[Senate Hearing 107-572]
[From the U.S. Government Publishing Office]



                                                        S. Hrg. 107-572



                               NOMINATION

=======================================================================

                                HEARING

                               BEFORE THE

                    COMMITTEE ON HEALTH, EDUCATION,
                          LABOR, AND PENSIONS
                          UNITED STATES SENATE

                      ONE HUNDRED SEVENTH CONGRESS

                             SECOND SESSION

                                   ON

 RICHARD H. CARMONA, OF ARIZONA, TO BE MEDICAL DIRECTOR IN THE REGULAR 
 CORPS OF THE PUBLIC HEALTH SERVICE, AND TO BE SURGEON GENERAL OF THE 
                         PUBLIC HEALTH SERVICE

                               __________

                              JULY 9, 2002

                               __________

 Printed for the use of the Committee on Health, Education, Labor, and 
                                Pensions


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          COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS

               EDWARD M. KENNEDY, Massachusetts, Chairman
CHRISTOPHER J. DODD, Connecticut     JUDD GREGG, New Hampshire
TOM HARKIN, Iowa                     BILL FRIST, Tennessee
BARBARA A. MIKULSKI, Maryland        MICHAEL B. ENZI, Wyoming
JAMES M. JEFFORDS (I), Vermont       TIM HUTCHINSON, Arkansas
JEFF BINGAMAN, New Mexico            JOHN W. WARNER, Virginia
PAUL D. WELLSTONE, Minnesota         CHRISTOPHER S. BOND, Missouri
PATTY MURRAY, Washington             PAT ROBERTS, Kansas
JACK REED, Rhode Island              SUSAN M. COLLINS, Maine
JOHN EDWARDS, North Carolina         JEFF SESSIONS, Alabama
HILLARY RODHAM CLINTON, New York     MIKE DeWINE, Ohio
           J. Michael Myers, Staff Director and Chief Counsel
             Townsend Lange McNitt, Minority Staff Director


                            C O N T E N T S

                              ----------                              

                               STATEMENTS

                         Tuesday, July 9, 2002

                                                                   Page
Kennedy, Hon. Edward M., a U.S. Senator from the State of 
  Massachusetts..................................................     1
McCain, Hon. John, a U.S. Senator from the State of Arizona......     1
Kyl, Hon. Jon, a U.S. Senator from the State of Arizona..........     2
Gregg, Hon. Judd, a U.S. Senator from the State of New Hampshire.     5
Frist, Hon. Bill, a U.S. Senator from the State of Tennessee.....     5
Sessions, Hon. Jeff, a U.S. Senator from the State of Alabama....     6
Carmona, Richard, M.D., MPH, FACS, to be U.S. Surgeon General....     6
Dodd, Hon. Christopher J., a U.S. Senator from the State of 
  Connecticut....................................................    15
Hutchinson, Hon. Tim, a U.S. Senator from the State of Arkansas..    18
Murray, Hon. Patty, a U.S. Senator from the State of Washington..    20
Reed, Hon. Jack, a U.S. Senator from the State of Rhode Island...    25

 
                               NOMINATION

                              ----------                              


                         TUESDAY, JULY 9, 2002

                                       U.S. Senate,
       Committee on Health, Education, Labor, and Pensions,
                                                   Washington, D.C.
    The committee met, pursuant to notice, at 10:05 a.m., in 
room SD-430, Dirksen Senate Office Building, Senator Kennedy 
(chairman of the committee) presiding.
    Present: Senators Kennedy, Dodd, Murray, Reed, Gregg, 
Frist, Hutchinson, Sessions, and Warner.

             Opening Statement of Senator Edward M. Kennedy

    The Chairman. We will come to order. Today the committee 
will consider the nomination of Richard Carmona to be the 
Surgeon General of the United States. I have an opening 
statement, but we are joined by two of our colleagues, and a 
former colleague as well, Senator DeConcini. We want to welcome 
them, as well as our nominee, congratulate our nominee for this 
very, very important and significant deposition, and at an 
appropriate time, Doctor, I will ask you if you will be good 
enough to introduce the members of your family, but at this 
time you are accompanied by two very distinguished members and 
good friends to Senator Frist and myself, and good friends to 
this committee, and we are delighted to have them here to say a 
word in your behalf.
    I recognize Senator McCain for whatever comments that he 
might make.

                  Opening Statement of Senator McCain

    Senator McCain. Thank you very much, Mr. Chairman. Thank 
you for holding this hearing. I want to thank you and Senator 
Frist for taking the time to consider this very fine American 
to serve as Surgeon General of the United States.
    Dr. Carmona's inspiring story is the living embodiment of 
the American dream. A high school dropout, Richard Carmona 
first served our Nation with the Special Forces in Vietnam, 
where he became a decorated Green Beret. Upon his return he 
obtained his high school equivalency and became the first 
member of his family to graduate from college. He went on to 
become a nurse, and later enrolled in medical school, 
specializing in trauma surgery.
    When he graduated Dr. Carmona relocated in Tucson, Arizona 
and established southern Arizona's first trauma center. Later 
he continued his education, obtaining a master's degree in 
public health from the University of Arizona where he now 
serves as a member of the faculty. As a professor Dr. Carmona 
trains future doctors in clinical surgery, public health and 
community medicine.
    Always in pursuit of more challenges, in 1986 Dr. Carmona 
joined the Pima County Sheriff's Department as a surgeon and a 
SWAT team leader. Today Dr. Carmona is a celebrated deputy 
sheriff. In fact, he has received the honor to ``Top Cop'' from 
the National Association of Police Organizations, and is one of 
the most decorated policemen in Arizona.
    In addition to his service to the community Dr. Carmona is 
a motivating community leader. He has stressed the importance 
of community preparedness and warned of the dangers of a 
biological assault long before September 11th. After the 
terrorist attacks Dr. Carmona recognized the psychological 
impact of the events on Tucson residents, and coordinated a 
team of mental health experts to assist him in dealing with the 
associated trauma. Due to his bioterrorism experience, he was 
also put in charge of implementing southern Arizona's bioterror 
and emergency preparedness plans.
    Mr. Chairman, Arizona will surely miss this outstanding 
man, and I know he will miss Arizona. Our Nation will gain an 
invaluable leader. With his military and law enforcement 
background, coupled with his demonstrated commitment to public 
health and community preparedness, Dr. Carmona is 
extraordinarily, perhaps uniquely qualified to address the 
needs of our Nation as Surgeon General.
    I thank you, Mr. Chairman, for allowing me to appear, and I 
look forward to the opportunity of seeing Dr. Carmona in this 
very important position.
    The Chairman. Thank you very much, Senator McCain, for your 
good words, strong words of recommendation, and we are glad 
that you are here. We know that you have other 
responsibilities, so we are glad to have you stay, but if you 
have to excuse yourself, whenever you want.
    Senator Kyl, welcome.

