ALASKA STATE LEGISLATURE  HOUSE HEALTH AND SOCIAL SERVICES STANDING COMMITTEE  February 13, 2020 3:04 p.m. MEMBERS PRESENT Representative Tiffany Zulkosky, Chair Representative Ivy Spohnholz, Vice Chair Representative Matt Claman Representative Harriet Drummond Representative Geran Tarr Representative Sharon Jackson Representative Lance Pruitt MEMBERS ABSENT  All members present COMMITTEE CALENDAR  PRESENTATION: 2019 NOVEL CORONAVIRUS - HEARD PRESENTATION: ALASKA CHILDREN'S JUSTICE ACT TASK FORCE - HEARD PREVIOUS COMMITTEE ACTION  No previous action to record WITNESS REGISTER ANNE ZINK, MD, Chief Medical Officer/ DPH Director Central Office Division of Public Health Department of Health and Social Services Anchorage, Alaska POSITION STATEMENT: Presented a PowerPoint during the overview and update of the 2019 Novel Coronavirus. PAM KARALUNAS Retired Chapter Coordinator Alaska Children's Alliance Chugiak, Alaska POSITION STATEMENT: Presented a PowerPoint on the Alaska Children's Justice Act Task Force. MIKE HOPPER, PhD Private Practice Psychologist Fairbanks, Alaska POSITION STATEMENT: Testified during the PowerPoint presentation by the Alaska Children's Justice Act Task Force. GAYLE GARRIGUES, Retired Attorney Fairbanks, Alaska POSITION STATEMENT: Testified during the PowerPoint presentation by the Alaska Children's Justice Act Task Force. ACTION NARRATIVE 3:04:07 PM CHAIR TIFFANY ZULKOSKY called the House Health and Social Services Standing Committee meeting to order at 3:04 p.m. Representatives Zulkosky, Spohnholz, Jackson, Tarr, Claman, and Drummond were present at the call to order. Representative Pruitt arrived as the meeting was in progress. ^Presentation: 2019 Novel Coronavirus Presentation: 2019 Novel Coronavirus    3:04:50 PM CHAIR ZULKOSKY announced that the first order of business would be a presentation on the Novel Coronavirus. 3:05:21 PM ANNE ZINK, M.D., Chief Medical Officer/Director, Central Office, Division of Public Health, Department of Health and Social Services, Presented a PowerPoint titled "2019 Novel Coronavirus Overview and Update." She pointed out that the name of the virus had been recently changed by the World Health Organization (WHO) to COVID-19. Dr. Zink stated that there were numerous corona viruses and she paraphrased slide 1 "Coronaviruses (general), which read as follows [original punctuation provided]: An enveloped RNA virus that may circulate in animal host or human host ? There are 7 coronaviruses that infect people ? People around the world commonly get infected with these four human coronaviruses: ? 229E, NL63, OC43, and HKU1. ? These account for 10-30% of common colds every year ? Spread by contact with infected secretions or by aerosol droplets DR. ZINK moved on to paraphrase Slide 2, "Coronaviruses (general), which read as follows [original punctuation provided]: Survivability outside the body: ? 1-2 hours on nonporous surfaces (e.g. hard surfaces) ? 8-12 hours on porous surfaces (e.g. soft goods) DR. ZINK introduced slide 3 "New Coronaviruses, which read as follows [original punctuation provided]: ? Sometimes coronaviruses that infect animals can evolve and jump from an animal reservoir to humans, causing illness and then are identified as a "new human coronavirus." ? We know of three recent times coronaviruses have moved from an animal to a human host ? SARS (Severe Acute Respiratory Syndrome) ? MERS (Middle Eastern Respiratory Syndrome) ? The name of this virus is COVID-19. Previously 2019- nCoV. 3:07:51 PM DR. ZINK moved on to slide 4, "2019 nCoV,and paraphrased the slide, which read as follows [original punctuation provided]: ? First reported by Chinese health officials on December 31, 2019 ? Likely very recently moved from an animal reservoir to humans ? Asymptomatic shedding is still unclear Incubation is between 2-14 days (mean is about 5 days) ? As of 1/13/20 there are 60,360 cases worldwide and 1,370 deaths (WHO) ? As of 1/13/20 - 15 confirmed cases in the United States in 7 states ? No deaths in the United States, but one US citizen died Wuhan City, China CHAIR ZULKOSKY asked to clarify that the date on the slide should reflect February 13, 2020. DR. ZINK expressed her agreement. 3:08:58 PM DR. ZINK presented slide 5, "Graph of nCoV cases to date,a graph depicting the number of reported cases worldwide, the upswing of numbers of reported cases in China, and the number of recovery cases. She reported that this spike in the upswing of reported cases in China had occurred since yesterday. She opined that this was likely because China had changed its definition of the virus through the use of different tests. She pointed out that this exponential growth of the virus was not being seen in the United States as it was in China. DR. ZINK indicated slide 6, "Case Fatality,which read as follows [original punctuation provided]: ? SARS had a case fatality rate (CFR) of ~10% ? MERS has a ~35% mortality rate and continues to circulate in animal reservoirs with sporadic zoonotic spillover ? Influenza H7N9 (bird flu) had about a 40% fatality ? Influenza averages 0.1% mortality ? H1N1 has a case fatality of ~0.03% fatality ? Ebola has roughly 60% fatality rate ? 