{\rtf1\mac\ansicpg10000
{\colortbl;\red255\green255\blue255;\red0\green100\blue17;\red0\green0\blue212;\red2\green171\blue234;\red221\green8\blue6;\red252\green243\blue5;\red242\green8\blue132;\red0\green0\blue0;}
\margl1440\margr1440\vieww9000\viewh8400\viewkind0

\f0\fs24\cf0 (Music)\
JACK BEALL: Our first\
general session focuses on\
International Disaster\
Response. I would like to\
introduce Dr. Erin Downey.\
Dr. Downey has 18 years of\
experience in public health\
and medical systems\
development. For 7 years\
collaboration with US Health\
and Human Services Hospital\
Preparedness Program (HPP)\
extended from implementing\
Emergency Management\
Initiatives at the local\
level for with 220 Louisiana\
hospitals to contributing to\
modelling strategies for\
measuring change in hospital\
preparedness levels\
nationally. She is the\
former director of the\
Emergency Preparedness for\
Louisiana Hospital\
Association for the HPP\
grant implementation where\
she served in the capacity\
for over 3 years including\
the Hurricane Katrina and\
Rita response activities.\
Erin is currently a US\
Department of State Fellow\
in Diplomacy Security and\
Development within the\
triple AS fellowship\
program. She is disaster\
preparedness policy analyst\
for the Office of Geographer\
and Global Issues. She is\
also been a planning\
committee member of the\
Integrated Training Summit\
for 5 years. Please welcome,\
Dr. Downey.\
(People clapping)\
DR. ERIN DOWNEY:\
Thank you. Good mooring and\
also welcome. As a fellow it\
is my responsibility to also\
disclose that the views I\
express up here with\
relation to the\
international response.\
International disaster\
response is not necessarily\
those of the state\
department. Each year the\
integrated training summit\
strives to provide a rich\
curriculum and program. For\
those of you who attend so\
that you can take viable\
lessons back to your\
colleagues in your\
respective rural -- in your\
respective rurals. We strive\
to provide the collaborative\
environment so that\
relationship can continue to\
be fostered and built in the\
local level and extend from\
the local to the state and\
into the national and the\
federal systems. We also\
support critical national\
preparedness planning and\
efforts that are aligned\
with the national response\
framework and the national\
health security strategy and\
policy or guidance documents\
that may recently be\
released that can also\
benefit you in your\
respective rural. At last\
year summit just four years\
-- four months, excuse me,\
after the devastating\
earthquake in Haiti, we saw\
how quickly US government\
resources can be deployed\
overseas and to maintain and\
sustain that deployment for\
an undetermined period of\
time. United States Agency\
for International\
Development (USAID) their\
Office of Foreign Disaster\
Assistance (AFDA) is our\
nation's lead response to\
disasters overseas. USAID,\
AFDA response on an average\
response or engages to an\
average of about 70disasters\
annually. Well a population\
counts continue to raise\
global risks and\
vulnerabilities\
geographically continued to\
rise. Global disasters\
continue to claim an impact\
to the lives of millions.\
The economic consequences of\
these disasters are either\
directly or indirectly felt\
by us all. In the last year,\
we have Haiti's ongoing\
recovery from the recovery\
of the earthquake as well as\
the cholera outbreak. We\
have Japan's triple\
catastrophe and we have a\
complex issue of Libya and\
what's occurring in the\
North African continent.\
These incidents are not in\
any way minimalize what's\
occurring at the homeland or\
on our soil with recent\
tornadic or flooding events\
that are occurring. Instead\
it is to say that as we\
continue to shore up and\
strengthen our national\
preparedness planning that\
in fact the international\
efforts are going to\
increase for us. The\
international pressures for\
us to be prepared to respond\
overseas will be increasing.\
With that I'd like to\
introduce our 4 speakers\
with us today. I'm delighted\
to introduce from the\
(USAID) US Agency for\
International Development,\
Mr. Larry Brady, is a\
professor of International\
Development at the US Army\
War College in Carlisle\
Pennsylvania where he is\
also a member of the Peace\
Keeping and Stabilization\
Program in El Salvador in\
the Central American/Mexico\
region. As a senior foreign\
officer Mr. Brady served for\
22 years in the USAID\
including assignments in Kenya,\
the Philippines, Bolivia,\
Israel, El Salvador and\
Washington DC. At the US\
Department of Defence the\
Office of the Undersecretary\
for defence and policy Ms.\
Mellisa Hansen. She's\
currently serving as the\
foreign affairs specialist.\
Her office resides under the\
Deputy Assist Secretary for\
Defence in partnerships,\
strategy and stability\
operations and humanitarian\
assistance, disaster relief\
and global health\
directorate. She's\
responsible for managing\
humanitarian assistance and\
foreign disaster issues for\
the Latin American and\
Caribbean region. She also\
receives the Department of\
Evacuation Policy Portfolio.\
Dr. Maria-Julia Marinissen\
serves as the director,\
sorry, the US Department of\
Health and Human Services,\
Office of Assistance\
Secretary for Preparedness\
and Response. Dr.\
Maria-Julia Marinissen\
serves as the director of\
Division of International\
Health Security and the\
Office of Policy and\
Planning. In this role she\
serves and provides an\
international programs to\
develop early warning\
infectious disease\
surveillance capacity in\
partner countries and\
coordinates the development\
of polices to provide\
international assistance\
during public health\
emergencies. She also serve\
-- she also overseas several\
international partnerships\
including the US Liaison to\
the Global Heath Initiative\
and as the chair person and\
as a chair for the Trial\
____ Health Security Working\
group under the North\
American Leaders Summit\
Framework. And from the US\
Department of Health and\
Human Service Center for\
Disease Control we have\
Capt. Daphne Moffet who is\
serving as the Deputy\
Director for the Health\
Systems Reconstruction\
Office and the Center for\
Global Health. Immediately\
following the January 12\
earthquake she deployed to\
Haiti to serve as the agency\
expert in environmental\
health, sanitation and\
toxicology which is\
currently responsible for\
coordinating public health\
strengthening efforts. She\
has been a commissioned\
officer for the US Public\
Health Service for 11 years\
holding multiple leadership\
roles within her category\
the corps and serves as the\
chairman of the Board of\
Directors for the National\
Commissioned Officers\
Association. Please join me\
in welcoming our speakers.\
(People clapping.)\
MR. LARRY\
BRADY: Good morning. Before\
I begin my remarks I would\
like to thank the Color\
guard for the presentation\
of the colors. I spent most\
of the last years working\
overseas and it gives me a\
great thrill every time I\
see our beautiful flag\
presented so thank you to\
the Color guard.\
(People clapping.)\
The US Agency\
for\
International Disaster\
Development has offices in\
approximately 85 countries\
around the world. Our\
mandate is to improve the\
lives of people in\
developing countries and to\
help build stable democratic\
trading partners with United\
States which in turn\
increases our security and\