                    Opening Statement of Senator Kyl

    Senator Kyl. Thank you, Mr. Chairman. I would like to put 
an introductory statement in the record and simply expand on 
the last point that Senator McCain made.
    Dr. Carmona's background is so broad and varied that one 
might call him a man for all seasons. But I think the last 
point Senator McCain made is important for us now. He is a man 
for this season. His unique background will qualify him to deal 
with the unique responsibilities that he will have in helping 
us in the war on terror. I think while we have had excellent 
Surgeons General in the past, with backgrounds in other areas 
of the medical field and health profession, at this particular 
time his unique background will serve him well and serve us 
well as we work our way through this war on terrorists with the 
bioterrorism issues that you and Senator Frist have been so 
active on, and many of the other things. So he, I think, is 
exactly the right nominee at this time, and in addition to all 
of the other ways that he will help and the other experience 
that he brings to the office, his experiences that will shed 
unique light on and inform his leadership with respect to the 
war on terror I think make him uniquely qualified at this 
particular point in time.
    I join my colleague in strongly recommending him to the 
committee and in volunteering in any way to assist this 
committee to move his nomination forward.
    [The prepared statement of Senator Kyl follows:]

                 Prepared Statement of Senator Jon Kyl

    Mr. Chairman, I am pleased to introduce Dr. Richard Carmona, the 
nominee to be Surgeon General of the United States.
    Dr. Carmona is exceptionally qualified for this important position 
at this crucial time. The President has announced that the new Surgeon 
General will address a number of important health issues, among them, 
helping America prepare to respond to major public health emergencies, 
such as bioterrorism.
    Dr. Carmona's education and extensive career in public service have 
prepared him to lead ably on all health issues facing Americans today. 
He received his medical education from the University of California at 
San Francisco and a Masters of Public Health at the University of 
Arizona. He is currently a Clinical Professor of Surgery, Public 
Health, and Family and Community Medicine at the University of Arizona, 
as well as Chairman of the State of Arizona Southern Regional Emergency 
Medical System. Dr. Carmona has published numerous scholarly articles 
on such varied subjects as emergency care, trauma care and responses to 
terrorism.
    He is also currently a Deputy Sheriff in the Pima County Sheriff's 
Department SWAT team and the National Association of Police 
Organizations named him the nation's Top Cop in 2000.
    Dr. Carmona has also been an administrator of a community hospital. 
Additionally, he was a Special Forces Medic and served in Vietnam, 
where he received the Bronze Star, two Purple Hearts, and a Combat 
Medical Badge.
    As you can tell, Mr. Chairman, Dr. Carmona not only has the medical 
experience to be Surgeon General, but also other experience that will 
be necessary for the Surgeon General position at this time.
    I have no doubt that Dr. Carmona will be an excellent Surgeon 
General and help our Nation deal not only with bioterrorism, but other 
pressing issues such as alcohol and drug abuse, and overcrowding in 
hospital emergency rooms. I trust he will receive a quick confirmation.
    I Thank you, Mr. Chairman.

    The Chairman. Thank you very much, Senator Kyl. These are 
strong recommendations, and we are delighted to have both of 
you make these presentations here today.
    I will make a brief opening statement, and ask our 
colleagues if they want to say a word, and then we will go 
right ahead with our statement from Dr. Carmona.
    The Surgeon General is the Nation's doctor. He is our 
country's principal official on health care and health policy 
issues. The Surgeon General leads the Public Health Service and 
the Service's Commissioned Corps, one of the seven Uniformed 
Services of the United States.
    This is one of the most important jobs in our national 
government. The Surgeon General promotes and protects the 
health of all Americans, whether it is providing care through 
the Public Health Service, addressing the threat of 
bioterrorism, urging our citizens to adopt healthy lifestyles 
and to stop smoking, or helping young mothers nourish healthy 
children. This position demands a person of extensive expertise 
and experience, who has demonstrated a strong commitment to 
improving the public health.
    Over the years our Surgeons General have enabled millions 
of our fellow citizens to live longer, fuller lives. We 
remember Dr. David Satcher's work on mental health and against 
the tobacco industry; Dr. Everett Koop's historic leadership on 
AIDS; Julius Richmond's pioneering work on Head Start; and of 
course, Dr. Luther Terry's landmark report on smoking.
    These are big shoes to fill, but today our country needs 
another such champion of public health. We need a strong and 
independent Surgeon General who will put public health first 
and leave politics and ideology well behind.
    Dr. Carmona comes to us with an impressive background. He 
has taken on many important responsibilities. He is a trauma 
surgeon, a decorated police officer, a former health 
administrator and a former Green Beret. He is the father of 3 
children. In addition to his heroic service in the Army and as 
a law enforcement officer, Dr. Carmona made his professional 
mark in the fields of trauma care and bioterrorism 
preparedness.
    It is my particular hope that he will bring the same 
commitment and the same success he has achieved in these fields 
for the people of Arizona to promoting the health of our 
Nation, from preventing tobacco use by our children and youth, 
to expanding access to health care, to addressing disparities 
in health among our Nation's communities, to improving 
childhood immunization rates, to fighting the AIDS epidemic.
    Dr. Carmona is supported by the National Safe Kids 
Campaign, the National Alliance for the Mentally Ill, the 
National Hispanic Medical Association, and by Dr. Phil Lee, the 
distinguished former Assistant Secretary of Health.
    So you are very welcome here, Dr. Carmona.
    I will ask my colleagues if they want to say a word, and 
then we will proceed with your presentation.
    [The prepared statement of Senator Kennedy follows:]

                 Prepared Statement of Senator Kennedy

    Today, the Committee will consider the nomination of Dr. 
Richard Carmona to be Surgeon General of the United States.
    The Surgeon General is the nation's doctor. He is our 
country's principal official on health care and health policy 
issues. The Surgeon General leads the Public Health Service and 
the Service's Commissioned Corps, one of the seven Uniformed 
Services of the United States.
    This is one of the most important jobs in our national 
government. The Surgeon General promotes and protects the 
health of all Americans, whether it's providing care through 
the Public Health Service, addressing the threat of 
bioterrorism, urging our citizens to adopt healthy lifestyles 
and to stop smoking, or helping young mothers nourish healthy 
children. This position demands a person of extensive expertise 
and experience, who has demonstrated a strong commitment to 
improving the public health.
    Over the years, our Surgeons General have enabled millions 
of our fellow citizens to live longer, fuller lives. We 
remember Dr. David Satcher's work on mental health and against 
the tobacco industry, and Dr. C. Everett Koop's historic 
leadership on AIDS. There's Dr. Julius Richmond's pioneering 
work on Head Start and, of course, Dr. Luther Terry's landmark 
report on smoking.
    These are big shoes to fill. But today, our country needs 
another such champion of public health. We need a strong and 
independent Surgeon General who will put public health first, 
and leave politics and ideology well behind.
    Dr. Carmona comes to us with an impressive background. He 
has taken on many important responsibilities. He is a trauma 
surgeon, a decorated police officer, a former health care 
administrator, and a former Green Beret. He is a father of 
three children. In addition to his heroic service in the Army 
and as a law enforcement officer, Dr. Carmona made his 
professional mark in the fields of trauma care and bioterrorism 
preparedness.
    It is my particular hope that he will bring the same 
commitment and the same success he has achieved in these fields 
for the people of Arizona to promoting the health of our 
Nation--from preventing tobacco use by our children and youth, 
to expanding access to health care, to addressing disparities 
in health care among our nation's communities, to improving 
childhood immunization rates and to fighting the AIDS epidemic.
    Dr. Carmona is supported by the National Safe Kids 
Campaign, the National Alliance for the Mentally Ill, the 
National Hispanic Medical Association, and by Dr. Phil Lee, the 
distinguished former Assistant Secretary of Health.
    So I welcome Dr. Carmona, and look forward to working with 
him closely in the days to come.

                   Opening Statement of Senator Gregg

    Senator Gregg. Mr. Chairman, let me thank you by moving 
this hearing so promptly on this nominee, and I am really here 
to hear from the nominee, so I reserve my comments and submit 
my thoughts to the record.
    I would say this, however, that the Surgeon General 
position--I agree with the Senator from Massachusetts--the 
Surgeon General's position is a critical position, and it is 
one which really defines a large amount of health care delivery 
in this country, and especially how we as a culture address 
certain issues, and Dr. Everett Koop, who was a New Hampshire 
person, set a standard which I think is the standard we should 
hope that Surgeons General in the future will try to reach, and 
I look forward to working with you, Doctor, to attain that 
standard.
    The Chairman. Senator Frist.

