Health security for our nation - Public Health Service

Three weeks after the 11 September attacks on the World Trade Center and the Pentagon, I walked around the horrible devastation at Ground Zero in New York City and visited with the rescue workers and medical support teams who were operating around the clock. The Public Health Service (PHS) had set up four medical treatment sites on the perimeter of the "pile" staffed by PHS Commissioned Corps officers and civil service personnel. The air was filled with dust and acrid smoke. High above Ground Zero, seven flags were placed in a row on a building ledge over a sign stating, "We will never forget." On the far left was the American flag and on the far right, the flag of the USPHS. The other flags were from the Army, Navy, Air Force, Marine Corps, and Coast Guard. Each of these uniformed services was participating in the rescue and recovery effort.

The PHS had a major role, with hundreds of personnel deployed to New York City shortly after the attack. They were responsible for providing medical care and mental-health services to the rescue workers, support to the New York City medical examiner's office, environmental testing, and epidemiologic surveillance. A few weeks later, additional PHS Corps officers were called to New York City and Washington, D.C., to investigate the anthrax attacks, test for exposure and dispense antibiotics.

PHS COMMISSIONED CORPS

The Commissioned Corps of the USPHS, one of the seven uniformed services, comes under the Department of Health and Human Services (HHS). HHS has two broad categories of responsibilities: (1) providing national health security and (2) advancing the health of the nation. The provision of national health security involves the prevention, detection and response to epidemics, bioterrorism, and food and drug threats. Under the Federal [Disaster] Response Plan, HHS is responsible for the provision of health care during disasters. To advance the health of the nation, HHS conducts biomedical research programs, provides public health infrastructure support, regulates food, drug and medical products, provides health care to Native Americans and other under-served populations, monitors the nation's health status and develops health promotion/disease prevention programs as required for special populations or situations. The all-officer Commissioned Corps consists of 5,600 officers who must meet the requirements for one of 11 professional categories: physician, dentist, nurse, pharmacist, engineer, therapist, dietician, veterinarian, scientist, environmental health officer, and health services officer. Officers typically serve in one of many career tracks including clinical services, regulatory affairs, public health practice and consulting, research, and public health program administration. About 20 percent of officers are detailed to other departments, including the Bureau of Prisons in the Department of Justice and Coast Guard in the Department of Transportation.

EMERGENCY OPERATIONS

The PHS Commissioned Corps has historically worked with the military services during both wartime and domestic emergencies. Although not a "military" service, the PHS Corps can be militarized during times of war or national emergency by a presidential executive order. PHS officers assigned to the Coast Guard and Department of Defense (DoD) automatically come under the Uniform Code of Military Justice. More recently the Corps contributed support to military operations during the Vietnam and Persian Gulf conflicts. In the last 10 years PHS officers have had significant leadership roles in the office of the Assistant Secretary of Defense for Health Affairs and in the TRICARE Management Agency.

The Office of Emergency Preparedness (OEP) is an office within HHS that manages and coordinates federal health, medical, and health-related social services and recovery to major emergencies and federally declared disasters, including natural disasters, technological disasters, major transportation accidents, and terrorism. Under the leadership of RADM Robert Knouss, USPHS, OEP has these responsibilities:

* Working in partnership with the Federal Emergency Management Agency (FEMA) and the federal interagency community to serve as the lead federal agency for health and medical services within the Federal Response Plan.

* Directing and managing the National Disaster Medical System, a cooperative asset-sharing partnership among HHS, DoD, the Department of Veterans Affairs (VA), FEMA, state and local governments, private businesses and civilian volunteers.

* Responsibility for federal health and medical response to terrorist acts involving weapons of mass destruction (WMD).

* Assisting the National Transportation Safety Board by identifying victims of commercial airline and other transportation disasters.

* Managing and deploying the Commissioned Corps Readiness Force (CCRF) on behalf of the surgeon general.

PHS Corps officers are deployed to emergencies directly by their agencies or through CCRF. In recent years, CCRF has provided health care to more than 4,000 Kosovar refugees brought to Ft. Dix, N.J., in Operation Provide Refuge and responded to numerous floods, tornadoes, hurricanes, and wildfires.