2019-nCoV is estimated to have about a 2% mortality rate DR. ZINK shared slide 7, "Transmission, which read as follows [original punctuation provided]: ? Early on, suspected animal-to-person spread ? Now, also known to be person-to-person spread ? Respiratory droplets when an infected person coughs or sneezes ? Close contact (about 6 feet) ? Unclear if transmitted through touching a surface or object ? It is unclear how easily or sustainably this virus is spreading between people ? 2019-nCoV has an R naught of about 2.5 (this means each infected person will transmit the virus to about 2.5 other people) ? Measles: >12 ? SARS: ~3 ? 1918 flu: ~2 ? 2009 H1H1: ~1.5 ? Seasonal Flu: ~1.2 3:12:32 PM DR. ZINK directed attention to slide 8, "2019 nCoV in the U.S." a map of the United States which depicted those states in which the virus had been positively identified. She noted that Texas had also just been added to those states. She moved on to slide 9, "Signs and Symptoms,which read as follows [original punctuation provided]: ? May look similar to the common cold or flu For confirmed 2019-nCoV infections, reported illnesses have ranged from people with little to no symptoms to people being severely ill and dying ? Fever ? Cough ? Shortness of breath ? Myalgia / fatigue ? Appears to disproportionally affect the elderly or those with underlying medical conditions DR. ZINK spoke about slide 10, "Comparing to the flu,which compared estimates of the 45 million flu cases, 810,000 flu hospitalizations, and about 61,000 flu deaths. She reported that about 40 percent of the U.S. population had received a flu vaccine, and it was estimated that those vaccines prevented 6.2 million flu illnesses, 91,000 hospitalizations, and 5,700 deaths. She explained that, as the symptoms were similar, this would put these in context, adding that there was not a vaccine for this novel coronavirus. She pointed out that a flu shot could help the hospitals from being overrun by people with similar symptoms who needed hospitalization. 3:14:05 PM DR. ZINK directed attention to slide 11, "Testing and Treatment,which read as follows [original punctuation provided]: ? CDC has developed a real time Reverse Transcription- Polymerase Chain Reaction (rRT-PCR) test that can diagnose 2019-nCoV in respiratory and serum samples from clinical specimens. ? On January 24, 2020, CDC publicly posted the assay protocol for this test. Currently, testing for this virus must take place at CDC. ? Currently testing can only be done at the CDC but on 1/5/2020 the CDC announced they will start to roll out testing to individual states ? Alaska Labs has been in communication with the CDC to gear up for testing. At the earliest, Alaska could start testing by March. ? There is no known treatment except for good supportive care. ? A vaccine or treatment is likely not going to be available in the near future. DR. ZINK introduced slide 12, "CDC Evaluation Flowchart,which detailed the steps for clinicians and hospitals to identify whether both exposure and illness were present, and then the steps to isolate, assess clinical status, inform, instruct, and advise the patient. She reported that currently there was no need to test people in Alaska unless they met one of these criteria. DR. ZINK shared slide 13, "PUI (Persons Under Investigation)," which offered criteria for determination whether someone needed testing. 3:15:58 PM DR. ZINK spoke about slide 14, "Notes on travel,which read as follows [original punctuation provided]: ? Jan 1, 2020 Huanan Seafood Wholesale Market was closed Jan 23, 2020 Wuhan City shuts down public transportation ? Jan 31, 2020 Presidential Proclamation suspends entry into the United States to foreign nationals who visited Mainland China in the past 14 days. Exempted persons include immediate family members of U.S. citizens, legal permanent residents and crew members of air travel DR. ZINK reported that the current federal quarantine order issued for the passengers returning from China was the first since the 1960s, and she presented slide 15, "Isolation vs. Quarantine,which read as follows [original punctuation provided]: ? Isolation and quarantine help protect the public by preventing exposure to people who have or may have a contagious disease. ? Isolation separates sick people with a contagious disease from people who are not sick. ? Quarantine separates and restricts the movement of people who were exposed to a contagious disease to see if they become sick. ? In addition to serving as medical functions, isolation and quarantine also are "police power" functions, derived from the right of the state to take action affecting individuals for the benefit of society. DR. ZINK added that, in the State of Alaska, the Department of Health and Social Services had the legal ability to issue quarantine, which was occasionally used, particularly for individuals with tuberculosis who posed a risk to others. She noted that the state had not done a mass quarantine. 