                   Opening Statement of Senator Frist

    Senator Frist. Thank you, Mr. Chairman, and I too have 
placed my opening statement in the record, but do want to 
comment on the position of the U.S. Surgeon General, that for 
the last 100 years has played a true leading role on health 
care matters facing the Nation.
    Former Surgeon General, Dr. C. Everett Koop, called the 
position, ``a high calling with an obligation to interpret 
health and medical facts for the public.'' If there is ever a 
time we need that sort of position, that sort of 
responsibility, it is today. That calling has never, never been 
more urgent, I believe.
    While Americans enjoy the most sophisticated and most 
advanced health care in the world, there are public health 
challenges that we must confront as we look into the future. We 
have recently experienced an under-prepared public health 
infrastructure, that despite recent attention, is not yet 
adequately equipped to meet the threat of bioterrorism. There 
are unacceptable levels of substance abuse, especially among 
our young people today. There is a growing prevalence of 
obesity and the serious conditions that may result from it.
    Given these challenges, I am pleased to join my colleagues 
in welcoming Dr. Carmona this morning. I look forward to 
hearing more about how his training and his energy will serve 
the Nation in this new role.
    Welcome, Dr. Carmona.
    Senator Kennedy. We are joined by Senator Sessions, if you 
want to say a brief word, we would be----

                 Opening Statement of Senator Sessions

    Senator Sessions. Just briefly, I would just emphasize that 
in addition to Dr. Frist's comments and yours regarding the 
primary functions of this office, the one that is so well 
known, it is good, as a former law enforcement officer, 
prosecutor myself, that you have real law enforcement 
experience. You have got combat experience with the military 
and decorated in a number of ways, with the Bronze Star and the 
Purple Heart in Vietnam. It is something that I think speaks 
well of your commitment to America. In addition to that, it 
will help you deal with the terrorist threat that we are facing 
today, and I think that background is particularly valuable at 
this time.
    Thank you, Mr. Chairman.
    Senator Kennedy. Thank you very much.
    Dr. Carmona, I will give you an opportunity to introduce 
your wife. I had the chance to meet her earlier. Then proceed 
with your statement.
    Dr. Carmona. Well, Senator, thank you for that opportunity. 
I thank you also for, if you will, getting me off the hook 
because I was sworn that I would not introduce her, and she 
just wanted to blend into the background, so I thank you.
    It is my privilege to introduce my wife, Diane, my partner 
and my compass for life.
    Senator Kennedy. You are very welcome here. Thank you for 
being here.
    Very good. You can proceed with your statement.

