allows us to work toward a 
common operating picture among multiple partners in real time. FEMA 
recently joined States in using this technology, allowing for greater 
collaboration between these partners. We are also using EMNET, a 
satellite-based information-sharing system, to ensure productive 
collaboration.
Commodity Warehousing
    FEMA Region V is piloting a new model for the storage and delivery 
of emergency supplies in the event they are needed for disaster 
response. We are working with regional food bank distribution centers 
to shave valuable time off FEMA commodity delivery. We will store FEMA 
commodities at no cost at six food bank centers located across Region 
V, in addition to utilizing commodities stored at FEMA's existing 
Distribution Centers that are located in coastal States. With this new 
initiative, an initial supply of commodities, such as water and Meals 
Ready to Eat (MREs), will reach disaster survivors more quickly and 
establish the supply chain from more remote centers.
    FEMA worked with Feeding America--the Nation's leading domestic 
hunger-relief non-profit organization--to develop the plan. Feeding 
America's mission is to provide nutrition support through a Nation-wide 
network of member food banks and engage the country in the fight to end 
hunger. The Region estimates that we will be able to store 5 to 7 
truck-loads at the distribution centers, which is enough to respond to 
a mid-size disaster. Commodities in storage include water, shelf-stable 
meals, and infant/toddler supplies.
    As we all know, all commodities have a shelf life. In the event 
that the food we put in storage is not used, our plan outlines a 
process that would allow the food banks storing the commodities to 
request, through FEMA's established surplus process, donation to that 
food bank before they expire.
    The new storage plan will deliver a number of other benefits to 
regional operations. For example, deliveries coming from distribution 
centers on the East Coast or in the South may be delayed by weather 
conditions or other disaster disruptions, making speedy delivery a 
concern. Region V will have initial supplies pre-staged locally which 
will increase the speed of delivery and decrease the potential for 
weather- or travel-related delays.
    The six food banks in Region V currently under consideration for 
this initiative are:
   Second Harvest Heartland, St. Paul, MN;
   Greater Chicago Food Depository, Chicago, IL;
   Northern Illinois Food Bank, Geneva, IL;
   Gleaners Food Bank of Indiana, Inc., Indianapolis, IN;
   Cleveland Food Bank Inc., Cleveland, OH;
   Gleaners Community Food Bank of Southeastern Michigan, 
        Detroit, MI.
Private-Sector Partnerships
    FEMA continues to expand its outreach to and engagement with the 
private sector. Region V has a full-time staff member who works to 
conduct outreach to a wide range of non-Governmental partners, 
including small, medium, and large business, as well as academia, trade 
associations, and other organizations. Throughout the year, FEMA's 
Private Sector staff works with the private sector to provide 
information on tools and resources to support preparedness, and 
integrate the private sector into the emergency management effort. 
FEMA's National Private Sector team is comprised of headquarters staff, 
10 regional liaisons, and a disaster workforce cadre of approximately 
40 reservists.
    During steady-state, non-disaster operations, this FEMA office 
focuses its efforts on ways to engage the private sector in activities 
ranging from education campaigns, to opportunities for providing 
feedback on National policies, to participation in joint exercises.
    FEMA established a special Private Sector Representative (PSR) 
position in 2010 to communicate, coordinate, and collaborate between 
public and private-sector stakeholders before, during, and after 
disasters. Unlike the full-time Federal positions established starting 
in 2008, a PSR is a member of the private sector who serves as a 
Special Government Employee (SGE) during their 90-day tenure with FEMA, 
effectively representing the entire private sector while they are a 
PSR.
    When the NRCC is activated, these special Government employees 
serve as critical liaisons between FEMA and private industry by 
leveraging private-sector coordination and collaboration capabilities 
and sharing situational awareness information.
    The PSR in Region V is currently filled by a representative from 
Walgreens. At FEMA Headquarters, representatives from eight companies, 
including Target, Big Lots, Brookfield Properties, Systems Planning 
Corporation (a small business), Verizon, Citi, Wal-Mart, and Dominion 
Power Company serve a similar role.
    FEMA has also been instrumental in helping to establish the 
National Business Emergency Operation Center (NBEOC). The NBEOC is a 
virtual network of National corporations, Federal, State, local, 
Tribal, territorial governments, and trade associations that have roles 
in disasters. Illinois is the only State in the Region that has a 
dedicated Business Emergency Operation Center (BEOC). The BEOC 
activates whenever the State Emergency Operations Center activates and 
provides situational awareness to the Regional Response Coordination 
Center and to the Regional Private Sector Liaison.
    In Indiana, we are actively engaged with the Northwest Indiana 
Information Sharing Workgroup. This group is comprised of the private 
sector, State, and local emergency managers, academia, faith-based 
groups, and other Federal agencies. This workgroup is part of the 
Homeland Security Information Network--Critical Sectors (HSIN-CS). 
HSIN-CS is a secure, unclassified, web-based system that serves as the 
primary, Nation-wide DHS information-sharing and collaboration system. 
Members of this group meet regularly and were active in planning for 
the recent NATO meetings in Chicago.
           faith-based, community, and volunteer partnerships
    Ultimately, FEMA is only one part of our Nation's emergency 
management enterprise. This effort is a shared responsibility and our 
partners at all levels help communities prepare for, protect against, 
mitigate, respond to, and recover from all hazards.
    The agency relies on our voluntary agency partners to help us 
support State and local governments by providing services that we may 
not be in the best position to provide. Our collective response is 
greatly enhanced by the on-going efforts of faith-based, community, and 
volunteer organizations. We depend on them as true partners to help on 
the front lines as well as behind the scenes, to receive and distribute 
commodities, manage and staff shelters and mass feeding facilities, 
provide counseling services and much more.
    During my emergency management career, beginning as the executive 
director of Chicago's Office of Emergency Management and 
Communications, then as the director of the Illinois Emergency 
Management Agency, and now as a regional administrator for FEMA, I have 
been a strong supporter of working closely with faith-based and 
community partners, and believe that their engagement is vital to our 
Nation's resilience.
    Whether it is through providing shelter, food, or clothing to those 
in need, removing debris to help communities begin the road to 
recovery, or helping families rebuild their homes, faith-based and 
community organizations have always played a vital role in meeting the 
needs of Americans. In an incident that generates mass casualties, the 
effective execution of these support functions will be essential to the 
region's preparedness and response.
    As regional administrator, I have charged our Region V team to work 
collaboratively with local, State, Tribal, and National partners to 
support faith-based and community leaders to determine how best to 
provide assistance to disaster survivors. With the support of the DHS 
Center for Faith-Based and Neighborhood Partnerships, we have been able 
to make strong progress over the past 4 years, hosting several events 
to strengthen those relationships. It is my belief that as we 
strengthen these partnerships today, we will be better-positioned to 
deliver essential services during our disaster response.
                                closing
    In Region V, we are continuously working to evolve our approach to 
preparing America's citizens to respond to the events that threaten 
their lives, homes, and livelihoods, and to better fulfill FEMA's 
mission. To that end, we are actively working with our Governmental 
partners at the State, Tribal, and local level, as well as with our 
non-Governmental partners to prepare for whatever may impact the Region 
and look forward to continuing that good work.
    I appreciate the opportunity to appear before you today and look 
forward to answering any questions you may have.

    Mrs. Brooks. Thank you, Mr. Velasquez.
    The Chairwoman will now recognize Sheriff Bowen.

 STATEMENT OF MARK J. BOWEN, SHERIFF, HAMILTON COUNTY, INDIANA

    Sheriff Bowen. Thank you, Chairwoman Brooks. Chairwoman 
Brooks, Senator Donnelly, Representative Walorski, 
Representative Young, and Members of the subcommittee, it is 
truly an honor to appear before you today. My name is Mark 
Bowen, and I am the elected sheriff of Hamilton County, 
Indiana. I would like to thank you for the opportunity to 
appear before you today, along with my esteemed colleagues, to 
discuss Central Indiana's preparedness for a mass casualty 
event.
    Mrs. Brooks. Excuse me, Sheriff. Is your mic turned on? 
Thank you.
    Sheriff Bowen. While Indiana still remains a wholesome, 
midwestern State known primarily for its agriculture and 
basketball, Central Indiana has grown into a thriving 
metropolitan community, making a name for itself throughout 
standing primary, secondary, and higher-educational 
institutions, affordable housing, low taxes, low crime rates, 
and high-profile events such as the NCAA Final Four, PGA BMW 
Championship, Indianapolis 500-mile race and mini-marathon, the 
Brickyard 400, and the 2012 NFL Super Bowl.
    As Indiana continues to grow, develop, and to host National 
events, it is more important than ever that we focus on our 
preparedness plans to protect Hoosiers and those who visit our 
fine State.
    As we have seen through incidents across the country, from 
Columbine to 9/11, to Hurricane Katrina, to Sandy Hook, and to 
the Boston Marathon bombings, Americans are vulnerable, and 
Hoosiers are no exception, as evidenced by the Indiana State 
Fair stage collapse, the Henryville tornado, and the Richmond 
Hills gas explosion. It is not a question of if a mass casualty 
event will occur in Indiana but when will it happen, how will 
it happen, to what magnitude it will happen, and will we be 
prepared for it when it does happen?
    Indiana has come a long way in the past 10 years when it 
comes to preparing for mass casualty events. The events of 9/11 
and other large-scale disasters have forced public safety to 
look at large-scale disasters not only from a local perspective 
but from a regional perspective as well. Indianapolis, Indiana 
and the surrounding region has been part of the Urban Area 
Security Initiative for the past 8 years. As a UASI region, we 
have worked diligently to meet the guidelines set out in 
Presidential Policy Directive 8. State and local officials in 
the Indianapolis urban area have been working in conjunction 
with the Indiana Department of Homeland Security to ensure that 
threat and hazard identification and risk assessments are being 
done and updated annually.
    Hazard mitigation plans are being implemented, core 
capabilities are being identified, assets are being secured, 
memorandums of understanding are being executed, and training 
is being conducted. Unfortunately, we cannot do all this work 
and then put it on a shelf until an event happens. We must be 
ever-vigilant, constantly updating our risks, evaluating our 
plans, updating our training, and maintaining our resources and 
equipment. Complacency can easily become our Achilles heel.
    This is where we need your help, the help of our local 
emergency management agencies, and the help of the Department 
of Homeland Security. Risk assessment, threat assessment, 
planning, training, resource allocation, communications and 
interoperability are just a few of the critical components 
necessary to our success in mitigating hazards and restoring 
order. While local first responders are the primary resources 
inserted into a mass casualty event, these resources are 
quickly overwhelmed and must rely on mutual aid from other 
jurisdictions, including State and Federal agencies.
    Through the cooperation of IDHS, Central Indiana has become 
a well-structured and well-organized UASI region and, by its 
virtue, become more stable and better prepared to deal with 
major events, including mass casualties. The State Fair, 
Henryville, and Richmond Hills are prime examples of success 
stories due in large part to the planning, training, 
organization, and teamwork that has been developed through the 
efforts of homeland security. It is critical that these 
agencies continue to function at a high level, especially in 
times of peace and serenity, in order to ensure that our local 
jurisdictions are up-to-date on their training, that they are 
conducting their threat assessments, updating their policies 
and procedures, maintaining their equipment, and following 
training in ensuring best practices, fostering and building 
relationships, establishing funding sources and conducting 
training so that we do not become complacent and be caught off-
guard when the event does happen.
    I want to thank you all for taking the time to meet with us 
here today and for your interest in Indiana's preparedness for 
mass casualties and for all that you do to keep the homeland 
safe and secure. Thank you.
    [The prepared statement of Sheriff Bowen follows:]
                  Prepared Statement of Mark J. Bowen
                             August 6, 2013
    Chairwoman Brooks, Ranking Member Payne, Senator Donnelly, 
Representatives Walorski and Young, and Members of the subcommittee, it 
is truly an honor to appear before you today. My name is Mark Bowen and 
I am the elected sheriff of Hamilton County, Indiana. I would like to 
thank you for the opportunity to appear before you today along with my 
esteemed colleagues to discuss central Indiana's preparedness for a 
mass casualty event.
    While Indiana still remains a wholesome mid-western State known 
primarily for its agriculture and basketball, central Indiana has grown 
into a thriving metropolitan community making a name for itself through 
outstanding primary, secondary, and higher educational institutions, 
affordable housing, low taxes, low crime rates and high-profile events 
such as the NCAA Final Four, PGA BMW Championship, Indianapolis 500-
mile race and Mini Marathon, Brickyard 400, and the 2012 NFL Superbowl.
    As Indiana continues to grow, develop, and to host National events, 
it is more important than ever that we focus on our preparedness plans 
to protect Hoosiers and those who visit our fine State. As we have seen 
through incidents across the country from Columbine to 9/11 to 
Hurricane Katrina to Sandy Hook to the Boston Marathon bombings, 
Americans are vulnerable and Hoosiers are no exception as evidenced by 
the Indiana State Fair stage collapse, the Henryville tornado, and the 
Richmond Hills gas explosion.
    It is not a question of if a mass casualty event will occur in 
Indiana but when it will happen, how it will happen, to what magnitude 
it will happen, and will we be prepared for it when it does happen?
    Indiana has come a long way in the past 10 years when it comes to 
preparing for mass casualty events. The events of 9/11 and other large-
scale disasters have forced public safety to look at large-scale 
disasters not only from a local perspective but from a regional 
perspective as well.
    Indianapolis, Indiana and the surrounding region has been part of 
an Urban Area Security Initiative (UASI) for the past 8 years. As a 
UASI region, we have worked diligently to meet the guidelines set out 
in Presidential Policy Directive 8. State and local officials in the 
Indianapolis Urban Area have been working in conjunction with the 
Indiana Department of Homeland Security to ensure that Threat and 
Hazard Identification and Risk Assessments (THIRA) are being done and 
updated annually, Hazard Mitigation Plans are being implemented, Core 
Capabilities are being identified, assets are being secured, 
memorandums of understanding are being executed, and training is being 
conducted.
    Unfortunately, we cannot do all this work and then put it on a 
shelf until an event happens. We must be ever-vigilant, constantly 
updating our risks, evaluating our plans, updating our training and 
maintaining our resources and equipment. Complacency can easily become 
our Achilles heel. This is where we need your help, the help of our 
local emergency management agencies (EMA) and the help of the 
Department of Homeland Security (DHS).
    Risk assessment, threat assessment, planning, training, resource 
allocation, communication, and interoperability are just a few of the 
critical components necessary for our success in mitigating hazards and 
restoring order. While local first responders are the primary resources 
inserted into a mass casualty event, these resources are quickly 
overwhelmed and must rely on mutual aid from other jurisdictions 
including State and Federal Agencies.
    Through the cooperation of IDHS, central Indiana has become a well-
structured and well-organized UASI region and by its virtue become much 
more stable and better prepared to deal with major events including 
mass casualties. The State Fair, Henryville, and Richmond hills are 
prime examples of success stories due in large part to the planning, 
training, organization, and teamwork that has been developed through 
the efforts of homeland security.
    It is critical that these agencies continue to function at a high 
level especially in times of peace and serenity in order to ensure that 
our local jurisdictions are up-to-date on their training; that they are 
conducting their threat assessments; updating their policies and 
procedures; maintaining their equipment; following trends and ensuring 
best practices; fostering and building relationships;, establishing 
funding sources and conducting training so that we do not become 
complacent and be caught off guard when the event does happen!
    Thank you all for taking the time to meet with us here today, for 
your interest in Indiana's preparedness for mass casualty and for all 
you do to keep the Homeland safe and secure.
                                Appendix
    Question 1. What are the main threats facing Indiana?
    Answer. Indiana like any other State across our great Nation is 
vulnerable to a multitude of threats both natural and man-made. In 2012 
a Threat and Hazard Identification and Risk Assessment (THIRA) was 
conducted by the Indianapolis Urban Area in accordance with 
Presidential Policy Directive 8. The following Threats and Hazards were 
identified.
Natural
            Acts of Nature
   Flood
   High Wind
   Snow
   Tornado
   Hail
   Ice
   Heat Emergencies
   Disease Outbreak
   Drought
   Epidemic
Technological
            Accidents or Failures of Systems
   HAZMAT
   Accidental Explosion
   Dam/Levee Failure
   Power Failure
   Airplane Crash
   Radiological Release
   Train Derailment
Human--caused
            Intentional Acts
   IED/VBIED
   Arson/Incendiary Attack
   Cyber Attack
   Chemical Agent
   Conventional Attack
   Hostage Taking
   Biological Attack (contagious)
   Biological (non-contagious)
   Aircraft as a Weapon
   RDD
   Food and Water Attack
   Nuclear Attack
   Agro-Terrorism
   Civil Disturbance
   Cyber Incidents
   Sabotage
   School Violence
   Terrorist Acts
   Active Shooter

    One of the primary natural threats/hazards facing Indiana is a 
tornado. Indiana is prone to tornados and has experienced many 
significant events in its history. The most recent event, an EF 4 
tornado that touched down in Henryville, Indiana in March 2012, is a 
prime example of the profound impact that a significant storm can have 
on a densely-populated community during peak hours.
    One of the primary technological threats/hazards facing Indiana is 
that of a hazardous materials explosion which could involve mass 
casualties, mass evacuation, and profound public health concerns.
    One of the primary human-caused threats/hazards would be an act of 
terrorism committed at a large-scale public event such as the Indy 500, 
the Brickyard 400, a Colts game, or any number of other large-scale 
publicly-attended venues.
    Question 2. What are we doing to prepare for these events?
    Answer. Indiana has come a long way in the past 10 years when it 
comes to preparing for mass casualty events. The events of 9/11 and 
other large-scale disasters have forced public safety to look at large-
scale disasters not only from a local perspective but from a regional 
perspective as well.
    Indianapolis, Indiana and the surrounding region has been part of 
an Urban Area Security Initiative (UASI) for the past 8 years. As a 
UASI region, we have worked diligently to meet the guidelines set out 
in Presidential Policy Directive 8. State and local officials in the 
Indianapolis Urban Area have been working in conjunction with the 
Indiana Department of Homeland Security to ensure that Threat and 
Hazard Identification and Risk Assessments are being done and updated 
annually, Hazard Mitigation Plans are being implemented, Core 
Capabilities are being identified, assets are being secured, 
memorandums of understanding are being executed and training is being 
conducted.
    Question 3. How well are we prepared for the range of threats 
facing our State?
    Answer. Overall, Indiana is positioned very well to deal with the 
range of threats facing our State. While we cannot possibly train for 
every possible scenario that may play out, we can and have identified 
what we believe to be the most likely threats and hazards facing our 
community. Public Safety Agencies and personnel have been briefed on 
these potential hazards and are enhancing their policies and procedures 
and their training as well. As a result of lessons learned from 
incidents that have taken place across the country, situational 
awareness has been elevated not only in the public safety arena but 
also in the private sector and by the general public. More attention 
has been given to pre-planning of events and to incident action plans. 
The National Incident Management System (NIMS) has become standard 
operating procedure and critical delays in responding to incidents, 
establishing command, assessing needs, and executing operating 
procedures has been greatly reduced.
    In 2012, central Indiana was tested on a number of occasions. One 
primary example would be the EF 4 tornado that hit Henryville, Indiana, 
in March. The tornado swept through a densely-populated community in 
the middle of the day causing catastrophic damage, killing several 
people, and injuring numerous others.
    Another noteworthy event was the Richmond Hill subdivision 
explosion in November 2012 which was determined to be a man-made event 
that resulted in the death of two people and the catastrophic damage to 
a 3-block radius in a residential community.
    These events were mitigated successfully using an all hazards 
approach and the NIMS model.
    Question 4. How does IDHS work with FEMA to plan for the various 
threats facing Indiana?
    Answer. This question is not applicable and left for IDHS response.
    Question 5. What assistance does the State receive from FEMA and 
the Federal Government?
    Answer. This question is not applicable and is left to IDHS.
    Question 6. What training do our first responders receive?
    Answer. Law enforcement first responders receive training in threat 
identification and assessment, first aid, hazardous materials 
identification and assessment, National Incident Management Systems 
(NIMS) procedures, perimeter security and containment, evidence 
preservation and collection, active-shooter training, and personal 
protective equipment (PPE) training.
    The training has not only been conducted within individual 
departments but in conjunction with other agencies across the region. 
Partnerships have been developed with schools, businesses, and crime 
watch organizations to include them in active-shooter and other 
scenario-based training.
    Question 7. What plans are in place at the various levels of 
government for the threats?
    Answer. Many areas of local government have taken a proactive 
approach to the threats and are assessing their policies and 
procedures, identifying critical infrastructure needs, establishing 
Continuity of Operation Plans and Continuity of Government (COOP & COG) 
plans, implementing training and executing memorandums of understanding 
with one another, and constantly updating these plans.
    Question 8. What exercises have been held in the past year?
    Answer. In the past year, table-top exercises have been conducted 
on scenarios that involved a mass casualty event at the Indy 500, an 
active-shooter/terrorist situation at the Fort Benjamin Harrison 
Finance Center, an airport mass casualty, a fair train mass casualty, 
and an active-shooter public/private partnership scenario with Rolls 
Royce.
    Hamilton County is currently working on a weather-related all-
hazards live training drill involving police, fire, and EMS that is 
scheduled to take place in October.
    Question 9. How have different jurisdictions worked together to 
plan for such events?
    Answer. Discussions and training have taken place through 
organizations such as the International Association of Chiefs of Police 
(IACP) and the Indiana Sheriff's Association (ISA). Through the 
Commission on Accreditation for Law Enforcement Agencies (CALEA), 
accredited agencies are required to implement and update all-hazard and 
unusual occurrence policies. Table-top exercises have taken place and 
full-scale exercises have taken place and/or are being discussed. 
Dialogue has increased throughout the region, assets and resources have 
been identified, memorandums of understanding have been executed, data 
sharing and interoperable communications have been discussed.
    Question 10. Are intra-state agreements in place to facilitate 
cooperation between jurisdictions?
    Answer. Many local jurisdictions have been in discussions with 
their neighbors to facilitate cooperation and many have executed inter-
local agreements to provide support in cases of emergency.
    Thankfully, the Mid-west mentality and desire to work together to 
get the job done remains strong!
    Question 11. Are the communications systems of the first responders 
able to talk to each other before, during, and after an incident?
    Answer. Central Indiana first responders work off of a number of 
different communications systems. Not all are interoperable before an 
incident takes place. In most cases, local jurisdictions are able to 
communicate with one another but when first responders have to travel 
outside of their primary areas of responsibility, communications can 
become an issue.
    Patches can be established through most systems or radios can be 
switched to the State Mutual Aid frequencies but this takes time and 
often results in poor connectivity.
    The State is working on enhancing the State-wide radio network and 
bridging the gap by bringing the system up to P-25 standards. Hamilton 
County has also implemented plans to enhance their radio infrastructure 
and bring it up to P-25 standards.
    Unfortunately, the burden is on local units of government to build 
and maintain these complicated systems and many simply can't afford it.

    Mrs. Brooks. Thank you, Sheriff Bowen.
    The Chairwoman now recognizes Chief Orusa to testify.