3:17:36 PM DR. ZINK shared slide 16, "Prevention,which read as follows [original punctuation provided]: There is currently no vaccine to prevent 2019-nCoV infection. The best way to prevent infection is to avoid being exposed to this virus. CDC always recommends everyday preventive actions to help prevent the spread of respiratory viruses, including: ? Avoid touching your eyes, nose, and mouth with unwashed hands. ? Avoid close contact with people who are sick. ? Stay home when you are sick. ? Cover your cough or sneeze with a tissue, then throw the tissue in the trash. ? Clean and disinfect frequently touched objects and surfaces using a regular household cleaning spray or wipe. ? Wash your hands often with soap and water for at least 20 seconds, especially after going to the bathroom; before eating; and after blowing your nose, coughing, or sneezing. ? If soap and water are not readily available, use an alcohol-based hand sanitizer with at least 60% alcohol. Always wash hands with soap and water if hands are visibly dirty. DR. ZINK pointed to slide 17, "An Outbreak,which compared a graph for a pandemic with no intervention to a graph for a pandemic with rapid intervention, which depicted a reduction to the overall peak number of cases and the health effects. She declared, "These viruses don't have passports; we live in a very international world, and we need to be prepared and ready." DR. ZINK moved on to slide 18, "Disaster Preparedness,a workflow chart that listed disaster management plans to respond, recover, plan and prepare, then mitigate. She added that it was then necessary to prepare for the next disaster using previous guidelines from SARS, MERS, and Ebola, slide 19, Preparing for the next steps, which read as follows [original punctuation provided]: ? Preparedness is something that we do, practice and prepare for ? Build on existing structures and lessons learned from the 1918 flu, H1N1, SARS, MERS, and Ebola ? Have recently updated Pandemic Influenza Plan that can be used as guidelines ? Exercised planning for a contagious pandemic in the "Ragin' Contagion" exercise from April 8-13, 2019 ? Have active Emergency Medical Countermeasures Management Plan ? DHSS EOC (Emergency Operations Center) stood up Jan. 24, 2020 ? Working closely with other departments, tribal, federal and local partnerships to run through all of the "what ifs" 3:19:44 PM DR. ZINK talked about the flight which landed in Anchorage bringing U.S. citizens home from China, and she noted that the 14-day quarantine window had closed on Tuesday, [February 11], ending the concern and risk for anyone working with the flight, slide 20, "A special case,which read as follows [original punctuation provided]: ? Asked to assist in the repatriation of up to 240 US citizens and their families on January 28th, 2020 ? Worked closely with federal, local, tribal and state partners to ensure Alaskans were not at any increased risk ? Passenger[s] have all cleared their 14 day quarantine period with no cases ? Alaska is more prepared from having the courage to carry out this mission DR. ZINK reported that, because of that repatriation mission, Alaska was further ahead in planning and preparation than most other states. She pointed out that it was necessary to keep the cargo ships and cargo flights moving, as almost 90 percent of medical equipment came from China, slide 21, "Looking forward Cruise Ships and Cargo,which read as follows [original punctuation provided]: ? Anchorage airport is one of the busiest cargo airports in the world ? Crew members of aircraft have FAA requirements which are slightly different than the general screening into the US ? Cruise lines are limiting passengers who are boarding with pre-boarding screening DR. ZINK addressed slide 22, "Strengths and Weaknesses, declaring that it was necessary to keep people informed with accurate information as we were actually fighting four epidemics: the novel coronavirus, as well as epidemics of fear, stigma, and misinformation. She paraphrased the slide, which read as follows [original punctuation provided]: ? Strong, centralized public health system including labs, epidemiology, emergency operations center ? Strong state, federal, Tribal, local partnerships Limited health care capacity and large distances ? Housing and quarantine challenges ? Supply chain challenges ? Rapid spread of fear, stigma and misinformation 3:22:02 PM DR. ZINK concluded with slide 23, "What is being done,which read as follows [original punctuation provided]: ? Health provider webinars ? Emergency operations meetings ? Daily national calls with federal partners including CDC and others ? Public messaging and media ? Interdepartmental preparedness planning including: ? DMVA, DEED, DOT, DOC, DPS and others DR. ZINK, in response to Representative Claman, explained that the diagram on slide 17 depicted a "general diagram of epidemics" to get an estimate of where things were, and not the coronavirus specifically. 