our national economic\
strength. OFDA or the Office\
of Foreign Disaster\
Assistance is an office\
within the USAID and they\
have been given by the\
president the responsibility\
of being the US government\
lead for foreign disasters\
worldwide. When a disaster\
happens they will\
immediately deploy having\
been ask to a country, it\
may be a developing county a\
developed country that may\
even be a restricted country\
such as Iran, North Korea,\
Cuba, always though it is a\
country who has asked for\
our assistance and one who\
will accept assistance from\
the US. Whenever a disaster\
happens via domestic or\
international, it is\
important to know what is\
needed when it is needed and\
where it is need. And always\
as you know there is an\
initial time of uncertainty\
without knowing great deal\
of confusion right after a\
disaster occurs. OFDA will\
immediately send a team\
there to assist but also an\
assessment team that goes\
about determining what the\
needs are, where those needs\
are and establishing an\
order of priority in order\
priority that is then used\
through the interagency\
system to provide services.\
Their mandate is similar to\
but not exactly the same as\
that of most NGOs. The first\
order of priority is to save\
lives. Second order of\
priority is to alleviate\
human suffering and third is\
to reduce the economic and\
social impact of the\
disaster. The first two\
saving lives and reducing\
human suffering happen at\
the individual level. The\
third one reducing economic\
and social impact happens\
at the local and the\
government level. Whenever\
there is a disaster the\
order sequence is rescue,\
relief, rehabilitate and\
reconstruct. When you get to\
the second two, the last two\
elements, rehabilitate and\
reconstruct the magnitude of\
the social and economic\
impact determined the degree\
of work that's required and\
if we can immediately move\
to minimize that impact then\
the overall reconstruction\
will be less and less. Where\
do we go to? We go almost\
any place. Since our\
inception in 1961 when\
President Kennedy\
established the agency we've\
been probably in every\
country in the world to\
provide assistance. When we\
go to these countries, we go\
with certain authorities and\
different modalities can be\
found with type of disaster\
and the magnitude of the\
disaster. In our funding and\
authorizing legislation we\
are given anonymous standing\
of authorization which says\
"No statutory or regulatory\
requirements shall restrict\
OFDA's ability to respond to\
the needs of disaster\
victims in a timely fashion"\
which basically gives us the\
authority to do almost\
whatever is needed to save\
lives and help people\
immediately. It removes a\
lot of the bureaucratic, I\
shouldn't I say that, a lot\
of legislative, (People\
laughing) a lot of the\
legislative hurdles that we\
normally have to go through,\
a lot of you know we have to\
go through so we can act\
quickly. Worldwide OFDA\
enjoys a very strong\
reputation of being one of\
the first ones to react when\
there's a disaster. One of\
the reasons we are able to\
do that is because we have\
regional offices established\
around the world that are\
responsible for specific\
geographic areas. In\
addition to those regional\
offices we have warehouses\
where relief supplies are\
prepositioned loaded on\
pallets ready to load on the\
airplanes to go to any\
country that needs them. But\
perhaps our greatest asset\
is that in many counties we\
have experts in disaster\
response with the great deal\
of experience, who knows the\
languages, know the cultures\
and know the race of the\
countries that they will be\
going in to. Meaning those\
people are US government\
employees. Many of those\
people are local hired\
people who are indigenous to\
those countries and our\
great assistance when we go\
in. Responding to a disaster\
overseas is different. Most\
of you probably have\
experience with domestic\
some of you probably have\
experience in Haiti maybe\
some other ones. Capt. Beck\
when he spoke talked about\
the improved resiliency of\
communities to respond to a\
disaster. One of the things\
about working within\
international disaster is\
that there is usually very\
little systems resiliency\
speaking of developing\
countries. The recent\
earthquake and tsunami in\
Japan was tremendous in its\
magnitude and yet that\
county had the systems\
established resiliency to do\
that. Contrary to most\
countries in the world where\
there are disasters those\
systems that resiliency did\
not exist and when we go in\
we have to learn how to cope\
within a different\
environment probably the\
best way to explain it is to\
quote movie you may\
recognize "We're not in\
Kansas Anymore." We don't\
own this place there. We are\
not the ones in charge. The\
host government is the one\
in charge. They will\
designate the lead. Many\
times they will designate\
through the United Nations\
the UN Development Program\
(UNDP), WHO will be there,\
PAHO will be there. It gets\
to be rather complicated and\
sometimes the host nation\
doesn't know what to do and\
needs to be led. In Haiti\
there were over 1000 NGO's.\
I have no idea how many\
countries, how many\
government agencies you\
probably heard of the fog\
war. There was a fog of\
relief particularly in the\
initial period. I remember\
seeing on CNN, Fox News all\
of the news channels shortly\
after the Haiti earthquake\
even sometime after, they\
were continually complaining\
about the slow process of\
providing relief without\
recognition for the\
tremendous fog of relief\
that occurs initially. There\
are number of challenges\
working in overseas and\
foreign countries. The\
infrastructure we will need\
to use to receive and\
distribute supplies is\
probably inadequate to begin\
with. After the disaster, it\
may be completely unusable.\
Communication systems that\
were somewhat adequate prior\
to the disaster may be\
non-functional or maybe\
quickly overwhelmed making\
your own com systems\
necessary. Data gathering is\
extremely difficult,\
languages, cultures,\
geographic isolation of\
communities, little access\
into remote area all will\
inhibit the ability to\
gather information which is\
necessary to develop an\
order of priorities. There\
will be many do gooders who\
show up. Many small NGO's\
many people who come with a\
very strong commitment to\
help. We don't know that\
environment will be like. We\
are not prepared. I spoke\
with one gentleman not long\
ago who told me he gone to\
Haiti to help out but he\
felt bad because two days\
after he got there he was\
sick and he was sick most of\
the time he was there. He\
became part of the problem\
rather than part of the\
solution. And when we go in\
to the foreign environment,\
you must be prepared to be\
self-sustaining in all ways.\
And you must be prepared to\
help those who are not\
prepared but who are there\
to help. Let me give you\
some lessons learned that we\
have. I'm not going to talk\
about ones that you have\
probably had learned from\
domestic ones but there are\
some perhaps are relevant\
internationally that could\
be a help to you. We as the\
US government have a\
national response framework.\
We do not have an\
international response\
framework. We need an\
international response\
framework so that we can\
better collaborate, better\
build the interagency\
response of US government.\
More is not always better\