    STATEMENT OF STEVEN ORUSA, FIRE CHIEF, FISHERS, INDIANA

    Chief Orusa. Chairwoman Brooks, Senator Donnelly, 
Representatives Walorski and Young, good morning. On behalf of 
the town of Fishers town council president John Weingardt and 
town manager Scott Faultless, thank you for the opportunity to 
discuss Central Indiana's preparedness for a mass casualty 
event.
    From the 2011 State Fair collapse to the 2012 Richmond 
Hills explosion to the Colonial Hills Baptist Church bus crash 
just last month, our firefighters, paramedics, and EMTs are at 
the tip of the spear during these tragic events, but they 
weren't the only first responders. Bystanders, neighbors, and 
people given the chance to go about their business decided to 
stay and help our personnel serve professionally and 
heroically. Mass casualty events are an amazing example of 
humanity, service, and teamwork.
    Both the work leading up to these events as well as quick 
action following the events highlight the significant progress 
that we as a region have made over the past years responding to 
mass casualty incidents. But there is still more work to do, 
and we are continuing to learn from these events to strengthen 
our preparedness and training and exercise programs as they 
relate to mass casualty and hostile situations.
    Marion and Hamilton counties have worked with FEMA to 
assess gaps and prioritize grants and investments. In 2012, we 
completed a Threat and Hazard Identification and Risk 
Assessment, the THIRA, a process for assessing regional 
capability gaps required by each State and urban area designed 
to prioritize investments and key deployable capabilities. Many 
of the capabilities demonstrated in the aforementioned events 
and aftermath were built or enhanced and have been sustained 
through the preparedness suite of homeland security grant 
programs, including UASI Urban Area Security Initiative Grant 
Program, and the State Homeland Security Program.
    As a former paramedic, UASI task force member and chief, I 
can attest to the importance of preparing our public safety men 
and women for whatever may come. Grant funds provided 
commodities and training that were essential in response 
incidents. In part because of the investment made in the 
system, and in no small part because of the outstanding work of 
our first responders, patients were triaged, treated, and 
transported in an orderly manner to the appropriate hospitals 
based on their needs.
    Mass casualty incidents are high-risk, low-frequency 
events. This means we cannot rely on our call volume alone to 
be safe and effective. In order to assess capabilities, 
identify gaps, and create improvement plans, we must conduct 
tabletop, functional, and full-scale exercises to improve and 
sustain our capacity and safely and effectively rise to the 
occasion of a mass casualty incident.
    Individual agencies can practice blocking and tackling, but 
until we scrimmage together and rehearse under game-like 
conditions, we cannot identify and analyze the gaps critical to 
improve capability. These operational readiness exercises 
provide us an environment where mistakes can be made and 
lessons learned when they are affordable, in a controlled 
training environment. The alternative is too costly.
    Quite simply, our preparedness system works like it should, 
but we need your help. The challenge is providing the backfill 
and overtime required to engage our people in realistic, high-
quality, scenario-based exercises and at the same time keep our 
communities protected. Historically, we have depended on UASI 
funding and State Homeland Security Program funding. Central 
Indiana did not qualify for UASI funding in 2013, and it is 
unknown for 2014. As a consequence, State Homeland Security 
funding may be reduced.
    In closing, our public safety men and women pride 
themselves on doing whatever it takes, no matter what the 
conditions, to serve those in need, but I believe we owe them 
more than that. We owe them a system which plans, organizes, 
exercises, and evaluates the capabilities. We owe them a system 
that prepares them to be successful. Our covenant with them is 
to do everything in our power to keep them safe and effective. 
When we commit them to harm's way, we commit their families to 
harm's way. We have no greater responsibility. We need your 
help to support UASI funding in Central Indiana.
    On behalf of the first responders we all serve, it is an 
honor and a privilege to be here today. Thank you for this 
opportunity, and I look forward to answering your questions.
    [The prepared statement of Chief Orusa follows:]
                   Prepared Statement of Steven Orusa
                             August 6, 2013
    Chairman Brooks, Ranking Member Payne, Senator Donnelly, 
Representatives Walorski and Young, and Members of the subcommittee: 
Good morning, I am Steven Orusa, fire chief for the Town of Fishers 
Department of Fire and Emergency Services. On behalf of town council 
president John Weingardt and town manager Scott Fadness, thank you for 
the opportunity to discuss central Indiana's preparedness for a mass 
casualty event.
    From the 2011 State Fair Stage Collapse to the 2012 Richmond Hills 
Explosion to the Colonial Hills Baptist Church bus crash last month, 
our firefighters, paramedics, and EMTs are the tip of the spear during 
these tragic events, but they weren't the only first responders. 
Bystanders, neighbors, and people given the chance to go about their 
business decided to stay and help our personnel serve professionally 
and heroically. Mass casualty events are an amazing example of 
humanity, service, and teamwork.
    Both the work leading up to these events, as well as quick action 
following the events, highlight the significant progress that we, as a 
region, have made over the past years responding to Mass Casualty 
Incidents. But there is still more work to do, and we are continuing to 
learn from these events and others to strengthen our preparedness and 
training and exercise programs as they relate to mass casualty and 
hostile situations.
    Marion and Hamilton Counties have worked with FEMA to assess gaps 
and prioritize grant investments. In 2012, we completed a Threat and 
Hazard Identification and Risk Assessment (THIRA), a process for 
assessing regional capability gaps required by each State and urban 
area designed to prioritize investments in key deployable capabilities.
    Many of the capabilities demonstrated in the aforementioned events 
and aftermath were built or enhanced and have been sustained through 
the preparedness suite of Homeland Security Grant Programs (HSGP), 
including the Urban Area Security Initiative (UASI) Grant Program and 
the State Homeland Security Program (SHSP).
    As a former paramedic, US&R Task Force member, and chief, I can 
attest to the importance of preparing our public safety men and women 
for whatever may come. Grant funds provided commodities and training 
that were essential in response to incidents. In part, because of the 
investment made in the system, and in no small part of the outstanding 
work of our first responders, patients were triaged, treated, and 
transported in an orderly manner to the appropriate hospitals based on 
needs.
    Mass casualty incidents are high-risk/low-frequency events. This 
means we cannot rely on our call volume alone to be safe and effective. 
In order to assess capabilities, identify gaps, and create improvement 
plans, we must use table-top, functional, and full-scale exercises to 
improve and sustain our capacity to safely and effectively rise to the 
occasion of a mass casualty incident.
    Individual agencies can practice ``blocking and tackling,'' but 
until we scrimmage together and rehearse under ``game-like'' conditions 
we cannot identify and analyze the gaps critical to improve capability. 
These operational readiness exercises provide an environment where 
mistakes can be made and lessons learned when they are affordable: In a 
controlled training environment. The alternative is too costly.
    Quite simply, our preparedness system works like it should, but we 
need your help. The challenge is providing the backfill and overtime 
required to engage our people in realistic, high-quality, scenario-
based exercises and at the same time keep our communities protected. 
Historically we have depended on UASI funding and SHSP funding. Central 
Indiana did not qualify for UASI funding in 2013 and it is unknown for 
2014. As a consequence SHSP funding may be reduced.
    In closing, our public safety men and women pride themselves on 
doing whatever it takes, no matter what the conditions, to serve those 
in need, but I believe we owe them more than that. We owe them a system 
which plans, organizes, exercises, and evaluates their capabilities; we 
owe them a system that prepares them to be successful. Our covenant 
with them is to do everything in our power to keep them safe and 
effective. When we commit them to harm's way we commit their families 
to harm's way. We have no greater responsibility. We need your support 
to return UASI funding to central Indiana.

    Mrs. Brooks. Thank you, Chief Orusa.
    I now recognize Mr. Hill to testify.

    STATEMENT OF JOHN H. HILL, EXECUTIVE DIRECTOR, INDIANA 
                DEPARTMENT OF HOMELAND SECURITY

    Mr. Hill. Good morning, Madam Chairwoman, Senator Donnelly, 
and Representatives Walorski and Young. Thank you for having us 
here today. I really represent the whole Department of Homeland 
Security, but also thousands of first responders, as Chief 
Orusa just indicated. So I certainly don't stand here 6 months 
into the job with all the rewards and success that we have had 
so far.
    I would also like to thank the panel members. It is a 
pleasure to work with them and to experience first-hand 
meetings with them and to do planning and work together.
    The Department of Homeland Security is committed to 
providing State-wide leadership, responsiveness to our public 
safety professionals, and subject-matter expertise to 
continually develop the State's public safety capabilities 
while working for the well-being of our citizens, property, and 
communities.
    Indiana Governor Michael Pence is committed to a 
coordinated public safety system in Indiana. To better provide 
for the needs of the States, it is essential for us to 
constantly evaluate our plans, preparedness, processes, and 
procedures. Therefore, Governor Pence, on his first day in 
office, invited me and his whole public safety team to his 
office to really address the need for public safety and 
preparedness in our State. One of the things that he directed 
me to do was to have an objective external view of our agency 
and conduct an assessment of the Department of Homeland 
Security to allow it to improve and take it really from good to 
great.
    One of the things that we have done is we have engaged a 
firm known by many people in the private-sector world of 
emergency preparedness and crisis communication, James Lee Witt 
and O'Brien, Witt O'Brien Associates. They are doing an 
assessment of our agency, and the report has just been 
delivered to me, and we will be engaging in some updates of 
that in the next 6 months.
    The assessment included experts from not only public 
safety, but they talked to people all throughout the State, and 
I look forward to working with our first responders to improve 
our response in the next few months.
    I have submitted a very lengthy report to the panel, and I 
am going to defer further discussions so we can get into 
questions, and I look forward to taking your questions later.
    [The prepared statement of Mr. Hill follows:]
                   Prepared Statement of John H. Hill
                             August 6, 2013
    Chairman Brooks, Ranking Member Payne, Senator Donnelly, 
Representatives Walorski and Young, and Members of the subcommittee, it 
is an honor to appear before you today. My name is John Hill, and I am 
the executive director of the Indiana Department of Homeland Security 
(IDHS). Thank you for inviting me to testify on Central Indiana's 
preparedness for a mass casualty event, and for your interest in this 
critically important issue. I would also like to thank Federal 
Emergency Management Agency (FEMA) Region V administrator, Mr. 
Velasquez, Sheriff Bowen, Chief Orusa, Mr. Chad Priest, and other panel 
members for their on-going partnership with IDHS' preparedness and 
response activities. The Indiana Department of Homeland Security is 
committed to providing State-wide leadership, responsiveness to our 
public safety professionals, and subject-matter expertise to 
continually develop the State's public safety capabilities while 
working for the well-being of our citizens, property, and economy. The 
agency was founded in April 2005, with the merger of the State 
Emergency Management Agency, State Fire Marshal's Office, Office of the 
State Building Commissioner, Public Safety Training Institute, and the 
Counter Terrorism and Security Council.
    Indiana's Governor, Michael R. Pence, is committed to a coordinated 
public safety system in Indiana. The goal of this system is to exhibit 
the maximum efficiency of primary public safety agencies in the State, 
while removing unnecessary redundancies where they exist and employing 
Federal, State, and local resources in a harmonized fashion.
    To better provide for the needs of the State, it is essential for 
us to constantly evaluate our plans, preparedness, processes, and 
procedures. Governor Pence on his first day in office directed me to 
undertake a thorough review of Indiana's emergency preparedness and 
response capabilities and report the findings to him. Realizing that an 
objective and external observation and assessment of IDHS would provide 
important feedback, the agency engaged Witt O'Brien to identify 
weaknesses and opportunities for improvement. Witt O'Brien is an 
internationally recognized authority in crisis and disaster management. 
The assessment included review by public safety experts to evaluate 
IDHS and other State and local organizations, which served as the basis 
for findings and recommendations to improve Indiana's readiness. Witt 
O'Brien recently submitted a draft of its report concerning the Indiana 
Department of Homeland Security. The report is being reviewed. 
Implementation will commence in the next month to improve Indiana's 
emergency management practices.
                   federal, state, local partnership
    The State of Indiana has spent considerable time, effort, and 
resources in preparing for, responding to, and recovering from 
emergency situations. Our State is organized into ten distinct 
districts, each a partner of the other nine, and all uniquely prepared 
for emergencies. Each county has its own emergency management agency or 
emergency manager, with significant training, preparedness, and 
mitigation opportunities for emergencies and disasters. Routinely, 
counties join together to train for and respond to emergencies in their 
respective district. This multi-layered approach--Federal, State, 
district, county, and city--creates multiple levels of partnership and 
preparedness.
    We have excellent coordination with our State and local partners--
organizations like the Indiana State Department of Health, Indiana 
National Guard, Indiana State Police, and county emergency management 
agencies, local police and fire departments, among others. In 
conjunction with Federal partners, such as the Federal Emergency 
Management Agency (FEMA), U.S. Department of Homeland Security (DHS), 
Federal Bureau of Investigation (FBI), Nuclear Regulatory Commission 
(NRC), Department of Energy (DOE), and Department of Defense (DOD), we 
work to create a safer, better-prepared State for Hoosiers.
                           emergency response
    Just as public safety requires the coordination of many multi-
faceted and fluid elements to be successful, there are several 
functional aspects to the diverse IDHS organization. One high-profile 
area, especially during times of emergency or disaster, is led by the 
emergency response and recovery division, which monitors situations 
around the State and provides coordination of Indiana's considerable 
resources to assist whenever and wherever needed.
    To coordinate Indiana's significant resources, we have a State 
Emergency Operations Center (EOC) that is staffed 24 hours a day each 
day of the year. The EOC serves not only as a communications hub for 
on-going public safety coordination throughout the State, but also as a 
command-and-control center during large-scale disasters where all 
necessary parties are represented with their respective emergency 
support function (ESF) linkage. ESF functions include both Governmental 
and private representatives.
    The EOC facility has been recently toured by responders from other 
States and countries, including representatives from the Australian 
Consulate in Chicago, and public safety professionals from Great 
Britain, Israel, and South Korea.
                           disaster recovery
    Long after the immediate response by emergency workers, the work of 
recovery for a community can be daunting. Homes and businesses may be 
affected; and, completing damage assessments is an incredibly important 
process. Once again, this necessitates careful coordination among 
Federal, State, and local authorities. These assessments are crucial to 
determining eligibility for individual and public assistance from FEMA.
    We have learned that local emergency managers need assistance from 
the State to properly understand and administer the assessment for 
damaged property. Chairman Brooks, you saw, first-hand as you toured 
flood-ravaged areas in April of this year, how many of your 
constituents suffered property loss, both individually and as part of 
their community infrastructure. As devastating as it was, the millions 
of dollars of loss did not qualify for Federal assistance. In recent 
years, the threshold to qualify for Federal disaster aid has steadily 
increased. Indiana must increasingly shoulder more of the financial 
burden for our residents. Fortunately, the Indiana General Assembly 
anticipated this and established a State Disaster Relief Fund (SDRF) 
which provides for limited financial assistance to individuals and 
communities under certain conditions. As a result of the April 2013 
flooding, Governor Pence declared an emergency for affected counties 
and the residents and communities were eligible to apply for SDRF 
compensation. Disbursements for the 2013 central Indiana flooding will 
be the largest ever awarded for disaster relief using the SDRF.
    An integral aspect of response and recovery is mitigation, which 
seeks to reduce or eliminate threats and risks of known hazards. 
Recovery and mitigation efforts go hand-in-hand with one another. 
Recovery operations evaluate damage that resulted from a disaster, and 
determine next steps to assist individuals. From that and other 
assessments, our mitigation efforts are born. By understanding the 
potential damage in a given disaster, we can better prepare for them 
and work to find ways to reduce or even eliminate risks associated with 
them. The Indiana Standard Hazard Mitigation Plan and Hazard Mitigation 
Grant Program provide a base and framework for mitigation efforts.
                         training and exercise
    Training and participation in simulated exercises is another key 
component to the IDHS' ability to coordinate the State's disaster 
preparedness. Exercises can range from seminars and drills, to full-
scale exercises involving hundreds of individuals from many areas of 
the State. In fact, IDHS has organized exercises that have included 
multiple States, and even observers from foreign countries. In the last 
3 years, IDHS has organized the training of more than 37,000 responders 
in classes that have connections to mass casualty, weapons of mass 
destruction, and CBRNE (chemical, biological, radiological, nuclear, 
explosive).
    The Muscatatuck Urban Training Center is a highly-regarded training 
complex that provides unique learning situations, and is in our own 
backyard. Having the ability to configure buildings or collapsed 
structures into real-life scenarios with role players not only improves 
the training environment, but also provides emergency responders with 
vital experience that exceeds a traditional classroom training 
environment.
    During one recent full-scale exercise, we had an international 
visitor in emergency management indicate he had never seen a facility 
like Muscatatuck in his considerable experience. The facility is used 
by emergency responders from around the world and includes military and 
civilian role players. Indiana is remarkably poised to not only better 
equip our responders but to also encourage regional and National 
training activities that are essential when faced with large-scale 
disasters such as an earthquake or WMD event. Even as we are now having 
this hearing, nearly 7,000 members of the U.S. military from NORTHCOM 
are engaged with local responders at the Muscatatuck venue in an 
exercise called Vibrant Response. Next week, Ohio authorities will 
deploy 150 responders and officials to coordinate a simulated WMD 
attack. Members of IDHS will be observing the exercise to learn how to 
adapt and apply our plans to different emergencies that may arise, and 
to better coordinate regional response that would be required should 
central Indiana experience a mass casualty event. I have directed our 
staff to fully participate in the Vibrant Response exercise in 2014 and 
2015.
    During my experience in working on Hurricane Katrina relief in 2005 
and coordinating numerous activities with the U.S. military active 
duty, reserve, and National Guard forces, I saw how critical it is to 
understand not only the resources and capability that active-duty 
forces bring to large-scale disasters, but also how coordination must 
be carefully integrated with civilian authorities for maximum 
effectiveness.
    A variety of training sessions are used to supplement exercises. 
These sessions can range from search-and-rescue and emergency medical 
services training, to hazardous materials (HAZMAT), radiological 
emergency, and terrorism and weapons of mass destruction (WMD) 
training. Our first responders have a wide array of learning tools 
available. Regular interaction and coordination within the public 
safety community, along with extensive training utilizing the National 
Incident Management System (NIMS), contributes to our State's response 
to emergency situations. For example, just in the past month, I 
authorized more than a dozen of our local responders to travel to wild 
fires in Alaska and California to better provide them with training to 
understand their importance in coordinating disaster response and 
organizing resources for appropriate deployment, all the while working 
within the NIMS framework. It is worthwhile to reiterate that the 
availability of Federal training grant dollars, State coordination, and 
local participation makes such shadowing/learning opportunities 
possible. Indiana is committed to an integrated approach in support to 
our local community emergency managers and responders.
                     strategies and tactical plans
    Planning is another important aspect to IDHS. The planning division 
is charged with establishing the strategies and tactical plans used 
throughout the State for emergency management, but it also includes 
multiple disciplines, including the State-level agencies of the Indiana 
State Department of Health, Indiana State Police, Indiana National 
Guard, Indiana Department of Transportation, Indiana Department of 
Correction, and Indiana Department of Environmental Management; local 
agencies including fire, law enforcement, emergency management, 
emergency medical service, and more; and Federal agencies, such as U.S. 
Department of Homeland Security, Federal Emergency Management Agency, 
U.S. Department of Energy, and the Federal Bureau of Investigation.
    IDHS has actively participated in the preparation, review, and 
publication of more than 50 plans or annexes to prepare for a variety 
of emergencies. Such plans require regular updates and validation. Our 
planning division is required to not only develop comprehensive 
emergency plans but must engage in the training and exercise of plans 
to ensure what is intended is being achieved.
                grants support local and state agencies
    Another important function within the IDHS Planning Division is 
grant management. Grant management works to effectively administer 
funding to local communities as provided either from the State or the 
Federal Government. These funds provided to IDHS are distributed 
throughout the State for training, exercise, equipment, and personnel. 
In 2012, more than $11 million in grant funding was awarded. More than 
$7.3 million of that total, or about 64.3%, went to locals, which 
includes support to county emergency management agencies, by paying 
half of the cost of directors and, in the counties where there are 
additional staff, 50% of the cost of assistant directors and support 
staff is reimbursed. More than $4 million, 35.7%, went elsewhere in the 
State. Even money that goes to the State is used to benefit and provide 
for locals. Currently 43 IDHS employees are grant-funded, for a total 
of more than $2.7 million annually. The majority of these positions 
directly support training, exercise, planning, and emergency response 
and recovery. Their work is ultimately for the benefit of local 
emergency response efforts.
    IDHS receives funding from four main Federal grants: The Homeland 
Security Grant Program (broken into the State Homeland Security Program 
and the Urban Areas Security Initiative), Emergency Management 
Performance Grant, Nonprofit Security Grant Program, and Hazardous 
Materials Emergency Preparedness Grant Program.
    The Homeland Security Grant Program (HSGP) plays an important role 
in the implementation of the National Preparedness System (NPS) by 
supporting the building, sustainment, and delivery of core capabilities 
essential to achieving the National Preparedness Goal (NPG) of a secure 
and resilient Nation. Delivering core capabilities requires the 
combined effort of the whole community, rather than the exclusive 
effort of any single organization or level of Government. This grant 
provides planning, equipment, training, exercise, and management and 
administrative funding to emergency prevention and preparedness to the 
State of Indiana. This funding has been used to support our district 
task forces. We are in the process of evaluating the 2014 HSGP grant 
funding proposals and will align any approved requests with the agency 
strategic plan and Governor Pence's Roadmap for Indiana.
    The purpose of the Emergency Management Performance Grant (EMPG) 
Program is to assist State, local, territorial, and Tribal governments 
in preparing for all hazards. Title VI of the Stafford Act authorizes 
FEMA to make grants for the purpose of providing a system of emergency 
preparedness for the protection of life and property in the United 
States from hazards and to vest responsibility for emergency 
preparedness jointly in the Federal Government, States, and their 
political subdivisions. The Federal Government, through the EMPG 
Program, provides necessary direction, coordination, and guidance, and 
provides necessary assistance, as authorized in this title, so that a 
comprehensive emergency preparedness system exists at all levels for 
all hazards. We use the EMPG primarily to support county emergency 
managers.
    The Nonprofit Security Grant Program (NSGP) provides funding 
support for target-hardening activities to nonprofit organizations that 
are at high risk of a terrorist attack and are located within one of 
the specific UASI (Urban Areas Security Initiative)-eligible urban 
areas.
    The Hazardous Materials Emergency Preparedness (HMEP) grant program 
is intended to provide financial and technical assistance as well as 
direction and guidance to enhance State and local hazardous materials 
emergency planning and training. The HMEP Grant Program distributes 
fees collected from shippers and carriers of hazardous materials to 
emergency responders for HAZMAT training and to Local Emergency 
Planning Committees (LEPCs) for HAZMAT planning. IDHS uses this grant 
to advance our CBRNE training and risk prevention efforts.
    A breakdown of these grants since 2010 is as follows.

----------------------------------------------------------------------------------------------------------------
                                                       2010            2011            2012            2013
----------------------------------------------------------------------------------------------------------------
HSGP--SHSP......................................     $11,326,441      $5,663,221      $2,801,316      $3,459,364
HSGP--UASI......................................       7,104,700               0       1,250,000               0
EMPG............................................       6,562,747       6,529,870       6,749,053       6,592,684
NSGP............................................               0               0          28,161               0
HMEP............................................         512,532         512,532         537,270         536,745
                                                 ---------------------------------------------------------------
      TOTAL.....................................      25,506,420      12,705,623      11,365,800      10,588,793
$ CHANGE (prev. year)...........................  ..............     -12,800,797      -1,339,823        -777,077
% CHANGE (prev. year)...........................  ..............         -50.18%         -10.54%          -6.83%
----------------------------------------------------------------------------------------------------------------

                        fire and building safety
    Also under IDHS's organizational umbrella is the State Fire 
Marshal, who leads IDHS's fire and building safety. This includes 
commercial building construction plan review, general building 
inspection, and specific responsibility for the compliance of elevators 
and boiler and pressure vessels. Inspections also occur for annual 
festivals, fairs, and other entertainment venues, including amusement 
rides. Arson investigators are also placed throughout the State to 
assist with local fire investigations when help is requested.
    IDHS' certification branch administers the licenses for 
firefighters, emergency medical services personnel, and conducts 
ambulance inspections.
                         mass casualty response
    The agency provides assistance with State-wide HAZMAT and CBRNE 
response and expertise. Many local communities have highly-qualified 
HAZMAT responders and central Indiana is fortunate to have considerable 
expertise when needed. Having capabilities such as CBRNE will be 
crucial during a mass casualty incident as a result of either an 
accident or terrorist attack.
    With volunteers from a variety of groups in the medical, mental 
health, and funeral director communities, the Indiana Disaster Portable 
Mortuary Unit (DPMU) is maintained by IDHS and is designed to relieve 
overwhelmed morgues where a disaster has occurred. It has all of the 
necessary tools which are required during such a mass casualty.
    Another organization crucial to the State's planning and response 
is the Office of Faith-Based and Community Initiatives (OFBCI). OFBCI 
works to link organizations to those in need by using grants and 
services. It advocates for volunteerism, including faith-based 
initiatives which make a difference in the community both before and 
after a crisis has endangered a community. The OFBCI offers support for 
Emergency Support Function 14, Long-Term Community Recovery. It also 
works with the Indiana Voluntary Organizations Active in Disaster 
(VOAD) team to provide support and relief in the aftermath of disaster 
situations. The combination of these two organizations assisted in 
harnessing the power of volunteers just last year when devastating 
tornadoes ripped numerous Indiana communities. Their efforts resulted 
in substantially lower costs, saving millions of dollars for those 
affected by the Southern Indiana tornado event recovery in 2012. Debris 
removal was an excellent example with not only volunteers, but 
strategic use of other State resources.
    Several of these aspects come into play when working to increase 
our preparedness for a mass casualty incident. Over the past 5 years, 
nearly $1.2 million in grant funding has been allocated toward 
preparedness, specifically for CBRNE or WMD events. From that, more 
than $850,000 has assisted central Indiana. This support provides 
equipment to our first responders, vehicles to aid in response and 
recovery, and training classes and conferences for added education.
    Chairman Brooks has properly identified the importance of focusing 
also on events that could result from terrorist activity or a 
consequence of man-made events. The recent tragic bombing during the 
Boston Marathon illustrates the need for integration and coordination 
among intelligence gatherers, fusion center analysts, law enforcement 
agencies, and local responders. Following the Boston bombing, Indiana 
adapted planning efforts for the events in central Indiana such as the 
Indianapolis 500 Festival Parade and 500 Mile Race. Traffic was 
diverted from critical infrastructure, screening techniques were 
employed that clearly elevated detection protocols and heightened 
intelligence activities all combined to improve threat identification 
and risk management at one of the country's largest sporting events.
    Our on-going preparedness is on three levels: Federal, State, and 
local. At the Federal level, we work with military and non-military 
entities to enhance safety efforts, train, exercise, and plan.
    Groups like FEMA and the FBI offer resources to aid in our 
preparation. FEMA Region V has been responsive to the needs of the 
State, especially during times of emergency. The FBI is a teammate of 
ours in CBRNE response and radiation training. The FBI also holds an 
annual conference on WMDs, which IDHS promotes and attends. IDHS 
recently held a comprehensive planning exercise involving policy 
leaders from IDHS, ISDH, Indiana Board of Animal Health, Indiana 
Department of Transportation, Indiana State Police, Indiana State 
Department of Agriculture, State Chemist, Department of Natural 
Resources, Utility Regulatory Commission and Indiana National Guard's 
53rd Civil Support Team to simulate an ingestion pathway from nuclear 
reactor radiation release and how it could affect Indiana residents and 
businesses. We also have established close relationships with the 
Nuclear Regulatory Commission and the Department of Energy to better 
prepare for and understand these lead Federal agencies' role in a 
nuclear disaster.
    State partners, including the Indiana State Department of Health, 
Indiana Department of Transportation, and Indiana National Guard 
regularly complement and enhance IDHS' work. We not only prepare for 
events in the future, but also strive to secure the everyday safety of 
our citizens.
                local agencies: key to indiana's efforts
    Local partners are really the backbone of Indiana's efforts. When 
an emergency or disaster occurs, local agencies and responders are the 
first to experience the event and they are best equipped and trained to 
handle the situation. Just over a week ago, Indianapolis witnessed a 
horrific mass casualty event with an overturned bus returning from a 
week of church camp. Tragically, four individuals lost their lives but 
a rapid and professional response by numerous fire and emergency 
medical personnel treated or transported over 30 injured passengers, 
several hospital staffs coordinated the treatment of the injured and 
law enforcement continues to conduct an in-depth analysis of the 
crash's cause. The response by professional local responders was an 
example of how well they have prepared for tragedy when our communities 
are affected.
    The Indiana State Department of Health (ISDH) and Red Cross also 
perform active roles in aiding our initiatives and furthering the 
overall emergency preparedness of our State. The IDHS and ISDH began 
the development of the Indiana Disaster Medical System, intended to 
provide a structure and protocols for the State to support local mass 
casualty response. In support of the Indiana Disaster Medical System, 
the ISDH is in the process of procuring a 50-bed mobile hospital to 
provide a medical facility for communities suffering from disasters and 
an operating location for medical and non-medical volunteers. The ISDH 
has also developed the Advance Medical Supply Unit, which contains the 
most common types of supplies that medical personnel on the ground may 
need during mass casualty response. The ISDH has also nearly completed 
development of the new volunteer management system, SERV-IN, which will 
be utilized to better manage both medical and non-medical volunteers.
    The Red Cross has several internal training courses for their 
volunteers, which closely reflect the training provided by IDHS. These 
courses provide information on the effects of weapons of mass 
destruction and terrorism, CBRNE events, and mental health 
considerations during a WMD or terrorist event. This training makes Red 
Cross an important partner during times of emergency. Volunteers are 
necessary in a variety of roles during mass casualties and perhaps even 
more importantly, in providing long-term care and support for those 
visibly injured and others who are mentally traumatized.
    IDHS, along with its partner organizations, casts a wide net over 
the State of Indiana. By coordinating activities and initiatives with 
Federal, State, and local partners, IDHS is working diligently every 
day for Indiana.
                               conclusion
    In closing, I would like to thank Chairman Brooks, Ranking Member 
Payne, Members of the Indiana Congressional delegation in attendance, 
and the Members of the subcommittee for calling this hearing today. The 
issues discussed here are vital to the lives not just of Hoosiers, but 
to all Americans. I am proud to work every day to provide for the needs 
of the State, and the safety of our citizens. I am committed to working 
with the committee and our public safety partners to promote a safer, 
more secure State for all.