3:22:55 PM REPRESENTATIVE TARR reflected on the opportunity to test the system when the plane landed in Anchorage with the repatriated U.S. citizens, and asked what had been learned that would strengthen any future response. DR. ZINK explained that the heightened tension with the national and international media was a good reminder for how quickly things can "get spun up." She shared that, upon landing, the plane had announced a medical emergency which created "a lot of scrambling and a lot of concern," and turned out to be a minor injury happening 9 hours earlier. She added that, although the pilots and crew never got off the plane in China and were in a separate airspace from the passengers, they left the plane and went into Anchorage, causing a lot of concern due to the misinformation. 3:25:28 PM CHAIR ZULKOSKY stated that the committee would take a brief recess. 3:25:43 PM The committee took an at-ease from 3:25 p.m. to 3:38 p.m. 3:38:19 PM ^Presentation: Alaska Children's Justice Act Task Force Presentation: Alaska Children's Justice Act Task Force  CHAIR ZULKOSKY brought the House Health and Social Services Standing Committee back to order and announced that the final order of business would be a PowerPoint presentation by the Alaska Children's Justice Act Task Force. 3:40:13 PM PAM KARALUNAS, Retired Chapter Coordinator, Alaska Children's Alliance, shared that she has worked in the field of child sexual abuse [prevention] for 35 years, was the founding manager of the Child Advocacy Center in Fairbanks, Alaska, has worked with the Alaska Children's Alliance for the past 15 years, and was a founding member of the Alaska Children's Justice Act Taskforce. She stated that much of the data and research presented had been prepared by Dr. Jared Parrish. She shared slide 2, "Introduction to the Alaska CJATF,and paraphrased the slide, which read as follows [original punctuation provided]: • Federally mandated and funded • Mission: Identify areas where improvement is needed in the statewide response to child maltreatment, particularly child sexual abuse, make recommendations and take action to improve the system. • Statewide, multidisciplinary membership • Legislation to improve protection & justice for children (starvation, serious physical abuse, privacy) • Focus on education: child abuse in Alaska, mandatory reporting, & best practices for the multidisciplinary response to child abuse MS. KARALUNAS addressed slide 3, "Overview of our presentation, and reported that Alaska had specific research on Alaska, which was not common among the states. 3:42:18 PM The committee took a brief at-ease. 3:43:50 PM MS. KARALUNAS returned to slide 3, which read as follows [original punctuation provided]: Newest research on child abuse and neglect in Alaska Including impact on state Opportunities for earlier intervention: Mandated reporting Commercial sexual exploitation of children in Alaska Specific requests for legislative changes MS. KARALUNAS introduced slide 4, "Adverse Childhood Experiences (ACEs), a collaborative study between Centers for Disease Control and Kaiser Permanente of 17,000 people, mostly white, mostly upper middle income with some college education, and not considered to be high risk. The graph on slide 4 depicted the percentage of significant connections between early childhood adversities and health problems in adults. These childhood adversities were divided into 10 categories: physical abuse, sexual abuse, emotional abuse, physical neglect, emotional neglect, mental illness, incarcerated relative, mother treated violently, substance abuse in the home, and divorce. Each category was determined to be one point, no matter the frequency. She addressed slide 5, "Findings, which stated that ACEs were very common, especially among people with physical health problems, and listed the findings by percentage. She reported that, although everyone had an 87 percent chance of having at least one ACE, there was a 50 percent chance of having 3 or more ACEs. 3:47:42 PM MS. KARALUNAS stated that the higher the score, the more likely it was for an individual to have health risks, slide 6, "Increased ACE score = increased likelihood:" She added that recent research had found more of a correlation between high ACEs score and heart disease than with those more traditional causes including hypertension and high cholesterol. She added that a high ACEs score also increased the risk for strokes, lung disease, osteoporosis related factors, or early death, as well as an increased risk for smoking, alcoholism, drug use, depression, suicide attempts, multiple sexual partners, intimate partner violence, or rape. She declared, the higher the ACEs score, the more likely to be a victim. MS. KARALUNAS moved on to slide 8, "Alaska ACEs snapshot,which listed the percentages of reported problems as analyzed from the Alaska Behavioral Risk Factor Surveillance System. She emphasized that, in Alaska, those with four or more ACEs were 49 percent more likely to be unemployed, 274 percent more likely to be unable to work, 92 percent more likely to earn less than $20,000 annually, and significantly more likely to report poor physical and mental health. She shared slides 9 and 10, "And it's not just one bad thing..." an Alaska specific graph which indicated the co-occurrence of adverse childhood experience exposures. 