Preparedness for Natural Disasters

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  • special supplement public health and the law 11

    Jose CorderoIt is a pleasure to introduce Vice Admiral Richard Carmona, 17th Surgeon General of the United States Public Health Service.

    Born and raised in New York City, Dr. Carmona dropped out of school and enlisted in the U.S. Army in 1967. He became a Special Forces weapons special-ist and medic and received his Army General Equiva-lency Diploma. He returned to civilian life a combat-decorated Vietnam veteran and enrolled in Bronx Community College where he earned an Associate of Arts Degree. Later he attended the University of Cali-fornia San Francisco, receiving a Bachelor of Science and then a medical degree. He was the top graduate in medical school and was awarded the prestigious gold-headed cane. He completed his surgical residency and received a National Institutes of Health-sponsored Fellowship in trauma, burns and critical care. Hes also a Fellow of the American College of Surgeons and is certified in correctional health care and quality assurance.

    In 1985, Dr. Carmona was recruited by the Univer-sity of Arizona and the Tucson Medical Center to estab-lish and lead the first Southern Regional Emergency Medical System. He was a professor of Surgery, Public Health and Community Medicine at the University of Arizona and the Pima County Sheriff s Department Surgeon and Deputy Sheriff. While working full-time, he earned a Masters of Public Health Policy and Administration from the University of Arizona.

    In 2002, Dr. Carmona was nominated by the presi-dent and unanimously confirmed by the Senate as 17th Surgeon General of the United States. During his term, he was frequently recognized for his outstanding performance and for issuing significant reports and calls to action. Dr. Carmona has published extensively

    and received numerous awards, decorations, and local and national recognition for his achievements.

    Richard H. CarmonaAs I thought about preparing for this conference, I considered what to say about my job and how it inter-sects with public health and law. Within my portfolio of responsibilities, legal authorities can delineate, clarify, and define what I can do. My duties can also plague me if they are not spelled out carefully and if people do not fully understand my roles and responsibilities.

    In fact, I recall in just the past year trying to work through many of the new presidential directives, National Security presidential directives, Homeland Security presidential directives, and authorities that relate to preparedness. I remember many late nights in meetings with various groups, some with lawyers and some without, arguing over the placement of a semi-colon or other grammatical mark to clarify the intent of a particular document. And, of course, in the midst of an emergency is not when you want to be doing something comparatively trivial like that.

    Some of the areas where these issues have come up include: syndromic surveillance, tobacco litigation, pandemic influenza, bird flu, HIPPA and EMTALA, Good Samaritan laws, general emergency prepared-ness and emergency health powers acts, small pox, vac-cines and other counter measures. In addition, there are global issues because my position has morphed in the last few years from being the United States Sur-geon General to that of a global position. Nearly every-thing I do or say has worldwide implications either directly or indirectly. I welcome the challenges.

    I also should mention to you that having been in this job about four years, I notice I am aging in dog

    Preparedness for Natural DisastersRichard H. Carmona

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    years. Its the toughest job Ive ever had. When my col-leagues ask me what it is like to be Surgeon General, I tell them its like being a surgical intern in perpe-tuity. There are no breaks, and the buck stops here, with me. Many days I want to go home because its tough balancing national and global needs. I am chal-lenged with infinite needs and finite resources every single day. When I have those down days, I look out at my United States Public Health Service Commis-sion Corps officers. I take note of what they do around the world in 800 locations making the country and the world a better, safer, more secure place every day. I recognize Im only the seventeenth person in the his-tory of this country to have the job of U.S. Surgeon General, and I know there is not a lot for me to com-plain about. In this position, you sacrifice a great deal. You dont see your friends and you dont see your fam-ily. This is a job you cannot plan for. This is a job that comes along once in a lifetime. It is an extraordinary opportunity.