    Mrs. Brooks. Thank you, Mr. Hill.
    The Chairwoman now recognizes Ms. Mack to testify.

    STATEMENT OF DIANE MACK, UNIVERSITY DIRECTOR, EMERGENCY 
         MANAGEMENT AND CONTINUITY, INDIANA UNIVERSITY

    Ms. Mack. Good morning, Chairwoman Brooks. I appreciate 
this opportunity to work with you again. Senator, Congressman, 
and Congresswoman, thank you also for the opportunity to share 
with you a university perspective.
    I represent the Office of Emergency Management and 
Continuity with Indiana University. IU has eight campuses 
within Indiana across a distance of 300 miles and with 
approximately 150,000 students, faculty, and staff. We also 
have centers in Wisconsin, Montana, and Kenya, and 6,000 world-
wide travelers each year. We abide by National voluntary 
emergency management standards and comply with Federal 
regulations, most notably the Higher Education Opportunity Act 
and the Clery Act.
    The Clery Act, while noble in its intent, is focused on 
after-the-fact data accounting. While IU abides by such 
regulations, our priority is on prevention, mitigation, and 
preparedness to reduce the need for response and recovery.
    In my office, the emergency management directors have 
somewhat different roles than local emergency managers. We are 
not just coordinators but rather we are expected to be in 
command of our largest incidents. We expand our own knowledge 
base through integration with other teams such as the FEMA 
Search and Rescue Indiana Task Force 1 and the State Incident 
Management Assistance Team.
    We have responded in command and general staff positions to 
the Henryville, Indiana EF-4 tornado, which covered 71 square 
miles, and to Hurricane Sandy on Long Beach Island, New York. 
We brought those lessons learned back to IU and applied them.
    The university environment offers unique challenges in 
addition to the age-old question of how to get teenagers to pay 
attention to anything. We conduct camps for access and 
functional needs children and support camps for children of all 
ages during the summers. We face increasing active-shooter 
threats, have thousands of laboratories, including 900 in 
Indianapolis alone, have experienced devastation due to 
flooding, and most campuses of all universities in Indiana host 
major events.
    For IU, in addition to our 60,000-person football venue, we 
host international swimming, diving, and track events, 
concerts, the Nation's largest half-marathon at IUPY in 
Indianapolis, and the Little 500 at IU in Bloomington. This 
year, the Komen Race for the Cure and Little 500 happened on 
the same day, and both occurred less than a week after the 
Boston Marathon bombings.
    With so many events of significant size, preparations for 
mass fatality and mass casualty incidents is forefront. Two 
weeks ago I presented on mass fatality and mass casualty 
incidents at the National Sports Safety and Security 
Conference. My focus in these efforts is to expand the 
traditional mindset of game-day operations and to the ``what-
if'' scenarios. We need to instill a sense of advanced planning 
and complete synchronization of public safety and event 
management in advance of a major incident. We need to have a 
standardized common operating picture for all responders and 
events management and ensure adequate plans, training, and 
exercises in advance. We have integrated this approach into IU 
football and are expanding to other events and campuses as 
well.
    In early June of this year, IU provided the Incident 
Management Team and served in unified command with the 
Bloomington Fire Department for a three-site search and rescue 
exercise that was spearheaded by the Indiana National Guard and 
Israeli Defense Forces. The lessons learned from this exercise 
cannot be replicated in a classroom or with any amount of 
equipment.
    For prevention of a mass casualty incident, equipment 
becomes key. But for the response to a mass casualty incident, 
the true ability to manage the situation lies not with the 
equipment but with the ability of the responders to mentally 
grasp the situation, adapt and be flexible, and work within a 
larger organizational structure than most have ever faced. The 
incident management perspective of command of the whole 
incident, which consists primarily of coordination of all 
resources and the setting of joint priorities rather than 
maintaining control of individual department resources, is 
paramount. These organizational and individual capabilities are 
honed through rigorous training and exercises that build on 
all-hazards plans.
    In advance of disasters, IU coordinates extensively with 
local, State, and National organizations. IU has excellent 
cooperation with law enforcement for active-shooter exercises, 
and we depend on local fire departments for day-to-day 
responses. We continue to work with these departments 
surrounding all IU campuses on the integration with IU's team, 
response teams, and command capabilities. IU has built incident 
management teams on each campus and a system-wide IM team. As a 
wholly-encompassed institution rather than individually-managed 
departments, IU has uniquely sustainable team capabilities, and 
we focus existing knowledge areas into incident command system 
roles. For example, purchasing becomes logistics. All faculty, 
staff, and students have a role in a disaster.
    In terms of funding for preparedness, IU is confronted with 
the funding quandary that exists for homeland security grants. 
IU is a quasi-State entity, which means that we are eligible 
for the State portion of homeland security funding. However, 
very little State funding is available, and local funding is 
not available directly for universities.
    We have been fortunate in our achievement of two emergency 
management for higher education grants over 5 years, but that 
funding stream is no longer available. Such funding, with 
refocused guidelines, would be helpful for universities, 
especially in regard to preparedness for other major incidents.
    In summary, universities are progressing in their planning 
for mass casualty and mass fatality incidents, and increased 
local coordination of Federal funding would assist progress. 
The incident command system works well for all jurisdictions--
Federal, State, local, Tribal, and universities--not just for 
incidents but also for major events; and all-hazards advance 
planning, including the ``what-if'' visionary components, will 
increase the efficiency and effectiveness of any response.
    I appreciate the opportunity to present this testimony and 
will answer any questions at the appropriate time. Thank you.
    [The prepared statement of Ms. Mack follows:]
                    Prepared Statement of Diane Mack
                             August 6, 2013
    Good morning Congresswoman Brooks, I appreciate this opportunity to 
work with you again. Senator, Congressman, and Congresswoman, thank you 
also for the opportunity to share with you a university perspective.
    I represent the Office of Emergency Management and Continuity with 
Indiana University. IU has eight campuses within Indiana, across a 
distance of 300 miles, and with approximately 150,000 students, 
faculty, and staff. We also have centers in Wisconsin and Montana, and 
6,000 world-wide travelers each year. We abide by National voluntary 
emergency management standards, and comply with Federal regulations, 
most notably the Higher Education Opportunity Act and the Clery Act. 
The Clery Act, while noble in its intent, is focused on after-the-fact 
data accounting, and while IU abides by such regulations, our priority 
is on prevention, mitigation, and preparedness, to reduce the need for 
responses and recovery.
    In my office, our Emergency Management Directors have somewhat 
different roles than local emergency managers. We are not just 
coordinators, but rather, we are expected to be in command of our 
largest incidents. We expand our own knowledge base through integration 
with other teams such as the FEMA Search and Rescue Indiana Task Force 
One, and the State Incident Management Assistance Team. We have 
responded in command and general staff positions to the Henryville, 
Indiana EF-4 tornado, which covered 71 square miles, and to Hurricane 
Sandy on Long Beach Island, New York. We brought those lessons learned 
back to IU and applied them.
    The university environment offers unique challenges in addition to 
the age-old question of how to get teenagers to pay attention to 
ANYTHING. We conduct camps for access and functional needs children and 
sport camps for children of all ages during the summers. We face 
increasing active-shooter threats, have thousands of laboratories, 
including 900 in Indianapolis alone, have experienced devastation due 
to flooding, and most campuses of all Indiana universities host major 
events. For IU, in addition to our 60,000-person football venue, we 
host international swimming, diving, and track events, concerts, the 
Nation's largest half-marathon at IUPUI in Indianapolis, and the Little 
500 at IU in Bloomington. This year, the Komen Race for the Cure and 
Little 500 happened on the same day, and both occurred less than a week 
after the Boston Marathon bombings.
    With so many events of significant size, preparations for mass 
fatality and mass casualty incidents is forefront. Two weeks ago, I 
presented on Mass Fatality/Mass Casualty incidents at the National 
Sport Safety and Security Conference. My focus in these efforts is to 
expand the traditional mindset of game-day operations into the ``what-
if'' scenarios. We need to instill a sense of advance planning and 
complete synchronization of public safety and event management in 
advance of a major incident. We need to have a standardized common 
operating picture for ALL responders and event management, and ensure 
adequate plans, training, and exercises in advance. We have integrated 
this approach into IU football and are expanding to other events and 
campuses as well.
    In early June of this year, IU provided the Incident Management 
Team and served in unified command with the Bloomington Fire Department 
for a three-site search-and-rescue exercise that was spearheaded by the 
Indiana National Guard and the Israeli Defense Forces.
    The lessons learned from this exercise cannot be replicated in a 
classroom or with any amount of equipment. For prevention of a mass 
casualty incident, equipment becomes key. But for the response to a 
mass casualty incident, the true ability to manage the situation lies 
not with the equipment, but with the ability of the responders to 
mentally grasp the situation, adapt and be flexible, and work within a 
larger organizational structure than most have ever faced. The incident 
management perspective of command of the whole incident, which consists 
primarily of COORDINATION of all resources and the setting of JOINT 
priorities rather than maintaining control of individual department 
resources is paramount. These organizational and individual 
capabilities are honed through rigorous training and exercises that 
build on all-hazards plans.
    In advance of disasters, IU coordinates extensively with local, 
State, and National organizations. IU has excellent cooperation with 
law enforcement for active-shooter exercises, and we depend on local 
fire departments for day-to-day responses. We continue to work with 
these departments surrounding all IU campuses on the integration with 
IU's response team and command capabilities.
    IU has built incident management teams on each campus, and a 
system-wide IMT. As a wholly-encompassed institution, rather than 
individually-managed departments, IU has uniquely sustainable team 
capabilities, and we focus existing knowledge areas into incident 
command system roles. For example, Purchasing becomes Logistics. All 
faculty, staff, and students have a role in a disaster.
    In terms of funding for preparedness, IU is confronted with a 
funding quandary that exists for homeland security grants. IU is a 
quasi-State entity, which means that we are eligible for the State 
portion of homeland security funding. However, very little State 
funding is available, and local funding is not available directly for 
universities. We have been fortunate in our achievement of two 
Emergency Management for Higher Education (EMHE) grants over 5 years, 
but that funding stream is no longer available. Such funding, with 
refocused guidelines, would be helpful for universities, especially in 
regard to preparedness for CBRNE and other major incidents.
    In summary, universities are progressing in their planning for mass 
casualty/mass fatality incidents, and increased local coordination and 
Federal funding would assist progress. The Incident Command System 
works well for all jurisdictions--Federal, State, local, Tribal, AND 
universities--not just for incidents but also for major events, and 
all-hazards advance planning--including the ``what-if'', visionary 
components--will increase the efficiency and effectiveness of any 
response.
    I appreciate the opportunity to present this testimony, and will 
answer any questions at the appropriate time. Thank you.

