Remarks as prepared; not a transcript

Vice Admiral Richard H. Carmona, M.D., M.P.H, FACS
Acting Assistant Secretary for Health
United States Surgeon General
U.S. Department of Health and Human Services

Navy Surgeon General’s Exercise in Operational Leadership
On board the USNS

Saturday, July 26, 2003

"The Role of Military Medicine in Civilian Emergency Response"

Thank you.

It’s great to be on board the Mercy, literally a floating hospital. The Mercy and its sister ship, the Comfort, already have a proud history of providing on-site care for U.S. forces engaged in combat, and of participating in humanitarian missions.

Many of you here have been involved in the recent war in Iraq. Thank you for your patriotism and your service to our nation.

We are here to look at some of the lessons of Iraq, and to prepare for future conflicts, from the perspective of providing care to our uniformed brothers and sisters, and to civilians as well, as the nature of warfare is changing.

As we do so, let’s remember: we are all standing on the shoulders of giants.

Both in military and in civilian health care, we’re building on the foundations provided to us by our forefathers in American history.

As the great American philosopher Thomas Merton said:

"My successes are not my own. The way to them was prepared by others. Therefore the meaning of my life is not to be looked for merely in the sum total of my own achievements. It is seen only in the complete integration of my achievements and failures with the achievements and failures of my own generation, and society, and time."1

As Surgeon General, one of my objectives is to assure that the Public Health Service Commissioned Corps and the civilian medical world are prepared to respond to the possible use of weapons of mass destruction. In so doing, I recognize that I too am standing on the shoulders of the brave men and women who came before me.

President Bush and Secretary Thompson have charged me with three priorities as Surgeon General, one of which is medical preparedness.

Those who preceded me were faced with very similar circumstances where infectious disease challenged available resources. That challenge has changed insofar as these infectious agents can now be weaponized and used in an attack.

How do you prepare a country whose people have always felt safe within their borders and never thought they’d be attacked?

People for whom attacks such as suicide bombings were something that happened somewhere else – never at home?

Just as we now understand that planes can be used as weapons, we must teach our citizens that germs can be used as weapons.

How do you build resilience in our people so that we can sustain our way of life in the face of these threats being thrust upon us? These are absolutely monumental challenges.

Our President is ready to meet them. He has asked that we work to develop a sustained strategy of homeland security. For Secretary Thompson, myself, and all of the public health professionals at the Department of Health and Human Services, that has meant focusing on an all-hazards approach to include bio-terrorism and emergency response.

Since 9/11, HHS, under the leadership of Secretary Thompson, has spent or requested $9.2 billion to prepare America for terrorist attack.

Here is how some of that money is being invested:

  1. Project BioShield: A 10-year, $6 billion comprehensive effort to develop effective drugs and vaccines to protect against biological and chemical attack. Last week, the House passed BioShield legislation.
  2. Enhancing the National Pharmaceutical Stockpile.
  3. State Grants: $2.5 billion in state grants. The largest investment in our public health infrastructure — ever.
  4. Smallpox and anthrax vaccines: We have accelerated development of new, safer smallpox and anthrax vaccines and acquired enough smallpox vaccine for every American, in the event of an emergency.
  5. We are also using the funds for research on biodefense at the NIH, building new health labs at CDC, and protecting the food supply through the FDA.

Secretary Thompson has also developed a state-of-the-art command center down the hall from his office to track public health emergencies anywhere in the world, and provide up-to-the-minute information to local responders and the media.

We have made huge progress linking state and local systems to national systems – putting together teams to be able to respond to these types of problems.

But, as the President has said, and as Secretary Thompson has said, the strength of this country is in our communities. It is not in the federal government going into a community and telling them what to do. It is in the community. And we recognize that all disasters are local events. So we have to work with the communities and link the local systems to the state and national systems.

The federal government can provide guidance, education and funding to local communities. But our role is mostly a supportive role: it is the communities linked together that will survive any and all of these events.

And we know there will be more. So we are doing our best to build that capacity, and that resilience into our people so that we can meet the threats that are thrust upon us. We must not forget that the psychological aspects of terrorism that often endure long after physical wounds are healed.

Military medicine has had a huge impact on our ability to take care of our military men and women at war, but it has also had a tremendous impact on how we practice surgery, trauma and emergency care for civilians today. In fact it is the basis for our civilian EMS.

Military medicine has led civilian medicine in many ways; particularly since World War II, when the generation before us first developed ways to provide combat casualty care as close to the battlefield as possible.

The early pioneers of civilian trauma surgery, such as Dr. Tom Shires, and Norm McSwain, developed their expertise first in the military. Military surgeons in all branches since the Civil War have led the way in improving the health of the nation through their wartime experiences. From sanitation to infectious disease and combat casualty care, this country owes the military a huge debt of gratitude.