    When I first came in as Surgeon General, if you had asked me about my position, I would have waxed and waned philosophically about public health issues, all of the epidemiologic trends in the country, and how we need to change the world in a lot of different ways. Yet, after some rough starts within the Beltway, that combat zone we call D.C., I knew my work was some-thing different. What I do every day is to preserve and protect the integrity and the dignity of the Office of the Surgeon General. This is probably the most important thing that I learned from sixteen predecessors. Five of them are still active, and they have mentored me and taught me.

    Preserving and protecting the Office of the Surgeon General is the currency by which we are able to parlay public health in a very diverse world and make changes that can change the world. It is a very subtle point, but one that is extraordinarily important because there are few positions in government where you have such immense presence and credibility. Its a privilege to serve as Surgeon General and all that you are able to do with that privilege to make the world a healthier, safer, more secure place. I made it to the position of Surgeon General following an arduous pathway. As I said before, you cant plan for this position. I was nom-inated, came to the White House, and went through a surrealistic experience. Then somebody reminded me I had to go through Senate confirmation after the nomination. Its like going through basic training or jump school or Special Forces training which puts you into a kind of pipeline.

    Pipelines are a metaphor for traversing a certain group of challenges. And as I entered that pipeline to the Senate, I recognized what had really changed was

    that I had become a public figure overnight. Every-thing I do, everything I say is now a matter of public record. Everything I dont do or dont say is a matter of public record because there is somebody who com-ments on it regardless, telling you their opinions about what they think you should be doing. I came to realize that pipeline to Senate confirmation is a Darwinian process survival of the fittest. They put you in and everybody gets to take shots at you. If you come out the other end with vital signs you can have the job. I managed to make it, got the job, and learned some hard lessons the first year.

    Much of who I am as Surgeon General is not from degrees or education, but from what I learned grow-ing up as a poor kid in New York City, in Harlem, first born in this country. I had parents who struggled and had substance abuse problems. I had two younger brothers and a sister and I became their surrogate parent. We were homeless when I was six. It was a real struggle until finally I saw the light and went into the Army. The Army gave me the opportunity to be successful after I failed so much in my life. I learned a lot of lessons growing up such as having to access public hospitals for care, and seeing the indignity of a mom who didnt want to take welfare because she was too proud, even though her kids were hungry and didnt have health care. That is what drives me today. The academic education has just complemented that upbringing. I understand the trials and tribulations of the average person who is struggling everyday just try-ing to make a living, get their kid through some educa-tion, and stay above water. For me this has really been an extraordinary journey.

    As I entered the job as Surgeon General, I asked myself, What do I do as Surgeon General? The statutory responsibility is pretty simple: to protect, promote and advance the health, safety and security of the nation. Sounds easy, but try to operationalize that responsibility and you start getting into the issue of what do you really have the authority to do. Much of what I do as Surgeon General is less by authority than it is more by presence and credibility and build-ing consensus with very diverse groups to move an agenda forward that will benefit the public and/or benefit the nation and/or benefit the world. As I began to formulate a portfolio, I was motivated by the fact that the clock seemed to be ticking faster than normal and that a four-year term would not be enough time to make a difference. When I arrived in Washington with the well-known arrogance of a surgeon, and having been a police officer, nurse and paramedic, I thought I understood the office and wondered what the other sixteen Surgeon Generals had been doing since there was so much left for me to do. Thats when those five

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    Richard H. Carmona

    surviving Surgeons General stepped in to mentor and befriend me. They taught me a great deal about the importance of the integrity and dignity of this job and how to survive within the Beltway.

    The job is not just about the portfolio or the pub-lic health of the nation. Its about incrementalism, or staying in the fight for any issue you think is important. When I first arrived, I thought I wanted to stamp out disease and famine and pestilence in a couple years. It doesnt work that way, so the biggest job I have on a daily basis is trying to achieve alignment among diverse groups of stakeholders who all have differ-ent views of the world. We all want to get to the same place, but everybody is coming from a different direc-tion. I am trying to provide that alignment under the auspices of being the Surgeon General and using the bully pulpit to try and move those agendas forward. The job is more about presence and credibility than it is about legal authority, although there are some legal authorities. I looked at the portfolio and spoke to the president and to the secretary of Health and Human Services at the time and tried to develop a strongly evi-dence-based portfolio for moving the nation forward.