         STATEMENT OF RICHARD CARMONA, M.D., MPH, FACS

    Dr. Carmona. Thank you, sir.
    Chairman Kennedy, Ranking Member Gregg, distinguished 
members of the committee, guests and staff, I am profoundly 
humbled and honored to come before you to be considered for 
this prestigious appointment as the U.S. Surgeon General.
    Three and a half months ago I began an unanticipated and 
uncharted journey into the unknown when I was nominated by 
President Bush to be the next U.S. Surgeon General. I am still 
numb and in disbelief at this extraordinary honor. No one could 
possibly anticipate this unique calling in their life, 
especially me. For in each successive milestone in my life, I 
have always felt quite blessed that I had achieved more than 
anyone in my family and more than I had ever dreamed. From 
meager beginnings to dropping out of high school, and finally 
finding significant life direction from my first real employer, 
the U.S. Army, and my then newly-adopted family, the U.S. Army 
Special Forces. There I was continually tested, challenged and 
held accountable as I developed essential survival skills that 
allowed me to survive not only in combat, but also equally 
important, prepared me for the battlefields of life.
    Courage, honesty, dedication, integrity and sometimes most 
important of all, tenacity, are some of those essential tools 
that were transferable to the real world as I embarked on life. 
From being a lifeguard at a public beach through being a 
soldier, medic, police officer, physician and surgeon, 
professor, researcher, public health officer, public health 
system CEO and community leader, I have found there is no 
greater endeavor than to serve one's fellow man.
    Now I may have the ultimate opportunity for public service 
before me, U.S. Surgeon General, the top doc, the people's 
doctor. This really is a surreal experience. As I related to my 
very young, inquisitive daughter, it is as if the fairy 
godmother reached out and touched me and cast me in the best 
Disney movie ever made.
    For many years some had wondered about my apparently 
disjointed career paths, military and police, special 
operations, emergency preparedness and management, search and 
rescue, paramedicine, medicine trauma surgery, public health 
and teaching. However, to me they were always complementary in 
regards to protecting the public's health, safety and welfare.
    Then came 9/11 and my 5 decades of careers suddenly all 
merged and took on a new and even more significant meaning as 
homeland defense and domestic preparedness became household 
words. Ironic as it may seem, I believe it was best summed up 
by one of our former county supervisors, who was quoted in the 
press as saying, ``Rich didn't know it, but he was training his 
whole life for this job as U.S. Surgeon General.''
    Over the last several months after my nomination I have had 
the opportunity and privilege to return to Washington 
frequently as I met many of you and others to prepare for this 
day. My perception of the awesomeness of our leadership and 
government has not lessened on any of my subsequent trips, but 
has rather heightened. Every trip here I feel like a very 
fortunate tourist who has been afforded the opportunity to 
witness the workings of the greatest government and country in 
the world.
    As I made my rounds on the Hill and had the privilege to 
meet many of you, I gained a better understanding of the 
enormous responsibility of the position of U.S. Surgeon 
General. I was absolutely overwhelmed by your hospitality, 
candor, graciousness and by the passion that you and your 
colleagues described your areas of interest and concerns 
relating to health, safety and welfare of our citizens.
    Among our many discussions, a common thread emerged: 
prevention. Whether the issue was counterterrorism, global 
health, AIDS, quality of health care, asthma, substance abuse 
or childhood obesity, maintaining health and wellness and 
preventing disease and injury was the highest priority for all 
of you, as I am happy to say it has always been for me.
    Of necessity and by direction of the President and the 
Secretary, the role of the U.S. Surgeon General has broadened 
significantly from that of traditional public health 
responsibilities to now include the expanded leadership role as 
part of the team addressing homeland defense and domestic 
preparedness. A significant part of this new preparedness 
endeavor is to build, strengthen and expand the Commissioned 
Corps of the U.S. Public Health Service. These are our unsung 
heroes, domestic warriors, who on a daily basis during peace 
and war are responsible for the Nation's public health. They 
can be found working in numerous essential capacities 
nationally, such as researchers at NIH and CDC, clinicians at 
the Federal Prisons and U.S. Coast Guard and within the Indian 
Health Service, just to name a few of the many areas of 
responsibility. More recently they have been highly visible in 
our National Office of Emergency Preparedness and in our 
Disaster Medical Assistance Teams and National Disaster Medical 
System.
    The events of 9/11 have thrust the new millennium upon us. 
Never before has the potential of the U.S. Surgeon General been 
so essential to the President, the Congress and the public. As 
the national leader and spokesperson for health issues, as well 
as the adviser to the President and the Secretary, the Surgeon 
General has the opportunity to bring the best scientific 
information forward, and articulate clearly and concisely, 
complex evidence-based science that has the ability to improve 
the health, safety and welfare of our citizens. From our brave 
first responders to mothers and fathers throughout America, we 
need the ability to deliver timely, uniform, user-friendly 
information that will empower the receiver to take appropriate 
individual or collective action in their daily activities that 
affect individual and public health as well as during 
catastrophic emergencies such as hurricanes, floods, disasters 
and the events such as occurred in 9/11. In our all-hazards 
approach, the public is an essential component of our team as 
our first responders.
    I also recognize that my ultimate success as Surgeon 
General will be co-dependent on the team I am on and the 
networks I can establish and work with to effect change. To 
that end, I also know that I must work diligently in order to 
establish my credibility with the Congress and other leaders. I 
will therefore strive to become your consultant, your ally and 
your spokesperson, as you attempt to navigate the sometimes 
rough seas of health and public policy development in your 
service to our Nation.
    Once again in my life I find myself in the enviable 
position of having exceeded my dreams. My goal now is simply to 
serve you and the public in an exemplary fashion so that my 
legacy would be that my presence made a significant difference 
for our country.
    Thank you very much for the privilege of coming before you 
to have my nomination considered.
    The Chairman. Thank you very much, Dr. Carmona.
    The Surgeon General is the Nation's doctor and his voice 
can make a fundamental difference on the way we live our lives. 
What do you hope to be able to accomplish as Surgeon General? 
What would you like your legacy to be most identified with?
    Dr. Carmona. Well, sir, thank you, Mr. Chairman, for 
allowing me to comment on that very broad question. I guess I 
would sum it up like this, that first I would hope to earn the 
respect of the public and Congress so that I earn the title of 
people's doctor. I would hope to lead, coordinate and 
articulate good science to the public and Congress so that we 
have an informed public and a Congress armed with pertinent 
information to formulate prudent health policy and public 
policy.
    Overall, if fortunate enough to be confirmed, I would hope 
that my legacy would be that the public, President and Congress 
feel that I performed in an exemplary fashion and that my 
presence made a significant difference to the health, safety 
and welfare of our citizens.
    The Chairman. Let me, if I could, ask you some questions 
that were raised in this Los Angeles Times story of yesterday, 
and in anticipation of the hearing they published an article 
reviewing your career, and raised a number of issues, potential 
controversies. Before getting into the specific questions 
relating to those issues, I wonder if you would like any 
opportunity to respond generally to the article?
    Dr. Carmona. Mr. Chairman, thank you for that opportunity. 
It is not often that we get to respond in public to press 
accounts of our activities.
    I would say in general I was quite disappointed. I think it 
is somewhat of a paradox that the article seems to be holding 
me accountable to what the press has reported on me over many 
decades of activity, and something that I cannot control and 
really have very little input to.
    But as the committee is aware, when assuming leadership 
positions, it is often necessary to make difficult decisions 
for the benefit of the organization or the majority. As much as 
possible, even after appropriate discourse, input, 
compassionate thought and empathy, decisions have to be made 
that sometimes are disagreed with. Most people move on, but 
unfortunately a few hold on to their sentiments. I believe this 
article presented some of those contrary opinions that have 
developed over the years.
    The Chairman. Well, let us start with your record of 
employment. You left the Tucson Medical Center with 
disagreements that ultimately led to litigation, and it said 
you resigned as the head of the Pima County Health Care System 
on the eve of a Board of Supervisors meeting at which you might 
have been fired. There was a quote, when you left, the system 
was carrying a $40 million deficit on a $55-million annual 
budget that was operating at 50 percent capacity. How do you 
respond to the allegations that you could not manage 
effectively this important health post?
    Dr. Carmona. Once again, Senator, thank you very much for 
the opportunity to respond to each of those issues briefly.
    Regarding the medical center litigation, this was a 
business dispute. It was a breach of contract litigation where 
the medical center breached a contract with me. The end result 
was that the medical center made a public apology to me and my 
family in two local newspapers, full-page ads, and they had to 
pay a large monetary settlement for this. As far as I was 
concerned, that ended the issue, and as it was a decade ago and 
has been far out of my mind since. I am still on the staff 
there at the hospital, and have many friends at the hospital 
and continue to work there when asked to do so.
    The Chairman. What about the point about your management 
skills though, the fact that this center ran into the kind of 
deficit situation that I have mentioned. Do you have any 
comment on that? As I understand it, this was an expanded range 
of services that were intended to be provided to the community. 
Some think that they were overstretched at the beginning of 
this and could not find the sufficient justification for those 
kinds of services, but what is your own kind of take on the 
reasons for the deficit?
    Dr. Carmona. Thank you, sir. I appreciate the comment once 
again to respond. Maybe I could put them all together, the 
resignation issue.
    I was originally recruited for the position of CEO of the 
county's health system and agreed to stay for a year. That was 
at the request of the Board of Supervisors after I had shared a 
voluntary commission to study the public health system. After a 
year they promoted me and asked me to continue to stay because 
the record will show that we were doing quite well on reversing 
some of the negative trends that had been at that hospital. At 
the end of 3 years I finally felt it was time to move on, and 
expressed this to the Board of Supervisors, who are the elected 
officials that oversee all of the health facilities in the 
county. By the fourth year I had been trying to leave, and I 
had put a very definite date on my time to leave at the end of 
that contract year, and I did so. It was not because I did not 
enjoy the work, it was because I originally came for a year. I 
extended that to 4 years and some people, for their own 
benefit, chose to characterize this as being forced out, but it 
was not so, and I think that is evident in letters that you 
have received about my tenure at that time.
    The deficit issue, the county health system is a county-
owned public entity that included the county hospital and many 
other assets, and was actually a business with revenues of 
approximately $300 million per year. The hospital accounted for 
about $65 million to $70 million per year. The so-called 
deficit was really accumulated over approximately 20 years and 
really started long before I even moved to the State of 
Arizona, and was actually primarily the result of providing 
indigent care at public facilities. Due to the method of 
accounting that the county used, it was called a debt or a 
deficit, when in fact it was really the cost of providing 
indigent care.
    For some time I worked with the Board of Supervisors and 
the county manager to restructure this and to change the 
accounting practices. I am happy to say that shortly after I 
left, the county manager did work on those recommendations and 
change that, and the so-called debt was eliminated totally from 
the county budget. So I am very proud of that record, and I 
stand on that record.
    The Chairman. Well, you did not eliminate the indigent care 
which you could have done----
    Dr. Carmona. No, sir.
    The Chairman [continuing]. As an economic factor, but you 
continued on that.
    Let me go to this board certification issue. According to 