particularly overseas with\
limited facilities, limited\
infrastructure. We have a\
tendency sometimes to throw\
huge resources at a\
problem. Sometimes that is\
not the right thing to do.\
There's a better need for us\
to understand urban relief\
operations in developing\
countries. We have pretty\
good expertise of that in\
United States and in other\
developed countries but we\
don't have a complete\
understanding of how to do\
that in developing\
countries. The information\
based in Washington always\
requires information\
particularly if it's a high\
profile disaster. USAID,\
OFDA, is designated by the\
president by NSC to be the\
reporting unit back to\
Washington. We all have\
requirement to report back\
to our home agencies our\
home and we all do it in\
different way. OFDA have a\
requirement to report for\
the US government response.\
We need to come up with\
standardized formats,\
standardized data bases so\
that can quickly began\
without taking time away\
from the people who need to\
be working on the relief and\
rescue operations but still\
gather the information that\
decision makers in\
Washington demand. We need\
to continue building on the\
interagency work. Since 2005\
since Iraq and the Asia's\
Tsunami, December 26, 2004 ,\
AID and DOD I think have\
made great head way in\
working together. They have\
the assets we have a lot of\
the expertise. We can fit\
very well together. We need\
to build that capacity\
strengthen more with DOD and\
build that even stronger\
with our inter agency\
brothers and sisters. Last\
but not the least; we need\
to learn how to incorporate\
modern technology into our\
rescue and relief responses.\
Haiti taught us some of that\
but there's a long way to\
go. Things like GPS-GS\
systems, Google has\
tremendous capacity of\
telecom, other IT giants out\
there have a great deal to\
offer. We need to work with\
them to find out how we can\
better use their facilities\
and with that my time is up.\
Thank you very much.\
(People clapping.)\
MS. MELLISA HANSEN: Good \
morning\
everyone. As Erin mentioned\
my name is Melissa Hansen. I\
work for the Department of\
Defence. I work in the\
Office of the Secretary of\
Defence in the Policy Shop\
and I work on the\
Humanitarian and Assistance\
Disaster Relief and Global\
Health Team. We have one of\
the longest titles I think\
in government type and my\
business type is very very\
small. But that's Washington\
for you. I'm here this\
morning to give you an\
overview of what the role of\
the Department of Defence\
and the military is in our\
foreign disaster relief\
operations. I'm very\
grateful to follow our\
colleague from USAID because\
DOD is very much a supporter\
of USAID in these\
operations. First off\
the military is not an\
instrument of first resort\
in responding to\
humanitarian crisis. But we\
are always in support of our\
civilian relief agencies.\
Specifically this is the\
department of state. We are\
in support of the US\
Ambassador who is the\
president's representative\
to the host nation and also\
USAID and specifically the\
Office of the US Foreign\
Disasters Assistance (OFDA).\
The US military may be\
involved in some unique\
circumstances specifically\
when the military can\
provide a unique capability.\
We will get into that in the\
later slide. What these\
types of capabilities are.\
When civilian response\
capacity is overwhelmed and\
also when civilian\
authorities request the\
assistance. We'll talk about\
that later. The actual\
requests of military\
assistance are very critical\
for our legal authorities.\
When the military is\
involved we do have some\
criteria. The mission should\
always be clearly defined.\
We want to know exactly what\
the military will be used\
for how long we think will\
be required. This helps\
avoid mission creep. We also\
want the risks to be very\
minimal to our personnel who\
we are deploying. We would\
look twice if it's a very\
dangerous situation always\
concerned for our personnel.\
Also the impact of other DOD\
missions would be analysed\
to ensure that responding to\
a disaster relief situation\
is not adversely affect\
other on-going missions. So\
for instance in the large\
disasters like Haiti, the\
on-going response in Japan,\
some senior decision makers\
were taking a hard look at\
how deploying assets to\
those theatres impact our\
other on-going operations in\
Afghanistan, future\
deployments and so on. I\
mentioned unique\
capabilities. What are they?\
This is a high level list,\
it's not completely\
inclusive but just some\
examples of what the\
military can bring to a\
disaster response. The most\
prevalent capability is\
transportation support\
system specifically air and\
sea lift. Quite frankly the\
military has the\
capabilities to take a lot\
of stuff to hard to reach\
areas very rapidly and so\
that seems to describe\
lot of disaster relief\
situations. In terms of air\
lifts this is both fixed\
wing and aircraft support\
from the US or other places\
abroad to the affected\
nation. And also helicopter\
rotary lift in country\
either from ship that may be\
anchored off shore or\
transporting from point A to\
point B in the affected\
country. And we're\
transporting teams,\
personnel relief commodities\
perhaps host nation\
authorities to survey the\
affected area. In terms of\
ready to eat food, the\
military actually keeps a\
stock of what's called the\
humanitarian daily rations.\
These are made by the same\
company who manufactures the\
military MRE's but they are\
specific humanitarian MRE\
culturally sensitive, hello,\
not vegetarian and so it's\
appropriate for populations\
who have no access to\
cooking utensils and the\
sort of thing in the\
aftermath of the disaster.\
In terms of medical\
services, field hospitals\
and military teams who are\
easily deployable maybe\
called upon to disaster\
area. DOD has a warehouse of\
non-lethal access property\
that we stock pile tents,\
cots, some medical supplies\
that may be drawn down for\
deployment to disaster area.\
We have capability for water\
purification treatment and\
also water production on\
ships, expeditionary\
engineering for instance the\
Army Corps of Engineers. And\
finally Imagery Surveillance\
and Reconnaissance. And this\
is used to develop a common\
operating picture to\
actually get a feel on how\
bad the scope of disaster\
is. For instance in Pakistan\
last summer with the\
flooding. I know that there\
was significant imagery\
taken to actually see how\
bad and extensive the\
flooding was. That said\
there are always issues for\
consideration when looking\
at these unique\
capabilities. So something\
that's not listed is above\
all I think the primary\
consideration is cost.\
Military assets are very\
expensive. And so we are\
always are considering how\
much it's gonna cost and\
weighing that against the\
overall humanitarian mandate\
and the response. In terms of\
lifts, some things that we\
consider is, is the military\
actually faster? Can we get\
it there via commercial\
means or is the military the\
most appropriate asset to\
get the teams or commodities\
to the theatre? Is it\
available and also were\
there any issues associated\
with having a military\
footprint in this country?\
In terms of ready to eat\
food is it the best fit to\
respond to the current\
situation? And this is what\
we rely very heavily on\
USAID, OFDA, to analyse the\
situation and determine and\