    The first issue was obvious: prevention. We are a nation that embraces care, but we dont spend a lot of time on health, wellness and prevention. I know that from my own childhood experience and I know it from being a trauma surgeon. Almost every patient I admit-ted on a daily basis through the ER at a trauma cen-ter didnt need to be there. People made bad decisions their entire lives or that particular day domestic violence, drugs, crime. The statistics are well known, especially by the Epidemic Intelligence Service (EIS) folks here at the Centers for Disease Control and Pre-vention (CDC). The fact is that most of the disease bur-den we pay for, and the economic burden that comes with it, is preventable. So I embarked on programs and plans to try and embrace prevention as vigorously as our nation had embraced care.

    We all know that if you show up the in the emer-gency room with a pulse, chances are you are going to live. Somebody will save you, in spite of yourself. And chances are you will repeat the same mistakes that brought you to the ER so you can be resuscitated again. That is part of the reason I went back to school as a middle-aged guy to do some work in public health. I didnt think I would stay there forever, but I knew I needed more information and education. I became a public health officer, a chief medical officer of a county hospital, a chief/CEO of a health system and then eventually becoming Surgeon General, never having planned for any of those positions. In retrospect, I can rationalize the circuitous route because it has made me a much more empathetic and sympathetic Sur-

    geon General. Having gone through all of those steps, working in the shoes of others as a paramedic, as a nurse, as a physicians assistant and finally becoming a physician, I know firsthand how important preven-tion is.

    The second area of the portfolio is preparedness. We are a nation at war. We are a nation that has had unprecedented challenges in the last five years. We are a nation that not only has to train its first responders, health care experts and providers, but a nation that has 300 million people who still dont understand these threats and challenges and what are they sup-posed to do about them. Should they shelter in place? Should they flee? I am reminded of an analogous situ-ation when I was a kid growing up in the 1950s and 1960s and we had Civil Defense. Every citizen under-stood that there was a Cold War and that something bad could happen to us. It looked bad, too, in terms of a nuclear event because the Russians at that time had nuclear capability. Yet every person, from Boy Scouts and Girl Scouts up to senior citizens, understood the threat and the need for Civil Defense. When the sirens went off, everybody knew where they were supposed to go. If you were a kid in the school, you went under a desk and remained quiet until the teacher spoke to you. We all felt a sense of safety and security. Today, weve lost the ability and the security of knowing what to do. The average citizen cannot grasp terrorism, weapons of mass destruction, emerging infections, or the threat of bird flu or small pox.

    We need to move toward a better understanding of the threats and challenges before us. Our providers, public health officers, and our other uniformed ser-vices are moving in that direction. What we cant forget is that there are 300 million people out there who still arent sure what they are supposed to do when things happen or what is expected of them as citizens, as a family, as a community, as a city, as a state, as a region, and then as a nation. Preparedness has an important place in the portfolio.

    The third area is health disparities. I was thrilled when I learned that the president and the secretary embraced this issue. Having been one of those dispari-ties before that term was coined, I have a bias here. Rec-ognizing that we are a nation divided by health, Mar-tin Luther King summed it up many years ago when he stated that the evil twin of racial discrimination is health discrimination. When we look at the metrics, we can see within the so-called minority populations African Americans, Hispanics, Native Americans and Anglo Americans in certain economic classes disen-franchised people who have a disproportionate disease burden and who have poorer outcomes than the rest of us. Even though they have access to health care, they

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    still have poorer outcomes. The variables that contrib-ute to that are quite complex and many treatises, books and papers have been written about it. Still, the fact remains that we have to recognize that health dispari-ties are a national problem because of the related dis-ease burden. The greatest indication of health status in this country, and maybe the world, is economic status. Those who are included among health disparities are a higher risk population not only for disease, but for our nations preparedness as well.