    Mrs. Brooks. Thank you, Ms. Mack.
    While typically the Chairwoman would recognize themselves 
for 5 minutes of questioning, it has come to my attention that 
Congressman Young, which is not uncommon in Congressional 
hearings as well, has to be other places. So I will defer my 
questioning to Congressman Young from Indiana.
    Mr. Young. Thank you so much, Madam Chairwoman. I really 
appreciate it. Sorry I can't be with everyone longer today.
    I want to start with a question. Try to limit your response 
to 1 minute each. Just very quickly, Chief Orusa, Sheriff 
Bowen, and Director Mack, you each indicated the importance of 
being properly resourced to fulfill your training mission and 
for other purposes, to make sure you are fully prepared for a 
mass casualty event.
    I want to know how do you measure the effectiveness of 
dollars spent? Of course, one metric might be the number of 
hours trained. Another might be conceivably the skill sets of 
individuals within your purview. Each of you take a turn at 
this so that we can assess as policymakers whether or not these 
monies are being spent and how they need to be spent.
    Sheriff Bowen. Well, obviously, that is a difficult 
question to answer and one that we hope we never have to 
answer. Certainly, it is important that we have the resources 
in play and that we have the training and those components in 
play to be able to deal with a hazard. But until we are 
actually tested, as Chief Orusa stated, we can block and tackle 
all day long, but until we are truly tested in an event, we 
really don't know what our true capabilities will be and 
whether our infrastructure will match up to what the needs of 
that specific event are.
    So while I would like to say that we have tested that 
equipment and that training in a real-life scenario, I am proud 
to say that we have not had to do that and hopefully will not 
have to.
    Mr. Young. Right.
    Chief Orusa. The Homeland Security Exercise and Evaluation 
Program is an excellent program, and it focuses on gap 
analysis, core capabilities, and improvement plans. So that 
tactical task-level section is addressed.
    Also, our training budgets through the State Homeland 
Security Program have very rigid budget requirements that we 
have to submit. So not only is there oversight financially, 
there is oversight from a core capability and improvement 
standpoint.
    Mr. Young. Thank you.
    Ms. Mack.
    Ms. Mack. I would also agree with the Homeland Security 
Exercise Evaluation Program. Coming up with objective criteria 
for measurement of such things is going to be very difficult. 
But we did demonstrate at this past year if the State had not 
provided the funding, if the homeland security funding had not 
come through and been applied to the Muscatatuck exercises, 
which allowed us to expand our capabilities and be able to 
manage that in an exercise environment, we would have had a 
much more difficult time for the Henryville tornado and also in 
Long Beach, New York. It was very clear that the people who 
worked at those exercises, those large State-level and 
National-level exercises, were much more prepared.
    Mr. Young. It can be very difficult. I know it is an 
imprecise science, trying to measure a low-risk, high-impact 
sort of event, and that is what we are dealing with here. It is 
hard to assess probabilities. But nonetheless, we do have the 
gap analysis, and an independent study has been commissioned, 
Director Hill, you indicated, to assess emergency preparedness 
and assess overall capabilities of our entire State operation. 
You indicate you are still reviewing that report, but within 
the next month or so we can expect to see implementation of 
some of the findings.
    Could you share with us some of the initial gaps identified 
within that report, sir?
    Mr. Hill. Sure.
    Mr. Young. Thank you.
    Mr. Hill. I appreciate the question, and I can understand 
that there is a lot of sensitivity to this because it is not 
intended really to replace what we have been doing. There has 
been a lot of tremendous work done in the last few years 
regarding the State of Indiana.
    I would say to you that one of the biggest gaps is making 
sure that we have integrated at the local level planning 
capability, not just at the State level. By that I mean do 
people at the Emergency Management Agency level in each county 
have resources that help them do planning, based upon what 
Chief Orusa said, in terms of threats, hazards, identification, 
risk analysis, the THIRA.
    One of our goals this year is to really get out into those 
local communities as a part of that and identify those risks at 
the local level, not just what Indianapolis thinks but what do 
the local communities identify as their risk? That is going to 
be critically important in doing that.
    In regard to the cost savings, Representative Young, I 
would just say to you that one of the things that we do to 
measure cost-effectiveness, in the Henryville tornadoes, FEMA 
actually assessed the damage, and they estimated debris removal 
at $40 million. Due to the resources, the tremendous work that 
was done with local agencies, Department of Corrections, not-
for-profit groups, we actually ended up with a bill of about 
$11 million. So that is one big cost analysis that we were able 
to do on the mitigation side after preparedness.
    Mr. Young. Thank you for your encouraging responses, and I 
yield back.
    Mrs. Brooks. I thank you, the gentleman from Bloomington. I 
really appreciate your participation in this panel today. I 
welcome you back to your hometown of Carmel and just really 
appreciate the interest that you have shown in ensuring that 
our first responders and our medical professionals have the 
resources that they need, and I just want to thank you for 
being here today.
    At this time, I would ask the gentleman from Granger, 
Indiana for any questions he might have.
    Senator Donnelly. Thank you, Madam Chairwoman. To all of 
you, thank you for your service, and to all the first 
responders.
    Sheriff Bowen, you had mentioned that Central Indiana first 
responders work off of different communications systems, and I 
was wondering if there is any effort now to try and be on the 
same system, and what issues this causes when an event occurs?
    Sheriff Bowen. Well, there are issues when an event occurs. 
Obviously, being on different communications systems causes 
breakdowns. Hamilton County is looking at moving forward with 
their communications technology to a P-25 platform, which is 
the state-of-the-art National recommended communications 
network. So we are moving in that direction. That will allow 
interoperability with the City of Indianapolis and other 
regions.
    So it is critical that communications are functioning at a 
high level. Any time that you are involved in a mass casualty 
incident, bringing folks together from other regions that have 
different types of communications systems, it is challenging. 
So there are things that can be done to network those systems 
together, but obviously it takes time and expertise.
    Senator Donnelly. Right. Are there any efforts or 
discussions going on to get everybody together as they go 
forward with communications purchases, for instance, with other 
sheriffs' offices or other counties or other cities, to see if 
we can all get on the same platform?
    Sheriff Bowen. There is certainly a move towards that. The 
State is working towards the P-25 system. Obviously, funding is 
a critical component to any communications network. It is very 
technical and very expensive, and the funding component is 
really the roadblock as we move forward.
    Senator Donnelly. Okay.
    Chief Orusa, thank you for your service. You come from a 
very fast-growing place. All you have to do is drive in in the 
morning to find that out.
    [Laughter.]
    Senator Donnelly. As you look at the challenges you have, 
how do you keep up with the businesses coming in, knowing what 
is in place in those businesses, in the subdivisions that are 
going in, in the various plants that are in Fishers? How do you 
make sure that you know what is going on there, and what 
requirements you have, and how do you cope with the growth that 
you are dealing with?
    Chief Orusa. Any challenges for us--and growth is well-
stated as one of them--the foundation of the organization and 
the operational philosophy and leadership philosophy is really 
that any challenge, whether it is growth, whether it is 
disaster, whether it is laying off fire fighters, whether it is 
no pay raises, has to do with our values and our mission. 
Through collaboration with all the people in our organization, 
we did a values audit and we re-wrote our values and our 
mission statement, and we adopted a certain leadership 
philosophy which means there is no more leadership out of self-
promotion, pride, or self-protection, fear. It is service-
driven, out of a dedication to a cause or relationship.
    So it starts with that, and then the next step is putting 
the best and brightest in our organization together to 
collaborate, to have a vision that anticipates the growth and 
identifies and defines what the challenges are, and then 
getting support from our policymakers financially to try to get 
ahead of that growth.
    Senator Donnelly. How do you get word, for instance, if a 
company is coming in to handle these particular chemicals or 
these particular things? How do you find that out?
    Chief Orusa. We have a fire prevention bureau, and we have 
an EMA director that works closely with our department head in 
economic development and business development. So right away, 
we are in the decision-making process. When that happens, we 
can identify that as a target hazard before it is built, 
identify and define any risks, and then try to prevent and 
mitigate those risks before they become----
    Senator Donnelly. Okay.
    Mr. Hill, we are a proud agricultural State that does an 
extraordinary job, and obviously a lot of fertilizer and 
related products are handled in our State as well. I was just 
wondering what the procedures are for those facilities that 
store fertilizer, that make fertilizer, what inspections are 
planned and what rules you have regarding that.
    Mr. Hill. Well, Senator, there is something called the 
Community Right to Know, and basically what it amounts to is 
any facility that has those kind of chemicals are required to 
report those various storage capacity and quantities on-hand to 
the State Department of Environmental Management.
    Senator Donnelly. Do you have an inspection plan that you 
work together with these locations to make sure--or, in effect, 
I think it is helpful to them to know, hey, here is how we 
would like you to handle these products?
    Mr. Hill. Yes. We are required to go out and inspect those 
sites, and just this year after the West, Texas event, I was 
very concerned about it and asked the fire marshal to come in 
and have a discussion with me, and we used a GIS application to 
identify any facility that stored fertilizers within 500 meters 
of any school, hospital, community gathering-place, and then we 
went out and personally inspected those facilities immediately 
to make sure we knew what was in the building, to confirm what 
they had reported was accurate; and then second, to make sure 
that they were, in fact, following fire building code safety.
    So those kind of processes are in place. There are a lot of 
facilities. We have an annual inspection where we go around and 
inspect them. We work with the State chemist, who is based out 
of Purdue University, and we also work with him very closely.
    Senator Donnelly. Very good. Thank you.
    I think I am out of time.
    Mrs. Brooks. Thank you.
    I must say, I attended the hearing on West, Texas and saw 
the diagram of that fertilizer plant explosion, and it was in 
very close proximity to a school and an apartment complex, and 
so there was incredible damage.
    At this time, I would ask the gentlelady from Jimtown for 
any questions she might have.
    Mrs. Walorski. Thank you, Madam Chairwoman.
    I think I have to address my remarks to Mr. Velasquez since 
we are talking also about Northern Indiana, and to Mr. Hill. 
Again, thanks for all of you being here.
    But I want to go back to the question that Senator Donnelly 
asked because I think it is applicable, especially in places 
like Northern Indiana, where it is a very diverse area where we 
have significant athletic--the University of Notre Dame--
activity just about every weekend in the fall, but also 
surrounded by rural areas. In many cases, there are fire 
territories and fire districts.
    I am just wondering, I guess, Mr. Velasquez, from the 
position of our proximity even to Chicago, closer to Chicago 
than we are to Indianapolis, does that present a different set 
of circumstances? If so, how is the communication handled 
between local, State, and Federal in the event of, say, an 
attack on Chicago? When the communication systems go down, what 
do you do in rural areas?
    Mr. Velasquez. That is a great question. I appreciate that. 
I will say that, obviously, as Director Hill mentioned, what is 
critically important as it relates to planning for whatever 
hazards may befall us is that integrated approach to emergency 
planning. That is one of the things that we have taken on at 
FEMA Region V as a priority, making sure that as we plan for 
whatever events may affect us, whether they are natural or 
whether they are on the terrorism side, to ensure that everyone 
is coming to the table from an integrated perspective to plan 
for those events. That is the only way that you can better 
understand capabilities and what people can bring to the table.
    I will mention one of the areas that we focused our 
attention on in the region and really embraced planning for is 
improvised nuclear devices and an improvised nuclear device 
detonation in a large metropolitan area. We have basically 
spearheaded one of the most comprehensive planning initiatives 
to confront this type of threat, and I can tell you that 
Indiana has been at the table with us with regard to that 
planning effort.
    We have partnered with the counties, the northern counties. 
In Indiana, folks have attended a number of our meetings to 
discuss the impacts of an event of this magnitude, the primary, 
secondary, tertiary effects of this type of an event, what 
evacuation would look like, what are those types of needs, what 
are the capabilities, how we can provide funding support 
through FEMA's public assistance program in terms of how we 
would provide funding for host States in an evacuation-type of 
a circumstance, how we would communicate, what would that mean, 
the wind speed, direction, plume, time, shielding. All of those 
factors play a role in our decision-making process, how we 
would communicate that.
    So I can assure you that we have taken on, as Director Hill 
has mentioned, a very integrated approach to planning, making 
sure that as we plan for whatever events may befall us, we are 
bringing everybody to the table to ensure that we have an 
effective and a coordinated response to an event.
    Mrs. Walorski. I appreciate it.
    Mr. Hill, what do we do in rural areas with volunteer fire 
departments in districts and territories?
    Mr. Hill. Volunteer fire departments are very important, as 
you know. Seventy percent geographically of our State is served 
by volunteer fire departments. One of the things that Governor 
Pence has asked me to do through our staff is to look at the 
feasibility of a State-wide Fire Academy. So he has dedicated 
funding in his budget. As you know, this was a pretty tight 
year. So we are going to be looking at, how do we improve fire 
service in the rural areas?
    I have been in contact with members of Noble County just 
recently and I learned that they have plenty of equipment, but 
they are having trouble staffing some of that equipment during 
the daytime because people are working. That is a very real 
issue that we have to address.
    To answer your question, we work regularly with them 
through our Fire Marshal's Office, but I also want you to know 
that I went around and visited every one of the 10 districts 
after assuming office, and I will be going around to those 10 
districts again after we get done with this assessment, talking 
through this.
    But there is tremendous capacity that has been built up 
both equipment-wise and organizationally in our 10 homeland 
security districts that make local response viable, as opposed 
to somebody coming in from Indianapolis and helping them.
    Mrs. Walorski. I appreciate it.
    Mr. Velasquez, just one quick question. So are we victims 
in Region V? Has sequestration taken resources that we need in 
Region V?
    Mr. Velasquez. We have done a good job of leveraging our 
resources, our capabilities. We have taken a very regional 
approach to leveraging resources. So I think we are doing a 
pretty decent job and making sure that we are leveraging all of 
those capabilities that exist in the region, and that regional 
approach is critical.
    Mrs. Walorski. I appreciate it.
    Madam Chairwoman, I yield back the remainder of my time.
    Mrs. Brooks. Thank you. I believe I mentioned in my 
statement the last week before heading back to Indiana I had an 
in-depth discussion with Doctor Tara O'Toole, who is the Under 
Secretary for the Department of Homeland Security's Science and 
Technology Directorate, because I wanted to ask her, because I 
didn't have a lot of knowledge about the consequences and 
threats in a mass casualty attack when a biological weapon or a 
nuclear weapon might be used. One of the issues we discussed 
was whether or not to evacuate an area when you don't have this 
kind of advanced warning, as Mr. Velasquez just talked about, 
of what is called an IND, or an improvised nuclear device 
detonation.
    What I am curious about, we have obviously, throughout the 
country and in Indiana as well, issues involving flooding or 
maybe have issues involving hurricanes on the East Coast. I am 
curious what kind of training and what kind of discussions take 
place in communities and in our communities here with respect 
to whether or not evacuation is necessary, and I think I will 
start with you, Mr. Hill.
    Mr. Hill. Well, it is a very probing--it is a very 
insightful question, but I will say a couple of things.
    Mrs. Brooks. Well, and if I could, because what Mr. 
Velasquez reminded us, and if you think about a nuclear device, 
you have to think about issues or an attack involving wind 
speed and the plume and the direction and all those things, and 
these are things that we don't think about very often here in 
Indiana. So, I am sorry.
    Mr. Hill. That is all right. Just last month, the policy 
team at State of Indiana met to deal with this issue of a 
nuclear mishap or intentional act, and we spent 5 hours in the 
policy room talking through scenarios. FEMA was there. They 
were doing an evaluation of us. This wasn't just something to 
make us feel good. We were being evaluated on our effectiveness 
in being able to do that.
    I can tell you that the key thing in this kind of decision 
is having the right people in the room that have expertise. For 
example, you mentioned in Northern Indiana the farms. You have 
to have people in the room who understand agriculture, who 
understand how this radiation can be transported, how it can 
move through food. I don't have that knowledge. We have to 
bring in the proper people to make those decisions.
    Second, I would say to you one of the things that amazed me 
at the Boston bombing was the way, when they asked for the 
people to stay in their homes, the way they did it. That is 
incredible for the City of Boston.
    So I think what we have to realize is that communication of 
expectations is going to be very important, through the media, 
social media, all kinds of venues, that we clearly communicate, 
after policy decisions are made, what we expect the public to 
do for their safety. It is going to be hard to keep people 
indoors when they want to get home to their families and so 
forth, but I think sometimes sheltering in place, from what I 
have been reading and studying, is a very key element in this 
decision making.
    Mrs. Brooks. Thank you so much.
    Sheriff Bowen, anything you would like to comment on with 
respect to evacuations?
    Sheriff Bowen. Well, obviously, this is critically 
dependent upon the size and scope of the incident and the 
accuracy of the intelligence, and the time frame for conducting 
an evacuation. It is important that we do get it right because 
we could run into the ``boy who cried wolf'' mentality if we 
continue to ask people to do things and it becomes unnecessary. 
Then we are going to lose the faith of the community. As Mr. 
Hill stated, in the Boston situation, it worked, and it worked 
very well. But we run the risk of crying wolf oftentimes, as we 
had seen in Hurricane Katrina when people were asked to leave. 
People had been through those types of incidents before and 
didn't respect the request to evacuate and chose to ride the 
storm out.
    Obviously, we are dealing with a much more catastrophic 
event than ever seen or ever prepared for, and that only leads 
to the situation for the mass incident and what we have to do 
in preparation and cleaning up afterwards and helping those 
folks.
    So if warnings are not heeded within the critical time 
frame, all we can do is shelter in place and hope for the best. 
It is very much a case-by-case situation, and as Director Hill 
said, we must rely on the experts in the field, the weather 
forecasters, the health experts, and those that are in the know 
to help make the best decision possible.
    Mrs. Brooks. Thank you. Thanks.
    Ms. Mack, I can't even imagine, having been in higher 
education at Ivy Tech as General Counsel. We didn't have 
residents, though, at Ivy Tech, and all of those students that 
you are responsible for. What kind of discussions do you have 
at IU?
    Ms. Mack. We are having those very similar evacuation 
versus shelter-in-place discussions. With our increasing 
population of international students, evacuation is incredibly 
difficult for them. So we have to take that into consideration 
as well. This is why we stress the all-hazards planning. In 
having those tools in your toolbox, depending on the scenario, 
depending on the situation on the ground, you can pick which 
tools you need for the appropriate situation and apply it.
    Mrs. Brooks. Thank you very much. My time is up.
    We are now going to start a second round of questioning, 
and I will yield to the gentleman from Granger.
    Senator Donnelly. I think this is the lightning round.
    [Laughter.]
    Senator Donnelly. Sheriff, at the end of the day when you 
sit there in your office and you think about the things that 
you are challenged with and you look at the scenarios that are 
possible, what is the one thing you say, look, this is the area 
we really need to get better at?
    Sheriff Bowen. Well, I would say that with regard to the 
challenges that we face, it is in making sure that we are 
training, preparing, identifying threats and hazards, working 
as a community to help protect our citizens not only from 
public safety but from the private sector as well. It is a 
group effort. It is an organized effort on all of our parts to 
help keep our communities safe.
    Senator Donnelly. Okay. Mr. Hill, this year at the Indy 
500, it was shortly after Boston, and one of the challenges we 
faced--and I know they were working very hard. But one of the 
challenges we faced was all the coolers coming in and all the 
traditions that we have had at the 500. How do you keep our 
traditions in place while at the same time keeping people safe 
and making sure that they can enjoy the race in safety? Are you 
working directly with the folks at the Indy 500 at the present 
time?
    Mr. Hill. Senator, following the Boston event, I attended 
the planning session for the Indianapolis 500, and we are 
integrally involved in the planning process leading up to that. 
One of the things that had to be discussed was the reality of 
what they just saw in Boston and how pervasive it was in terms 
of the public's endangerment. So we made a decision, not me 
personally but the Public Safety Committee, the chief of the 
Speedway Police and so forth. They made an intentional effort 
to bring up this cooler issue, and it wasn't very pleasant at 
the time but most people understood why it was important, that 
we protect our people coming to that event.
    There was also another key part of that planning process 
that was adjusted that they hadn't done previously. They 
blocked off Georgetown Road, which then protected the whole 
backside of the infrastructure from having any kind of 
opportunity for an IED or any kind of mass explosion there. So 
there were some very specific things that were integrated into 
this year's planning process as a result of that Boston 
process. In fact, I attended a de-brief from the Fusion Center 
in Boston with the FBI, and we talked about that. As a result 
of that, we led to some of these discussions.
    Senator Donnelly. Is that a process that for next year you 
have already begun working together with the 500 folks?
    Mr. Hill. Well, the people meet monthly leading up to that, 
so they are already meeting for next year's event. So this is 
an on-going process. It began really before last year, but it 
is something that is institutionalized, and it is a very 
effective tool in working through planning for these major 
events.
    Senator Donnelly. Thank you.
    Ms. Mack, when you take a look at the challenges you face, 
do you have a list of scenarios you go through on a constant 
basis, or develop additional ones as you go through? How does 
that take place, that you look and go here are the 10 biggest 
challenges we face, here are the newest challenges we face? How 
does that process work?
    Ms. Mack. We do have, in addition to our all-hazards plan, 
a comprehensive emergency management plan, and we have hazard-
specific annexes. Inasmuch as we try to avoid management by 
shiny object, we do realize that we need to capitalize on 
certain situations. As much as that is not a situation we ever 
want to be in, we do need to make sure that we are harnessing 
the energy, as it were, for example, with Boston. It was a 
tragic situation, but we did need to make changes for that. As 
Mr. Hill was saying with the 500, the public will understand 
your changes when you implement changes after a big situation.
    Senator Donnelly. I found they are always willing to step 
up and do whatever is necessary. I am just wondering, do you 
have somebody who is like the designated person who brings up 
the difficult scenarios and the difficult problems that may 
arise in events when you get together?
    Ms. Mack. Absolutely. When we do our planning, I have three 
certified emergency managers certified by different sources who 
work with us and who are very good at poking holes in our plans 
and making sure that they are the best that they can be.
    Senator Donnelly. Thank you.
    Thank you, Madam Chairwoman.
    Mrs. Brooks. Thank you.
    I now turn to the gentlelady from Jimtown.
    Mrs. Walorski. Thank you, Madam Chairwoman.
    My question is, you know, I am proud to be a Hoosier, and I 
think we do all things well. So my question is: When it comes 
to best practices and kind-of back to what Congressman Young 
was asking prior on best usage of dollars spent, how it is 
measured? You all have been involved in training. Sheriff, I 
know you have, and the fire fighters have as well. Then I 
guess, Mr. Hill, you are new to the game. But as you look 
across the country and you go to all of these different 
exercises and you have colleagues around the country, my 
question is: What best practices have you been able to pick up 
and implement in the State of Indiana so that you can really 
say, you know what, I saw that, I learned it, and it is 
something we should do here? What would that be for all of you? 
What do we do well?
    Mr. Bowen.
    Sheriff Bowen. Well, I think as Hoosiers, we are all 
willing to step up and do, as Senator Donnelly said, what is 
necessary to make sure that we are protecting our community. I 
think through social media and other avenues, the communication 
between the folks in our communities has grown. The gathering 
of intelligence and the sharing of that information in an 
effort to make our area much safer has increased.
    So I think we need to continue to expand upon that again. 
It is not just public safety. It is not just police and fire 
and homeland security here to protect the citizens in our 
communities. It is our communities as a whole. I think that, as 
you say, Hoosiers are willing to step up and do their part to 
make sure that we are keeping our area safe.
    Mrs. Walorski. Mr. Orusa.
    Chief Orusa. Well, I agree with Sheriff Bowen. It is about 
the people that participate in the interoperability and the 
relationships that you build ahead of a disaster. But most 
notably, the lessons learned were in the Super Bowl last 
February, where we created the use of a playbook. An incident 
action plan is a management tool. But the planning section 
chief, I believe he is in the room, Tom Seevack, created a 
playbook, and it had supplemental information such as responder 
life safety information, weather, contingency plans, key 
personal contact information mapping, and now that has been 
recognized as a best practice and it is being used at other 
venues that hold the Super Bowl.
    So we are grateful for that. It is about the people, and we 
have really talented people in Indiana.
    Mrs. Walorski. Great. Thanks.
    Mr. Hill.
    Mr. Hill. Just briefly, I would say two things. First of 
all, there has been referenced on the panel about Muscatatuck 
Urban Training Center. I think we can't overstate that enough, 
how important that is for our people to have real-life 
experiences. So I would just mention that.
    But second, I think Indiana has done a very good job, again 
credit to my predecessors, in integrating the National Incident 
Management System, NIMS, and incident command structures that 
allows us to have a common architecture for communication, not 
necessarily the technology but the manner in which we 
communicate with one another. We are all talking from the same 
script. I think the formation of these teams throughout the 
State that allow us to communicate and respond locally to 
emergencies, I know that my work in the State police 30 years 
ago, there just was not the local capacity to respond to some 
of these major emergencies that we have today. Frequently, I am 
hearing about emergencies that are being handled totally by the 
local people without any involvement from outside sources. I 
think that is a tribute and a testimony to some of the progress 
that has been made.
    Mrs. Walorski. I appreciate it.
    Ms. Mack, any comments on the university level?
    Ms. Mack. I would agree with what all the panelists have 
said, and it has allowed us, based on the teams that have been 
built up largely with this funding and the integration of the 
incident command system, we have been able to move beyond that 
and integrate other facets of disaster response such as 
volunteers and donations management, those kinds of things 
which are really advanced emergency management.
    From a college perspective, we know that if anything 
happens on any of our campuses, we are going to have thousands 
of people, right then and there, who are ready to respond, and 
we need to have our process and procedures and structures in 
place to be able to handle that and have them help us with the 
response, instead of being part of another thing we need to 
take care of.
    Mrs. Walorski. I appreciate it. Thank you.
    I yield back my time. Thanks.
    Mrs. Brooks. Thank you. I appreciate all the testimony that 
everyone has given today, and you each brought a very unique 
perspective to this topic, and you have given us a lot to think 
about.
    But in a bit of a lightning round as well, as you 
suggested, you have an opportunity which is a little bit 
unusual to have Members of both chambers, the House of 
Representatives and the United States Senate, here. Coming 
here, we want to hear from you what is it Congress could be 
doing or should be doing to help you in your efforts, to help 
you.
    I think I will just start with you, Ms. Mack, and work 
backwards, this way on the panel. What can you state briefly? 
What can Congress be doing to assist you to make sure that you 
all are sleeping even better at night?
    Ms. Mack. Well, I would request a couple of things. First 
of all, a funding line for universities I believe needs to be 
reinstated Nation-wide. There were limited numbers of emergency 
management for higher education grants that were distributed. 
There were only two rounds of grants, and that has disappeared. 
So I would request that.
    I would also request the continuation and even expansion of 
preparedness training and exercise funding for that. That is 
what will move us forward in the development of our skill sets 
and our ability to respond from all levels of government, 
including the university.
    I would also ask you to look at the Clery Act and 
potentially even refocus it. Instead of it being an accounting 
of the crimes that have occurred, look forward, look forward to 
the prevention and mitigation part of it, really gear it 
towards what is this doing to really achieve the objective of 
it. The intent is to reduce crime, especially on university 
campuses, and then also compare the campus crime rates, which 
it really focuses on, to the surrounding areas. I think you 
will find that universities have a much lower crime rate even 
than the surrounding areas, but that is not factored into the 
equation.
    So those are the things that I would request from a 
university perspective.
    Mrs. Brooks. Thank you.
    Mr. Hill.
    Mr. Hill. I would just say a couple of things. First of 
all, the UASI Urban Area Security Initiative funding is really 
a critical component. I think the way in which that is done is 
a little bit uncertain to us out here in the real world. We got 
a document, and I understand there is a document, but there is 
a lot that goes into evaluating those security areas, and this 
last appropriations cycle I think they limited it to 25, and 
Indiana did not factor in.
    One of the things that concerns me is that Indianapolis has 
done big events for so long that we are sometimes viewed as 
being acceptable in that area and not as big a risk, and I 
don't think the State should be penalized because they have 
done a good job in the past. There is still a lot of backfill, 
a lot of work that needs to be done to bring off these events. 
So that is one of the things.
    Then second, I think continued oversight at the Federal 
level for FEMA is important. The THIRA process to me is 
critical, but we need guidance, and we need it out sooner. This 
is certainly not any discredit to my colleague on the panel 
today because I know that he doesn't have anything to do with 
this, but at the headquarters level we need to have that 
guidance out. It is very important.
    Mrs. Brooks. Thank you very much.
    Chief Orusa.
    Chief Orusa. Operational readiness exercises are key to 
keep our people safe and effective in harm's way. We can write 
all the policies and procedures, we can have all the tabletop 
exercises, but until we have scenario-based training, which is 
funded through UASI, and training and exercise grants, we can't 
have crisis rehearsal and stress inoculation so they can 
function in that gray environment during a disaster, where they 
are forced to problem-solve and decision-make in a combat 
environment. It is very, very expensive to do that training, 
and we depend on the Federal Government to provide us the 
funding to do so, and it is critical that we give our people 
those skill sets.
    Mrs. Brooks. Thank you, Chief.
    Sheriff Bowen.
    Sheriff Bowen. I would concur with Mr. Hill and Mr. Orusa. 
I haven't seen the benefits of being in a UASI region. It is 
important that we continue to fund those programs. EMA, IDHS, 
Homeland Security as a whole has been an integral part in 
making sure that Indiana has come together regionally, not just 
locally but regionally to prepare, to train, and plan for 
unknown hazards and all hazards, and it is important that we 
continue to provide that training and that regional approach to 
the training.
    As local agencies, we can train on our own. But as we all 
know, our resources will be immediately overwhelmed in a 
critical incident, and it is going to require those efforts 
from those other agencies and that cooperation to manage a mass 
incident.
    So we would ask your assistance in considering to fund 
those projects and to help us as we move forward.
    Mrs. Brooks. Thank you.
    Mr. Velasquez.
    Mr. Velasquez. Thank you, Chairman Brooks. We appreciate 
certainly the offer, and we also appreciate the committee's 
support of our department and our programs. In addition to 
supporting the President's budgetary requests and other 
programmatic requests, I think Members of Congress can 
certainly help us in the area of encouraging individual 
preparedness.
    You mentioned September as National Preparedness Month, and 
individuals play a crucial role in helping to prepare this 
Nation for crisis. If we can get more and more individuals 
prepared to develop a preparedness mindset in this country, we 
would be in a better place and reduce the amount of casualties 
that we have in this country as a result of disasters and other 
crisis situations. So, thank you.
    Mrs. Brooks. Thank you.
    I would like to thank the witnesses for their valuable 
testimony. This panel is going to be dismissed.
    I do want to allow the members of this panel to realize 
that Members of the subcommittee may be submitting questions to 
you in writing, and the hearing record will be open for 10 days 
for you to respond in writing if you should receive any further 
questions.
    So at this time, the clerk will prepare the witness table 
for the second panel.
    Again, I thank you all so very much for your testimony 
today.
    We will be having those on the second panel please proceed 
to the witness table. Thank you.
    Our first witness is Mr. Chad Priest, the chief executive 
officer with the MESH Coalition, Inc. Prior to joining MESH, 
Mr. Priest was an attorney at the law firm of Baker and 
Daniels, practicing public health and health care law in 
Indianapolis, and in the Washington, DC offices. He served on 
active duty in the United States Air Force as a family practice 
primary care optimization nurse, and while in the military he 
specialized in emergency preparedness-related issues.
    Next on our panel is Dr. Virginia Caine. She is the 
director of the Marion County Public Health Department. Dr. 
Caine is a past president for the American Public Health 
Association, the Nation's oldest and largest public health 
organization, and was the recipient of the National Medical 
Association's 2010 Practitioner of the Year Award. Throughout 
her career, Dr. Caine has worked to promote and advance public 
health locally, Nationally, and internationally through 
innovative programs and unprecedented collaborations.
    Next on the panel is Dr. Louis Profeta. He is the medical 
director of disaster preparedness at St. Vincent Hospital. Dr. 
Profeta served as the clinical instructor of emergency medicine 
at Indiana University and is the founder of Emergency Room 
Advice Safety and Education. Dr. Profeta also authored the 
popular book, ``The Patient in Room 9 Says He's God.'' Sounds 
like an interesting read.
    Next on our panel is Dr. Cliff Knight. He is the chief 
medical officer of the Community Health Network, a position he 
has held since October 2009. Dr. Knight had previously served 
as vice president of medical affairs for Community Hospital 
North and Community Hospital East. Before assuming that role in 
2007, he was director of Community Family Medicine's residency 
program, and his peers honored him as the Family Medicine 
Teacher of the Year.
    Next on the panel is Dr. R. Lawrence Reed. He is the 
director of trauma services at Indiana University Health 
Medical Hospital. Dr. Reed's past professional responsibilities 
have included associate chief of the Trauma Service and 
Surgical Intensive Care Unit at Herman Hospital in Houston, 
Texas; and director of the Surgical Intensive Care Unit and 
director of the Trauma Center at the Duke University Medical 
Center, just to name a few. Dr. Reed has authored more than 60 
periodical articles and 27 book chapters, most on the topic of 
critical care.
    At this time, I would now like to turn to Senator Donnelly 
for any introductions he might have.
    Senator Donnelly. Madam Chairwoman, I want to thank the 
witnesses for being with us, for sharing their views on this 
extraordinarily important topic. With that, I would be happy to 
turn it over to you.
    Mrs. Brooks. Okay.
    Senator Donnelly. Oh, and I would like to introduce also 
Dr. Obeime. Dr. Obeime has worked for the Sisters of St. 
Francis since July 1996. She helped start and served as medical 
director of the St. Francis Neighborhood Health Center from 
1998 to 2010, when she became the director of Community and 
Global Health at Franciscan St. Francis Health. I want to 
mention that the Sisters of St. Francis provide medical care 
across our State, do an extraordinary job from Lake Michigan to 
the Ohio River, and please let the Sisters know we are in their 
debt for all of their hard work.
    Dr. Obeime graduated from the University of Benin in 
Nigeria in 1998 and completed a clinical genetics fellowship in 
Family Medicine residency at IU in 1996. Dr. Obeime is board-
certified in family medicine, bariatric medicine, and hospice 
and palliative medicine.
    Thank you so much for being here with us today.
    Mrs. Brooks. I would just now like to thank all of the 
witnesses who have also submitted full written statements, and 
those will appear in the record.
    At this time, the Chairwoman will now recognize Mr. Priest 
to testify for 5 minutes.

  STATEMENT OF CHAD S. PRIEST, CHIEF EXECUTIVE OFFICER, MESH 
                        COALITION, INC.