validate the requirements\
for the military. We work\
very closely with our\
interagency partners on this\
validation. In terms of\
emergency medical services\
it's pretty rare actually\
that the military is\
deployed for medical support\
but there are situations in\
which perhaps the hospital\
or multiple hospitals have\
collapsed the \i USNS\
Comfort\i0  may be deployed. But\
all of these are taken by\
case to case basis and there\
is no set package for these\
capabilities to be deployed.\
The same thing for the water\
and the engineering and\
research and the imagery,\
the ISR Imagery Surveillance\
and Reconnaissance. Perhaps\
a host nation may if we are\
doing over flight request\
that their personnel\
accompany US military\
personnel on these imagery\
reconnaissance flights to\
ensure that they understand\
what's going on. And this is\
all taken on a case by case\
basis. Now there are some\
capabilities that may seem\
intuitively to be military\
assets but actually they\
don't fall within our best\
practices and best fit. The\
first one is fire fighting.\
Due to domestic role of the\
guard in fighting wild fire\
out in California and so on\
there is often a first\
reaction to call on the\
military to respond to fires\
abroad. But actually the US\
Department of Agriculture is\
the lead agency for fire\
fighting and the military\
actually is not our best\
fit, the US military in\
responding to these, there's\
cost assets, cost issue and\
also timing. It takes us up\
to a week or longer to\
mobilize these assets to\
deploy overseas and so\
you've lost a lot of time.\
So we do rely on USAID and\
OSDA to help respond to\
these. It's not a military\
best fit. Same thing with\
the bridging and the boats.\
The military does keep a\
stock of portable bridges in\
these zodiac boats in their\
stocks but it is for our war\
fighting on going missions\
in areas abroad. And so if\
they are drawn down for\
disaster relief we are\
depleting our internal stock\
and so these were usually\
the commodities that can\
better purchased by USAID\
and others. The military is\
usually not our best\
provider for these. And in\
terms of ready to eat food,\
except for the humanitarian\
daily rations that I had\
mentioned, MRE's were\
generally not advisable for\
use to those missions. MRE's\
are very high in calories\
not culturally sensitive and\
generally not what disaster\
victims need. I want to say\
that they are never used or\
never a good option but just\
in terms of our world best\
practices generally not what\
we recommend providing. This\
slide it's our -- it could\
be highly democratic but\
also very necessary process\
for employing the department\
of defence in foreign\
disaster relief support. And\
I just highlight a couple of\
pertinent points on this\
process slide. The process\
starts when the US\
ambassador in country issues\
and disaster declaration and\
from there USAID determines\
the requirements and\
validates the Department of\
Defence requirements for the\
response. The Department of\
State then issues a formal\
request for the military to\
be used and then that\
ultimately needs to be\
approved by the secretary of\
defence. That's very\
important because if these\
boxes are not checked\
deploying the military to a\
foreign country without\
these it could be termed an\
invasion so it's not\
something that we generally\
like to avoid. (People laughs)\
Now all that's to say if\
there are lives at risk\
there is ability for the\
combatant commander in the\
field within 72 hours to\
provide immediate response\
with the help from\
Washington to follow. For\
instance if we have a team\
off shore in the Philippines\
and they are right there in\
theatre and determination is\
that they can respond to a\
disaster we don't also like\
the optics of military\
personnel being on the field\
not doing anything because\
they are waiting for\
signature from Washington\
and so as the bumper sticker\
at the bottom there is an\
ability to respond within 72\
hours to save life or limb.\
DOD provided support for 10\
disasters in FY 2010. It was\
a busy year for and this is\
about I guess 1/7 of overall\
disasters USAID responded to\
more than 70. And so weren't\
involved in so many number\
of disasters but they tend\
to be the larger scale. So\
this is a bit of a less you\
can see by far the largest\
disaster that DOD ever\
responded to is the\
earthquake in Haiti. And you\
can also get a feel for\
activities. You can see in\
every one of these blocks\
air lift has been provided.\
Going on providing support\
to Chile, Kyrgyzstan,\
Guatemala, Pakistan was\
another very large response\
for the department. In terms\
of our lessons learned\
communication is absolutely\
critical. We talked about\
the fog of relief and that\
is certainly true and so we\
-- it is absolutely critical\
that DOD, USAID, State\
Department and all other\
response agencies, HHS, CDC\
to be in communication\
before, during and after the\
response. And this ensures\
that information sharing  is\
prevalent and it reduces\
duplication of effort. The\
role of DOD is not limited\
to the actual response\
operations. We do have a\
steady state humanitarian\
assistance program that it\
aimed that enhancing host\
nation capacity to respond\
to disasters internally.\
This can be provision of\
excess property, building\
emergency operation centers\
and also doing some medical\
training. Disaster\
mitigation is incredibly\
important because in\
enhancing the host nations\
capacity to respond to\
disasters it does reduce the\
likelihood that DOD and\
others will need to respond\
in the future and so I'll\
just close with a case\
example of building cyclone\
shelters in Bangladesh which\
is a highly cyclone prone\
area. Since 2000 USAID has\
provided 245+ multipurpose\
shelters and help to provide\
disaster contingency plans\
and trainings to ensure that\
over 25 million people\
living in disaster prone\
areas who had access to\
these emergency relief\
supplies within 72 hours of\
the disaster and when\
cyclone Sidr stuck in 2007\
the government provided\
shelter for about 1.5\
million people and 2168\
suitable cyclone shelters.\
As a result of these\
shelters being built through\
this joint effort between\
USAID and DOD, only 4200\
lives were lost versus a\
140,000 in 1991 and 150,000\
in 1997. So you can see that\
in mitigation at least in\
this case was a success\
story. Thank you for your\
time this morning and I will\
turn it over to my colleague\
from HHS.\
(People clapping.)\
DR. MARIA MARINISSEN: Good\
morning everyone. I think\
that we should try a couple\
of languages because this is\
international session. So\
bonjourno buendia, bon jur.\
That's a much as I can say.\
So thanks so much to the\
organizers for inviting our\
division and for inviting us\
to participate in this\
international session. I'm\
obviously is hard to talk\
about the role of the\
Department of Health and\
Human Services on\
international public health\
emergency preparedness and\
response after USAID and DOD\
two agencies that typically\
do that. So I'm going to\
talk a little bit about the\
role of the Office of the\
Assistant Secretary of\
Preparedness and Response\
and then my colleague Capt.\
Daphne Moffet will talk\
about the role of CDC on\
international preparedness\
and response. So as you can\
see in the next slide I'm\
sure you're very familiar\
with HHS but the role of our\