The diversity and depth of the PHS Corps' ability to respond, I believe, is best demonstrated in three very recent events. They are the PHS responses to Tropical Storm Allison, the 11 September attacks, and the anthrax attacks.

TROPICAL STORM ALLISON

On 9 June 2001, OEP began deploying federal assets to assist the city of Houston and the surrounding area after it received sustained torrential rains from Tropical Storm Allison. Not only were more than 38,000 homes damaged, with more than 11,000 deemed uninhabitable, but several hospitals of the Texas Medical System in downtown Houston were in various stages of crisis. Emergency rooms and critical care operations were closed, and about 1,400 patients were transferred to outlying hospitals. Health-care personnel from the Houston area were unable to report to work, and hospitals that remained open operated under limited power.

The PHS response consisted of the following

* OEP deployed commissioned officers (intensive care nurses, physicians and pharmacists) and civil service personnel who worked with the local hospital system. Three ambulatory clinics were set up around the downtown area. In seven days of operation, they treated approximately 1,400 patients.

* The Food and Drug Administration deployed a team of individuals who did an epidemiological evaluation of food borne illnesses and reviewed the status of restaurants, food warehouses, groceries and manufacturers.

* The Centers for Disease Control and Prevention (CDC) assisted in the evaluation of vector-borne diseases in the flood areas, particularly equine and St. Louis encephalitis. CDC epidemiologists were instrumental in the formulation of a plan to control this vector.

* Regional HHS emergency coordinators were deployed to work on problems dealing with the allocation of medical resources, preventive medicine, mental health issues, environmental concerns, vector control, and relationships with all local, state and federal players.

In July and August, environmental health officers and an environmental engineer deployed to Houston to assist the city and FEMA. These officers inspected municipal buildings, wrote policy, and made recommendations for mold amelioration.

11 SEPTEMBER ATTACKS

Within minutes of the attacks on the World Trade Center and the Pentagon and the plane crash in Pennsylvania, HHS went into emergency operation. A "Push-Pack" from the national pharmaceutical stockpile, accompanied by PHS Corps officers, was flown to New York City in seven hours despite the national shutdown of the air traffic system. A Disaster Medical Assistance Team (DMAT) of approximately 35 Corps officers was immediately activated and on standby the same day to go to the Pentagon; existing assets met the medical needs in Washington, D.C., so the DMAT redeployed to New York City.

Following the 11 September attacks, 2,000 personnel (including approximately 325 PHS officers):

* Participated in medical treatment teams with 85 officers who worked in five clinics located at Ground Zero for several weeks.

* Provided 19 officers for mental-health support to the rescue workers and other responders at Ground Zero.

* Provided 15 dental officers with training in forensics to support the NYC Office of the Medical Examiner.

* Provided 18 officers to the NYC Office of the Medical Examiner to support the examiner's efforts by collecting and collating ante-mortem records and post-mortem records in a computer database.

* Provided 65 officers as liaisons to the FEMA Emergency Support Team, FBI Strategic Intelligence and Operations Center, the Disaster Field Office, and the OEP Emergency Operations Center.

* Provided environmental sampling teams to sample homes and offices in the vicinity of Ground Zero for toxic substances (still in process).

* Provided two medical officers to the NYC Department of Health.

* Provided three officers for the USN Comfort when stationed in NYC.

* Provided 43 officers--physicians, nurses, and pharmacists--to the National Naval Medical Center to backfill Navy personnel deployed on the USN Comfort.

* Staged a medical team of 25 officers at the Capitol during the president's address to Congress, 20 September.

* Sent more than 50 medical epidemiologists to NYC to monitor for disease outbreaks.

ANTHRAX ATTACKS

The anthrax letters sent to Florida, New York City, and Washington, D.C., were the first significant bioterrorism events to occur in this country. The CDC immediately dispatched Epidemic Intelligence Officers (EIS) and civil service personnel to Florida and later to New York City and Washington. Within hours of the discovery of the letter received at Senator Daschle's office, the PHS Corps was asked to assist in evaluating Senate personnel and to provide antibiotics. During the following weeks, PHS officers were involved in a number of activities:

* At the request of Secretary of HHS Tommy Thompson, I assigned Deputy Surgeon General RADM Kenneth Moritsugu to Capitol Hill to work full-time with the congressional leadership on anthrax issues and help coordinate the response.