3:50:15 PM MS. KARALUNAS shared slide 11, "Maltreatment burden in Alaska, declaring that the health care impact was very high. She reported that annually 10 percent of children in Alaska were reported to the Office of Children's Services (OCS) and that 34 percent of adults in Alaska had some ACE experience as a child. She declared that cumulatively 37 percent of the Alaska population had some childhood trauma. She directed attention to slide 12, "Trauma impacts can start prior to birth,which included prenatal exposures and experiences which impact brain development in utero and genetics. She added that children exposed to prenatal trauma were much a higher risk for hospitalization from asthma. She discussed slide 13, "What is epigenetics?" and reported that childhood trauma impacts genes, which helps to explain intergenerational trauma. She noted that, as genes could be turned on and off, people could be helped after trauma. 3:54:47 PM MS. KARALUNAS discussed the Alaska Pregnancy Risk Assessment Monitoring System (PRAMS), which allowed for mothers to be interviewed in the hospital with a follow up process, slide 14, "New emerging data resources." She stated that currently more than 33,000 children born between 2009 and 2011 were being followed in Alaska for medical issues, law enforcement issues, and child protection reports, among others. She indicated slide 15, "Pre-birth household dysfunction to predict ACE Score, reporting that dysfunction during the 12 months prior to birth and pregnancy generated higher ACE scores. MS. KARALUNAS moved on to slide 16, "PRAMS questions used to measure pre-birth household dysfunction ACEs,and stated that the risk of contact with OCS increased with the increased number of pre-birth household dysfunctions. She reported that there was a stepwise association and an accumulation of ACEs with the more stresses that occurred prenatally, slide 17, "Pre-Birth Household Dysfunction and ACE Score." She reported that adjustments for maternal race, education, or age did not change these outcomes. She introduced slide 18, "Impacts continue after birth, which compared the synaptic density at birth, at six years, and at fourteen years. She pointed out that the synapsis showed a regression at 14 years old, hence a decrease in the function of the brain, and a high level of vulnerability. 3:59:46 PM MS. KARALUNAS shared slide 19, "Development influenced by both negative and positive factors,and stated that brain development was also influenced by positive factors such as meaningful relationships. She discussed slide 20, "Adverse Childhood Experiences (ACE), stating that the more ACEs documented, the higher risk of developing later health and social problems. MS. KARALUNAS pointed to slide 21, "Risk (incidence) among children,and reported that there was a cumulative incidence of contact with OCS among children born in Alaska. She stated that the study had tracked these children for nine years and measured the cumulative incidences. Moving on to slide 22, "ALCANLink Study, she relayed that of the children born between 2009 and 2011, before their ninth birthday, one in three had been reported to OCS, one in four had been screened in to OCS, one in eight had their OCS case substantiated, and one in sixteen had been removed from their home by OCS and placed in foster care. 4:02:43 PM REPRESENTATIVE TARR reported that, in 2019, there were more than 23,000 OCS protective service reports filed in Alaska, and, of these, more than 11,000 were screened in for investigation. REPRESENTATIVE JACKSON said that these numbers brought a lot of questions. MS. KARALUNAS replied that Alaskans were often hurt. She explained slide 23, "Types of maltreatment, which read as follows [original punctuation provided]: Screened in by OCS in 2019: Neglect: most common type 59.4% Most common cause of child deaths Most commonly linked to parental substance abuse Mental injury 22.5% Example: Exposure to DV Physical abuse 11.4% Sexual abuse 6.6% 4:07:17 PM CHAIR ZULKOSKY asked for the definition of "screened in." MS. KARALUNAS explained that OCS would review a report and then determine through their records whether there should be further investigation by an OCS worker. 4:08:00 PM MIKE HOPPER, PhD, Private Practice Psychologist, introduced slide 24 "Different life trajectories: Two roads to travel,and said that, although there were two paths, the path that led toward trauma and chaos was often hidden. These were people who had survived multiple ACEs, did not want anyone to know, and wanted to forget about from where they came. He noted that he did not know how he could have survived and kept going and expressed his own amazement that the rate of suicide was low. He shared a personal anecdote, reading from a book about immigrants, and suggested replacing the images with those for children who experience ACEs. He stated that people who had suffered ACEs felt like strangers who did not belong in our society, as they had grown up "on very, very