department is basically to\
protect the health of all\
American people and to\
provide essential health and\
human services. Under the\
national response framework,\
you are very familiar with,\
the emergency support\
function number 8, the HHS\
secretary has the lead for\
public health emergencies\
and assumes control of all\
federal assets except for\
those of DOD to respond in\
support of state and locals.\
In 2006 when congress pass a\
pandemic Hazard Preparedness\
Act the HHS secretary\
delegates the authority to\
coordinate the response to\
the assistant secretary for\
preparedness and response.\
Here is a picture of Dr.\
Lurie the assistant\
secretary. Just to give you\
an idea of where we are and\
I know this is very small\
and you hardly can see the\
boxes, you can see on top\
the office of the secretary\
of HHS and to the right and\
left what I call the staff\
divisions and in the center\
the operating divisions of\
HHS. Among the operating\
divisions you have the\
Center for Disease Control.\
On the picture you have FDA\
you have NIH and as you can\
see in the red rectangle is\
the office of the assistant\
secretary. So we're\
considered a staff division.\
However we do have a lot of\
operating functions with a\
large office with a large\
budget so we consider\
ourselves actually kind of\
hybrid division.\
Basically, to go a little\
more in detail into the role\
and the functions of ASPER\
and the organization you all\
know as I say that we have a\
lead on public health and\
emergency preparedness. We\
have a key role on the\
policy and planning process\
to be ready in response. We\
help build federal emergency\
medical operational\
capabilities and one of our\
key missions is the advance\
development and acquisition\
of medical counter measures\
for chemical biological,\
radiological and nuclear\
threats as well as pandemic\
influenza. We acquire these\
medical counter measures and\
they go to the strategic\
national stock pile managed\
by CDC. I'm sure you are\
familiar with this you know\
anthrax vaccine, small pox ,\
potassium iodide for example\
and now the pandemic\
influenza vaccine antivirus\
that were deployed to H1N1.\
We also managed programs to\
strengthen the capabilities\
of our hospitals to be ready\
for public health\
emergencies obviously and we\
manage the national disaster\
medical system that as you\
very well know augments the\
capability of the state and\
locals during the response.\
And as you can see at the\
bottom we have 5 offices, 5\
main offices the first one\
is the Biomedical Advance\
Research and Development\
Authority (BARDA) who is in\
charge of medical counter\
measures, the Office of\
Preparedness and Emergency\
Operations (OPEO) under\
which we have the National\
Disaster Medical System, the\
hospital preparedness\
program. And then we have\
the Center for the Office of\
Policy and Planning under\
which we have the\
International Health\
Security Division. Then we\
have two other offices that\
deal with acquisition grants\
and of course budget very\
critical. So within the\
Office of Policy and\
Planning as I say is our\
division. Our mission is to\
provide leadership and\
international programs,\
initiatives, policies that\
enhance the US and global\
public health emergency\
preparedness and response.\
And this is dictated by law.\
These, our mission come from\
the PAHPA from the Pandemic\
and All-Hazards Preparedness\
Act. Why do we work or why\
do we care about\
international security given\
that ASPER was initially\
created with you know very\
strong domestic purpose? I\
like to show always these\
pictures. You can see in the\
first spot the origin of\
emergent infectious disease\
events in the last 4 years.\
In the past you know many of\
these infections will emerge\
and stay locally but if you\
look at the center picture\
this is a network, it's a\
network of global\
transportation in the last\
few years. So diseases that\
stay before were endemic and\
will stay there now can\
travel all over the world.\
Not only are diseases cargo\
food, the risk for\
international public health\
emergencies is growing and\
we've seen it in the last 2\
years. So our national\
health securities strategy\
recognizes that and states\
that the health of each\
nation is dependent on the\
health of other\
international partners of\
all nations basically. This\
is very important. Global\
health is not just about\
people getting sick but is\
also about you know that's\
air and  about\
global prosperity economic\
and social development, it's\
a critical condition for all\
these other things to move\
forward. Why not to say in\
the last years health and\
health security have also\
helped advanced many of the\
defence and diplomatic\
issues has been considered\
as one of what we call the\
soft diplomacy tools is a\
huge international\
engagement through health\
and health security. So my\
next slide and again this is\
small for you to see but\
this is just as you can see\
on the top a recollection of\
somewhat international\
disasters and some of the\
domestic event so that they\
had huge global\
implications. As you can see\
you know at the beginning of\
the slide the 9/11 and the\
Anthrax attack in our\
country in 2001. Immediately\
after this event happened,\
the ministers of health of\
the G7 group plus Mexico\
director general of the\
World Health Organization\
and the health commissioner\
of the European Commission\
realized that we did not\
have among the health\
ministers any type of\
preparedness for these types\
of events. So they created\
the Global Heath Security\
Initiative or GHSI at the\
ministerial level so the\
minsters of health of all\
these countries get together\
every year since 2001 to\
discuss preparedness for\
chemical, biological,\
radiological evens and\
pandemic influenza. And\
obviously now we are moving\
into how do we apply\
everything we learn to last\
in 10 years to all hazards\
preparedness for all type of\
disasters. So you can see\
also on top the SARS event\
in 2003. You can see you\
know in 2005 Hurricane\
Katrina and you can see at\
the bottom the creation of\
ASPER a such under the\
Pandemic and All-Hazard\
Preparedness Act. Once you\
know we have a little bit of\
a break there in 2007 and\
2008 to really work on our\
preparedness. Then H1N1 was\
a change in point for our\
engagement in our\
international activities.\
Erin asked us to talk a little\
bit about our personal\
experiences with these and\
when H1N1 hit it was a true\
challenge for our\
department. We started to\
deal obviously with the\
domestic situation but at\
the same time we started to\
get more people request for\
assistance for antivirals,\
diagnostic, personal\
protective equipment,\
technical expertise and\
later on vaccine. So we were\
certainly not organized to\
respond to that so it took\
you know ASPER our division\
in collaboration with the\
Office of Health Affairs and\
our colleagues from CDC and\
the rest of the government\
to figure out how we will\
respond in a concerted way\
to those and I'll talk a\
little bit more about that\
in the future and then you\
know almost half of the year\
or later we have Haiti. That\
was the first time that we\
deployed a National Disaster\
Medical Assistance\
internationally. The first\
one we deploy health care\
medical personnel and\
obviously CDC has a huge\
presence in Haiti during the\
earthquake and then during\
the cholera outbreaks. And\