your records you completed your surgery residence in 1985 and 
began working at the trauma center in Tucson shortly 
thereafter. You only became board certified in 1993. That was 
late in your career and coincided with your departure from the 
Tucson Medical Center. The Los Angeles Times claims that you 
failed the Surgery Board twice before passing in 1993. How do 
you account for this, and does this reflect on the issues of 
competency or capacity in the medical profession?
    Dr. Carmona. Mr. Chairman, once again, thank you for 
allowing me to comment on these issues. These are issues that 
have been brought forth before in a public forum in the press, 
and were actually part of that initial litigation that you 
spoke of as we opened the session. There was never any issue 
with my competence. I passed the required test for the American 
Board of Surgery in the time allotted by the American Board of 
Surgery. That is a voluntary process. No one has to undergo 
these testing. Most of us do it on a voluntary basis. The Board 
of Surgery has a window of opportunity that you can apply and 
take the test. I did so, and passed within the time.
    As far as my competency or the capacity as a medical 
professional, a single test is probably not a very good 
indication of anybody's specific knowledge. I would say that 
probably my couple of decades of practice would be a far better 
indicator of my level of competence. I think as you can from my 
record and my numerous performance evaluations from the 
university, from the hospital I have worked at, from 
organizations that I have leadership positions, they have all 
been exemplary. The fact is, is that my peers even voted me the 
physician of the year during that time. So I do not think that 
anybody has ever questioned my competency or my ability to 
practice as a surgeon, and then I think all of my evaluations 
have been superior, and again, I fall back and stand on my 
record that I think I have had a very good record and have 
served my patients well, especially the indigent patients that 
I fought very hard to maintain programs for in the under-served 
areas in Arizona.
    The Chairman. Well, all those letters will be made a part 
of the records, and it is impressive, the sort of uniform 
expressions of both respect and appreciation by your patients 
that we have received. It is impressive.
    The Los Angeles Times also reported that you sought board 
certification in emergency medicine, and that according to the 
Times you claimed in a sworn statement to have worked 5,000 
hours in that capacity, but that it was not the case. Did you 
make a mistake or was there a question? What was the issue that 
was raised with this?
    Dr. Carmona. Mr. Chairman, once again thank you for 
allowing me to address this issue.
    First I probably should be able, if you do not mind, just 
briefly explain the process that was in place at the time. In 
the early 1990s, late 1980s, the American Board of Emergency 
Medicine was a relatively new board and had sent out 
information to all physicians who had practiced in the area of 
emergency care, that if you would like to sit for the emergency 
boards, you could do so on a voluntary basis. You needed to 
submit your hours and what experience you have had in emergency 
medicine, and you could do that without having taken a formal 
residency, and this was a so-called grandfather clause that 
most every board has had as it is developed. I chose at that 
time, after consultation with our emergency medical director in 
the ER, to provide an application and let them evaluate that 
application.
    So there were no errors on the application. I filled it out 
truthfully, and I submitted the hours that I spent. Now, as you 
can imagine, as a trauma surgeon I spent almost all my time in 
the emergency room taking care of very severely injured 
patients. In addition, when I was a resident and a fellow, I 
did a lot of emergency room work, so-called moonlighting. All 
of those type of hours and training and experience can count 
toward that exam. Initially the board sent me a letter and 
said, ``Fine, we accept your hours and you can sit for the 
exam.'' A physician who was a competitor, who was also involved 
in that initial litigation--a lot of this goes back to that 
initial litigation--sent a letter to the board and said, well, 
he thought that my training was too concentrated in trauma and 
not enough broadly defined. So it was not so much the amount of 
hours. It was that I was more a trauma surgeon than I was with 
general ER medicine.
    The board asked me to reapply and spend a considerable 
amount of time redelineating my hours specifically. At that 
time I did not have the time to reapply and an application, and 
since I did not intend to practice emergency medicine, I chose 
not to pursue this any further. Again, this was never an issue. 
I was never accused of any impropriety. The application was 
made out entirely truthfully, and this only arose during the 
course of that litigation, and I might add that the judge who 
was involved in that litigation dismissed this because there 
was no evidence associated to support it.
    The Chairman. Thank you. I am taking some time here, and I 
will ask just one other question that related to the article, 
and then we will go to our other colleagues on some of the 
public health issues, but I think it is important that these 
issues be put to rest.
    There is the issue of the confrontational sort of style. 
The Times reported that this was an issue that was raised 
particularly with regard to the county commissioner, threats 
that you made to her. What is your response to those charges 
about how you treated the county commissioner and the 
suggestion of that confrontational style?
    Dr. Carmona. Mr. Chairman, once again thank you for the 
opportunity to respond.
    As I am sure the committee of distinguished Senators knows, 
you know, when you are in certain leadership positions and a 
body of elected officials appoints you to be an agent of 
change, to change the status quo, to bring contemporary 
management techniques to a dying system that is struggling to 
care for indigent patients. At times that is upsetting to 
people who live in the a status quo for a long time.
    Because of that, sometimes those of us who do step out 
might be characterized as confrontational. I probably say that 
at times that might be one of the more benign adjectives that 
might be associated with taking a leadership role, but I would 
say emphatically that I always treated my patients, my staff 
and co-workers with the greatest respect.
    I came up through the system as a registered nurse. I have 
worked just about every position in the health care system. I 
know what it is to be in the trenches, and I respect those 
workers because they are the ones at the bedside every single 
day.
    The commissioner in question is a civilian volunteer who 
was an adviser to the elected officials who hired me to do the 
job. She had no health care background. She had no management 
experience, and often there were disagreements because of that 
lack of knowledge in these very specific areas that were needed 
to run an organization, but never was there any yelling, 
screaming, or unprofessional activity, only professional 
disagreements.
    The Chairman. I appreciate your response to these questions 
that were raised in the article. I have a number of other 
questions in public health, but I think we will go now to my 
colleagues to ask questions, and then I will come back to those 
issues. If we could, we will try to follow the 7-minute rule.
    Senator Gregg.
    Senator Gregg. Thank you, Mr. Chairman, and I appreciate 
you asking those questions also. I think it is appropriate to 
put it on the record, and I think the doctor's responses were 
accurate, excellent and certainly point out the article had 
some failings in its substance and its depth of coverage.
    I am wondering, as we look at this issue of terrorism, 
which is something that has consumed a lot of us in the 
Congress and a lot of Americans, and obviously the 
administration.
    We have this three-legged stool of first responders. We 
have fire, police and public health. I am wondering what you 
think we need to do in the area, or if you even had the 
opportunity to think about it in a comprehensive way, in the 
area of creating our public health system in this country to 
better deal with the potential of a terrorist attack that would 
bring weapons of mass destruction.
    Dr. Carmona. Senator Gregg, thank you very much for the 
opportunity to address that. As you know, a subject that is 
near and dear to my heart that I have worked with for many 
years prior to 9/11. I think that one of the things that 9/11 
did was to bring to the forefront some of the deficiencies that 
we have in our public health system to include emergency 
response. When we look at our public health system, ideally 
what we would like to see is a continuum, I believe, that 
begins in the smallest communities with the first responders, 
police, fire, EMS responders, most of whom struggle to get 
training, most of whom have equipment needs, have 
organizational needs, but do the best they can. As you are 
probably aware, many of our responders are volunteers in many 
of our smaller communities around the United States. So that 
the process really begins in the smaller communities and moves 
up to a state level and a national level. I think at the 
national level, our U.S. Public Health Service and all of its 
assets really provide the leadership with the Surgeon General, 
with the Congress, so that we can integrate all of these assets 
to be able to respond in a timely fashion, in what we have 
termed in the field an all-hazards approach.
    Our first responders respond every day to car accidents, 
fires, explosions, all types of disasters, manmade and 
otherwise, and we have to ensure that they are available and 
trained and equipped to be able to respond to all of these 
hazards, that we are not becoming a specialty area of 
bioterrorism. You mentioned weapons of mass destruction. 
Bioterrorism is but one of many threats. It is a significant 
threat, there is no question, but our responders need to be 
trained in an all-hazards approach so that they may respond to 
all of these events. The fact of the matter is, that a 
terrorist event, statistically, although very important, is 
much less likely than the every-day catastrophes that we deal 
with in our lives, and these same responders are the ones that 
respond. Being able to integrate local communities in a 
regional system through their States, having Federal assets 
that assist in the education, training and providing equipment 
for those responders, and really what I would see is working 
toward creating a seamless system, that is, where we start at 
the lowest community, right up to the Federal system, because 
our experience and the literature has shown us that in any 
disaster, it is the local community that is going to keep those 
citizens well and alive for the first 48 to 72 hours even 
though the Congress may release Federal assets, it takes a 
little while to get there with few exceptions. So that is what 
I would envision as being able to create this continuum. This 
continuum, right up to the Federal level, strengthens our 
emergency response, it strengthens our public health 
infrastructure.
    Senator Gregg. Most of the Surgeon Generals who have been 
extremely strong figures and have given this country excellent 
leadership, have had a single thematic view, a single thematic 
approach that has dominated their position and allowed them to 
give identity to that issue, take that issue and bring its 
visibility up amongst the American public, and as a result 
actually impact that issue in a positive way.
    I am wondering if you--and I think many of them stumbled 
into those issues after they got into the job, so I do not 
presume you come in here with that thematic issue in place, but 
if you do, I would like to know it, and if you do not, I would 
be interested in what you might think are the options out there 
that you would be pursuing.
    Dr. Carmona. Thank you, Senator. Well, as I said in my 
opening statement, I was just elated at the passion by which 
all of you that I had a chance to meet with, expressed your 
interest in health care and what you thought needed to be done 
for our citizens. Many of those issues, as I pointed out in my 
opening statement, of great diversity, counterterrorism, the 
bioterrorism portion within it, obesity, asthma, childhood 
problems, immunizations. Really the central theme that emerged 
to me that I was so happy to hear from all of you was 
prevention. So if I had one central theme to bring forward in 
this very, very vast array of challenges that faced us, is 
prevention because every one of those things we look at, 
including the threats of weapons of mass destruction are 
amenable to good prevention practices.
    I hope to, with your guidance, with the opportunity to 
serve, be able to bring forth strong prevention in every one of 
the areas that you all have pointed out to me, but not to the 
exclusion of dealing with care or dealing with other 
traditional public health issues, but I think we really need to 
shift the paradigm to as society of prevention, rather than one 
that waits for its citizens to become sick or ill and dependent 
upon the government for services.
    Senator Gregg. Thank you.
    The Chairman. Senator Dodd.
    Senator Dodd. Thank you very much, Mr. Chairman.
    Thank you, Doctor, for being here, and for your response to 
some of the earlier questions.
    Mr. Chairman, I would ask unanimous consent that an opening 
statement will be included.
    The Chairman. All the statements will be included.