unsafe grounds." He pointed out that, as these individuals tried to be invisible, it was difficult to pick them out of general society until they entered jail or a psychiatric hospital. He reminded the committee that 40 percent of Alaskans had suffered from ACEs. 4:13:49 PM MS. KARALUNAS continued with slide 24, and explained that the neural pathways for flight, fight, or freeze can become hardwired. She declared that there was also resiliency and rewiring. She moved on to discuss slides 25 and 26, "Disproportionality: Why?and reported that Alaska Native/American Indian children were significantly represented in child maltreatment reports and deaths. She stated that they were three times more likely to be reported to OCS. She reported that 48 percent of the children seen at CACs in FY 19 were Alaska Native or American Indian, although they were only 14 percent of the population. She emphasized that new research had shown this was not a part of the culture. She stated that it was necessary to adjust for the background of historical trauma, racism, and the genetic factor, and it was evident that the risk was related to the social ills, including poverty, intimate partner violence, substance abuse, and poor mental health. She declared that Alaska did not have a higher amount of child abuse in the Alaska Native population because it was part of the culture, instead it was part of what had been happening for generations. She emphasized that the question should not be "what's wrong with you?", but should be "what happened to you?" 4:17:44 PM MS. KARALUNAS shared slide 27, "What Does Child Maltreatment Cost Alaska?" and slide 29, "Alaska estimates:" She acknowledged the difficulties for balancing budgets, but pointed out the cost annually for child maltreatment, between $631 million and $10.7 billion. She reported that the cost just for the substantiated OCS reports was $82 million for childhood health care, child welfare, and special education. She noted that almost 41 percent of adult Medicaid enrollment was linked to ACEs. She suggested that decreasing ACEs and improving the response to child maltreatment could save Alaska almost $92 million annually. She moved on to slide 30, "Also below the surface: CSEC, and spoke about the commercial, sexual exploitation of children. 4:19:34 PM GAYLE GARRIGUES, Retired Attorney, stated that the commercial sexual exploitation of children had probably been going on for a millennium even as law enforcement was just becoming aware of it, slide 31, "Commercial Sexual Exploitation of Children (CSEC) is:" which read as follows [original punctuation provided]: Sexual activity involving a child in exchange for something of value, or promise thereof, to the child or another person or persons Treating a child as a commercial and sexual object A form of violence against children Words matter: not "child prostitution" MS. GARRIGUES declared that, as words conjured images, they matter, and she paraphrased slide 32, "Sex Trafficking,which read as follows [original punctuation provided]: CSEC victims are victims of sex trafficking when there is a third party exploiter who profits from the  exploitation  Sex trafficking in which a commercial sex act is induced by force, fraud, or coercion,  or in which the person induced to perform such an act  has not attained 18 years of age (or under 20 in  Alaska) 4:23:21 PM DR. HOPPER reported on slide 33, "Intersections of Abuse, and stated that child exploitation already occurred within a secret environment, as it was behind closed doors, and was a "very, very hidden part of our society." He offered a comparison with the difficulty and courage of women to speak out against powerful men in the MeToo movement, and how difficult it was for young girls to also speak out. He added that young boys were also sexually abused at a rate not that far from young girls. He shared an anecdote of the intersection of child prostitutes and child sexual exploitation, pointing out that most of the sexual exploitation was committed by people who did not have to pay for it. 4:27:02 PM MS. GARRIGUES shifted to slide 34, "Pathways to Entry:" which read as follows [original punctuation provided]: Parents selling/trading children for sex Violence and force Kidnapping Seduction Fear, coercion, blackmail False advertising for "modeling," "acting," or "dancing" opportunities Peer recruitment Internet enticement through social media, gaming, or profile-sharing sites Survival MS. GARRIGUES shared anecdotes for each of these pathways. 