    Mr. Priest. Good morning, Chairwoman Brooks, Senator 
Donnelly, Congresswoman Walorski, and the staff of the 
subcommittee. On behalf of the MESH Coalition, we appreciate 
the opportunity to be before you today, and we applaud your 
commitment and dedication to the important issues that we have 
been discussing.
    I would like to share three points with the committee 
today. First, I want to briefly describe what the MESH 
Coalition is and how through our coalition partners, many of 
whom are seated here today, we are building resilience in the 
health care community and Central Indiana.
    Second, I would like to discuss that our public-private 
coalition model that we have developed here we believe is one 
of the most sophisticated and progressive models in the United 
States. We believe it is replicable throughout the United 
States, and we think that is an imperative to promote health 
care resilience.
    Finally, I would like to discuss how we might partner to 
build sustainable and resilient funding for health care 
emergency management that isn't solely reliant on grants but 
that takes health care entities in their usual financial 
reimbursement models and considers those so that we can be 
assured of continued funding for this important work.
    At the outset, I am pleased to report that through the work 
of the partners here next to me and coalition partners all over 
Central Indiana, we believe we are uniquely well-prepared to 
respond to events here in Central Indiana. While it would be 
hubris to guarantee a successful response to any incident, 
especially those that would overwhelm any region's ability to 
respond, such as a widespread biological attack or a nuclear 
attack, we believe that the systems and processes that we have 
built here are some of the most robust and sophisticated in the 
Nation.
    The MESH Coalition is a Nationally-recognized nonprofit, 
public-private partnership that enables health care providers 
to respond effectively to emergency events and remain viable 
through recovery. Our programs increase capacity in health care 
providers to respond to these events such as mass casualties. 
It protects our critical health care safety net and promotes 
integration and coordination between the Government and the 
private sector.
    Our subscribing partners include the Marion County Public 
Health Department, the Richard Roudebush VA Medical Center, 
Community Hospitals of Indiana, Franciscan St. Francis Health, 
Wishard Health Services, Indiana University Health, St. Vincent 
Hospital, the Indiana University School of Medicine, and the 
Indiana University School of Nursing. We routinely work with a 
wide array of partners, including our State partners like the 
State Department of Health and the Department of Homeland 
Security.
    All of these partners recognize an essential truth, and 
that is that we are, in fact, better together. None of our 
health care facilities and organizations can go it alone in a 
crisis, and even in a competitive health care environment, what 
you see here today is a recognition that we all must come 
together when the going gets tough.
    MESH does a few core things. We provide health care 
intelligence services to the health care community to allow 
them to prepare and respond to events. We utilize social media 
not only to push information out but to monitor and predict and 
analyze threats. We issue a daily intelligence brief to health 
care providers across the city. We conduct community-based 
planning which brings people together from disparate 
professions and backgrounds. An example would be the building 
of the Super Care Clinic at the Super Bowl, a primary care 
model that actually helped manage surge throughout the event.
    We conduct sophisticated legal, regulatory, and financial 
policy analysis, recognizing that the delivery of health care 
is essentially a complex business enterprise, as well as a 
clinical one. Health care viability depends in large measure on 
sustaining revenue cycles to continue operations, and we pay 
very close attention to that.
    Finally, we recognize that effective response, the 
difference that makes a difference between hospitals that do 
well in crisis and those that don't, are good clinicians that 
can make good decisions under tough conditions. To that end, we 
provide advanced clinical training to technicians, doctors, and 
nurses to make them better prepared to respond when the going 
gets tough.
    We had a unique funding approach at MESH that pairs 
traditional emergency management funding with private support. 
Our hospitals have not just made a brief or casual commitment 
to emergency management; they have made that commitment with 
their dollars, and that has built the MESH Coalition. It is a 
model that is unique. We are extremely proud of the vision that 
these health care leaders have had in building our coalition, 
and we are also helping to promote this through partners such 
as the Northwest Healthcare Response Network in Seattle, and 
the Northern Virginia Hospital Alliance, which operates in the 
National capital region, leveraging our communities.
    We know that grant funding in and of itself is not a 
sustainable model for health care emergency management. As 
stewards of public resources, we have to find creative ways to 
incentivize health care response. However, there is, in fact, a 
Federal role here, and as you all know, that Federal role is 
most helpful when it is sustainable and it continues on. 
Hospitals do deserve a predictable way to manage emergency 
issues.
    I want to thank you for your leadership in this area. Thank 
you for including us on this distinguished panel. We are 
pleased to be here. I look forward to discussing this with you 
further.
    [The prepared statement of Mr. Priest follows:]
                  Prepared Statement of Chad S. Priest
                             August 6, 2013
    Good morning Chairman Brooks, Senator Donnelly, Congresswoman 
Walorski, Congressman Young, and staff of the subcommittee. On behalf 
of the MESH Coalition, we appreciate the opportunity to discuss health 
care emergency management in Central Indiana with you today and applaud 
your commitment and dedication to this important issue.
    I am pleased to report at the outset of my testimony that as a 
result of the cooperative efforts of Central Indiana health care, 
public health, emergency management, and public safety partners through 
the MESH Coalition, the health care infrastructure in Central Indiana 
is well-positioned to respond and recover from a wide range of crises 
and emergencies. While it would be hubris to guarantee a successful 
response to any incident, especially those that would almost certainly 
overwhelm any region's ability to respond, such as a direct nuclear or 
widespread biological attack, Central Indiana is a National leader in 
health care infrastructure resilience and we believe our systems and 
processes are some of the most robust and sophisticated in the Nation.
    I would like to address how we have developed this resilience, in 
part, through closely-coordinated cooperation among the public and 
private sectors through the MESH Coalition. The MESH Coalition is a 
Nationally-recognized, nonprofit, public-private partnership that 
enables health care providers and organizations to respond effectively 
to emergency events and remain viable through recovery. We provide 
health care intelligence, community-based planning, policy analysis, 
and clinical training to our health care, public safety, public health, 
and emergency management colleagues. Our programs increase capacity in 
health care providers to respond to emergency events, including mass 
casualties, protect our critical health care safety net, and promote 
integration and coordination between the Government and private sector.
    Today, I would like to share three points with the committee:
    1. The public-private partnership coalition model that our partners 
        have developed here in Central Indiana is one of the most 
        progressive and sophisticated models of health care emergency 
        management in the United States, and we believe that this model 
        can, and should, be replicated throughout the United States.
    2. Through a comprehensive portfolio of programs, the MESH 
        Coalition is continuously improving Central Indiana's ability 
        to mitigate, prepare, respond, and recover from both small and 
        large-scale emergency events.
    3. We believe that in order to promote the spread and adoption of 
        health care coalitions, we must work together to find creative 
        and cost-effective means of providing sustainable, on-going 
        support to these efforts, while maintaining appropriate 
        stewardship of public resources.
                        the mesh coalition model
    The MESH Coalition enables health care providers to respond 
effectively to emergency events and remain viable through recovery. 
Through the MESH Coalition, health care providers, public health 
practitioners, emergency medical service providers, emergency managers, 
law enforcement agencies, fire departments, and private businesses are 
working together to plan, train, share information, and shape policies 
that protect the health care system and facilitate an effective 
emergency response. Our public-private partnerships increase capacity 
in the health care system to respond to emergency events, protect our 
critical health care safety net, and promote integration and 
coordination between the Government and private sectors.
    This unique partnership was founded as a grant project of the 
Indiana University School of Medicine and Wishard Health Services with 
a $5 million award from the United States Department of Health and 
Human Services Emergency Care Partnership Grant Program. MESH was one 
of five organizations funded through this Program to develop innovative 
models for health care emergency management, and was the only non-
profit successfully formed because of the award.
    Our Board of Directors is comprised of hospital chief executives 
and clinical leadership, as well as community partners. These entities 
include: The Indiana University Schools of Medicine and Nursing, The 
Marion County Public Health Department, Richard Roudebush Veterans 
Affairs Medical Center, Community Hospitals of Indiana, Inc., 
Franciscan St. Francis Health, Wishard Health Services, Indiana 
University Health, and St. Vincent Hospital & Health Care Center, Inc.
    One of the unique aspects of MESH that helps us be successful is 
our funding model, which pairs public grant funding with private fee-
for-service and subscription funds--meaning that our coalition partners 
have all put ``skin in the game,'' creating powerful incentives for 
executive and system engagement in critical emergency management 
activities. While historically we have received Federal grant funding 
from the Emergency Care Partnership Program, the Urban Areas Security 
Initiative (UASI) program, and the Metropolitan Medical Response System 
(MMRS), subscription fees from partnering health care organizations are 
nearly 45% of our total revenues. In addition, our fee-for-service 
programs continue to minimize the gap between private and public 
funding streams. This is of particular importance given that there have 
been significant reductions in Federal grant programs, and we 
anticipate further cuts in the future.
                      central indiana preparedness
    Central Indiana communities are as prepared as any other across the 
country to respond to an emergency event. However, we believe that an 
effective response is a necessary, but not sufficient, condition to 
safeguard the health care infrastructure during crisis events. It is 
critical that we improve the overall resilience of our health care 
system to respond to a range of threats, then quickly return to 
baseline operations in order to provide effective care to our 
community. The MESH Coalition helps build resilience through four core 
services: (1) Health care intelligence services; (2) community-based 
planning; (3) policy analysis; and (4) clinical education and training. 
I would like to take a moment to describe how each of these services 
better prepares Central Indiana to respond to a mass casualty event.
Health Care Intelligence Services
    In order for health care providers to effectively manage 
significant increases in patient volume during major mass casualty 
incidents, they must operate from a Common Operating Picture. To build 
this Common Operating Picture every day, the MESH Coalition conducts 
real-time monitoring of disparate data streams for potential threats to 
the health care sector. These data streams include open-source sites 
such as news media and weather, restricted sources such as homeland 
security and other access-controlled portals, and radio communication 
sites such as those streaming aircraft and public safety radio traffic. 
In addition, we monitor and utilize social media platforms such as 
Twitter and Facebook, an area in which you, Chairman Brooks, have been 
an extraordinary proponent.
    The threats we detect are distributed to our partners via email, 
social and news media, public safety information channels, and the MESH 
Daily Situational Awareness Brief. The Brief is an email we send daily 
to health care providers, emergency managers, and public health 
professionals throughout Central Indiana, and it provides specific, 
actionable information on threats to the health care sector, from 
severe storms to emerging infectious diseases and everything in 
between. What makes the Brief unique is the inclusion of specific 
action steps that allow recipients to immediately improve their 
preparedness for potential emergency events. The Brief is frequently 
used in hospital team meetings and bed huddles as an intelligence 
source and discussion initiator.
    At the direction of the Marion County Public Health Director, and 
in cooperation with the Indianapolis Division of Homeland Security, we 
also serve as the Marion County Medical Multi-Agency Coordination 
Center (MedMACC). The MedMACC is staffed and operational 24 hours a 
day, 7 days a week, 365 days a year to provide a critical link between 
Marion County health care facilities, the Marion County Public Health 
Department, the City of Indianapolis, and the Indianapolis Division of 
Homeland Security. The MedMACC is activated to support everything from 
mass casualty incidents like the recent bus accident on the northeast 
side of Indianapolis, to supporting emergency responders during large-
scale events like the Indianapolis 500, to coordinating health care 
response during disasters like the stage rigging collapse at the 
Indiana State Fair in August 2011. In 2012 alone, the MedMACC was 
activated 17 times.
    During an activation, the MedMACC manages hospital surge by 
assisting with the distribution of patients during mass casualty 
incidents. For example, during a mass casualty incident, the MedMACC is 
dispatched and completes just-in-time hospital emergency department 
polling. We relay this information to field command units via public 
safety radio systems to facilitate better patient transport decision-
making and avoid overwhelming any one facility. During large-scale 
emergency events, the MedMACC provides direction through an executive-
level Policy Group consisting of individuals from various health care 
entities throughout Marion County, many of whom serve on our Board of 
Directors. The MedMACC also has the capability to identify and secure 
resources for health care providers and organizations during emergency 
events, to assist public health authorities in providing care to 
vulnerable populations during crisis events, and to provide just-in-
time subject matter expertise on Chemical, Biological, Radiological, 
Nuclear, and high-yield Explosives (CBRNE) threats, as well as 
emergency medical, legal, and policy issues. In the event of an area-
wide or regional mass casualty incident, we can also deploy critical 
resources such as core medical supplies, and up to four Multi-Agency 
Support Tactical Facilities, which are equipped to function as 
emergency mobile field hospitals. An example of one of these facilities 
is deployed outside today in coordination with the Hamilton County 
Emergency Management Agency.
Community-Based Planning
    Health care in Central Indiana is, to say the least, a highly-
competitive enterprise. In many communities, intense health care 
competition has made it challenging--or impossible--to bring providers 
together to prepare for disaster and crisis events. We are fortunate in 
Central Indiana, as our health care organizations fully understand that 
coming together to plan for emergency events saves lives and is in the 
best interest of everyone. In fact, our health care partners have made 
a commitment to not compete on safety or emergency management issues 
and the MESH Coalition is the result of that commitment.
    Traditionally, health care emergency planning has focused on 
preparing hospitals to be ``floating islands'' capable of withstanding 
emergency events and remaining open to provide patient care. This 
approach has resulted in redundant spending on equipment and supplies 
in hospitals across the country. Working in silos is not an effective 
approach to emergency preparedness. Through MESH, Central Indiana 
hospitals team up to share resources and engage in joint emergency 
planning. Each month, Hospital Preparedness Officers throughout 
Indianapolis work together in MESH working groups to collaborate on 
policy, training, and exercises. Using this community-based approach, 
we include stakeholders such as hospitals, first responders, and other 
local officials to coordinate and prepare for potential threats, as 
well as large-scale anticipated events such as the Indy 500 and the 
NCAA Final Four. This enables staff to develop effective plans and 
programs while generating new knowledge about health care emergency 
management.
    One example of this innovative approach to health care emergency 
planning is highlighted by our community's preparation for Super Bowl 
XLVI, where we created the Super Care Clinic. As part of the Super 
Bowl Village, and in partnership with the Super Bowl Host Committee, 
the Super Care Clinic represents an innovation in how volunteers and 
attendees are treated at large-scale events. Located inside 
Indianapolis' Union Station, this fan-facing forward medical station 
served as a clinic for fans, but was intentionally designed as a surge 
management strategy in the event of a mass casualty incident. In an 
extraordinary gesture, caregivers from Community Health Network, 
Franciscan Alliance, Indiana University Medical Group, St. Vincent 
Medical Group, Wishard Health Services, and Indiana University Health 
volunteered their time to work at the clinic during the entire week of 
Super Bowl activities. This was the first clinic of its kind to be 
created in the United States and serves as a model for providing health 
care services during other mass gathering events.
    MESH has also established a host of professional working groups to 
address emergency preparedness issues for vulnerable populations. The 
Sexual Assault and Domestic Violence Working Group, for example, works 
to ensure that health care organizations are able to detect and respond 
to domestic violence during emergency events, and that residential and 
non-residential Sexual Assault and Domestic Violence providers are able 
to continue perform essential functions during an emergency event. 
Similarly, the Maternal/Child Health Working Group works to ensure the 
needs of new and expectant mothers and their children are considered in 
the disaster planning process. This group, in coordination with 
providers at Riley Hospital for Children at Indiana University Health 
and Peyton Manning Children's hospital at St. Vincent, is currently 
developing a registry of Central Indiana home ventilator-dependent 
children, with the ultimate goal being to provide early warning during 
emergency events. This registry is the first of its kind in Indiana and 
is designed to engage patients and families in strategies that increase 
community resiliency by protecting access to electricity during natural 
weather events. Weather-related power outages are common in Indiana and 
loss of electricity can be catastrophic to these patients and their 
families.
    Beyond facilitating regular working groups, we also recognize that 
the health care response in Central Indiana is critical to both 
Regional and State-wide response. By working together with the Marion 
County Public Health Department and the Indiana State Department of 
Health to plan for seasonal flu outbreaks and emerging threats such as 
the Middle East Respiratory Syndrome Coronavirus (MERS CoV) and the 
Avian Influenza A virus, we have helped the Central Indiana health care 
community maintain necessary readiness to respond to all types of 
biological hazards, whether they are naturally occurring or an act of 
terrorism.
    We have also taken a leadership role in wider community-planning 
efforts. For example, in 2011 we designed, coordinated, and executed 
the first full-scale exercise between the City of Indianapolis and the 
Central Indiana health care community, which focused on testing 
portions of the downtown Indianapolis Evacuation Plan, and have also 
worked with local, State, and Federal partners to plan for terrorist 
incidents by participating in the Joint Counterterrorism Awareness 
Workshop Series.
Policy Analysis
    Health care systems are in the business of taking care of patients 
and saving lives, not necessarily responding to disasters. Moreover, 
they generally do not have the resources to address the policy, legal, 
and regulatory issues associated with emergency events. The MESH 
Coalition is a resource for our partners because we can provide 
objective analyses of the most pressing disaster-related policy issues 
facing Coalition partners. This analytical work supports our mission to 
enable health care providers to respond effectively to emergency events 
and, importantly, remain viable through recovery. In other words, we 
help our coalition partners to think not only about responding to 
disasters, but also to plan for long-term sustainability following an 
emergency event.
    Revenue cycle protection is a considerable factor in ensuring the 
availability of health care during and after an emergency event. In a 
large-scale emergency, care may be administered at Alternate Care 
Sites--substitute locations that serve to expand the capacity of a 
hospital or community to accommodate or care for patients. Given the 
limited scope of FEMA public assistance grants, reimbursement through 
Federal Health Care Programs such as Medicare and Medicaid is critical 
to a hospital's financial viability when care is provided in an 
alternate location. However, depending on State licensure rules, these 
Alternate Care Sites may operate outside of the scope of the hospital's 
existing license, creating compliance issues, which may jeopardize 
reimbursement.
    Several States have developed solutions that allow hospitals to 
establish an Alternate Care Site without jeopardizing reimbursement. 
For example, the Arizona Department of Health Services permits 
hospitals to provide off-site services without a separate license 
during a public health emergency declared by the Governor. In North 
Carolina, at the request of the State Emergency Management Agency the 
Division of Health Service Regulation can waive rules for hospitals 
providing temporary services during a declared emergency. In Texas, the 
law exempts temporary emergency clinics in disaster areas from 
licensure requirements.
    In addition to these statutory solutions, many State departments of 
health are granted broad waiver authority during emergencies. For 
example, the New Jersey Department of Health has the authority to waive 
hospital-licensing rules upon determining that compliance would create 
a hardship for the hospital and that the exception would not adversely 
affect patients. We in Indiana, on the other hand, have no mechanism 
for waiving hospital licensure requirements. As such, MESH is actively 
working with the Indiana State Department of Health to ensure that safe 
and effective health care can be provided in an Alternate Care Site, 
while at the same time enabling hospitals to receive reimbursement for 
their services and thereby protecting the long-term viability of our 
health care infrastructure following a large-scale emergency event.
    It is also important that clinicians and policymakers understand 
the nuances of what the Institute of Medicine has come to refer to as 
``crisis standards of care,'' or the optimal level of care that can be 
delivered during a disaster. Clearly, this complex issue has far-
reaching implications in terms of one's ethical responsibility and 
legal liability. Even during an emergency event, victims are entitled 
to expect reasonable care under the circumstances. The ISDH has taken a 
leadership role on this issue by providing guidance for providers on 
how to develop consistent procedures for allocation of scarce resources 
in the event of an officially-declared public health emergency, in 
addition to recommending an ethical framework and clinical algorithms. 
MESH Coalition staff have also sought to protect individuals' rights to 
reasonable care, and support effective health care response, by 
effectively explaining this issue to health care providers both locally 
and Nationally.
Clinical Education and Training
    Locally, one of MESH's most important contributions to Central 
Indiana is the clinical education and training we provide to a wide 
array of stakeholders. While traditional health care emergency 
management education and training programs have focused on emergency 
management core-knowledge such as the Incident Command System (ICS), 
evidence from mass casualty and disaster events demonstrates that 
effective health care response requires--first and foremost--well-
trained clinical providers who are able to make good decisions under 
tough conditions. As a result, we have developed and implemented 
courses in emergency response and clinical decision making that are 
hands-on, practical, and utilize high-fidelity simulation to prepare 
providers to respond to all-hazards scenarios. To date we have trained 
thousands of responders, including physicians, nurses, EMTs, 
Paramedics, police officers, firemen, and members of the public.
    The benefit of courses being developed and conducted by the MESH 
Coalition is that we are capable of reaching a wider range of 
participants than any single organization, and we are able to provide 
centralized resources, thereby lowering per-unit costs. Group offerings 
such as Simple Triage and Rapid Treatment (START) training, mass 
casualty exercises, limited-resource emergency care courses, and 
operational hazardous materials training also give participants from 
different health care organizations the experience of learning 
together. This method creates consistency between and among providers, 
which in turn leads to a uniformity of response during an emergency 
event. In addition, we offer regular Continuity of Operations planning 
workshops, Emergency Operations Planning workshops, and crisis 
communications workshops to partner organizations in order to further 
build our community's response capacity.
    To facilitate learning opportunities from around the world, we also 
coordinate an annual Grand Rounds series that brings National and 
international experts in health care emergency response to Indianapolis 
to present cutting-edge ideas and programs. These events are free, open 
to the public and, through our partners at the Indiana University 
School of Medicine, eligible for Continuing Medical Education and 
Continuing Education Units at no cost to attendees. The 2012-2013 Grand 
Rounds series included presentations on Continuity of Operations 
Planning by Dr. Paul Kim, M.D., who is the director of incident 
management integration for the National security staff in the White 
House, and on Denver's mass casualty emergency response to the Aurora 
Colorado theater shootings by Christopher Colwell, M.D., who is the 
chief of emergency medicine at Denver Health.
    In addition to our group trainings and Grand Rounds, we have a 
strong commitment to clinical education, as evidenced by our multi-
disciplinary internships and fellowships. Each year we provide 
opportunities for physicians, nursing students, public health graduate 
students, law students, and librarians to learn from a team of 
dedicated professionals and gain valuable experience in health care 
emergency management. In 2012, MESH collaborated with the Indiana 
University School of Medicine to create a Disaster Medicine Fellowship. 
The fellowship just welcomed its first fellow, who will spend time this 
year travelling with our executive staff to Monrovia, Liberia, where 
they will help that community's largest hospital redesign its emergency 
department and help build the hospital's emergency management plan. 
Concurrently, we will have an opportunity to learn from hospital and 
community leaders about how they have maintained health care resilience 
through significant social crises. This experience will no doubt 
provide valuable strategies that can be implemented in our own 
community and further enable us to better respond in situations where 
resources are limited.
                            the path forward
    As previously noted, we are extremely proud of the vision our 
Central Indiana partners have had in the development the MESH 
Coalition. We are also convinced that the future of health care 
emergency preparedness is directly tied to the development of public-
private health care coalitions such as ours. The U.S. Department of 
Health and Human Services has also acknowledged this future by 
requiring Hospital Preparedness Program and Public Health Emergency 
Preparedness grant program grantees to form strong and resilient 
coalitions.
    We are helping to promote ``coalition building'' through our 
partnership with the Northwest Healthcare Response Network in Seattle 
and the Northern Virginia Hospital Alliance in the Capital Region and 
Virginia. This partnership, the National Healthcare Coalition Resource 
Center (NHCRC), is sponsoring an annual National Healthcare Coalition 
Preparedness Conference, and is available to provide technical 
assistance and training opportunities to assist communities in meeting 
their grant deliverables to develop functional health care coalitions.
    However, there are challenges associated with the current funding 
mechanism and, as stewards of public resources, we must be creative 
about incentivizing the development of health care coalitions, funded 
in part by the private health care sector. This does not mean, however, 
that there is no role for Federal support. While grant funding is not, 
in and of itself, a sustainable solution to protecting and preserving 
public health and safety, private-sector health care should not be 
solely responsible for preparing and responding to issues of National 
significance. For example, in preparing to respond to CBRNE mass-
casualty events, many of which would constitute acts of war against the 
United States, the Federal Government must remain a strong funding 
partner. Hospitals cannot, and should not, be expected to shoulder this 
burden alone. Hospitals deserve a predictable way to manage the expense 
of providing care during an emergency event. Indeed, the coalition 
model must continue to be a strong public-private partnership, and not 
become a private-private partnership.
    Chairman Brooks, Senator Donnelly, Congresswoman Walorski, 
Congressman Young, and staff of the subcommittee, on behalf of the MESH 
Coalition, I thank you for the opportunity to provide testimony on our 
efforts to prepare Central Indiana to respond to a mass casualty event. 
We are thrilled to be included today, and hope that you will continue 
to advocate for proven, cost-effective best practices in health care 
emergency response. We also hope that our experiences will provide 
insight for coalitions across the country. Finally, we look forward to 
working with you to creatively incentivize private-sector participation 
in health care preparedness.
    Thank you again for your leadership on this important topic; I am 
happy to respond to any questions my might have.

    Mrs. Brooks. Thank you, Mr. Priest.
    The Chairwoman now recognizes Dr. Caine to testify for 5 
minutes.