                   Opening Statement of Senator Dodd

    Senator Dodd. I welcome you to the committee, Doctor, and 
you have, if confirmed, have some big shoes to fill in your 
predecessor. Dr. Satcher was very highly regarded by many of us 
here, and he took on some strong issues, tough issues. He 
appeared recently before this committee talking about teenage 
suicide and was very compelling in his testimony that he 
offered.
    So this job has been--over the years, there have been those 
who suggested it sort of had lost its utility and value, 
something the Surgeon General associates more with the Civil 
War, I guess, than 20th century or 21st century needs, but I 
think some of your predecessors certainly have indicated that 
they can make this job extremely important, as being sort of 
the Nation's general practitioner, if you will, and asked to 
cover a wide range of issues.
    The bully pulpit that you are given to educate people, to 
educate members of Congress, the public at large, is 
tremendously valuable. So I do not subscribe to those or join 
with those who suggest that this office has lost its value. If 
anything, I think its value has been increased and enhanced, 
particularly because the people who have held the office have 
made it such, because they have made it important.
    Dr. Koop certainly is a wonderful example of someone who 
made it compelling. He is one of the few cases, I actually 
voted against Dr. Koop when he was here, and I, on two 
occasions, have written to people after the fact and apologized 
for my vote, and that was one of them. He did a remarkable job, 
and my vote against him was wrong, and I told him so afterwards 
and regretted it.
    I am sure I the only member here ever to cast a vote like 
that over the years.
    [Laughter.]
    But I do regret it. He did a wonderful job.
    Let me raise just a couple of issues with you, and I would 
just like to sort of get some sense of what you might do, 
utilizing the position you have to address some of these 
questions.
    I have a great concern about the growing problem of obesity 
in the country, among young people particularly. It is 
staggering the percentage, 61 percent of adults, 13 percent of 
children, suffer from this disease today. It is costing us a 
tremendous amount. If you want to just look at it in dollars-
and-cents terms, which some people are only impressed by that, 
the estimates are about $117 billion annually as a result of 
related health problems associated with obesity. I wonder if 
you might just share with us some thoughts on how you would 
deal with that, number one.
    No. 2--I'll just ask a series of questions and then give 
you an opportunity to respond--smoking is still a huge problem, 
tobacco, and there has been a reluctance on the part of some 
over the years because of the obvious interests involved, but 
still I think the numbers hold up. Some 3,000 kids start 
smoking, is it every day? Is that the number? I think it is on 
a daily basis, and so it does not go away. Now there are recent 
reports about the added impact on women, if recent reports are 
accurate, in terms of what needs to be done. There will be 
pressures, I suspect, not to focus on that as much, but I still 
think it is a major issue.
    HIV/AIDS, again, the leading killer of young black men 
between the ages of 25 and 44. I would like to know what the 
Surgeon General is going to do. We just had the international 
conference, I would like to know what you thought of that, and 
what role you believe you can take and what efforts have you 
made to come up with some better answers to this.
    The nursing shortage is the third issue that I wanted to 
raise with you. We have a huge shortage of those people in our 
country, and I wonder what you would do to attract qualified 
candidates to the profession.
    Lastly, the issue of medical errors. It is estimated by the 
Institute of Medicine that 98,000 people die every year due to 
medical errors in this country. We have had hearings on it here 
in the past, and again it is, I think, a proper role for the 
Surgeon General to take that issue on as well, and I would be 
very interested in hearing your responses to what you might do 
in those specific areas I have raised.
    Dr. Carmona. Senator Dodd, thank you so much for the 
opportunity to address these issues. I know in my meeting with 
you, you were very passionate about many of these, and I was 
absolutely impressed with the degree and depth of knowledge you 
had on this, probably more so than many of my colleagues in 
medicine, and I thank you again for the opportunity to discuss 
some of these issues.
    The childhood obesity issue is one that has been growing, 
as you know, and it parallels a lot of things in our society, 
probably the most important being the increasing sedentary 
lifestyle we have as we become more technologically advanced, 
and children tend to sit before video games and computers, and 
the average child watching maybe 5 hours of TV a day in the 
United States, physical fitness programs in schools which are 
diminishing because of cost or, for other reasons, they are 
being supplanted by academic pursuits, and what we are building 
is really a young population of very sedentary individuals at a 
young age, which is potentially catastrophic as they reach 
middle age years later.
    That what we can do, what I could do, if empowered as the 
surgeon general, would be to use that bully pulpit that you 
spoke of to be very forceful, to be able to bring together the 
best science from our Federal partners at NIH, at CDC, at the 
various agencies within HHS that deal with the issues of 
children, specifically to childhood obesity, and be able to 
bring the best science to the community.
    What I mean by that is the evidence-based work that says, 
here are programs that work, here are programs that we can 
apply that are culturally competent, that are geographically 
sensitive to get our children moving, to get them away from 
that sedentary activity, have them be active participants in 
life, encourage schools to be promoters of physical fitness 
programs, not just standing in the yard during a break, but to 
have activities.
    I think that is a message that the Surgeon General can 
carry strongly to families, to local communities, to school 
boards, to the children themselves, to have messages out there 
that say these are cool things to do, to have their role models 
give those messages in the media and see their role models 
encouraging them to do that.
    I think this is a multifactorial problem that really has no 
single answer, but one that the Surgeon General could lead the 
charge with a multi-disciplinary team, and that is how I would 
approach that, and I would approach it with great vigor because 
I have equal passion, as you have expressed.
    The issue of smoking, as has been pointed out, certainly a 
couple of our previous Surgeon Generals have been very vocal in 
this area, the last being Dr. Koop, who really established I 
think the benchmark for the bully pulpit as it relates to 
smoking. Smoking is an epidemic. There is no question about it, 
and there are some very significant problems in our society 
that we still have to deal with, and I think you pointed out 
already the issue of adolescent smoking being on the rise.
    So, again, I think the same model, looking at what is the 
evidence for programs that work in various populations. Again, 
they have to be culturally sensitive. You know, the program we 
do in an Indian Nation may not be the same as what we do in 
inner-city Boston because of the cultural differences, language 
differences. We have to take into account geography, we have to 
take into account who the professionals are that can deliver 
the messages in those areas.
    But, once again, with the partnership we have, I have been 
so impressed with the expertise that is basically at the 
fingertips of the Surgeon General in NIH, in CDC, the 
researchers, the people who study these problems around the 
country and being able to bring that good science to bear and 
say this is a program that works, use the evidence-based 
medicine to empower children not to smoke. It is tougher for 
adults when they have had those habits. As you know, there is 
no sure-fire way to quit smoking. It takes a lot of 
determination and a lot of support, but people are successful.
    I would like to be able to vociferously be able to address 
those issues on the behalf of the Congress, with the good 
evidence-based medicine that I know is out there, and where it 
is not, to have pilot projects that would move ahead with this 
type of education.
    Shall I go on, Senator, to the other areas?
    Senator Dodd. I do not want to encroach on the time of 
others.
    The Chairman. Briefly, do you want--these are obviously 
important.
    Dr. Carmona. Thank you, sir.
    Just briefly, on the HIV, as we all know, the meetings in 
Barcelona have put forth a rather ambitious agenda which is 
necessary to deal with HIV. CDC has a 5-year plan that they are 
looking at to work with communities to develop culturally and 
geographically competent messages for prevention and for care.
    The Surgeon General needs to keep this global health 
perspective in front of him because this is a worldwide 
epidemic. This epidemic knows no borders. So, again, I think 
that the Surgeon General has the opportunity to step forward 
and to be able to provide good science information to those who 
need this information to embark on good prevention and care 
programs, and this should be devoid of any race, religion or 
other stigmatizing factors because often that is a problem with 
HIV is that there is a stigmata of having that. We need to get 
away from that.
    This is a public health problem that is a global problem 
that needs to be addressed as a public health problem, and once 
again I think it is a wonderful opportunity for the Surgeon 
General to step forward.
    The nursing shortage issue is quite a complex one. As you 
know, I was a registered nurse. I know what it is like to be in 
the trenches, and be unappreciated, and underpaid, and now, 
even worse, where there is a shortage, having to spread 
yourself so thin. My daughter is a University of Arizona 
graduate, and a registered nurse, and a trauma nurse, and so I 
have daily contact with how difficult the problems are for 
nursing. Yet I am one of the strongest advocates of nursing 
because I have been there, and I know that I may spend 5 or 10 
minutes at the bedside, but it is the nurse that is 24 hours at 
the bedside with that patient.
    So I intend to, if given the opportunity, be a forceful 
advocate for nursing and to work with nursing leadership to 
develop evidence-based programs that can recruit and retain 
nurses because they are the backbone of our health care system, 
absolutely necessary.
    The last issue you brought up, Senator, was the medical 
errors and the Institute of Medicine, almost 100,000 people 
yearly dying because of errors, and that is a multifactorial 
process that starts with education of physicians, with peer 
review processes in hospital, with being able to freely, and 
without any sense of retribution, discuss errors and make 
appropriate changes within medical staff.
    What we really want to do here is to eliminate the 
disparity in health practice. Various doctors practice 
different ways, they order a lot of different things, yet the 
outcomes are the same. We need to use good evidence-based 
medicine to determine best practices so that we can eliminate 
these type of problems that have been delineated in the 
Institute of Medicine Report. Again, I think it is an ideal 
area where the Surgeon General can work with the leaders in 
these areas to bring that information forward.
    Thank you, sir.
    Senator Dodd. Thank you very much.
    Thank you, Mr. Chairman.
    The Chairman. Senator Hutchinson