later on during the Japan\
event that was complicated\
with radiological accident we\
send such amount of experts\
from ASFER and from CDC to\
help with the US embassy and\
the US-Japan working group.\
We were heavily involved in\
discussion with Japan the\
provision of medical\
countermeasures on potassium\
iodine as well as\
collaborating with the idea\
in the state department and\
DOD in support of the\
response. But again every\
time that one of these\
incidents happen we deal\
with the bureaucratic\
hurdles that Larry mentioned\
today because unlike AID or\
DOD we don't have explicit\
authorities to provide\
international assistance. As\
such we don't have funding.\
We don't have legal\
protection for our personnel\
that are going to be\
deployed. We don't have --\
they don't have licenses to\
work in other countries.\
When we try to deploy\
medical counter measures\
from our stock file most of\
these products are not\
approved by FDA. Although we\
have protections here in\
United States for our\
manufacturers and our\
providers, those regulations\
were not applied\
internationally. So it's a\
whole thing that we have to\
go over every time that we\
are called by the United\
States government to provide\
assistance. So we're working\
on it. We're working very\
hard on it and we're taking\
a 3 prong approach to this\
issue. Number 1. We are\
enhancing our international\
engagements some\
partnerships as I say we\
work with the global health\
security initiative. We\
created American Health\
Security Working Group so\
we're working very closely\
with Mexico and Canada on\
preparedness for all hazards\
and right now we're very\
much focused on the lessons\
learned from pandemic\
influenza and how that\
applies to all biological\
threats and infectious\
diseases. We have a number\
of bilateral collaborations\
with several countries. We\
also have some capacity\
building programs. We team\
up with CDC to enhance\
surveillance capacity for\
infectious diseases in a\
number of developing\
countries through BARTHA,\
our Medical Counter Measure\
Agency. We're helping\
developing countries build\
vaccine manufacturing\
capacity. So we are now in\
the situation like what we\
were during H1N1 there was\
this worldwide shortage of\
vaccine. And third we're working\
on developing the HHS\
international response\
policies and capabilities.\
You know internally with our\
other US government partners\
so we're working on training\
for our personnel for\
international deployment. We\
are engaging with other\
agencies on reconstruction\
stabilization efforts and we\
are working really hard on\
developing the policy and\
assistance framework for\
international response. In\
my next slide and I don't\
want you to you know go over\
this whole diagram but I\
will show you what we did in\
H1N1 as they say was very\
very complicated when we\
were getting multiple\
request for HHS assets. So\
we work closely with White\
House and our colleagues in\
interagency to setup this\
process and if you look at\
the third column the bubble\
there has the HHS\
international team that\
became the center for\
receiving all the requests\
for assistance for\
antivirals, personal\
protective equipment,\
diagnostics, etc etc. So we\
established a series of\
principle under which the\
United States and specially\
HHS will provide assistance\
which involved the\
assistance will enhance\
global health security and\
will directly or indirectly\
benefit the United States.\
We will provide the\
assistance when it help\
maximize the recovery of\
these countries and we will\
do so in a way that is \
aligned to foreign policy,\
the objectives of state\
department, DOD and other\
agencies. And when possible\
we will team up with other\
international partners to\
make sure that we can\
maximize the help and to not\
create a burden on domestic\
resources because there's\
always a balance. HHS assets\
are for domestic purposes.\
So every time that we need\
to provide international\
assistance the first things\
that we need to think about\
is how is that going to affect\
our domestic preparedness\
and response capabilities.\
So we did provide a lot of\
assistance during H1N1. We\
donated antivirals to Mexico\
in the first two weeks. We\
donated antivirals to pan\
American health\
organizational that were\
distributed to 15 countries.\
Then our secretary making\
the announcement and Dr.\
Ross from PAHO in front of\
the antiviral boxes. And\
then we donated or we\
pledged the donation of 25\
million doses of H1N1\
vaccine from HHS to the\
World Health Organization.\
And we ended up donating\
about 16 million doses to\
more than 10 countries and\
that was a huge huge\
enterprise to get that done.\
And talking about vaccines\
and antivirals this was not\
only the case for pandemic\
influenza where we received\
request for 14 countries for\
antivirals and 16 countries\
for vaccine but what we're\
having in the last 10 years\
request from several\
countries, Mexico, United\
Kingdom, France, Uganda,\
Thailand, Argentina, and\
they keep coming. Most\
recently from Japan during\
this event. And as I say\
given the big challenge here\
is that most of these\
counter measures are not\
approved by FDA and by law\
what we have in the stock\
piles in our stockpiles are\
to provide for the health\
security of the United\
States. So we have huge huge\
issues so when we were\
working for more than 2\
years on this framework for\
how we're going to provide\
assistance to other\
countries. As you can see\
how complicated it is. I\
think that in that framework\
in that wide diagram we have\
every single agency in this\
government being part of the\
decision making process to\
deploy domestic assets for\
international assistance\
including all the lawyers\
and regulators that you can\
imagine. The same thing\
applies to the deployment of\
personnel. I mean our\
National Disaster Medical\
System was engineered for\
domestic purposes so we\
don't have a mechanism to\
provide license to our\
personnel to practice in\
these countries. We don't\
have a way to confer\
liability protections. So\
we're working really hard in\
overcoming those challenges\
and also in coordinating\
with other agencies. You can\
see a yellow how the IRCT\
will coordinate with DOD,\
AID and state department on\
the ground under the\
leadership of the Ambassador\
in the country. How it will\
coordinate with the Untied\
Nation cluster which is\
something that we did in\
Haiti. And how obviously\
what we try to coordinate\
to___ as possible with the\
host nation. And that's what\
we will do on the ground on\
the other side of the\
diagram we have the\
coordination with all other\
agencies, the RTM, AID,\
state department and DOD\
through our secretaries\
operation center. Again this\
is all draft. This are all\
policies that we're working\
on but I just want to give\
you the idea of how much we\
are thinking of a process\
that is as Dr. Yesky say is\
very integrated with the\
rest of the government.\
Finally moving forward and\
just to finish my talk you\
know, internationally what\
we continue fostering the\
partnerships what we found\
for example now trying to\
deploy KI Japan is that\
because of the work we did\
in the last 2 years when we\
knew that Japan may need KI\
we were able to sort of get\
organized in one afternoon I\
have you know the SNS ready\
to deploy and our contact\