    STATEMENT OF VIRGINIA A. CAINE, DIRECTOR, PUBLIC HEALTH 
     ADMINISTRATION, MARION COUNTY PUBLIC HEALTH DEPARTMENT

    Dr. Caine. Thank you. Good morning, Chairman Brooks, 
Senator Donnelly, and Congresswoman Walorski; and our hosts, 
Mayor Brainard and County Commissioner Christine Altman. I 
would like to thank you for the opportunity to come here today 
to discuss our efforts to prepare for a mass casualty event in 
Marion County. I hope this is the first of many opportunities 
to work with the subcommittee.
    The Marion County Public Health Department is responsible 
for the Emergency Support Function 8, which functions in a 
National response framework, which means that the health 
department is not only responsible for the public health but 
the medical care needs of the entire population of Marion 
County during an emergency event. This can include anything 
from medical treatment to providing clean drinking water and 
sanitation. In addition, the health department is also 
responsible for coordinating Emergency Support Function 11 
activities, which identifies food, water, our ice needs, and 
temporary shelters for animals in the aftermath of an 
emergency.
    One of our most important responsibilities, though, is 
protection against chemical, biological, nuclear, radiological, 
and high-yield explosive threats. To monitor and respond to 
these threats, the health department operates an environmental 
emergency response team which collaborates with our local and 
State partners, which includes the Indianapolis Fire 
Department, the Hazardous Materials Team, the Indiana 
Department of Homeland Security, and the Indiana State 
Department of Health. Because of this team, Central Indiana 
maintains an excellent state of readiness.
    We are also responsible for coordinating the U.S. 
Department of Homeland Security's Bio-Watch Program. In 
partnership with the Indiana Departments of Environmental 
Management and Health, the Indianapolis Metropolitan Police 
Department, the Indiana Department of Homeland Security, 
Hamilton County Health Department, the U.S. Army Civil Support 
Team, and the FBI, we do daily monitoring for the potential of 
airborne bioterrorism threats which occur.
    So, one of the things that we responded to was a suspicious 
powder, including a recent incident at Riley Children's 
Hospital at Indiana University Health. We are the only health 
department's environmental emergency response team, the only 
team in Indiana, that keeps a ready supply of appropriate test 
kits to detect ricin, as well as anthrax, botulism toxin, and 
poxvirus. While these kits are very costly to maintain, we have 
made our capabilities a priority, and we believe that the 
financial investments are necessary to be able to respond to 
any events that occur.
    This proved to be a valuable investment because last year, 
when letters containing ricin were being mailed across the 
country, we were the only public health department in the State 
of Indiana with the ability to test for ricin.
    Another important function for Marion County is that during 
a biological threat event, we run the point-of-dispensing 
system. We are responsible for delivering critical medications 
and vaccinations from either the strategic National stockpile 
or the State strategic stockpile to the citizens of Marion 
County.
    We routinely work with our collaborating counties that are 
part of the District V hospital and public health department's 
programs collaboratively, doing training exercises, and our 
best demonstration was the Super Bowl, where we worked with the 
FBI, the Environmental Protection Agency, and other Federal 
agencies in supporting this event.
    We maintain a volunteer medical reserve corps.
    Last, I just want to say that Marion County has a 
population of nearly 1 million people, approximately one-sixth 
the State of Indiana. One of our essential stints is our 
public-private partnership with our health care providers. And 
not only the hospitals; we work with community health centers, 
urgent care facilities, dialysis centers, social workers, 
psychologists, to build up a great health care sector in 
Central Indiana.
    One of our key partners is Wishard Health Services. It is a 
safety-net hospital in Central Indiana. It is one of only two 
Level I trauma centers in the city and routinely provides 
support to mass casualty events. They have a special obligation 
to vulnerable populations during and following disaster mass 
casualty events, and they take that responsibility seriously.
    Shortly, they are going to move to a new facility, and they 
are going to have the opportunity to test its ability to 
evacuate an entire hospital and relocate patients, and they are 
going to do it by the incident command system.
    So we are looking forward to it, and I want to thank the 
staff for giving us an opportunity to testify on our efforts to 
prepare Central Indiana for a mass casualty events. Thank you 
for your leadership and your emphasis on this important area of 
emergency preparedness. Thank you.
    [The prepared statement of Dr. Caine follows:]
                Prepared Statement of Virginia A. Caine
    Good morning Chairwoman Brooks, Senator Donnelly, Congressman 
Young, Congresswoman Walorski, and staff of the subcommittee. On behalf 
of the Marion County Public Health Department, I would like to thank 
you for the opportunity to come here today to discuss our efforts to 
prepare to respond to a mass casualty event in Marion County. I hope 
this is the first of many opportunities to work with this subcommittee.
    Today I would like to share some of our response capabilities here 
in Marion County and emphasize the importance of building partnerships 
between the public and private sectors. Here in Central Indiana, we 
have built a truly unique health care coalition that allows the Health 
Department, Emergency Medical Services, and other public agencies to 
effectively collaborate and to work together with our private sector 
health care partners. We are prepared to respond to all hazards, 
whether natural disasters, disease outbreaks, terrorist threats, or 
weapons of mass destruction, because we have built a coalition that 
enables all partners to work together to respond.
                      the health department's role
    The Marion County Public Health Department is responsible for 
Emergency Support Function (ESF) 8 functions under the National 
Response Framework, which means the health department is responsible 
for the public health and medical care needs of the entire population 
in Marion County during an emergency event. This can include everything 
from medical treatment to providing clean drinking water and 
sanitation. In addition, the health department is responsible for 
coordinating Emergency Support Function (ESF) 11 activities which 
entails identifying food, water, and ice needs and temporary shelter 
for animals in the aftermath of an emergency.
    One of the most important responsibilities of the Health Department 
is protection against chemical, biological, radiological, nuclear, and 
high-yield Explosive (CBRNE) threats. To monitor and respond to these 
threats, the Health Department operates an Environmental Emergency 
Response team that collaborates with local and State partners including 
the Indianapolis Fire Department Hazardous Materials (HazMat) team, the 
Indiana Department of Homeland Security, and the Indiana State 
Department of Health. This team plays a very important role, especially 
concerning our response to chemical and biological threats. Because of 
this team, Central Indiana maintains an excellent state of preparedness 
for chemical and biological threats.
    Marion County Public Health Department is also responsible for the 
coordinating activities under the U.S. Department of Homeland 
Security's BioWatch program. In partnership with Indiana Departments of 
Environmental Management and Health, Indianapolis Metropolitan Police 
Department, Hamilton County Health Department, the U.S. Army Civil 
Support team and the FBI, daily monitoring for the potential of 
airborne bioterrorism threats occurs.
    Our Environmental Emergency Response team responds in conjunction 
with the Indianapolis Fire Department HazMat team to secure, sample, 
and process hazardous or suspicious materials, especially when 
biological hazards are suspected. They respond to all incidents 
involving suspicious powders, including a recent incident at Riley 
Children's Hospital at Indiana University Health. Marion County Public 
Health Department's Environmental Emergency Response Team is the only 
team in Indiana that keeps a ready supply of appropriate test kits to 
detect ricin, as well as Anthrax, Botulinum toxin, and poxvirus. While 
these kits are very costly to maintain, we have made our CBRNE 
capabilities a priority and have made the financial investments 
necessary to be able to respond when these events occur. This proved to 
be a very valuable investment last year when letters containing ricin 
were being mailed around the country and we were the only Public Health 
Department in Indiana with the ability to test for ricin.
    Another important function that the Marion County Public Health 
Department performs to protect our community during a biological threat 
event is to run the Point of Distribution (POD) system that would be 
responsible for delivering critical medications or vaccinations from 
either the strategic National stockpile or the State strategic 
stockpile to the citizens of Marion County. In addition to running 
these points of distribution, we would also maintain communications 
with the public to keep them informed of the biological threat and the 
best practices they can take to respond to that threat. We continuously 
plan and regularly conduct trainings and drills to ensure that we could 
effectively distribute vaccines and medication to protect the 
population of Central Indiana in the event of either a natural or a 
terrorist biological threat.
    Because we have invested in a great team, which allows us to 
maintain a high level of preparation to respond to environmental 
emergencies, we are also called on to lend assistance and to be a 
resource beyond the borders of Marion County. We routinely work with 
the surrounding counties to provide mutual aid support, engage in 
collaborative planning, and participate in mutual training exercises 
with local, State, and Federal agencies so that we can be prepared 
across the entire Central Indiana Region. One of the best 
demonstrations of this collaborative spirit was evidenced in during the 
Super Bowl last year, where we maintained a 24-hour support team that 
worked with the FBI, the EPA, and other Federal agencies involved in 
supporting the event.
    Marion County also collaborates to ensure that we have a resilient 
community by maintaining a volunteer Medical Reserve Corps. We keep an 
on-going registry of licensed medical providers who have the ability to 
serve in the event of a disaster or attack by a weapon of mass 
destruction, and we call upon these volunteer providers for assistance 
during emergency events. These providers include physicians and nurses 
to provide immediate medical attention, but we also go beyond the 
immediate medical needs to maintain a registry of volunteers who can 
treat the deeper health needs of the community, including social 
workers and psychologists. We recently had an opportunity to deploy 
some of these volunteers to assist the Central Indiana community when 
we responded to the home explosion in Richmond Hills. Our social 
workers and community psychologist partners worked together with us to 
help that community heal after dozens of people were evacuated from 
their homes in response to the explosion.
             the importance of public-private partnerships
    Marion County has a population of nearly 1 million people, or 
approximately one-sixth of the population of the entire State of 
Indiana. When you include the population of the surrounding counties of 
Central Indiana whose residents are not technically a part of our 
service area, but who frequently utilize hospitals and other care 
providers within Marion County, health care facilities in Marion County 
could be asked to service the medical needs of up to 1.7 million 
people. The majority of all health care emergency response needs would 
have to be met by private-sector providers. One of the things we 
realized early on was the critical importance of working together with 
the private sector to plan for major disasters or weapons of mass 
destruction.
    In order for the Health Department to effectively perform its ESF-8 
functions, we also determined that it was essential to form strong 
partnerships between and amongst the private hospitals, as well as with 
local public safety partners who would be able to facilitate 
appropriate responses to emergency events. In order to bring about this 
capability, we collaborated to form a non-profit health care coalition, 
the MESH Coalition. MESH is an organization that helps health care 
providers, who are competitors in regular business, work together with 
the Health Department, public safety agencies, and other private-sector 
organizations to prepare and respond to treats in Central Indiana. No 
other city has the kind of partnership between public agencies and the 
private health care sector that we have formed here in Marion County.
    Our spirit of partnership with private-sector health care providers 
is not limited to hospitals, but also extends to the other health care 
facilities within the county. We partner with dozens of other provider 
organizations, including community health centers, urgent care 
facilities, dialysis centers, social workers, and psychologists to 
built preparation throughout the health care sector in Central Indiana. 
One of our key partners is Wishard Health Services. It is the safety 
net hospital in Central Indiana. Wishard is one of only two Level 1 
Trauma Centers in the city, and routinely provides support to mass 
casualty events. They have a dedicated vice president-level executive 
who is responsible for emergency management issues. Wishard has a 
special obligation to vulnerable populations during and following 
disaster/mass-casualty events and takes that responsibility seriously--
leading to innovation in outreach and disaster management for these 
patients. They will shortly be moving to a new facility, in which it 
will have the opportunity to test its ability to evacuate an entire 
hospital and relocate patients. Wishard will use emergency management 
principles, including the Incident Command System (ICS) to organize the 
move. Wishard houses/hosts MESH, and was an early founding member of 
the coalition. Our philosophy is that to develop a prepared community, 
a community which can be resilient in responding to and recovering from 
a public health crisis, you must first build a healthy community. A 
healthy community foundation is required in order to respond to a 
natural disaster or terrorist situation, which means that people in 
that community must have access good quality health care, a strong 
social support fabric, and the public resources they need to address a 
crisis situation.
    Chairwoman Brooks, Senator Donnelly, Congressman Young, 
Congresswoman Walorski, and staff of the subcommittee, I would like to 
thank you for the opportunity to testify today on our efforts to 
prepare Central Indiana for a mass casualty event. I would also hope 
that our the accomplishments we have made in building a public-private 
health care coalition are something that other cities can benefit from 
to improve their health care systems' ability to respond emergencies.
    Again, thank you for your leadership and your emphasis on the 
importance of emergency preparedness.

    Mrs. Brooks. Thank you so much, Dr. Caine.
    I now call on Dr. Profeta to testify for 5 minutes.

   STATEMENT OF LOUIS M. PROFETA, M.D., F.A.C.E.P., MEDICAL 
   DIRECTOR OF DISASTER PREPAREDNESS, ST. VINCENT HOSPITAL, 
                     INDIANAPOLIS, INDIANA

    Dr. Profeta. Chairwoman Brooks, Senator Donnelly, 
Representative Walorski, thank you for allowing me the 
opportunity to come speak here and for taking an interest in 
this very important topic.
    The development of pre-hospital and emergency management of 
victims of mass casualty disasters arose in the mid-19th 
Century in the United States to address the needs of wounded 
soldiers in battle. This concept continued to grow with the 
birth of municipal and hospital-based ambulance services, 
followed by the development of emergency medicine services in 
the mid-1950s.
    In the infancy of development of EMS and emergency medicine 
and emergency systems, Indianapolis experienced one of the 
worst disasters in the 20th Century. On October 31, 1963, at 
the Indiana State Fairgrounds Coliseum during the opening night 
of the Holiday On Ice show, a gas leak explosion under the 
grandstands killed 74 people and resulted in 400 casualties. 
Fifty-four people were dead at the scene, 20 died in subsequent 
days, 165 people were admitted, and 209 were treated and 
discharged home.
    Many sustained injuries as bad as, if not worse than, those 
that we saw in the Boston Marathon explosion because many of 
these people were killed in crush injuries and a subsequent 
fire that erupted within the Coliseum.
    In 1963, there was no social media. There was no 
comprehensive mass casualty plan, no 24-hour news, no 
sophisticated trauma centers. Indianapolis EMS had just started 
to use two-way radio communication to coordinate ambulance 
dispatch, but there was no practical means to triage and 
distribute mass casualty patients throughout the city.
    In this case, in this instance, the dying were evacuated 
from the burning Coliseum. They were pulled into a nearby 
cattle barn, and a major attempt was made to transport and 
triage this huge number of casualties. St. Vincent's Hospital 
alone saw well over 100 patients from this disaster, with more 
than 50 needing to be admitted, and most requiring surgical 
intervention. Nearly all of the 400 casualties arrived at local 
emergency departments in less than 2 hours, and most within 30 
minutes. In fact, the first patient showed up at St. Vincent's 
Hospital, and that is how St. Vincent's found out about the 
explosion, because he showed up with bad injuries and said, 
hey, the Coliseum just exploded.
    What is remarkable is that the injury patterns that we saw 
in the Coliseum explosion were very similar to those that we 
would expect in a suicide bomb attack in Israel, and also what 
we saw in Boston. St. Vincent's Hospital's prevailing disaster 
plan was developed from our knowledge and our reflection on 
these past tragedies. At St. Vincent's Hospital, we have 
modeled our mass casualty strategy, including emergency 
department mobilization staging, on the tactics and the 
procedures followed by several Israeli hospitals and military. 
Israeli expertise is considered second-to-none in organizing 
hospitals' methods of response to a mass casualty incident.
    Specifically, we studied the strategies utilized by the 
Western Galilee Hospital in Northern Israel, as well as Magen 
David Adom, which is the Israeli version of the American Red 
Cross, to respond to acts of terror. Their emergency processes 
are predicated on speed, simplicity, reproducibility, and 
security.
    At St. Vincent's Hospital, in the event of a multi-casualty 
incident, we begin by evacuating our entire emergency 
department and mobilizing all of our patient cots to the 
turnaround entrance to the emergency department to facilitate 
and allow easy off-loading of EMS patients.
    Next, a seasoned emergency physician triages curbside so 
that we can send those valuable ambulances and paramedics back 
out onto the street with little to no delay. In fact, we can do 
this within 2 to 3 minutes, have those people back out on the 
streets and taking care of more casualty victims. We believe 
our system would function very well in a Boston-type event, but 
we also believe it would operate expertly in a Coliseum-
magnitude explosion.
    Certainly, the disaster response in the Boston Marathon was 
well-organized, it was well-coordinated, it was well-planned, 
but it occurred in the middle of a situation where you were 
near seven of the finest medical centers in the world and where 
you already had 200 EMS providers, medical tents, and support 
personnel staged at the location near or around the event.
    Some years ago, following September 11, St. Vincent's 
Hospital reviewed the injury pattern data from prior Israeli 
suicide studies and structured our emergency department's 
disaster response based on those studies. For example, if there 
are 100 victims in a suicide bombing, we can expect that 18 to 
20 percent are going to die at the scene, 6 percent are going 
to need emergency intubation in our department, 5 percent are 
going to need chest tubes, 12 to 18 percent will require 
immediate surgery, and 8 percent are going to require 
laparotomies. In addition, 35 to 40 percent of those patients 
are going to require admission to the hospital, and the rest 
will be considered walking wounded.
    Therefore, in the face of a large casualty, St. Vincent's 
emergency department can be confident in saying we can take 100 
patients because we already know what we are getting. There is 
no need for an extensive, multilayered, mobile command center 
running interference. In fact, Boston was lucky when compared 
to other suicide bombing instances such as the Park Hotel 
bombing in 2002 in Israel. They actually had less fatalities 
and less serious injuries than what we really should have 
expected in an event like that.
    On a yearly or biannual basis, St. Vincent's experiences 
events that cause patient surgeons in our emergency department. 
They largely go unnoticed because they don't involve a bomb and 
they don't involve a novel organism. Certainly, there have been 
significant pan-flu epidemics with H1N1 at a time when these 
have overwhelmed our emergency department in terms of volume 
but not in terms of acuity. In other words, we have a lot of 
patients, but they are really not that sick.
    Because of the lack of high acuity in surgeries such as 
these, the ED can easily accommodate these extra patients 
without a huge strain on the system. However, the last couple 
of years we have seen weather events, ice storms in particular, 
that have resulted in surges where the average patient volumes 
in some of our emergency departments were 100 patients greater 
than what we might typically see in a 24-hour period of time, 
and most of those people came within a 12-hour window. Many of 
them had serious fractures, head injuries. Some of those people 
even died, especially our elderly who were on concomitant blood 
thinners.
    Statistics actually show that in a city the size of 
Indianapolis, we are going to see 1,000 injuries that require 
emergency department visits on every single day of significant 
ice accumulation, and we handle those completely fine, all the 
hospitals do, without a whole lot of attention from the media.
    In closing, as a community and as a State, we have 
certainly come a long way in regards to preparedness since the 
1963 Coliseum events, and an increase in terrorist-type attacks 
have drawn disaster preparedness into the spotlight. New 
organizational structures such as the Indiana Emergency 
Management Agency Field Services Division, MESH, have sprung up 
to help coordinate when disasters strike. The reality, however, 
is that we have made very little improvement to disaster 
coordination and communication when these events actually 
occur, and we have made very little advancement in 
communication and coordination since 1963.
    This can be illustrated in the recent bus mass casualty 
event that occurred on July 27. The first responder efforts 
were amazing. The EMS efforts were amazing. But there certainly 
was a breakdown in communication, both externally and 
internally, that led to an emergency department only 4 miles 
away from this mass casualty event completely mobilized, 
completely evacuated, only to get two patients from this event. 
So certainly those are issues that we need to address, again 
both internally and externally.
    We have to place a greater emphasis and expect more Federal 
support for advanced communications in time of disaster. As 
hospital systems, we have to adopt the attitude that united we 
stand and divided we fall. I want to thank you for the 
opportunity to speak here today.
    [The prepared statement of Dr. Profeta follows:]
                 Prepared Statement of Louis M. Profeta
                              Aug. 6, 2013
    The development of pre-hospital and emergency management of victims 
of mass casualty disasters arose in the mid-19th Century in the United 
States to address the needs of wounded soldiers in battle.\1\ This 
concept continued to grow with the birth of municipal and hospital-
based ambulance services, followed by the development of emergency 
medical services in the mid-1950s.\1\
---------------------------------------------------------------------------
    \1\ Blackwell, Tom, MD, FACEP. ``Prehospital Care of the Adult 
Trauma Patient.'' Up to Date. Up to Date, 29 May 2013. Web. 31 July 
2013.
---------------------------------------------------------------------------
    In the infancy of the development of EMS and emergency medicine, 
Indianapolis experienced one of its worst disasters in the 20th 
Century. On October 31 in 1963 at the Indiana State Fairgrounds 
Coliseum during the opening night of the Holiday on Ice show, a gas 
leak explosion under the grand stands killed 74 people and resulted in 
nearly 400 casualties.\2\ \3\ Fifty-four people were dead at the scene 
and 20 died in subsequent days; 165 people were admitted and 209 were 
treated and discharged home.\2\ \3\ Many sustained injuries as bad if 
not worse than those in the recent Boston Marathon bombing because the 
explosion was also accompanied by fire. Most of the victims who died 
immediately were either crushed or severely burned.\3\
---------------------------------------------------------------------------
    \2\ ``RetroIndy: The 1963 Coliseum Explosion.'' Indianapolis Star. 
N.p., 17 Apr. 2013. Web. 31 July 2013.
    \3\ ``Coliseum Explosion.'' Coliseum Explosion. Indianapolis Star, 
10 July 2001. Web. 31 July 2013.
---------------------------------------------------------------------------
    In 1963 there was no social media, no comprehensive mass casualty 
plan, no 24-hour news, no sophisticated trauma centers. Indianapolis 
EMS had just begun to use two-way radio communication to coordinate 
ambulance dispatch, but there was no practical means to distribute and 
triage mass casualty patients throughout the city.\4\ In this case, the 
dying were evacuated from the burning Coliseum, pulled into a nearby 
cattle barn and an attempt was made to prioritize for transport to 
local hospitals.\2\ \5\ The vast majority of victims self-
transported.\5\
---------------------------------------------------------------------------
    \4\ ``Indianapolis EMS to Mark 125 Years of Service Indianapolis 
EMS.'' Indianapolis EMS to Mark 125 Years of Service Indianapolis EMS. 
Indianapolis Department of Public Safety, 17 May 2013. Web. 31 July 
2013.
    \5\ Drabek, Thomas. ``DISASTER IN AISLE 13 REVISITED.'' DISASTER IN 
AISLE 13 REVISITED. N.p., 18 May 1995. Web. 31 July 2013.
---------------------------------------------------------------------------
    St. Vincent Hospital alone saw well over 100 patients from this 
disaster, with more than 50 needing admission and most requiring 
surgical intervention. Nearly all of the 400 casualties arrived at 
local emergency departments in less than 2 hours and most within 30 
minutes.\5\ Surprisingly, the injury patterns, morbidity, and mortality 
of the casualties sustained that day are remarkably similar to those 
sustained by both suicide bombing victims in the Middle East, as well 
those injured in the Boston Marathon bombing. St. Vincent Hospital's 
prevailing disaster plan has developed from our knowledge of and 
reflection on these past tragedies.
    At St. Vincent Hospital, we have modeled our mass casualty 
strategies, including emergency department (ED) mobilization and 
staging, on the tactics and procedures followed by several Israeli 
hospitals and military. Israeli expertise is considered second-to-none 
in organizing hospitals' methods of response to a multiple casualty 
incident (MCI).\6\ Specifically, we have studied strategies utilized by 
the Western Galilee Hospital in Northern Israel, as well as the Magen 
David Adom (the Israeli version of the Red Cross), to respond to acts 
of terror. Their emergency processes are predicated on speed, 
simplicity, reproducibility, and security.\7\
---------------------------------------------------------------------------
    \6\ Leichman, Abigail Klein. ``The Israeli Sharing His Mass 
Casualty Expertise in Boston.'' ISRAEL21c. N.p., 24 Apr. 2013. Web. 31 
July 2013.
    \7\ ``Preparing for Emergencies: A SPECIAL MEETING OF THE RED CROSS 
WITH MDA ISRAEL.'' MDA ISRAEL. N.p., 25 July 2013. Web. 31 July 2013.
---------------------------------------------------------------------------
    At St. Vincent Hospital, in the event of a multi-casualty incident, 
we begin by evacuating our entire emergency department (ED) and 
mobilizing all of our patient cots to the driveway at the entrance to 
the ED to allow easy offload of EMS patients. Next, a seasoned 
emergency physician triages curbside, so that we can send ambulances 
back out with little to no delay in the transfer of other injured. This 
procedure allows EMS vehicles and personnel to be back out on the 
streets and in service within 2-3 minutes of arrival to the ED.
    We believe our system would function very well in a Boston-type 
event, but we also believe it would operate expertly in a Coliseum-type 
explosion as well. Certainly, the disaster response to the Boston 
Marathon bombing was well-organized, well-coordinated, and well-
planned.\8\ Fortuitously, this multi-casualty incident occurred in a 
location near seven of the finest hospitals and medical centers in the 
world. In addition there were already more than 200 EMS providers on-
scene with medical tents and equipment on-hand.\8\
---------------------------------------------------------------------------
    \8\ Krisberg, Kim. ``Preparedness Paid Off in Boston Marathon 
Bombing Response.'' JEMS.com. Journal of Emergency Medical Services, 1 
July 2013. Web. 31 July 2013.
---------------------------------------------------------------------------
    Some years following the September 11 attacks, St. Vincent Hospital 
reviewed the injury pattern data from prior Israeli suicide bombing 
studies and structured our emergency department's disaster response 
based on those studies. For example, if there are 100 victims in a 
suicide bombing, we can expect 18-20% to die at the scene, 6% to need 
emergency intubation in the ED, 5% to need chest tubes, 12-18% to 
require immediate surgery, and an additional 8% to require 
laparotomies. In addition, 35-40% of the victims will need to be 
admitted; the remainder of the patients will be walking wounded.
    Therefore, in the face of a large casualty incident, St. Vincent ED 
can be confident in saying, ``we can take 100 patients'' because we 
already know what we are getting. There is no need for an extensive, 
multi-layered mobile command center running interference. In fact, 
Boston was lucky when compared to similar events such as the Park Hotel 
bombing in 2002 in Netanya, Israel; statistics show that many more 
people could have been killed at the scene in Boston.\9\
---------------------------------------------------------------------------
    \9\ ``Passover Suicide Bombing at Park Hotel in Netanya-27-Mar-
2002.'' GxMSDev. Israeli Ministry of Foreign Affairs, 27 Mar. 2002. 
Web. 31 July 2013.
---------------------------------------------------------------------------
    On a yearly or biennial basis, St. Vincent experiences events that 
cause patient surge issues in our ED. These events may largely go 
unnoticed because they do not involve an explosion or a novel organism. 
Certainly there have been significant panflu epidemics with H1N1 and 
these at times have overwhelmed the ED in terms of volume but not in 
acuity. In other words, the ED may see a lot of patients who are not 
really that sick. Because of the lack of high acuity in surges such as 
these, the ED accommodates the extra patients without a huge strain on 
the system.
    However in the last couple years, a few weather events (ice storms) 
have resulted in surges where average patient volumes in some of our 
EDs were 100 patients more than average over a 24-hour period with most 
of that surge showing up in a 12-hour window. In addition, in one of 
those events, a large percentage of patients had serious fractures and 
head trauma, which required significant resources and often admission. 
In fact, statistics show you can expect 1,000 emergency injury visits 
per day in a city the size of Indianapolis for each and every day of 
significant ice accumulation.\10\
---------------------------------------------------------------------------
    \10\ ``Work-Related Injuries Associated with Falls During Ice 
Storms.'' Centers for Disease Control and Prevention. Centers for 
Disease Control and Prevention, 15 Dec. 1995. Web. 31 July 2013.
---------------------------------------------------------------------------
    In closing, as a community and as a State, we have certainly come a 
long way in regards to preparedness since the 1963 Coliseum explosion. 
An increase in terrorist-type attacks has drawn disaster preparedness 
into the spotlight. New organizational structure such as the Indiana 
Emergency Management Agency and Field Services Divisions along with new 
organizations such as MESH have sprung-up to help coordinate events 
when disasters strike. The reality however, is that we have made very 
little improvements to disaster coordination and communication when 
these events actually occur and have made very little advancement in 
communication and coordination since 1963. This was perfectly 
illustrated in the recent bus crash mass casualty event that occurred 
on Saturday, July 27. St. Vincent Hospital and Trauma Center, the 
second-busiest trauma center in the State of Indiana only received two 
patients from a mass casualty event not more than 4 miles away. We were 
not only the closest hospital, we were the closest trauma center, and 
more than likely mobilized had the most organized disaster plan in the 
city, yet only received two patients from this tragedy. We must place a 
greater emphasis and expect more Federal support to advance 
communications in the time of a disaster. There is no place for 
territorial imperatives and imperialistic attitudes from individual 
hospitals and EMS agencies during a disaster response. As hospital 
systems, we must adopt the attitude that united we stand and divided we 
fail.

    Mrs. Brooks. Thank you, Dr. Profeta.
    The Chairwoman now recognizes Dr. Knight for 5 minutes. 
Thank you.