                Opening Statement of Senator Hutchinson

    Senator Hutchinson. Thank you, Mr. Chairman, and thank you, 
Dr. Carmona, for your testimony and your willingness to serve.
    Senator Gregg, in his questioning, brought up the issue of 
bioterrorism, and I would like to focus briefly on one aspect 
of bioterrorism. One of the most feared scenarios is a 
bioterrorist attack upon our homeland, and the anthrax attacks 
of last fall really revealed the vulnerabilities that we have 
to biological weapons.
    During our discussion in my office, we talked some about 
the need for vaccines. The Department of Defense, of course, 
has very specific, very particular, extraordinary requirements 
for vaccines for a whole range of pathogens that might threaten 
our troops. Unfortunately, in my estimation, at least, the 
Pentagon, over the last decade, has decided to rely entirely 
upon the private sector for the production and the provision of 
those critical vaccines, and it has been a very unsatisfactory 
experience.
    The Department of Defense about a year ago, in July, issued 
a report in which it recommended the establishment of a 
Government-owned, contractor-operated vaccine production 
facility. Your predecessor, Surgeon General Satcher, submitted 
a letter endorsing the GOCO as a part of that report, and I 
would ask, Mr. Chairman, if that letter from Dr. Satcher could 
be made a part of the record.
    The Chairman. It will be made a part of the record.
    [The letter of Surgeon General Satcher was not received by 
press time.]
    Senator Hutchinson. In his letter, Dr. Satcher strongly 
endorses the GOCO and says that ``under the proper conditions, 
it could assure the availability of these vaccines for 
military, as well as for eventual civilian use, should the need 
arise.'' In fact, he said,

          We want to encourage DOD to proceed with plans to develop a 
        GOCO vaccine production capability and offer our technical 
        assistance with the resources available to HHS. We believe that 
        it can yield many benefits for meeting defense, as well as 
        civilian, vaccine needs.

    Now the vaccine industry, as you know, and we all know, is 
in a state of crisis itself with basic childhood vaccines even 
facing shortages today. We are down to only four companies that 
are producing vaccines, which causes me to be deeply concerned 
about 100-percent reliance upon the private sector to provide 
these vaccines, both from a military, as well as civilian 
perspective.
    In view of Dr. Satcher's endorsement of the GOCO, and given 
our discussion about it, I am wondering if you have given this 
idea further thought and if you could comment upon the whole 
concept of having a government-owned, contractor-operated 
vaccine production facility to provide both for our military 
and, hopefully, the protection of our civilian population.
    Dr. Carmona. Thank you, Senator. I am happy to comment, and 
thank you for the opportunity.
    This is an area that is quite complex, and there are a few 
options available.
    First of all, I think the premise for the GOCO was largely 
so-called market failure, that the private sector had no 
incentive to stay in the immunization business because there 
was no financial incentive to do so, and so when various 
diseases were eliminated, like smallpox in the past, they 
geared down and moved into other areas of biotechnology, and so 
we do not have the capacity to produce immunizations as we did 
once before.
    So I think that Dr. Satcher and others were correct to look 
for other opportunities because I think, as the Surgeon 
General, I am sure Dr. Satcher was looking more globally and 
saying, well, I need to ensure that our citizens have the 
appropriate immunizations. If the private sector cannot do it, 
well, what more compelling reason than for the Government to 
step into anything to protect its citizens than that there is a 
market failure? There is no compelling reason for the private 
sector to be involved.
    So I think it is worthwhile pursuing. I think it is going 
to require some more study as to the details as to how it is 
done, but I think it is a very viable option that we should 
continue to look at.
    Senator Hutchinson. I appreciate that. To me, it is almost 
an insurance policy for the American people, and the private 
sector is going to continue to find that small markets, high 
start-up costs, and potential liability concerns will make them 
reluctant to be a fail-safe provider of those vaccines. So 
thank you for your willingness to look at the GOCO, and I look 
forward to working with you on it.
    Thank you, Mr. Chairman.
    The Chairman. Senator Murray.