4:31:12 PM MS. GARRIGUES spoke about slide 35, "What you need to know:" which read as follows [original punctuation provided]: Within 48 hours of becoming homeless, one in three children will be approached by a trafficker In Alaska, common age of recruitment is 14-16 years Average lifespan once recruited is 7 years MS. GARRIGUES moved on to paraphrase slide 36, "Alaskan Risk Factors,which read as follows [original punctuation provided]: Population with high amounts of historical trauma and trauma exposure Transient male-dominated industries Transient male-dominated industries placed in rural areas next to communities with high amounts of historical trauma Rural and Urban Celebrated history of prostitution MS. GARRIGUES directed attention to the glamour of the celebrated history of prostitution, offering an example of the Fairbanks "Golden Days" and the streets named for madams. MS. GARRIGUES discussed slide 37, "Current Status of CSEC in Alaska,which read as follows [original punctuation provided]: Loyola University/Covenant House Study 2016 65 youth surveyed locally (641 Nationally) 1 in 5 Identified as trafficking victims Nationally 1 in 4 Identified as trafficking (labor/sex) victims locally 1 in 4 females as sex trafficking locally 200 victims served in last two years between 5 Anchorage providers 10 current minor child cases FBI Law enforcement report an increase of online recruitment More cases of traffickers creating explicit images/videos of minors MS. GARRIGUES shared that it was necessary to learn the ways to investigate cases and what to look for. She pointed to some protocols for examinations of sex traffic victims as this entailed different questions and questioning techniques. She pointed out that the images from these cases last forever on the internet. 4:37:01 PM REPRESENTATIVE TARR asked about the bills currently introduced by the governor. MS. GARRIGUES said that she would speak about that. MS. KARALUNAS shared that the author of the studies by Loyola University referenced on slide 37 had indicated that the stories from children in Alaska were the most horrific. 4:38:23 PM DR. HOPPER reported on slide 39, "How do we create the best future for our children's lives?" a graph reflecting the trajectory of health development from the early ages, 6 months to 5 years of age. He noted that with the lack of opportunities, including health service and education, children were found to not do as well. DR. HOPPER moved on to slide 40, "What can we do?" which read as follows [original punctuation provided]: Reasons for hope: Healing is possible Our brains can always learn We can all help build resilience in children We can all help protect children DR. HOPPER expressed his disagreement with any suggestion to survivors that their brains are damaged, as the brain was "unbelievably resilient." He reported that these kids protected their own brains under the worst possible conditions, while trying to forget because there was nothing they could do about abuse and neglect. He noted that, however, "down the line it's a threat that remains ever present, that's what called a traumatic memory." He referred to these memories as "warning lights." He added that most people did not recognize these warnings "of their own past calling to them, warning them of what can happen." Instead, many people would begin to act as if this were all happening again. He expressed his awe of the survivors. 4:44:25 PM MS. GARRIGUES added that her work with sexual assault and abuse victims had shown them to be "some of the bravest people because they had to come into the courtroom and talk cogently about some of the worst experiences in their lives." She shared slide 42, Earlier recognition & intervention: Mandatory Reporting, and slide 43, "Mandatory reporting gaps, stating a desire to "tinker with the mandatory reporting statute." She paraphrased from slide 43, which read as follows [original punctuation provided]: EMS & paramedics (trainings) Clergy (multiple cases involving clergy as perpetrators & protectors of perpetrators) Animal control & veterinarians (research links between animal cruelty & child abuse) Guardians Ad Litem (GALs) (CASA volunteers are required already) Judges (recent case reporting not required, no immediate notification) 4:47:51 PM REPRESENTATIVE PRUITT asked whether clergy were currently mandatory reporters for child sexual abuse. MS. GARRIGUES replied that, in Alaska, clergy were mandatory reporters for elder abuse but not for child abuse. She said that the requirement for mandatory reporters varied from state to state. REPRESENTATIVE PRUITT shared the story of a confession to a clergy that was subsequently reported, resulting in a suit from the confessor. MS. GARRIGUES acknowledged a case in Alaska when a clergy also worked as a mental health therapist and reported an abuse. This had resulted in litigation regarding confessional privilege, but the law had determined there was not any privilege for a mental health counselor. She noted that the rules of evidence provided an exception for mandatory reporting for clergy. She offered her belief that a clergy exception for mandatory reporting protected the perpetrator, not the child. REPRESENTATIVE PRUITT clarified that the incident he relayed had occurred outside Alaska. 