    STATEMENT OF H. CLIFTON KNIGHT, CHIEF MEDICAL OFFICER, 
                    COMMUNITY HEALTH NETWORK

    Dr. Knight. Good morning, Chairwoman Brooks, Senator 
Donnelly, Representative Walorski, and the staff of the 
subcommittee. On behalf of Community Health Network, we 
sincerely appreciate this opportunity to discuss Indiana's 
preparedness for a mass casualty event with you today. Your 
commitment and dedication to this important issue shows a 
proactive interest that we do sincerely appreciate.
    My name is Cliff Knight. I am a family physician, and I am 
the chief medical and chief academic officer for Community 
Health Network. Today I want to provide you with some basic 
background information about our organization, our engagement 
with emergency preparedness efforts, and our concerns regarding 
being optimally prepared for the potential of catastrophic 
events in Central Indiana.
    We are based in Indianapolis, and Community Health Network 
is a private, not-for-profit system consisting of six general 
acute hospitals, a cardiovascular-focused acute care hospital, 
a freestanding rehabilitation hospital, as well as hundreds of 
ambulatory sites of care, encompassing a full spectrum of both 
primary care services and subspecialty services. In addition, 
we provide extensive homecare-based services. We have 
approximately 13,000 employees and host 2 million patient 
encounters each year across all of our facilities.
    Each of our acute care hospitals provides emergency 
services. Internally, we provide extensive educational 
programming for in-the-field emergency medical providers, and 
we meet or exceed all the standards of the Joint Commission 
related to emergency preparedness. To accomplish this, we train 
staff, we track supplies, and regularly communicate with our 
teams regarding issues and trends of importance.
    Throughout our facilities, we also perform drills using a 
variety of scenarios multiple times per year. Community has an 
emergency operations plan, as well as a surge plan. Utilizing 
resources throughout our district support structure, we are 
able to help support patient influx as necessary. As a 
district, we drill for severe patient influx on an annual basis 
at least.
    In Indiana, we believe our greatest and most likely risks 
are related to natural disasters such as tornadoes and 
earthquakes. However, we take very seriously the plausibility 
of a terrorist-initiated disaster resulting in a surge in acute 
care needs. We aim to be prepared in ways that accommodate the 
needs that would arise from a variety of causes.
    Community Health Network actively participates in 
activities with the MESH Coalition, as well as the Indianapolis 
Coalition for Patient Safety. We found that both organizations 
uniquely are suited to support our efforts to coordinate and 
standardize approaches to issues common to all the hospitals in 
Indianapolis.
    For example, our involvement in the Indianapolis Coalition 
for Patient Safety has resulted in our participation in city-
wide efforts to standardize approaches to addressing influenza 
outbreaks, both H1N1 and seasonal, and the resulting surges in 
patient care.
    Though we are confident in our preparedness for adequately 
responding to mass casualty situations, we strongly believe 
that there is more that can and should be done to optimally 
prepare. Our greatest fears are around our ability to quickly 
mobilize enough health care providers and staff in response to 
an emergent need. We, of course, have designated on-call 
personnel, but would need to mobilize additional resources 
quickly. We believe this can be accomplished through 
communication avenues utilizing standard methodologies--cell 
phones, text messages, social media, and public 
communications--but this is a theoretical given that 
communications may be interrupted in a large-scale event with 
widespread damage.
    To address this, we urge continued focus on supporting 
redundancies and refinements in public communication 
infrastructure as a safeguard.
    Another area of concern is related to the reality of 
funding for training and education of our personnel. As 
economic forces require us to function more efficiently, it 
becomes problematic to regularly remove providers and staff 
from their primary functions in order to free them up to focus 
on training and education.
    In addition, our observation is that we need to be more 
fully involving hospitals and EMS providers in training and 
education. There seems to be a lack of funding to support this 
involvement for private hospitals and private EMS services.
    In order to accomplish broader coordination and improved 
participation in preparation, Federal funding to support these 
efforts would be helpful.
    Thank you all for this opportunity to provide a status 
report regarding our emergency preparedness in Central Indiana 
and for your commitment to improving our capabilities, and I 
look forward to providing any other additional information for 
clarification or questions you may have.
    [The prepared statement of Dr. Knight follows:]
                Prepared Statement of H. Clifton Knight
                             August 6, 2013
    Good morning Chairman Brooks, Senator Donnelly, Congresswoman 
Walorski, Congressman Young, and staff of the subcommittee. On behalf 
of Community Health Network, we appreciate this opportunity to discuss 
Central Indiana's preparedness for a mass casualty event with you 
today. Your commitment and dedication to this important issue shows 
proactive interest that we sincerely appreciate.
    Today, I plan to provide you with some basic background information 
about our organization, our engagement in emergency preparedness 
efforts, and our concerns regarding being optimally prepared for the 
potential of catastrophic events in Central Indiana.
                        community health network
    Based in Indianapolis, Community Health Network is a private, not-
for-profit system consisting of 6 general acute care hospitals, a 
cardiovascular-focused acute care hospital, and a free-standing 
rehabilitation hospital as well as hundreds of ambulatory sites of care 
encompassing a full spectrum of primary care and sub-specialty 
services. In addition, we provide extensive home-based services. We 
have 13,000 employees and experience 2,000,000 patient encounters each 
year.
                   emergency preparedness engagement
    Each of our acute care hospitals provides emergency services. 
Internally, we provide extensive educational programming for in-the-
field emergency medical providers. We meet or exceed all standards of 
The Joint Commission related to emergency preparedness. To accomplish 
this, we train staff, track supplies, and regularly communicate with 
our teams regarding issues and trends of importance. Throughout our 
facilities, we also perform drills using a variety of scenarios 
multiple times per year. Community has an Emergency Operations Plan as 
well as a surge plan. Utilizing resources through our district support 
structure, we are able to help support patient influx as necessary. As 
a district, we drill for severe patient influx at least annually.
    In Indiana, we believe our greatest and most likely risks are 
related to natural disasters such as tornadoes and earthquakes. 
However, we take very seriously the plausibility of a terrorist-
initiated disaster resulting in a surge in acute care needs. We aim to 
be prepared in ways that accommodate the needs that would arise from a 
variety of causes.
    Community Health Network actively participates in activities with 
the Managed Emergency Surge in Healthcare (MESH) Coalition as well as 
the Indianapolis Coalition for Patient Safety (ICPS). We have found 
both organizations uniquely suited to support our efforts to coordinate 
and standardize approaches to issues common to all hospitals in 
Indianapolis. For example, our involvement in the ICPS has resulted in 
our participation in city-wide efforts to standardize approaches to 
addressing influenza outbreaks (both H1N1 and seasonal) and the 
resulting patient surges.
                            needs assessment
    Though we are confident in our preparedness for adequately 
responding to mass casualty situations, we strongly believe there is 
more that can and should be done to optimally prepare.
    Our greatest fears are around our ability to quickly mobilize 
enough health care providers and staff in response to an emergent need. 
We of course have designated on-call personnel, but would need to 
mobilize additional resources quickly. We believe this can be 
accomplished through communication avenues utilizing standard 
methodologies (cell phones, text messages, social media, and public 
communications) but this is theoretical given that communications may 
be interrupted in a large-scale event with wide-spread damage. To 
address this, we urge continued focus on supporting redundancies and 
refinements in public communication infrastructure as a safeguard.
    Another area of concern is related to the realities of funding for 
training and education of our personnel. As economic forces require us 
to function more efficiently, it becomes problematic to regularly 
remove providers and staff from their primary functions in order to 
focus on training and education. In addition, our observation is that 
we need to more fully involve all hospitals and EMS providers in 
training and education. There seems to be a lack of funding to support 
this involvement for private hospitals and private EMS services. In 
order to accomplish broader coordination and improved preparation, 
Federal funding to support these efforts would be helpful.
    Thank you all for this opportunity to provide a status report 
regarding emergency preparedness in Central Indiana and for your 
commitment to improving our capabilities. I look forward to providing 
any additional information or clarifications that may be helpful.

    Mrs. Brooks. Thank you, Dr. Knight.
    The Chairwoman now recognizes Dr. Reed to testify.

  STATEMENT OF R. LAWRENCE REED, II, M.D., F.A.C.S., F.C.C., 
    DIRECTOR OF TRAUMA SERVICES, INDIANA UNIVERSITY HEALTH 
                       METHODIST HOSPITAL

    Dr. Reed. Thank you, Chairwoman Brooks, Senator Donnelly, 
and Congresswoman Walorski. Thank you for the opportunity to 
discuss this very critical task. Put very simply, preparedness 
saves lives. IU Health has a proven history in treating the 
unexpected, the complex, and the unique, and does so with the 
highest standard of patient quality care and outcomes.
    Our work is, by its very nature, frenetic, yet requires 
precision. No two cases are the same. Yet, we remain fully 
prepared and ready for events that no one wants to acknowledge 
could happen, let alone see. It is like having an army primed 
and ready for a battle you hope you will never have to fight.
    IU Health is home to two of only three Level I trauma 
centers in Indiana. IU Health Methodist is a verified Level I 
trauma facility. Wishard-Eskenazi is the other Level I trauma 
facility in Indiana, and Riley Hospital for Children at IU 
Health is the State's only pediatric Level I trauma center. 
This verification comes with immense responsibility and 
unparalleled dedication. We strive continually to refine, hone, 
and improve our efforts. Being a Level I trauma center means we 
have highly-skilled medical talent immediately available on-
site 24/7, two trauma surgeons in-house, around the clock, a 
full emergency medical team, including emergency physicians and 
nurses, neurosurgeons, orthopedic surgeons, anesthesiologists, 
critical care specialists and hospitals, all on-site, day or 
night, ready to provide immediate specialized care before 
patients--tens, hundreds, or thousands--even hit our doors.
    We have the resources at Methodist. We have 35 operating 
rooms, a fully-stocked blood bank and critical supplies. The IU 
Health system includes our lifeline fleet of critical care 
transport comprised of six helicopters and five bases 
throughout Indiana. Senior administrators throughout the State 
are on call 24/7 with the infrastructure and ability to 
immediately call in or send out support to and from sister 
facilities.
    In the more than 100 years of Methodist history, we have 
never gone on diversion for trauma or emergency service, which 
is unusual for a private hospital.
    Although surge management starts at the scene of an 
accident, we have elaborate plans in place at the hospital and 
emergency department should patients show up at our doors 
unannounced. A 
24/7 on-duty team is constantly assessing patient flow and 
care, and by virtue of being a large hospital with coverage by 
multiple specialties and resources that many hospitals don't 
have, we have experience with the cases that others can't 
treat.
    Indianapolis is home to major activities, teams, and 
events, and IU Health plays a major role in supporting most of 
these. IU Health is the exclusive provider to the Indianapolis 
Motor Speedway and Lucas Oil Stadium, among others, where we 
care for thousands of fans each season. Indianapolis hosts 
sizable events, including the State Fair, the Super Bowl, the 
NCAA Final Four basketball tournaments, big-name concerts, and 
numerous conventions. Emergency preparedness is integral to the 
planning and success of them all. We have a seat at the table 
in the advanced planning for these major public events and 
embrace our leadership responsibilities.
    But, IU Health cannot do this alone. We are proud to be 
part of a larger community with established emergency 
preparedness systems and dedication to the charge. This is 
where you see the community at its best, as public and private-
sector resources unite to address and plan emergency 
preparedness. Planning and innovation has come more to the 
forefront for the city and State, as well as local agencies, to 
work with them, hospitals, and Government to prepare for the 
event of a mass casualty, be it a natural disaster, weapons of 
mass destruction, or other. We share a goal and collaborate 
rather than compete.
    MESH has been a valuable partner in leading preparedness 
efforts and sharing intelligence and extending their expertise, 
and we are fortunate to have a National leader and partner 
based here in Central Indiana. IU Health is fully committed to 
supporting the private-sector requirements of this partnership 
in hopes that the funding needed for the public effort remains 
in place. IU Health regularly hosts hazard vulnerability 
assessments, preparedness drills, and shares best practices 
with others in the community.
    After any major U.S. incident, local or National, we are 
privy to an after-action report and gap analysis which we can 
use to further refine our plans. IU Health is in constant 
communication with MESH, other hospitals, and partners in 
immediate District V and throughout the State, all with the 
united goal of being prepared to offer the best unexpected 
medical care to patients.
    Just last week, or actually 2 weeks ago, we treated an 
influx of patients we received from an overturned bus accident 
that involved three fatalities. We reattached a severed hand, 
which can be the difference between a fairly normal life and 
one of inconvenience and extreme handicap.
    Following the 2011 State Fair stage collapse, before we 
could even call in additional resources to prepare for the 
arrival of many injured patients simultaneously, our staff 
members were already reporting for new and unexpected work on a 
Saturday night without even being called. We did not have to 
activate our disaster plan. Our team knew they would be needed 
and responded immediately. It was an impressive showing of 
dedication and commitment and of typical Hoosier values as we 
handled a serious community emergency seamlessly. Other 
hospitals in Indianapolis--Wishard-Eskenazi, Riley at IU 
Health, St. Vincent's--also helped manage several of these 
victims. Because of our proximity and our resources, the worst 
injuries came to IU Health Methodist.
    IU Health uses its size and scope to help further 
continuing education and build better relationships. IU Health 
recently held a training exercise at the IMS to educate first 
responders, increase standards of care, and build better 
relationships. We were able to present unique and complex cases 
of our Level I trauma team and better understood first 
responders' needs of being in the field.
    IU Health is a key part of the Indianapolis and Indiana 
emergency network. We do things no other systems in the State 
can handle. We appreciate your interest and welcome your 
continuing support of our efforts to maintain readiness and 
serve fellow Hoosiers in time of crisis. Thank you.
    [The prepared statement of Dr. Reed follows:]
               Prepared Statement of R. Lawrence Reed, II
                             August 6, 2013
    Thank you for the opportunity to discuss this very critical topic--
put very simply, preparedness saves lives. IU Health has a proven 
history in treating the unexpected, the complex, and the unique and 
does so with the highest standard of patient quality, care, and 
outcome.
    Our work by its very nature is frenetic yet requires precision. No 
two cases are ever the same, yet we remain fully prepared and ready for 
events that no one wants to acknowledge could happen, let alone see. 
It's like having an army primed and ready for a battle you hope you 
never have to fight.
    IU Health is home to two (of only three) Level 1 Trauma centers in 
Indiana: IU Health Methodist is a verified Level 1 Trauma facility 
(Wishard-Eskenazi is the other) and Riley Hospital for Children at IU 
Health is the State's only pediatric Level 1 Trauma center. This 
verification comes with immense responsibility and unparalleled 
dedication. We strive continually to refine, hone, and improve our 
efforts.
    Being a Level 1 Trauma center means we have highly-skilled medical 
talent immediately available on-site 24/7: Two trauma surgeons, a full 
emergency medical team including emergency physicians and nurses, 
neurosurgeons, orthopedic surgeons, anesthesiologists, critical care 
specialists, and hospitalists--all on-site, day or night, ready to 
provide immediate specialized care before patients (tens, hundreds, or 
thousands) even hit our doors.
    We have the resources: 35 operating rooms; a fully-stocked blood 
bank and critical supplies; our LifeLine fleet of critical care 
transport, comprised of six helicopters and five bases throughout 
Indiana; senior administrators throughout the State on-call 24/7 with 
the infrastructure and ability to immediately call in, or send out, 
support from sister facilities. In the more than 100 years of Methodist 
history, we have never gone on diversion for trauma or emergency 
services, which is very unusual for a private hospital.
    Although surge management starts at the scene of an accident, we 
have elaborate plans in place at the hospital and emergency department 
should patients show up at our doors unannounced. A 24/7 on-duty team 
is constantly assessing patient flow and care. And by virtue of being a 
large hospital with coverage by multiple specialties and resources that 
many hospitals don't have, we have experience with the cases that 
others can't treat.
    Indianapolis is home to major activities, teams, and events and IU 
Health plays a major role in supporting most of these. IU Health is the 
exclusive health care provider to the Indianapolis Motor Speedway and 
Lucas Oil Stadium, among others, where we care for thousands of fans 
each season. Indianapolis hosts sizeable events, including the State 
Fair, the Super Bowl, NCAA Final Four Basketball Tournaments, big-name 
concerts, and numerous conventions, and emergency preparedness is 
integral to the planning and success of them all. We have a seat at the 
table in the advanced planning for these major public events and 
embrace our leadership responsibilities.
    But IU Health cannot do this alone. We are proud to be a part of a 
larger community with an established emergency preparedness system and 
dedication to the charge. This is where you see the community at its 
best, as public and private-sector resources unite to address and plan 
emergency preparedness. Planning and innovation has come more to the 
forefront for the city and State as we work with local agencies, 
hospitals, and Government to prepare for the event of a mass casualty--
be it a natural disaster, WMD, or other. We share a goal and 
collaborate rather than compete.
    MESH has been a valuable partner in leading preparedness efforts, 
in sharing intelligence and in extending their expertise, and we are 
fortunate to have a National leader and partner based here in Central 
Indiana. IU Health is fully committed to supporting the private-sector 
requirements of this partnership and hopes that the funding needed for 
the public efforts remains in place. IU Health regularly hosts hazard 
vulnerability assessments, preparedness drills, and shares best 
practices with others in the community. After any major U.S. incident, 
local or National, we are privy to an after-action report and gap 
analysis which we can use to further refine our plans. IU Health is in 
constant communication with MESH, other hospitals, and partners in our 
immediate District V and throughout the State--all with a united goal 
of being prepared to offer the best unexpected medical care to 
patients.
                  key learnings & what is working well
    Just last week we treated an influx of patients received from an 
overturned bus accident that involved several fatalities; we reattached 
a severed hand which can be the difference between a fairly normal life 
or one of inconvenient and extreme handicap. Following the 2011 State 
Fair stage collapse, before we could even call in additional resources 
to prepare for the arrival of many injured patients simultaneously, our 
staff members were already reporting for work on a Saturday night. We 
did not have to activate our disaster plan. Our team knew they would be 
needed and they responded immediately. It was an impressive showing of 
dedication and commitment . . . and of typical Hoosier values . . . as 
we handled a serious community emergency seamlessly. Other hospitals in 
Indianapolis--Wishard-Eskenazi, Riley at IU Health, St. Vincent's--also 
helped manage several of these victims. Because of proximity and our 
resources, the worst injuries came to Methodist.
    IU Health uses its size and scope to help further continuing 
education and build better relationships. IU Health recently held a 
training exercise at the IMS to educate first responders, increase 
standards of care, and build better relationships. We were able to 
present unique and complex cases of our Level 1 Trauma team and better 
understand first responders' needs of being in the field.
    IU Health is a key part of the Indianapolis and Indiana emergency 
network. We do things no other systems in the State can handle. We 
appreciate your interest and welcome your continuing support of our 
efforts to maintain readiness and serve fellow Hoosiers in times of 
crisis.

    Mrs. Brooks. Thank you, Dr. Reed.
    The Chairwoman now recognizes Dr. Obeime to testify.

   STATEMENT OF MERCY OBEIME, DIRECTOR, COMMUNITY AND GLOBAL 
  HEALTH, FRANCISCAN ST. FRANCIS HEALTH, INDIANAPOLIS, INDIANA

    Dr. Obeime. Good afternoon, Congresswoman Brooks, Senator 
Donnelly, and Congresswoman Walorski. I have lived in District 
V and worked in District VII since 1996. I am here today 
representing Franciscan St. Francis Health to discuss the 
ability----
    Mrs. Brooks. Excuse me. Could you pull the mic a bit closer 
to you? Thank you.
    Dr. Obeime. Sorry. I am here today representing Franciscan 
St. Francis Health to discuss the ability of the Central 
Indiana community to respond to a mass casualty event. I am 
also here accompanied by Diana Leonard, our full-time disaster 
management coordinator. She is responsible for our three 
Central Indiana hospitals and serves as a liaison to community 
response partners, as well as ensures organizational 
preparedness through planning and training.
    Franciscan St. Francis Health is one of the largest health 
care providers in Indiana, with campuses in Carmel, 
Indianapolis, and Morrisville. We are a division of Franciscan 
Alliance, one of the region's largest Catholic health care 
providers. Our mission is continuing Christ's ministry in our 
Franciscan tradition, and we strive to adhere to every word of 
the mission statement.
    In order to be continuing our hospital, we must be able to 
continue to operate through disasters and other emergency 
events. We continuously strive to develop comprehensive and 
innovative strategies for emergency preparedness, response, 
recovery, and mitigation.
    Since our founding, our values have been rooted in 
Franciscan tradition and the spirit of St. Francis of Assisi. 
The health care professionals at Franciscan St. Francis exhibit 
compassionate concern for the patients we serve and strive for 
Christian stewardship, a just and fair allocation of human, 
financial, and spiritual resources.
    It is our job to help meet the basic medical needs of 
vulnerable populations here in Indiana. Effective health care 
emergency preparedness requires carefully considering the needs 
of vulnerable populations. Vulnerable populations can be at 
greater risk during disaster and crisis events. The social 
determinants of health, socioeconomic status, age, gender, 
ethnicity, education, disability, and immigration status all 
contribute to a lack of equity and access to opportunities and 
increased vulnerability to hazards.
    Serving culturally-diverse populations is challenging. Our 
health system has a large presence on the south side of 
Indianapolis, which is home to a large Burmese and Hispanic 
population. Emergency events call for the engagement of the 
entire community, and we strive to break through language and 
other cultural barriers to meet our health care objectives.
    You may recall in June 2012, dozens of Indiana children 
were sickened and injured when a dangerous chemical combination 
in a neighborhood pool created a toxic gas. Then in November, 
we were called to assist the victims of the Richmond Hill's 
explosion. Because of our hazardous materials and emergency 
preparedness training, as well as our partnerships with 
community responders, we were able to successfully manage this 
patient surge, care for our patients, and achieve positive 
health outcomes for all involved.
    Franciscan St. Francis Health was an early founding member 
of the MESH Coalition, and we have remained a strong member. We 
have also leveraged social media as a source of health care 
intelligence and utilized platforms such as Facebook and 
Twitter to distribute information to our community. By 
collaborating with other hospitals, we can prevent redundancies 
in emergency planning and create an efficient response 
framework among area hospitals.
    Chairwoman Brooks, Senator Donnelly, Congresswoman 
Walorski, thank you again for this opportunity to speak before 
your subcommittee. Emergency preparedness is vital to health 
care not only in Central Indiana; it is vital across the globe. 
We at Franciscan St. Francis Health appreciate your dedication 
to this important area. We stand ready to assist the community 
in times of need. Thank you very much.
    [The prepared statement of Dr. Obeime follows:]
                   Prepared Statement of Mercy Obeime
                              July 6, 2013
    Good morning Chairman Brooks, Senator Donnelly, Congresswoman 
Walorski, Congressman Young, and all others with us today. I'm here 
representing the staff of Franciscan St. Francis Health to talk to you 
about our mission, specifically preparing the Central Indiana community 
to prepare for emergencies and disasters.
    Franciscan St. Francis Health is one of the largest health care 
providers in Indiana with campuses in Carmel, Indianapolis, and 
Mooresville. We are a division of the Franciscan Alliance, one of the 
region's largest Catholic health care providers. Our Indianapolis 
hospital offers cutting-edge technology and facilities, including the 
south side's only comprehensive cardiac and vascular care program. We 
have been ranked by multiple outlets as a Top 100 Hospital and have 
received recognition for clinical excellence and outstanding patient 
experience.
    Since our founding, our values have been rooted in the Franciscan 
tradition. In the spirit of Francis of Assisi, the health care 
professionals at Franciscan St. Francis exhibit compassionate concern 
for the patients we serve and strive for Christian stewardship--a just 
and fair allocation of human, financial, and spiritual resources.
    Since 1996, I have been fortunate to serve as the director of the 
Franciscan St. Francis Neighborhood Health Center at Garfield Park, 
where we provide primary medical care as well as health education for 
Hoosier families who lack access to affordable health care. Serving 
Indiana's underprivileged communities for the past 17 years has been a 
challenging but extremely rewarding experience.
    It is our job to help meet the basic medical needs of vulnerable 
populations here in Indiana. Effective health care emergency 
preparedness requires carefully considering the needs of vulnerable 
populations. Social factors often cause populations to be at greater 
risk during disaster and crisis events. Not unlike the social 
determinants of health, socio-economic status, along with age, gender, 
ethnicity, class, disability, and immigration status, all these factors 
determine lack of equity in access to opportunities and increased 
exposure to hazards. During Hurricane Katrina in 2005, for example, and 
most recently following Hurricane Sandy, this social vulnerability to 
disasters was widely evident as children, women, minorities, and the 
poor were disproportionately affected. Serving culturally-diverse 
populations also presents challenges. Our health system has a large 
presence on the south side of Indianapolis, home to a large Burmese 
population. Emergency events call for the engagement of the entire 
community, and we strive to break through language and other culture 
barriers to meet our health care objectives.
    Like most hospitals, we have not been strangers to emergencies. 
Last summer, dozens of Indiana children were sickened and injured when 
a dangerous chemical combination in a neighborhood pool created a toxic 
gas. Our acute care hospital in Indianapolis received 25 patients, all 
of whom required decontamination due to chemical exposure. Because of 
our hazardous materials and emergency preparedness training, as well as 
the partnerships with community responders, staff was able to 
successfully manage the surge in patients, while achieving positive 
health outcomes for those affected by the incident.
    Additionally, Franciscan St. Francis Health--Indianapolis was 
called to assist the victims of last fall's Richmond Hills home 
explosion. Among the items lost in the event were the medications of 
numerous neighborhood residents. Our hospital offered its services to 
provide a mobile clinic, working with a local pharmacy to meet the need 
for maintenance medications for the residents of Richmond Hills. While 
the mobile clinic was never deployed, Franciscan St. Francis stood 
ready to assist the community in its time of need.
    The mission of Franciscan St. Francis is continuing Christ's 
ministry in our Franciscan tradition, and we strive to adhere to every 
word of the mission statement. In order for our work to be 
``continuing,'' our hospitals must be able to continue to operate 
through disasters and other emergency events. Franciscan St. Francis 
Health--through individual and collaborative efforts--continuously 
strives to develop comprehensive and innovative strategies for 
emergency preparedness, response, recovery, and mitigation. We maintain 
a full-time disaster management coordinator for our three Central 
Indiana hospitals who serves as a liaison to community response 
partners, as well as enhance organizational preparedness through 
planning and training. Having this resource has allowed us to conduct 
full-scale emergency drills and streamline our emergency response plans 
into operational checklists. We conduct an annual Hazard Vulnerability 
Analysis, a method used to identify the most likely potential dangers 
to specific health care providers and to provide action plans for 
mitigating and responding to those vulnerabilities. We have upgraded 
our equipment, including a robust communications system that operates 
across our three campuses. All campuses are also in the process of 
becoming certified as ``storm-ready'' by the National Oceanic and 
Atmospheric Administration.
    While Franciscan St. Francis Health takes the initiative in 
creating comprehensive disaster management policies for our hospitals, 
we realize that true emergency preparedness cannot exist in a vacuum. 
We engage with other health care providers and public safety officials 
in order to create an efficient, collaborative emergency management 
system. Franciscan St. Francis Health--Indianapolis was an early, 
founding member of the MESH Coalition, and we have remained a strong 
partner since. MESH is a health care non-profit organization focused on 
giving hospitals the accurate information and resources to respond to 
emergency events and remain viable through recovery, promotes 
collaboration between Marion County hospitals in the area of emergency 
management, and provides invaluable resources we could not afford 
individually. Our membership with MESH has proven to be very beneficial 
over the years, allowing St. Francis to participate in many community 
initiatives, including the Super Care Clinic during the 2011 Super Bowl 
in Indianapolis, as well as hosting Nationally-recognized emergency 
management professionals in the MESH Grand Rounds Series.
    Another significant area in which MESH provides assistance is 
health care intelligence. During mass casualty incidents, MESH helps us 
better manage patient surge by notifying our emergency department how 
many patients are being transported to our hospital. MESH serves as the 
Medical Multi-Agency Coordinating Center (MedMACC) for Marion County, 
providing hospitals with real-time intelligence, including news and 
weather, public safety radio traffic, information from restricted 
homeland security portals, and social media. Franciscan St. Francis has 
also leveraged social media as a source of health care intelligence, 
and utilizes platforms such as Facebook and Twitter to distribute 
information to our community.
    MESH also assists Franciscan St. Francis with emergency planning by 
serving as a liaison with non-traditional emergency responders as well 
as researching real-world emergencies in order to identify strategies 
and tactics that were successful. We also participate in MESH's 
Hospital Preparedness Officers Working Group, where emergency 
management professionals meet to collaborate on Best Practices for 
training, education, emergency planning, and exercises. By 
collaborating with other hospitals we can prevent redundancies in 
emergency planning and create an efficient response framework among 
area hospitals.
    Chairman Brooks, Senator Donnelly, Congresswoman Walorski, and 
Congressman Young, thank you again for the opportunity to speak before 
this subcommittee today. Emergency preparedness is vital to health care 
here in Central Indiana and across the country. We at Franciscan St. 
Francis Health appreciate your dedication to this important area. I am 
happy to respond to any questions this subcommittee might have.