with AID and everything was\
taken care of. But what\
happened is that again Japan\
was not ready to receive the\
counter measure because of\
all the regulatory and legal\
issues especially on the\
liability protections area.\
So we need to keep working\
with our international\
partners to develop\
international mechanisms and\
protocols for respondent to\
public health emergencies.\
And domestically our main\
focus is to finalise this\
policies, discuss with our\
interagency partners in a\
way that all of these are\
aligned with eventually an\
international emergency\
response framework.\
Hopefully our efforts can be\
part of that international\
emergency response framework\
and part of the public\
health annex. We want to\
continue enhancing the\
relationship with our\
partners. It's great to be\
here. It's not only about\
the United States\
government, it's about also\
the capabilities of the\
States and the locals. We\
have a number of cross\
border initiatives where our\
states work with our\
counterparts in Canada and\
Mexico and they are making\
great progress. In the last\
bullet one of the main\
issues is to keep working\
towards establishing\
explicit authorities for HHS\
to be able to provide\
international assistance.\
Okay. Thank you so much for\
your attention.\
(People clapping)\
CAPT. DAPHNE MOFFET: Good\
morning everyone. And thank you\
Dr. Marinissen for your\
presentation and to my other\
colleagues in the panel. I'm\
going to briefly discuss\
this morning CDC's role in\
international emergency\
response. Basically the\
agency's approach to public\
health emergency\
preparedness internationally\
is very similar to domestic\
approach but with the added\
complexities of the country\
ministry of health dynamics\
and other international\
partners and aid relief\
agencies and NGO's later on\
top of that. Just as we\
would insure all elements of\
infrastructure and\
operations and their\
functionality in the\
domestic response so we do\
the same in international\
arena. Assessing the health\
system infrastructure,\
informs the country\
capabilities and the type of\
response that's needed in\
the deployment phase as well\
as in the reconstruction\
phase. So what is it that we\
do? That is our fundament\
philosophy. We build country\
capacity through\
international health\
regulations implementation.\
We monitor and contain\
emerging health threats. We\
deploy experts 24/7 at the\
country request. We respond\
to international\
emergencies. We re-establish\
the strengthen public health\
systems and we coordinate an\
average global health\
security activities with\
internal and external\
partners. Our overall global\
heath security approach is\
as shown on this slide\
across the emergency\
continuum so preparedness is\
actually part of CDC's name\
and we take that to heart.\
So we start with building\
capacity in countries. We\
monitor and detect threats.\
We respond to international\
emergencies and we\
reconstruct health systems.\
So one advantage that we\
have is we do have some\
prepositioned assets and\
countries across the world.\
This map gives you an idea\
of where we work. We are\
approximately 178 staff.\
This is just within the\
global disease detection and\
emergency response. We have\
additional international\
assets throughout the world\
with the PEPFAR programs and\
other programs. We have 74\
headquarters, 38 in the\
field, 60 local staffs and 9\
DC liaisons . As I mentioned\
earlier the importance of\
having people who are\
already in the countries\
that may be affected or at\
lease within those regions\
is their understanding of\
the culture and also fluency\
in the language. I'm going\
to talk a little bit about\
than in my lessons learned\
slide in a moment. The\
foundation of our work is\
surveillance and as such\
we've been designated as the\
WHO collaborating center for\
implementing surveillance\
and response capacity. This\
designation provides an\
opportunity to develop\
regional and country work\
plans with WHO and country\
partners and to identify\
close gaps and country\
ability to comply with the\
IHO requirements. We have a\
global disease detection\
operations center which\
monitors international\
threats and security agency\
briefs to tract potential\
outbreaks. This particular\
group of folks basically has\
-- they responded to three\
outbreaks within the past\
year and in 25 countries\
some of the disease\
including marburg Ebola,\
monkey pox. So our operation\
center basically has a data\
report that's issued and\
this differs a little bit\
from some of the other\
threads that you might be\
able to sign on to because\
the CDC report is ground\
truth and so this is just an\
illustration of some of the\
outbreak status and this was\
from last year from June 17\
to July 1 and there's a\
confirmation on outbreaks\
and confirmed polio cases\
that are noted on this map.\
And these are updated daily\
by the way. This was just an\
example. So why\
international disease\
surveillance? The rationale\
for this is three fold\
really. The inability of\
some countries to promptly\
detect and report events,\
the reluctant of some\
governments to report to the\
global community and the\
potential for an unknown\
disease event public health\
emergencies of international\
concern. So I want to talk a\
little bit about an example\
and Haiti provides a great\
example of some recent\
international deployments\
and I have the privilege to\
deploy and work with many\
people in this room I know\
right after the earthquake\
in January. This is a\
picture of some members of\
our field team when we were\
at the Getskin Field\
Hospital. How many people\
here were actually deployed\
to Haiti for the earthquake?\
Yes, okay. And I wanted to\
talk a little bit about how\
we deploy people. We were\
asked to think about from\
commanding control structure\
how CDC deploy assets? One\
way was several of us were\
deployed through an IRCT as\
part of a newly established\
public health branch. Some\
PHS officers were also\
deployed from CDC to Haiti\
through OFRD to support the\
medical missions and\
responses on the comfort\
mercy in the biton. We also\
had PHS and civil servants\
who were deployed at the\
request of the Ministry Of\
Health in Haiti to help\
assist in re-establishing\
the surveillance system. We\
also had PHS officers who\
were deployed with Southcom\
to Florida to Haiti and we\
had CDC's EIS officers as\
part of those contingents.\
So as mentioned before, the\
staff in there drives a lot\
of domestic deployments and\
however with the\
international deployments\
they come to a variety of\
mechanisms. At CDC we have\
staff who were deployed\
again at the request of the\
country's Ministry Of\
Health. They can also be\
deployed or seconded to WHO,\
UNICEF, PAHO, so we have a\
variety of entrées into a\
particular international\
disaster. So what was the\
lesson learned from the\
earthquake? We were involved\
in a rapidly establishing\
the internally displaces\
persons disease surveillance\
system or the CAMP based\
surveillance system right\
after the earthquake. The\
principal finding and\
looking at the backwards of\
this were the logistic and\
operational challenges were\
very similar to those that\
have been described in other\
humanitarian emergencies.\
The coordination of\
geographically dispersed\
organizations was\
particularly difficult.\
There were health cluster\
meetings that were held and\