In Vietnam, we saw, for the first time, the use of rotary air assets in both tactical and strategic support of ground operations. For the first time, we had the ability to provide definitive care to a wounded soldier, due to the availability of ‘medevacs,’ in the ‘golden hour.’

As a Special Forces medic during Vietnam, I saw the coming of age and impact this had on military and civilian operations. I was honored to be a part of this truly revolutionary change in the way battlefield medicine was provided.

The momentum continues in the war with Iraq.

The military is pioneering many advances in telemedicine, moving the clinician farther forward and the patient farther back.

Telemedicine provides for moving ‘intelligence’ forward, meaning providing advice and suggestions to the ‘man on the ground’ from the very best clinicians we have available, while at the same time moving the patient ‘back’ to the clinician by allowing for the movement of information (imagery, information, vital signs) away from the battlefield and back to the experts.

Today we can take full color, high-resolution motion pictures and send them over the cell network. We can sample the atmosphere, perform field wet chemistry tests and transmit the vital signs of hundreds of patients simultaneously from anywhere in the world.

This ability has revolutionized medicine on the battlefield. But it also impacts civilian medicine as well, because there is a need for the technology right here at home. It may be as difficult to treat a patient in rural Tennessee as in the desert of Iraq.

As we work on preparedness issues, those in the civilian sector will continue to rely on our military counterparts for support, for expertise, and for coordination and resources.

The Department of Defense is one of four sponsors of the National Disaster Medical System, the main federally-sponsored civilian medicine response to disasters. The military supports the DMATs and its hospitals are available to receive civilians injured during an emergency – even those airlifted from far away.

All regions of the country are working on disaster preparedness plans that include ‘surge capacity’ in local hospitals for large numbers of casualties. In the Washington, D.C. region, for example, three military hospitals are playing a role in the emergency preparedness plan for that area, along with 17 civilian facilities.

VADM Cowan, the other Surgeons General and I are working on a plan to align our considerable healthcare resources in new and innovative ways to meet the new challenges of terrorism and weapons of mass destruction.

The Mercy and the Comfort could also provide surge capacity for civilians when the ships are not deployed. In fact, the Comfort was used to support operations during the World Trade Center. It was docked near the WTC site and provided medical care and quarters to the disaster relief workers.

While technology and material are vital to our missions, it is people, more than anything else, who keep our nation safe today, and who will protect it tomorrow. No amount of equipment will ever replace the people that are there to use it.

We are increasing our emphasis on preparing people, not just sharing information and equipment. Offering training and establishing guidelines is key to our response, and that is where we are shifting our emphasis.

Military physicians and other health professionals have the kind of specialized training which would be needed to treat casualties more commonly found in combat: such as those inflicted by chemical, biological and conventional weapons, which now threaten civilian populations as well.

What is needed most now is communication and coordination between the uniformed services and civilian medical establishments. We each have assets and resources that could be called upon in the event of a disaster like 9/11. But there are different roles and procedures that need to be discussed and worked out.

For instance, in an emergency, will our different communication systems talk to each other? Is our detection and management equipment compatible? Who will perform triage in a mixed civilian/military casualty population? What authority will each side have, and what criteria will be used? Who will pay?

We need to work these issues out, and that’s why operational exercises such as this are so important.

September 11th and the anthrax emergency brought a new type of warfare tactic to American shores, by targeting civilians. Perhaps most important, gone are the days when the military and civilian sectors can each perform their missions separately. Together we are a formidable team.

The very nature of terrorism means that our own civilians are, in effect, combat casualties.

Americans will not draw a distinction between the colors of our uniforms in the event of another disaster. They will, however, draw distinctions and make judgments about how rapidly we respond, how coordinated our efforts are, and how effectively and compassionately we treat them.

To do so we must share our resources and assets and develop plans that draw on our individual areas of expertise. This will require of all of us to ‘think outside the box.’

We must train jointly. We must train as we deploy and respond.

Particularly on the civilian side, we need to come up to speed and train our physicians to deal with the effects of chemical and biological weapons, as well as more conventional weapons.

Our leadership must continue to work together.

The Surgeons General of all the branches, including the Public Health Service Commissioned Corps, are already working together very closely on a number of issues which affect all of us as we serve the American people.

Secretary Thompson recently announced a plan designed in part to bring the status of the Commissioned Corps to 100% deployability by 2005. This will enhance our ability to respond more quickly to medical needs and threats.

We must keep working hard, and working together.

No matter the color of our uniforms – green, khaki, or navy, let’s remember that we all serve the same colors – red, white and blue.

As you move toward Sea Power 21 – although we need the collective and cumulative knowledge and we will rely on the rich Navy history and traditions – what is needed most is your leadership, your example in the face of adversity, and your ability to adapt and overcome in the face of all threats. The war is at home now, and your country depends on you.

Let’s roll.

Thank you.


Thomas Merton, "No Man is an Island"

Last revised: January 9, 2007