    Mrs. Brooks. Thank you, Dr. Obeime.
    At this time, I will recognize myself to begin the line of 
questioning.
    As we have learned in the aftermath of the Boston bombing, 
the Boston EMS utilized the Metro Boston Central Medical 
Emergency Direction System to alert area hospitals of the mass 
casualty event and route patients, and this coordinated 
response between EMS medical personnel along that marathon 
course and area hospitals undoubtedly saved many lives.
    In Central Indiana, what I would like to hear is: How are 
we coordinating? Are we holding exercises for a large-scale 
event, either individually in your own hospitals or 
collectively? I think I would like to hear from each of you 
very briefly in how are we working together on a day-to-day 
basis before any mass incident.
    We will go ahead and start with you, Mr. Priest.
    Mr. Priest. In Central Indiana, in partnership with Marion 
County and some regional areas as well, the Indianapolis Fire 
Department, the Indianapolis EMS, and MESH, we operate the 
Marion County Medical Multi-agency Coordinating Center. It is a 
mouthful. We call it the MedMACC. The MedMACC's job is to 
facilitate communication from scenes, such as the bus accident 
that was discussed today, and local hospitals. As I think Dr. 
Reed mentioned, surge management does start in the field, and 
that means that we need to be able to tell our responders which 
hospitals have availability, leaving the decisions to transport 
in the hands of those professionals.
    Mrs. Brooks. Thank you.
    Dr. Caine, coordination among, or training?
    Dr. Caine. We originally did a training with the 1,000 U.S. 
postal workers in Indianapolis with the fire department and a 
number of our hospital partners just recently. We also, about 2 
years ago, did a partnership looking at the chemical and 
biological threats in our community, as well as we have had 
exercises with the hospitals looking at radiological threats, 
and we have been fortunate enough to have some of our Federal 
agencies come down, the U.S. Army, helping to support some of 
our exercises.
    So we have numerous training and exercises that we try to 
do with the various Governmental agencies, as well as our 
hospitals and community partners.
    Mrs. Brooks. Thank you.
    Dr. Profeta.
    Dr. Profeta. In regards to coordinating with a lot of the 
hospitals directly, we really don't do that much coordination. 
To be honest, we make sure that we are prepared no matter what. 
Methodist I don't think calls us to ask us what our capacity 
is. I don't recall ever calling Methodist or IU, and vice 
versa. We certainly should be doing it more if we need to, but 
I have no doubt that I can pick up the phone and talk to any 
emergency department, the personnel at any of those 
institutions, and they would gladly be able to communicate, and 
vice versa with us.
    We do a lot of internal training. We run our own drills. We 
do a lot of tabletop exercises, active-shooter scenarios, fire 
exercises, how do we evacuate the hospital, how do we evacuate 
the emergency department and mobilize pharmacy. We take part in 
the District V drills, HAZMAT training. We work with Lighthouse 
Readiness Group to further train our faculty, and overall we 
try to be real active in doing at least two drills a year with 
patients, and tabletop drills continuously, and drills at the 
safety huddles at the beginning of each day.
    Mrs. Brooks. Thank you.
    Dr. Knight.
    Dr. Knight. Thank you. Some different drills that we 
participate in, I got to witness a drill that was done at MESH 
recently. They have a command center where they do keep track 
of surge capacity in each of the emergency departments around 
the city. So if there were an event, MESH can act as a 
centralized coordinator to identify the capacity in each of the 
different emergency departments. So the emergency departments 
don't need to call each other and find out how much space there 
is in each of those.
    Mrs. Brooks. To clarify, are you all involved in MESH? Are 
all of the hospitals here at this table partners in MESH?
    [Chorus of ayes.]
    Mrs. Brooks. Okay.
    Dr. Knight. Within our facilities, we have facility-
specific training drills on at least an annual basis. For 
example, in our emergency departments, we have decontamination 
showers. We want to make sure that folks really know how to use 
those when the time comes, so they will actually go through the 
motions of using those, as well as tabletop exercises for 
leadership to make sure we know how to deploy personnel 
appropriately throughout the facilities. Then we do participate 
within our district along with other emergency preparedness 
exercises that are done.
    Mrs. Brooks. Excellent. Thank you.
    Dr. Reed.
    Dr. Reed. Yes. Sometimes it seems like we are in a drill 
every day. Our emergency department sees somewhere on the order 
of 300 patients daily. During the summer surge, we sort of 
prepare, as trauma is seasonal, and disease. So from May 
through October, we are at full heat handling things. But we do 
have internal drills, coordinated drills with outside 
facilities, EMS, MESH, other facilities throughout the State.
    The thing that we also have at IU Health that is a little 
unique is this bridgeline process, that when there is some 
event within the health care system, the downtown facilities 
and IU Health, there is an immediate linkage between 
administrators and directors and executives about the situation 
and what is going to be done to solve those issues, anything 
from steam factories blasting to electrical problems to 
internet situations. So there are a lot of resources, and 
usually they are in practice sometime during the week, if not 
daily.
    Mrs. Brooks. Okay, thank you.
    Dr. Obeime.
    Dr. Obeime. At St. Francis, we collaborate with our 
community partners. Since I started working at St. Francis, 
part of my FTE was assigned for me to be able to work with Dr. 
Caine and the Marion County Health Department. We have also 
worked with MESH. We know that the people who may be most hurt 
will be the vulnerable who need the most help. We also do a lot 
of internal training for HAZMAT, mass casualty, active-shooter. 
We also have WMD exercises. We do all of these on both a local 
and regional basis.
    Mrs. Brooks. Thank you very much.
    I now yield 5 minutes to the gentleman from Granger.
    Senator Donnelly. Thank you, Madam Chairwoman.
    Mr. Priest, the Super Care Clinic was pretty much the first 
of its kind for a mass gathering like that. What is your 
biggest challenge to re-creating that at other events here in 
Central Indiana or throughout our entire State?
    Mr. Priest. Thank you for acknowledging that. It was the 
first of its kind. I don't know that we have a biggest 
challenge to re-creating it. I think the biggest challenge is 
to get another big event so we can do it. Producing that sort 
of fan-facing health and wellness program, which really for 
fans looked like a clinic but for us was an emergency 
management strategy, is something we are prepared to do.
    Senator Donnelly. Well, let me ask you this. Eighty-five 
thousand people go to a football game in one part of the State, 
65,000 in another part of the State, 58,000 in another part of 
the State on any given weekend. Do the lessons of MESH 
translate to those events?
    Mr. Priest. They do. In fact, I have been fortunate enough 
to work with my colleague, Dr. Dan O'Donnell, with Indiana 
University to actually look at their football program and how 
to adopt if not exactly a Super Care Clinic model, something 
that is similar, again looking at fan-facing health care.
    Senator Donnelly. This is not Indiana-specific, but 
obviously there will be another Super Bowl next year. I think 
it is in New York. Have you had any conversations with those 
people about the things you have learned so that our fellow 
citizens of this country have the same benefit of the talents 
that all of you brought to our Super Bowl?
    Mr. Priest. Senator, New Jersey personnel came to the Super 
Bowl here to observe our operations, and we certainly will make 
ourselves and have indicated we will make ourselves available 
to help them re-create this. We would certainly like to be 
helpful.
    Senator Donnelly. Thank you.
    Dr. Reed, your network goes across the State, from one end 
to the other, and in many cases when you look, Methodist is the 
final trauma center. That is where some of the very, very most 
difficult cases occur. Do you work together with your fellow--
not only IU locations, but other hospital unit locations in 
places like Terre Haute and Richmond, Fort Wayne, to try to 
provide best practices and to coordinate with them?
    Dr. Reed. Yes, we do. We communicate with them when they 
have patients to transfer to us on a fairly consistent basis. 
Terre Haute is one of our big providers for that kind of 
service, as well as Reed Hospital in Richmond. I am also on the 
Governor's trauma care committee, where all the trauma 
directors in the State, as well as their administrative staff 
and people within the State, the Departments of Health and 
Homeland Security, interact to help develop an actual trauma 
system within the State of Indiana. We are actually one of only 
three States that doesn't have a formal trauma system. We are 
about halfway through putting things together.
    But it is a significant need that is increasingly 
recognized, because by getting trauma care not just something 
that can be delivered at Methodist's doorstep but something 
that can be out there in the community where the patient can 
get care faster, or even faster, is very beneficial. We are 
actually starting to build our own IU Health trauma system 
within the State. We have had consultations and site visits 
from the American College of Surgeons for IU Health in 
Lafayette and IU Health----
    Senator Donnelly. That was the other question I was going 
to ask you. Are the lessons that you have learned here being 
transported to not only the IU network but to all health care 
providers throughout the State?
    Dr. Reed. Yes. A number of other hospitals are looking at 
becoming trauma centers, Level III or Level II trauma centers, 
not that they necessarily need to ramp up their resources. They 
already are seeing these trauma patients coming into their 
facilities. But by being a verified center, that ensures that 
not only do you have the resources but they work well, because 
it is a process of managing the patients. It is actually 
reviewed in the act of obtaining verification. So that gets 
that quality level of care closer to the patient.
    Senator Donnelly. Dr. Knight, what is the thing we need to 
do better the most right now as you look at the scenarios that 
we have to deal with on a regular basis? For want of a better 
way to put it, what keeps you up at night?
    Dr. Knight. Well, I think that the more we can cooperate 
and work together in preparedness, the better off we all are, 
because if we can share those expenses of the training and 
education and share that preparation, then as a community we do 
a better job when those times come. So things like the MESH 
Coalition, the Indianapolis Coalition for Patient Safety, and 
our district preparedness are all very important so that we are 
working more in a coordinated fashion than as individual health 
care systems. So I think the more we can do to emphasize that, 
the better off our patients are and the communities are that we 
serve.
    Senator Donnelly. Thank you.
    Thank you, Madam Chairwoman.
    Mrs. Brooks. Thank you.
    Now, if the gentlelady from Jimtown has any questions.
    Mrs. Walorski. Thank you, Madam Chairwoman.
    I am interested in, obviously, the concept of this MESH at 
events, but I am also very aware of the fact--and you are all 
saying the same thing. The difference between a planned event 
versus an element of surprise, like the bus turnover just a few 
weeks ago, where all eyes are on the Super Bowl, the 500, and 
the plan is there, and it all comes together.
    But, for example, with the bus rollover, which was 
unexpected. Nobody knew, thought, or ever conceived that that 
was going to happen 5 minutes away from the designation, back 
to the church. So when that happens, who takes over then? Dr. 
Profeta, when you talked about there was a place right here, 
who takes over and says----
    Dr. Profeta. At the scene?
    Mrs. Walorski. At the scene. Who takes over?
    Dr. Profeta. The first responder, whoever is the first 
responder at the scene.
    Mrs. Walorski. Right. Then do all the hospitals immediately 
engage with the first responders?
    Dr. Profeta. Not necessarily. I mean, if they call, we 
engage. But we go ahead and just engage on our own. We activate 
the plan. We get things moving.
    When the State Fair collapse took place, the same thing 
happened to us. People and doctors started coming in. We didn't 
have to call and respond to them. But we have three systems set 
up in our emergency department in case each one of them fails 
to notify mass numbers of people. Obviously, we monitor social 
media, just like anybody else.
    But in terms of who initiates the communications at the 
scene, it can be variable depending on who shows up. There can 
be breakdown. The more levels of interference you have between 
a mass casualty event and the hospital that is nearest to that 
event, the greater likelihood you have of people being routed 
to the wrong facility, deferred to preferential facilities, or 
not reaching the location they need to be.
    Also, think about it, a vast majority of people, especially 
in a mass casualty event, they are not going to come by 
ambulance. History shows that they are going to self-transport, 
and there is no way of controlling that flow of people. They 
know where the emergency departments are. They don't know where 
the MESH tent is. They don't know where the secondary command 
center is. They know where their local emergency departments 
are, and they are going to throw their kids in the car and they 
are going to go driving there. That is what we are prepared 
for.
    Mrs. Walorski. My second question is this: I just want to 
kind of throw out to the panel. In my previous tenure as a 
State representative, we were briefed at one point--this is a 
couple of years ago--on global pandemic of bird flu and what 
the State of Indiana was going to do, and it was the first 
chance I had to actually look at a State-wide comprehensive 
plan of exactly how county facilities, county fairgrounds were 
going to be used to operate.
    Is there, for this issue of a bioterror attack, a mass 
casualty attack on the State of Indiana, does that State matrix 
exist where in the event that our entire State, outside even of 
the population of Marion County, does that plan exist where we 
know exactly who is doing what?
    Dr. Caine. Yes. I am also actually a practicing physician. 
I am in the Division of Infectious Diseases at Indiana 
University School of Medicine. Yes, there is a State plan that 
exists. It was actually established by the Indiana State 
Department of Health. It was broken down into 10 districts that 
we had to prepare for avian flu, and I want to say that for our 
H1N1 event that happened, we were able to vaccinate over 
200,000 children in the City of Indianapolis and hundreds of 
thousands of adults only through the collaboration of all of 
our hospital partners and a lot of our contracting agencies 
that we use in order to do this.
    We have a number of pre-prepared, established sites that 
are already designated. We have to inspect them every year with 
our security police, even the FBI, in terms of having the 
preparation for all of our governmental efficiencies, who is 
going to do those vaccinations and at what point.
    Mrs. Walorski. So my final question is this: In the event 
of an unanticipated mass casualty event like that, and even 
aside from just pandemic types of flus and those kinds of 
things, the rule of thumb is our country and our State has 
about a weekend's worth of groceries for people to buy and 
gasoline for people to consume.
    What is the rule of thumb in the hospital networks State-
wide? How long can you go before there would absolutely have to 
be Federal intervention at a level higher than what you all can 
do?
    Dr. Profeta. Can I----
    Mrs. Walorski. Yes.
    Dr. Profeta. I always get amazed every year when we start 
talking about influenza. If we look at last year's influenza 
outbreak, the vaccine conferred maybe a 50 percent immunity to 
the people that were exposed to it. Fortunately, the flu was 
not that virulent.
    But if you want to say what keeps me up at night, it is not 
nuclear weapons or an anthrax exposure. It is influenza. If we 
have an outbreak with a serious strain of influenza, a one-
protein change, and the vaccine does not confer immunity to the 
vast majority of people and it is highly infective, we are 
going to have 50-plus percent of our health care providers 
sick, and that includes in nursing homes. I mean, do you think 
our support teams or people like our porters and housekeeping 
and food services and all those people that end up being sick 
are going to show up to work, especially if you have something 
with a high mortality ratio?
    So I think the entire infrastructure collapses under that 
situation. Again, when you have a virulent strain of flu with a 
vaccine that does not confer high immunity and a high fatality 
ratio, a lot of people are going to refuse to come to work. No 
matter how well you think you are going to prepare for an event 
like that, it is not going to happen. The system is going to 
break down.
    Mrs. Walorski. Thank you, sir.
    Dr. Profeta. So make sure you have enough food to feed 
people out in the community.
    Mrs. Walorski. I appreciate it.
    Thank you, Madam Chairwoman.
    Mrs. Brooks. Okay, thank you.
    As we gave the last panel, we would love the opportunity to 
hear from you in a little bit of a lightning round, a bit. As 
you have Members of Congress here from both the Senate and the 
House, what is it that Congress can do to ensure that we can be 
as ready as we possibly can for a mass casualty event?
    I think we will start this way and work our way back this 
time, to wrap up, and if we could just be very brief. We really 
appreciate all of you incredibly busy professionals running 
major hospital systems and important systems like MESH, we 
appreciate that we have kept you longer than we thought that we 
might, but this is so very important.
    What can Congress do? What can we do to help?
    Dr. Obeime. I will make two comments. The first one is we 
cannot forget those who cannot take care of themselves. The 
system is set up, if you listen to what everybody has said--the 
people who do not understand the language, who cannot read, who 
cannot write, they will not be able to do anything for 
themselves. We need to make sure everybody in their local 
community knows who their neighbors are, knows who is going to 
take care of them.
    The second point is I work for a private institution, I 
have for almost 18 years, and I think we have done a wonderful 
job of taking care of a lot of people. Every day we hear about 
cuts in reimbursement. We hear about cuts in a whole lot of 
things. We can work by faith, but we also know that we need 
money to take care of people. We need money to pay for things.
    If we continue to have cuts, that makes it impossible for 
organizations like ours to do the work that we do. Many people 
will suffer because we can no longer provide the services that 
we provide for them now. I know that the Affordable Care Act is 
active and everybody is talking about it, and I know it does 
not include everybody. We need to make sure we are looking out 
for everyone. It takes only one apple to spoil everything, and 
we cannot leave anyone behind.
    Mrs. Brooks. Thank you, Dr. Obeime.
    Dr. Reed, thank you.
    Dr. Reed. Yes. Refraining from further reimbursements and 
health care cuts would be the No. 1 priority. As you know, in 
order for us to maintain an infrastructure, we have to have 
revenue in excess of what it costs us to take care of the 
patients because there is no mechanism to provide for 
infrastructure like preparedness, and if we are not prepared, 
we really don't have a system.
    So our system right now is totally based upon how much 
extra revenue we were able to generate from the payments we 
received over the cost it took us to take care of the patient. 
So further reductions in those reimbursements for the care are 
going to lead to cuts in places we can cut. We can't really cut 
while taking care of a patient, but a lot of those excesses may 
disappear, and that leads to infrastructure reductions.
    So refraining from further cuts in health care 
reimbursement is critical.
    Mrs. Brooks. Thank you.
    Dr. Knight.
    Dr. Knight. I have two things. One is, again, sort of on my 
theme I guess of coalition and working together. The MESH 
Coalition, the Indianapolis Coalition for Patient Safety, and 
the work we do with the district in preparedness, especially 
the two coalitions, MESH and the Indianapolis Coalition for 
Patient Safety, those are subscription memberships. We pay to 
be part of those coalitions as hospital systems, and I think it 
really helps us as a community. So any grant funding that could 
go to support MESH and the Indianapolis Coalition for Patient 
Safety, I think that makes us better prepared as a community 
for those sorts of things.
    The second thing is echoing what you have heard, and that 
is when we train and educate our staff, that is a fixed cost. 
That is an expense that there isn't any reimbursement attached 
to. As we continue to be pushed to be more and more efficient 
in health care, our fixed costs are what we are having to cut 
out. So if we don't have some scholarships or something like 
that that we can use for education and training for our staff, 
those are the sort of things that are going to be cut out.
    Mrs. Brooks. Thank you, Dr. Knight.
    Dr. Profeta.
    Dr. Profeta. The grants, the money is like $20,000 per year 
per hospital. The Carmel Marching Band I think can make that in 
a bake sale in a week.
    You know, the infrastructure, when we talk about 
accommodating these huge surges in patients, any of our 
hospitals, if we have to accommodate 500 or 1,000 patients that 
require beds, not the walking wounded, our infrastructure is 
going to break down. If you go to Rambam Hospital, for example, 
in Haifa, it is a hospital the size of St. Vincent's Hospital, 
they have the ability to move 2,000 extra patients into their 
parking garage, which becomes a state-of-the-art hospital 
complete with operating suites, infrastructure built for oxygen 
suction, electronic monitoring.
    We are going to be putting people in the hallways. We 
constantly are looking for waiting rooms where we can stack 
patients. We don't have a comprehensive--none of the hospitals 
really do--a comprehensive, well-thought-out location that is 
completely wired from a computer standpoint, from a life 
services standpoint. If there was any place where money could 
go, it is building out that infrastructure at all the 
individual hospitals, especially the major hospitals like St. 
Vincent's, Methodist, IU Health, St. Francis, and Community. 
Start there, increase the capacity to expand to 500 or 1,000 
patients that require in-patient management, and then we can 
work out into the periphery.
    Mrs. Brooks. Thank you.
    Dr. Caine.
    Dr. Caine. I just want to also encourage that we continue 
to have our Federal funds that go to the Department of Homeland 
Security, primarily UASI, but also the MMRS. That is the 
Medical Metropolitan Response funding that goes to local health 
departments, as well as State health departments. It is so 
critical for our training, and I don't want us to also forget 
Wishard Hospital and Eskenazi Hospital that primarily focuses 
on the vulnerable populations.
    Mrs. Brooks. Thank you, Dr. Caine.
    Mr. Priest.
    Mr. Priest. I think you have heard from the panel that a 
lot of the problems we are facing are related to the grant 
funding. As you know, the grant funding is not sustainable. It 
has not been responsive to communities such as ours, where it 
has gone up and down, and now in many cases eliminated. I think 
as stewards of public resources, we have to get a little 
creative, and I think there are some opportunities in health 
care to do that, particularly when we are being asked to 
respond to issues of National significance.
    I think one of the things to think about is using models 
such as pay-for-performance models, incentive payment systems 
that exist in our current medical reimbursement system, to fund 
this important work that is not merely accruing to the benefit 
of hospitals but that truly is part of our community's 
preparedness structure.
    Mrs. Brooks. Well, thank you all so very much. This has 
been valuable testimony, again not just for Central Indiana. 
But because it has been webcast, hopefully many other 
communities around our country will think about the medical 
preparedness of their own communities.
    I might remind you that the Members of the subcommittee may 
have additional questions. I know that I had several, and we 
will ask you to respond to those in writing, and the hearing 
record will be open for 10 days.
    I just want to thank you all so very much. I want to thank 
the City of Carmel. I want to thank Commissioner Altman, who is 
here; Chief Green, who is here from Carmel Police Department, 
all of your assistance in helping us put this incredible 
hearing on.
    I want to thank everybody who came and listened and 
learned, from the first responders that you heard from on the 
first panel, from the medical professionals.
    I certainly believe, as I started out this hearing, that 
failing to prepare is preparing to fail, and these are all 
professionals that work day in and day out trying to ensure 
that we do not fail in the critical issue of keeping our 
communities safe. So I just want to thank you all so very much.
    This subcommittee stands adjourned.
    I thank my colleagues for joining me today. Thank you.
    [Whereupon, at 12:36 p.m., the subcommittee was adjourned.]

                                 

```