    As we consider prevention, preparedness and health disparities, we cannot ignore an unprecedented child-hood obesity epidemic. Nine million kids are overweight or obese. Two out of three Americans are overweight or obese. There are unparalleled rates of type 2 diabetes and, now, hypertension in children. This is not simply a disease process. Its also a preparedness issue because what will these children look like in twenty or thirty years? In regular meetings with Army, Navy and Air Force Surgeons General, the Coast Guard Comman-dant, and other national leaders, we have voiced grave concerns. Who will be the firefighters, the paramedics, the police officers, the soldiers and sailors of the future if the generation we are raising now will be too laden with disease to take those positions in our society?

    What I also recognize is that for the Surgeon General to be successful in addressing prevention, prepared-ness and health disparities, we need a common cur-rency. That currency is health literacy. We are largely a health illiterate society. The average person does not understand complex health messages. Most of my colleagues who dont practice genetics, for instance, would be hard pressed to explain what is going on in the Human Genome Project today. Yet what is hap-pening is extraordinarily important because there are great benefits to society.

    When I need information or explanations or have a question, I can pick up the phone and speak to a world expert, often at the CDC, the National Institutes of Health or anywhere else. Of course, whats great about my job is that people take or return a call from the Sur-geon General right away. My experience is very, very different from that of the average person. I know that.

    The toughest part of my job is taking the best sci-ence in the world and translating it in a culturally competent manner. Mind you, Im not just referring to language. Im actually talking about health literacy. When I arrived at the Office of the Surgeon Gen-eral four years ago, I asked the staff to tell me about communications how and why they were done. I was particularly interested in the Surgeon General Reports. The staff explained they were peer reviewed, evidence-based, annotated publications for our peers to define the state of science. Other people told me

    the communications were for the people because they need to understand. I concluded that maybe we had failed. The writing is at a graduate school level. Yet, when we ask educational experts around the country what level is needed to communicate with the masses, the universal answer is to write at a sixth or seventh grade level.

    Thats why any communication that comes out of my office now, whether Calls to Action, workshops, or Surgeon Generals Reports, is accompanied by a Peo-ples Piece. For example, were taking a smoking report that is over 900 pages of science written at a graduate school level and condensing it to thirty pages at the sixth to seventh grade level, and were adding lots of pictures so the average mom and dad can show their kids a picture of what a bad lung looks like when they explain why it is bad to smoke. We also have an inter-active Web site.

    I was also confounded at times about literacy as it related to the legal side. I think both professions, legal and medical, have a jargon of their own that often alienates and confuses others. Now Im a reasonably educated guy and when I am reading through Home-land Security presidential directives, or National Security presidential directives and trying to look at lines of authority, I sometimes have trouble figuring out what the lawyers were trying to say. Thats why I tell my staff that if its necessary to write some com-munications at a high level, then we need to have some kind of simpler document for everyone else. My plea is for all of us to simplify our messages, because part of what the country struggles with is a lack of health literacy. I would ask that we all take a step back and see if there is a way that we can make messages easier to understand.

    Regarding natural disaster preparedness, let me go into a few areas of Hurricane Katrina specifically. Katrina resulted in the largest deployment of U.S. Pub-lic Health officers in the history of the country over 2,500. A little over a year ago, I was in the command center as this rolled out. There are many wonderful outcomes related to Katrina, many heroic deeds and people who worked days and nights endlessly, without eating or sleeping. But I also want to point out some of the challenges, barriers and complications that we faced in trying to move through a rapid response to Katrina, at all levels. Let me make clear that every level of government and non-governmental organiza-tions has some culpability, if you will, for not having the most efficient systems. I am not blaming anyone. Ill be the first to raise my hand as a federal official to say we could have done it better in a lot of areas, although we did very well in some areas. The Katrina Report has pointed that out.