* Three hundred and ten PHS Corps officers (mostly physicians, pharmacists and nurses) performed 7,000 nasal swabs. They documented 37,000 patient visits mostly to provide antibiotics. Teams of officers were deployed to the U.S. Capitol, D.C General Hospital, State Department, HHS headquarters buildings, and to New York City to dispense antibiotics to more than 11,000 postal workers.

* Thirty-six officers were deployed to the HHS command center and the Office of Homeland Defense.

* The CDC sent EIS officers (most of them PHS Corps officers), in addition to other officers from the Environmental Protection Agency and National Institute of Occupational Safety and Health, to investigate all the positive cases of anthrax.

In addition, I testified before Congress on "Risk Communication and Bioterrorism" and participated in numerous media interviews to answer questions about the evolving situation.

THE RESERVE CORPS

Like the other six uniformed services, he PHS Commissioned Corps has both regular and Reserve officers. The Reserve component was authorized in 1918, based on experiences in World War I that indicated the PHS needed to augment its regular force in times of war and other national emergencies. The Reserve Corps officers are either on active duty or in the Inactive Reserve.

Officers in the PHS Inactive Reserve, called the Inactive Reserve Corps (IRC), do not receive compensation or benefits other than accrual of longevity credit for base-pay purposes, should they later be recalled to active duty. Recall to active duty, either for short tours to meet special needs or for extended active duty, is voluntary on the part of the officer except when, in time of war or emergency involving the national security, the president, by executive order, militarizes the Corps. Currently there are 2,500 IRC officers, nearly half of whom are physicians.

In the event of a national emergency, the IRC is essential to the HHS for sustained deployments. Only one Reservist, however, has been activated since 11 September for emergency operations. With major program reductions in the mid-1990s, there has been a substantial reduction in the use of the JRC. With a renewed focus on national health security, however, there is strong interest from Congress and others in developing a robust PHS IRC. We plan to utilize the JRC more effectively to:

* Respond in times of public health emergencies, including natural or man-made disasters, to provide direct on-site support or indirect support by backfilling active-duty positions temporarily vacated.

* Meet staffing shortages in support of the ongoing missions of the USPHS, including health services to high-risk and under-served populations, vital research to improve the nation's health, and safe food and drug supply maintenance for the nation.

* Activate Reserve PHS officers to augment armed forces and other federal medical facilities when requested.

Efforts are now underway to restructure the IRC as a two-tier organization, parallel to the DoD and Coast Guard Reserve components consisting of:

* The Ready Reserve Corps (RRC), which will maintain its skill and availability for active-duty recall by completing monthly drills and an annual two-week summer camp necessary for obtaining retirement credit. RRC commissions will be appointed to enhance the needed skill capability and readiness of the Ready Reserve. Short tour assignments to meet identified PUS needs will be regularly posted on the Ready Reserve Web site and matched with Reserve officer specialty and availability.

* The IRC, similar to DoD Inactive Reserve, will continue to be a resource that can voluntarily be called to active duty, but will have no drill obligations. This group of officers can be called to active duty involuntarily by executive order.

In response to a congressional request, the surgeon general of the Army recently reviewed current authorities and legislation that would be necessary to augment Army medical facilities with Reserve PHS officers. The review found that current authorities allow for that use of PHS Inactive Reservists. The subsequent report to Congress included recommendations to enhance the secretary of HHS's authority to recruit, retain and deploy PHS Reservists by providing officers with the ability to earn non-regular retirement credit, authorize drills and provide a legal obligation for employers to release without penalty officers called to active duty. Currently PHS Reservists do not have parity with DoD Reservists, severely restricting any incentive to participate and limiting the secretary's ability to deploy them in times of public health need.