4:51:57 PM REPRESENTATIVE TARR shared background on a prospective bill she was drafting for mandatory reporters, which included clergy. MS. GARRIGUES relayed that in Alaska there were privileges found for information that may be used in court. She added that each member of the Alaska Children's Justice Act Task Force was a subject matter expert if further specific information was requested. REPRESENTATIVE TARR shared that animal control and veterinarians had been considered as aggravators with violent crimes in her prospective bill. MS. GARRIGUES replied that aggravators happened after someone had gone to court, whereas she was working toward early and effective intervention, prior to going to court. MS. KARALUNAS stated that there was clear research making the connection between abused animals and abused children in a home. DR. HOPPER pointed out that, as dogs would bark when abused, there were often animal control people investigating before there were social workers investigating. 4:55:34 PM MS. KARALUNAS addressed slide 44, "Early & effective intervention," which read as follows [original punctuation provided]: Child Advocacy Centers Multidisciplinary response Child focused Forensic interview Medical exam Mental health services Support & advocacy Information sharing Nearly 33,000 children & their families served since 1996 MS. KARALUNAS moved on to paraphrase slide 45, "Protective Factors: Focus on adults, which read as follows [original punctuation provided]: Supportive, nurturing, stable family Supportive social networks Caring adults outside family Household rules, monitoring of child Parental employment Adequate housing Access to health care, other services Community safety Community involvement Cultural connectedness MS. KARALUNAS addressed slide 46, hat can you do?" which read as follows [original punctuation provided]: Realize this affects ALL of us in Alaska Make your decisions using a trauma-informed lens "It's not what's wrong with you, it's what happened to you" Support community-based & system-wide approaches to strengthen children and families 4:56:51 PM MS. GARRIGUES explained slide 50, "SB 165/HB 225: "An Act relating to sex trafficking..." which had been introduced by the governor and were related to sex trafficking, bringing the prosecution up to date. She declared support for the legislation, especially support for the prosecution that the patrons had to register as sex offenders. She emphasized that, although there was support for the recommendation that a victim of sex trafficking may seek to vacate any prostitution convictions, this needed to go further as these sex trafficking victims often committed other crimes, all a result of the trafficking and not because of their own free will. She urged that the statute be amended to add more convictions that could be vacated. She suggested that for more successful prosecutions of trafficking it would be necessary for safe harbor protections, such as housing and support, to help the victims and "go after the real bad guys." She stated that mandatory training was necessary for law enforcement officers, so they know what questions to ask, for prosecutors, and for judges to better understand. She referenced the proposed bills SB 168 and HB 228 which had come forward primarily because of a decision made by the Supreme Court that required a way for people on the sex offender registry to be removed. These bills would set up the process for this, clear criteria for the courts to consider, with a clear and convincing standard of proof, and would provide for victim notification and for the victim to provide input. It also added other registrable crimes. She declared support for the proposed bills. 5:01:04 PM MS. KARALUNAS concluded with slide 53, "How will you be a champion for Alaskan children & families?" 5:01:27 PM REPRESENTATIVE SPOHNHOLZ expressed appreciation for the long- time work addressing child abuse and neglect in Alaska by the task force. She suggested that there were many additional preventative measures to reduce the impact for child abuse, such as additional positive supports for children's lives. She referenced a federal program, the "Family First Prevention Services Act," which suggested in-home parenting support, nurse home visiting programs, and substance abuse and mental health services. She reported on the investment in after school prevention programs with supportive adults. She declared that offering even more positive programs would "save money, save lives, and have healthier people over time." 5:04:08 PM DR. HOPPER asked the committee for a dedicated fund for foster kids to have access with transportation to organized sports, noting that this "would change thousands of lives." REPRESENTATIVE JACKSON shared that there was "a massive amount of money that is coming but the federal government is being very mindful in how they're going to focus it." She suggested that investment back into foster kids would break the cycle. DR. HOPPER expressed his agreement that there were foster kids who had been identified as "being in the cycle." 5:05:20 PM CHAIR ZULKOSKY offered her belief that this was a topic of broad concern and listed some follow up items, which included: how to address historic trauma, issues of child welfare, and mandatory reporting. 5:07:02 PM ADJOURNMENT  There being no further business before the committee, the House Health and Social Services Standing Committee meeting was adjourned at 5:07 p.m.