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    Richard H. Carmona

    The first challenges we faced involved specific authorities. As we saw the hurricanes coming, the fed-eral government wanted to send people down, position them so we would have situational awareness, have boots on the ground to handle the first emergencies, and set up a command post. We were told we were overstepping our bounds, that the situation was a local and state one. Then the mayor and the governor disagreed over who had authority over certain areas. The importance of authorities was paramount in this particular case because it delayed the deployment of essential resources.

    During some of the early discussions when we saw things unraveling, we discussed ways to deploy if the governor told us not to. The lawyers said we were treading on states rights and determined that basi-cally the only authority the president had would be to superimpose the federal government on the state. In turn, that would have meant owning the state once we showed up. The ramifications were huge. When I look at a lot of those early barriers, it was about under-standing specific authorities as they relate at a local, state and then federal level. When I look at our par-ticular contribution when we finally got down there at a federal level, we have the department of Home-land Security. Many of those folks are my friends and theyre talented, smart and experienced, but for the first time they were really being challenged with 22 federal agencies and 180,000 new employees, all of whom came from other areas, trying to come together and figure out where the authorities lie, who is in lead and so on.

    One of the biggest problems we had was the failure to integrate multiple complex resources in a timely fashion in order to function as a seamless system and serve the American public. That cant be done with-out an understanding of the authorities, incident command, and that although 20 chiefs from different departments may show up with three or four stars on their shoulders, there is still only one person in com-mand. You cannot run resuscitation, or a disaster, by committee. One person has to be in charge and that was not clearly delineated.

    For the first time in the history of our country, the government did not have enough resources physi-cians, nurses, paramedics and others acutely avail-able to be able to respond. In a matter of days, one of our senior officers put together a data base and we credentialed 3,400 health professionals. We deployed over 1,000 volunteers for the first time in our history, which also required going through authorities. We couldnt pay them as civilians, so they had to become temporary federal employees. Liability was an issue, too. How could we make sure they were creden-

    tialed? How about licensure portability? Were they in good standing? In about 72 hours we linked up with national boards of nurses, paramedics and others and used their data bases to put together an ad hoc sys-tem that allowed us to credential people very quickly. Once again we encountered issues that are germane to the legal profession, such as portability and moving licenses across states. Some states called and claimed authority over who could practice in the state. With people sick and dying and being transferred there wasnt time to deal with a state credential process as well as our own. We were very hampered in being able to move things forward.

    We also ran into problems within our national response plan because we have responsibility for ESF8 which is health, public health and medicine. We were in the midst of sending doctors, nurses, therapists, paramedics, and everybody we could to the various areas that were affected. But we dont have our own Air Force, which means we had to be integrated with ESF1, which is transportation. ESF1 and ESF8 had never rehearsed anything. When we called to say we needed a plane because we had critical patients in New Orleans, we learned the Federal Emergency Manage-ment Agency (FEMA) has a contract with a private provider because of their authority. The private pro-vider had never flown patients before. When we told them we not only needed a plane but respiratory ther-apists, doctors, nurses and so on to accompany critical patients, the request had to go to NorthCom, which is the Northern Command for military, in order to get permission to send it back to me. I knew that was not going to work, authority or no authority.

    I picked up the phone and called General Selva from TransCom, which is the U.S. Air Force Transportation Command. I said, General, I need some help. As a military person, he understood requirements. All I needed to say was, I have x number of critical patients at this location. I didnt have to tell him what size plane or tell him how many doctors. I didnt have to tell him how many ventilators or how much medicine. It all came as a package. Its the just in time inven-tory system that was just sent out.