Historically, Congress has asked for the establishment of a Reserve Affairs Office in HHS and updates on the progress of revitalizing the Reserve component. A 1998 report to Congress was fairly extensive in its recommendations to develop the PHS Reserve. As envisioned, the Office of Reserve Affairs will oversee and manage the Inactive Reserve Corps (IRC); maintain a database on officer availability and specialty; organize Ready Reserve training, monthly drills and summer camp; identify and match-up short tours and officer specialties; recruit and commission officers directly into the Ready Reserve who have the unique skills needed for special deployments; maintain the readiness of a Reserve force through ongoing training; and deploy officers as needed during official activation of the Ready Reserve.

Congress has requested another report from HHS, due in March 2002. House Bill Report 107-229, dated 9 October 2001, states: "The Commissioned Corps of the U.S. Public Health Service and its Reserve Component provide unique competencies to respond to a bioterrorist attack.... [T]he lack of a formalized inactive Reserve program may further impact the Corps' ability to respond in times of national emergency. The Committee requests that the Secretary report on the Department's actions and plans for strengthening and revitalizing the Commissioned Corps and its Reserve Component no later than March 1, 2002. The report should comment on any structural and/or legislative changes necessary to ensure that the Corps can readily be mobilized for response in times of emergency."

I am convinced that a strong RRC/IRC is vital for our national health security. With the reduction in federally staffed clinical-care programs, the breadth and depth of active-duty clinicians available for deployment is shrinking. It only makes sense that we emphasize a strong deployable RRC/TRC to balance this loss.

NATIONAL HEALTH SECURITY IN THE FUTURE

Throughout my tenure as surgeon general, I advocated for the health and well-being of all Americans. One important area that I have continuously emphasized is the necessity for a strong public health infrastructure throughout the country. Not only is it needed to improve the health of all Americans--a strong public health infrastructure is the greatest defense against bioterrorism. As the surgeon general, I am well aware that public health efforts are often a hard sell among competing priorities at all levels of government. Typically, it is not until there is an urgent reason to act, like the response to the anthrax attacks, that the public begins to appreciate the value of public health.

As with the rest of the public health infrastructure, the PHS Commissioned Corps is not always outwardly visible, nor is its role as the premier federal resource when the country is faced with a disaster or serious public health issue always understood. I believe, however, that the value of the Corps is, and will continue to be, more fully realized and appreciated in the aftermath of the 11 September attacks. We anticipate that the Corps will be involved in significant public health challenges, both man-made and natural--many that we cannot even imagine today. We hope that both the Public Health infrastructure and the Corps will be supported and ready.

The work of the PUS Corps is far from over and its vigilance must continue. The nation is depending on the PHS Corps to defend and protect its health. The Public Health Service Commissioned Corps has the leadership, skills, experience and compassion to tackle these challenges.

RELATED ARTICLE: VADM David Satcher, USPHS, is the surgeon general of the United States; until 20 January 2001, he also served as the assistant secretary for Health, Department of Health and Human Services. He was appointed to these positions 13 February 1998. Admiral Satcher received a baccalaureate degree from Morehouse College in Atlanta, Ga., in 1963, and his M.D. and Ph.D. from Case Western Reserve University in Cleveland, Ohio, in 1970. From 1982-1993, Admiral Satcher served as president of Meharry Medical College, Nashville, Tenn. In 1993, he was appointed director of the Centers for Disease Control and Prevention, a component of the Public Health Service, in Atlanta. In that capacity, Satcher directed national health promotion and disease prevention programs. He is also a member of ROA. Admiral Satcher's spouse is Nola Satcher and they have four children.

SURVEY OF SURGEON GENERAL'S REPORTS

In addition to overseeing the Commissioned Corps, one of the major responsibilities of the surgeon general is to focus Americans' attention on important public health issues. The primary and most enduring way to carry out that responsibility is through the Surgeon General's Reports.

The first, released in 1964 by Dr. Luther Terry, was a landmark report, Smoking and Health: Report of the Advisory Committee to the Surgeon General of the United States that brought new attention to the hazards of smoking. Its release led to the passage of the Cigarette Labeling and Advertising Act of 1965. Since then, nationwide efforts to prevent tobacco use have emerged. As a result, we have reduced the prevalence of smoking in the United States to 24 percent. Nevertheless, smoking is still the leading cause of preventable illness and death in this country.

