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

  • special supplement public health and the law 13

    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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