    Then I needed help with the issues of force protec-tion. My guys were down there, not protected, in an area where there was looting and people with guns. I could have asked ESF6, but ESF6 was having trouble because law enforcement officers from other states were told not to bring weapons to the area because they were not legally allowed to be law enforce-ment officers in another state. Once again, I picked up the phone. This time I called General Blum from the National Guard and told him I needed help. The result: I got National Guard down there to save the

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    day because, of course, the authorities are different. I can go through many other examples where authority, health and public health have clashed with one another while trying to serve the American people. I speak for my colleagues in the leadership positions when I tell you that we desperately need your best practices and best thoughts about how to remove these barriers and challenges for us, so that in the future we never have to go through something like this again.

    I want to emphasize that we are using Hurricane Katrina as an example, but in your deliberations, in your breakout sessions, in your discussions with your colleagues, remember the subject is preparedness for all hazards. The infrastructure that we must put together is one that can work in a seamless fashion, can surge when necessary at a local, state and fed-eral level, can provide the essential services to the American public and then return to pre-hazard activ-ity levels. That is the desirable end point. It is a com-mon infrastructure that will serve all hazards. For me its even been a bigger problem or challenge because now we have global issues such as when the tsunamis struck in Indonesia or the recent earthquakes in Paki-stan. I have officers in 800 locations around the world. Not only do we deal with authorities in the continen-tal U.S., we deal with authorities in international law, with cultural barriers and with legal barriers.

    In closing, I emphasize all-hazard preparedness and response, and I emphasize the need for health and legal literacy as it relates to authorities and the inter-section of public health, medicine and the law. What we are trying to achieve with our assets in the United States, is what we, in uniform, call joint interoperabil-ity. It is the ability to act in a purple uniform, as they jokingly say in the service. Act in a uniform that is not blue, not white, not green, but rather function as a sin-gle-uniform service. The argument I and many of my colleagues make is that the average citizen doesnt care if its the Army or the Navy or the Public Health Ser-vice that saves them. They just want to be saved. And if the local and state resources are exceeded and your federal government has to come in, we have to move forward as one, understanding clearly the authorities so we can move forward and not have to second guess each step along the way. I say the same for local and state government. Achieving joint interoperability is not going to be easy, but as we move to that platform, it is important that we prospectively plan, train and use scenario- based training. We cant be satisfied with

    table tops. We need to deploy in the field, mix it up, perfect the communication system, check the just in time inventory system and make sure everybody understands the authorities and what specific lane they have responsibility for. It simply wont work if the first time we deploy together is when we are shaking hands with all the people that show up and are asking where they came from.

    Last, but not least, it is important that every-body understands that everybody cant be in charge, whether there are 25 fire chiefs and police chiefs on site or if there is an Army general and a Navy admiral. In a single, unified command, there is only one com-mander, and that is the purpose of NorthCom, our Northern Command in the United States today. Their job is to integrate those resources and have single command presence. When we go to the field, it doesnt mean that were in charge. I responded to many, many emergencies as have my officers. You subordinate your command to the command that is in place and that is designated by legal authority to be the incident commander. Hence, everyone has to understand the national response plan, national incident manage-ment system and the incident command system.

    With all that said, I tend to be the eternal opti-mist. I see so much good that came out of this, not only learning but an unprecedented response by this nation and other countries in our time of need. We performed admirably and heroically, but we could have performed better. The Katrina Report basically outlines many of the changes that we have to make. All of us recognize that Katrina was the incident that manifested the cracks in our system. It could have been a terrorist event or a bio event. Now we have a window of opportunity during which to step up. We are still the greatest nation in the world. Nobody could respond to something like this as we did. I think it is magnificent that we are willing to air our dirty laundry and put the reports out that say we could have done this better. Now lets get together and do it. And for me, as Surgeon General, it is just another one of many challenges that I have before me to work with my col-leagues to try to make the system better on behalf of the American public. I ask all of you to help us out. Figure out how we can deal with these legal authori-ties and the intersection of public health and medicine and legal authorities so that we truly can surge and become the seamless system that we need whenever challenged.

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