REPORTS SINCE 1998

Since 1998, when my tenure as surgeon general and assistant secretary for health began, we have released three smoking-related Surgeon General's Reports. The first, Tobacco Use Among Racial/Ethnic Minority Groups, stressed the need to curb rising smoking rates among minority teenagers. Another smoking-related report, Reducing Tobacco Use, highlighted the fact that nearly 25 percent of adults continue to smoke and tobacco use among our youth has increased since the early 1990s. Yet through comprehensive antismoking efforts--involving social, economic, educational, and regulatory modalities--smoking rates among teens and adults could be cut in half within a decade.

We noted in the Surgeon General's Report on Women and Smoking that the smoking rate among women has nearly doubled since 1965. Today, women account for 39 percent of all smoking-related deaths each year in the United States. In fact, lung cancer has become the leading cause of cancer death among U.S. women, surpassing breast cancer.

MENTAL HEALTH, SUICIDE, ORAL HEALTH

We have recognized the need to focus on areas that have not been examined in past Surgeon General's Reports: mental health, suicide and oral health. To address these areas, we have released several landmark reports, bringing increased awareness and action to these pressing health challenges. From those reports, new public health initiatives have been generated, many of them aimed at reducing the stigma that prevents progress in these areas.

We used the 1999 Surgeon General's Report on Mental Health as an opportunity to dispel the myths and stigma surrounding mental illness. Drawing on the last quarter-century's revolutionary advances in understanding the brain and mental disorders, the report underscored the fact that mental health is fundamental to overall health and well-being and that mental disorders are real, common, and treatable. In fact, we conservatively estimated that one in five people experience a diagnosable mental disorder each year. We also noted that 80-90 percent of the time, we can treat people with mental illnesses and return them to productive lives.

Children also feel the impact of the stigma of mental illness. We noted in the Surgeon General's mental health supplement, Children's Mental Health, that each year one in 10 children experiences a mental disorder severe enough to cause some level of impairment, yet, fewer than one in five receives treatment.

Broader mental health findings focus on the availability of effective treatments for mental illness and allude to the unique problems confronting minorities with mental illnesses. In August 2001, a supplement, Mental Health: Culture, Race and Ethnicity, reported on major disparities in access, availability and quality of mental-health services for racial and ethnic minorities. Consequently, minority populations experience greater disability and limitations from mental illnesses than their white counterparts--not because their illnesses are more severe or more prevalent than whites, but because of the barriers they face in accessing care and services.

One of the most, if not the most, tragic consequences of untreated mental illness is suicide. We estimate that 80-90 percent of the people who die by suicide are suffering from a diagnosable mental illness. To address that problem, we released National Suicide prevention Strategy in May 2001, which followed the Call to Action to Prevent Suicide released two years earlier. The strategy outlines measures the nation can take to bring about the social change needed to advance attitudes, policies, and services aimed at preventing suicide.

Another landmark report is The Surgeon General's Report on Oral Health, which was released in May 2000. That report found a significant disparity between racial and socio-economic groups in oral health and ensuing overall health issues. Based upon these findngs, we called for action to promote access to oral health care for all Americans, especially the disadvantaged and minority children found to be at greatest risk for severe medical complications resulting from minimal oral care and treatment.

Throughout history, Surgeon General's Reports have helped frame the science on vital health issues to help educate, motivate and mobilize the public. In each of the reports released since 1998, we have emphasized the need to improve access to health care and the need for quality healthcare services for all people. The reports have emphasized these facts: children seem to suffer a disproportionate burden when it comes to lack of access; there is a need to eliminate disparities in health; stigma can have a devastating impact on many lives; and this stigma that surrounds many sensitive public health issues needs to be erased. With each report, we have tried to show the critical need for more research, especially in the area of health promotion and disease prevention.

These reports are only the first step. They will not be complete until they have been embraced and acted upon by the American people. We need to establish programs at the community level and work to bring about the kind of social, economic legislative and regulatory change, needed to better protect and advance Americans' health.

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