I don't think they were\
intended to be in secret\
locations but when you're in\
Haiti driving around\
sometimes they seems like\
they were in secret\
locations. So just getting\
to a health cluster meeting\
was challenging. There was\
rapid health care provider\
turn over and there was in\
adequate infrastructure to\
build upon. However I'm\
going to fast forward from\
there to the Haiti cholera\
outbreak. I've been involved\
in Haiti a lot this last\
year. So we did learn quite\
a few lessons from our\
response to the Haiti\
earthquake. With the Haiti\
cholera outbreak on October\
19th the ministry of health\
was alerted to the\
increasing cases of acute\
watery diarrhea that was on\
the 19th. On the 20th there\
was a positive rapid test\
done for vibrio cholerae. On\
October 21st there was\
culture confirmation of\
cholera in country. This\
rapid response and\
identification was possible\
partially due to the\
existing PETFAR platform in\
Haiti. So the HIV-AIDS\
response that's been there\
for many years but also\
because of the on-going\
post-earthquake\
reconstruction in public\
heath response activities.\
So I think this audience\
will appreciate an IMS\
structure. So we were asked\
also to think about how does\
your agency or where are you\
sit? Actually falling into\
an organizational structure\
we actually do have a\
commanding control\
structure. Our CDC directors\
at the top and then\
underneath there my points\
for this slide is a couple--\
one of which is this is\
actually one of the IMS\
structures that we had for\
the colors response. The IMS\
structure actually morphs\
over time. So in October we\
stood up by the time we\
stood down in March the\
structure had changed. There\
were certain elements that\
remain the same but there\
were several elements that\
had to change based on the\
response change. So we\
revised this weekly. We\
looked at it to see if it\
still meeting the needs and\
we had weekly staffing\
meetings and structure\
meetings and if you'll note\
there is a small Haiti flag\
at the bottom of several of\
those boxes and this is\
important because this is\
what our CDC Haiti country\
office response effort look\
like so usually you have to\
integrate the okay here's\
CDC Atlanta and DC and then\
here is the country office\
and what we're going to be\
doing to combat cholera when\
we were there. So this is\
a working draft. I wanted to\
see this and also so we have\
several pieces of this. When\
you're trying to find staff\
that you want to deploy you\
really need to know your\
asset what do you have?\
What's available? Do you\
have language skills? We\
learn the huge lesson from\
this response. Franc-a-\
phones? We really need to\
consider our language\
capabilities at the agency.\
Technical skills, diplomacy\
skills and cultural\
competencies. Those are\
several areas that we've\
been tracking and some of\
the lessons that we've\
learned from this are\
basically that we need to\
send a few more people to\
FSI I think will be is one\
-- my boss is there right\
now so I think he won't\
disagree. For those number\
of CDC deployments to Haiti\
we had 383 CDC staff that\
are deployed to Haiti since\
the earthquake. 147have been\
deployed for the cholera\
response. 49 of those were\
EIS officers. And one of the\
I think one of the lessons\
learned from this gain is we\
had several people who might\
be able to deploy for 2\
weeks but we have fewer\
people who were able to\
deploy for a longer trunk of\
time strictly over 30 days.\
They didn't have the\
department of state training\
that they needed to do this.\
We are remedying that right\
now and trying to get more\
people into the pipe line so\
that they are able to deploy\
for longer stretches of\
time. The things that in\
international deployment you\
need that longer deployment\
time in order to have those\
relationships on the ground\
that functions well. There\
has been a lot of fatigue\
with responder turn over in\
Haiti. So there were great\
lessons learned. You already\
heard about this morning\
from my panel colleagues but\
in addition to what we learn\
to is to build upon\
pre-existing relationships\
and structures. Know what's\
already there and build on\
top of that. Guide rather\
than replace the government.\
This is absolutely critical\
when you deploy\
internationally that you are\
working with that government\
with their ministries and\
that you are moving them in\
a direction that will lead\
them to and improve at least\
to the level they were prior\
to the emergency but to\
consider beyond that. So\
focus on capacity building\
from the very beginning. Are\
there efforts while you're there\
that you should engage in\
that go beyond just the\
response phase? And initiate\
them early. The end state are\
our goal is a world prepared\
to detect and mitigate\
urgent public health threats\
and humanitarian\
emergencies. While there was\
previous slide which I\
enjoyed very much about the\
fog of relief, that fog of\
relief you have to be able\
to navigate through because\
these are also our partners\
and the keys here are to\
ensure that you have good\
working relationships and\
frequent communication with\
partners all partners across\
the board who are involved\
in response and\
reconstruction. Thank you\
very much.\
(People clapping.)\
DR. ERIN DOWNEY: Well\
thank you. The purpose\
of this session was to\
give you insight into the\
complexities of what\
international response means\
as a US government agency\
and as you move in to this\
sessions the focus areas, we\
encourage you to keep this\
in mind as you sit in in any\
international flavour sort\
of sessions. So I just would\
like to ask you to join me\
in one more time in thanking\
these extraordinary speakers\
because I truly appreciate\
your presence. \
(People Clapping)\
DR. ERIN DOWNEY: Thank you. So\
were going to\
wrap up with some closing\
housekeeping items and then\
we're going to be dismiss\
and have a break which will\
just be outside this door so\
you're just a moment away.\
Tonight is the grand opening\
reception for the 2011\
Disaster Response and\
Recovery Expo at 5 o'clock\
the doors will open in the\
Loghorn exhibit hall EF.\
Complementary food will be\
served. The 5k fun run will\
be tomorrow starting point\
will be outside of the tour\
lobby entrance of the hotel\
at the right of the main\
lobby. Starting time is\
promptly at 6:30. We\
encourage you to take part\
on that. Due to the rain\
that we had this week, we\
will be moving the yoga\
session to the Texas\
ballroom CD. This activity\
is scheduled on Thursday May\
5 at 6:30am. Tomorrow night\
there are three late breaker\
sessions. One the corrective\
action program at 5:30 at\
Texas 4-6, 4 to 6, 4, 5 and 6.\
The second is the direction\
and regulatory\
standards/guidance for\
health care systems that's\
at 5:30 at Grapevine C and\
then the third late breaker\
session will be the ESFA\
safety and health tower hall\
meeting at 5:30 in Grapevine\
B. Remember to scan your\
badges as you move into each\
of these sessions and\
evaluation stations are\
located next to the\
registration desk in the Loghorn\
foyer. Please be sure\
to provide your comments and\
feedbacks each day of your\
session this is how we\
improve it for the following\
year. One more time I want\
to thank you all for being\
part of the Integrated\
Training Summit. Please\
enjoy the sessions.\
(People clapping.) \
(Music.)\
}