                  Opening Statement of Senator Murray

    Senator Murray. Thank you very much, Mr. Chairman, for 
having this hearing. I think it is long overdue. Dr. Carmona, 
thank you so much for being here today and for being willing to 
take this on. I think we need a really strong and vocal Surgeon 
General right now to help us address the many issues you have 
talked with all of us about, and certainly health care is a top 
agenda item for many of us.
    I am really pleased to hear your focus on prevention, and 
you just mentioned the immunization shortage a minute ago. I am 
hearing from more and more doctors in my State that this is 
critical, and I am just curious what you think we can do to 
better get the private sector to produce these immunizations. 
There are a lot of children in our State, and it must be 
nationwide at this point, that are not having access to 
immunizations. Once you delay them, parents do not bring them 
back in. If they are not on that schedule, it is very hard to 
get them back on track.
    What do you think should be done about that?
    Dr. Carmona. Yes, Senator, thank you for allowing me to 
comment on that very important issue.
    As Senator Hutchinson brought up just moments ago, I think 
that the Government has a role here in ensuring that the 
adequate amount of immunizations are available in a timely 
fashion for all of our--not just children because it is also 
some adult immunizations that are in short supply, pneumococcal 
vaccine and others. So it is really across the board.
    I think, as far as what can we do, well, I think we can 
work together with Congress to see are there ways to 
incentivize the private sector to step up their investment in 
biotechnology. As Senator Hutchinson pointed out, it is pretty 
costly to get started. It is pretty costly to gear up, and when 
they look at the returns on their business investment, a lot of 
the businesses shy away from that, but that cannot be a 
deterrent to us because, as Surgeon General, and obviously as 
Congress has a vested interest in protecting our public, we 
have to ensure that the immunizations are available.
    So my feeling, at this point, is to, if given the 
opportunity to serve, to be able to look at what has been done 
up until now in-depth and be able to look at all of the options 
before us, and then to delineate with Congress what should be 
the appropriate role of Government here. If there is a market 
failure for the private sector, then I think the Government 
needs to step up and ensure that our citizens have access to 
these vaccines in a timely fashion.
    Senator Murray. It is becoming a critical issue, I know, 
and I would like to work with you on that because I think just 
allowing it to move forward as it is, and profits being what 
they are, I think we are going to see this grow if we do not 
deal with it at this level.
    The other issue on prevention is really getting information 
to parents and consumers and making sure people know the right 
information. It is not that we have too little information, I 
think any more it is that we have too much information. I am 
hearing from a lot of people that young high school students, 
in particular, are sort of turning a deaf ear to nutrition, 
that there is just every day you open up the paper, and it is a 
new report that you should or should not eat whatever you 
thought you could the day before.
    How do we deal with all of the conflicting and confusing 
messages and how would you, as Surgeon General, help parents 
get the right information so that we can raise healthy 
children?
    Dr. Carmona. Thank you, once again, Senator.
    In my opening remarks, I alluded to some of the needs of 
our public and how the Surgeon General might be able to address 
some of those through uniform, predictable information, 
evidence-based information that is articulated to the public in 
a manner they can understand, not as the scientists talk, but 
at the grassroots' level for the public. I am elated that just 
recently you all approved a friend and colleague, Dr. Elias 
Zerhouni, at NIH, and then Dr. Julie Gerberding at CDC, both 
friends of mine and coworkers. I go back many years with Dr. 
Gerberding.
    But these are the head scientists for our country, and the 
relationships I already have with them I think will foster 
being able to develop very uniform, timely, culturally 
competent messages so that our families are not getting mixed 
messages.
    I do not think it is any maliciousness. I think that, in 
the exuberance to get research out, people read and the media 
reports on sound bites from different projects that are often 
confusing: Well, you know, immunizations could be bad because 
they could cause this or they could cause that or using 
estrogens can cause this or cause that, and it becomes very 
confusing for the nonmedical professional.
    I think one of the things that the Surgeon General can do 
is synthesize that information and be able to speak to the 
public very concisely and say here is what the research is 
about, here is how we translate this to the bedside so that you 
can make a decision for your family with your physician and 
your community, and that is what I would hope the Surgeon 
General could do in that respect.
    Senator Murray. Very good. I wanted to ask you another 
question, which I am sure you have strong feelings on, and that 
is the issue of child restraints. The National Transportation 
Safety Board released a report titled, ``Putting Children 
First,'' which identified 10 different areas where Government, 
industry and individual citizens needed to work together to 
make sure a child is safe, however they are traveling in an 
automobile or a bus or whatever, and one of the focuses was 
inadequate child restraint laws.
    The report actually cited a Washington State accident, 
where a 4-year-old was strapped into an adult seat belt and was 
called, and my State, as a result of that, just passed a law 
requiring children less than 6 years of age or 60 pounds to 
ride in a booster seat. That just went into effect a couple of 
days ago.
    As Surgeon General, how would you approach the issue of 
child restraints and safety belts?
    Dr. Carmona. Senator, once again, thank you for allowing me 
to address--this is an issue near and dear to my heart because, 
as a trauma surgeon for many years, and involved with the 
National Safe Kids Campaign in the State of Arizona with my 
colleagues, we worked very hard to put in place seat-belt 
restraint laws, not only for children, but for adults, pool 
safety, a number of other issues involving child safety.
    From the standpoint of the Surgeon General, I think you 
have the bully pulpit. What is unique, maybe, to my background 
is I have been in the trenches as a trauma surgeon to see those 
children ejected from automobiles, and have to care for them, 
and spend time in the ICU with them and operate on them, so I 
know how devastating it can be. I am a father, I have four 
children, and I know that devastation that comes to a parent.
    So that, again, using that bully pulpit to make sure that 
parents understand, working with Safe Kids Coalition and other 
national organizations, the American Academy of Pediatrics, and 
others, who are very strong proponents of safety initiatives 
for children, I would hope to get that message out in 
partnership with all of these groups.
    Now the other thing that is interesting with the seat 
restraints is that there have been studies that show, even when 
they are used, parents often use them incorrectly. They are not 
buckled correctly. So now we have a projectile that is a child 
in a seat, but it was not strapped in correctly. So, once it is 
used, we have to ensure that the appropriate education takes 
place and that it is used correctly.
    Senator Murray. I thank you. I know my time is up, but just 
let me ask really quickly, as a trauma surgeon, you must also 
see vehicle crashes as a result of drunk driving. How will you 
use your bully pulpit on that issue?
    Dr. Carmona. Well, the statistics are promising, in that we 
have seen a drop in DUI, driving under the influence, and 
injuries caused from it, but it is still significant, and I 
would characterize it as epidemic, and I think, again, that is 
the bully pulpit of the Surgeon General, so that we educate the 
public to see the immense amount of harm it causes with 
drinking and driving.
    This is not really an area of social responsibility, and we 
have to get that word out that this is unacceptable in our 
society because you are not only risking your own life, you are 
risking the lives of innocent people on the road by driving 
under the influence, not just alcohol, but any intoxicating 
substance.
    Senator Murray. Thank you very much, Mr. Chairman.
    Again, thank you, Doctor.
    The Chairman. Senator Sessions.
    Senator Sessions. Thank you, Mr. Chairman.
    Dr. Carmona, we thank you for your leadership and service 
to your country. As the Nation prepares to deal with the 
terrorism threat to this country, it seems to me that there is 
a need to make sure that physicians and emergency medical 
personnel are trained to deal with a weapons-of-mass-
destruction-type attack on this country. It is not going to be 
the Federal authorities on the scene first, it is going to be 
the local hospitals, and physicians, and nurses and emergency 
medical personnel that are going to be out there responding.
    Do you think we can do a better job of training and 
preparing those people for the eventuality of a terrorist 
attack like that?
    Dr. Carmona. Yes, sir. Senator, I thank you for allowing me 
to respond to that.
    It is really a very significant issue for us, and the 
reason being that most physicians who have been educated prior 
to 9/11 did not have education in weapons of mass destruction, 
which, as you know, break into conventional and specialized 
weapons, and so when we talk about bioterrorism, when we talk 
about unique chemical threats, most physicians, at most, have 
read an article about that. They really have not had 
significant training because, apparently, there was no need for 
that training.
    So part of strengthening our infrastructure at the 
community level is to ensure that all of our physicians have 
the requisite training and equipment to be able to deal with 
the threats that may be thrust upon us in the future, that we 
are preparing for, the contingency planning, and that includes 
everything from recognition of disease in a bio situation; 
i.e., smallpox. Most physicians have never seen a case of 
smallpox. Most physicians have never seen a case of anthrax. So 
you may have read it in a book going through medical school, 
and that is the last you have heard of it.
    So it is not an indictment of the system, it is just that 
we never had to educate our doctors. So I think, in our 
community, I know, and nationally, in speaking to 
organizations, there is a concerted effort, through specialty 
organizations, to step up the ability of our physicians to be 
educated rapidly so that they can meet the needs of our 
patients, when and if, a WMD event occurs.
    Senator Sessions. I think you are correct, and your 
background in the military special forces, as a medic and 
emergency room physician should give you some ability to 
communicate that message.
    Will you take a lead in encouraging this country to do a 
better job of preparing our forces around the country to be 
ready for this kind of event?
    Dr. Carmona. Yes, sir, Senator. Again, if you give me the 
privilege to serve, I fully intend to take a leadership 
position in this area because it is an area of my expertise, 
and it is one that I believe in passionately, and also, I mean, 
I would really be wasting the resource of my many years of 
experience and training in this area in not sharing it with my 
colleagues and for the benefit of the country.
    Senator Sessions. Well, I think that is important, and I am 
glad to hear you say that, and I think we talked about it 
earlier in personal conversations.
    At the Barcelona Conference, there has been a recommitment 
of sorts to dealing with the problem of AIDS in America, and 
one group of numbers that came out of America was that we have 
a large number of people who are at risk who are positive for 
AIDS that did not know, an extraordinarily high number of 
people who were positive, did not know they were positive. I 
think, if people knew they were positive, despite what some 
might say, most would take strong steps to ensure they did not 
infect a partner with AIDS.
    Are you concerned about us losing some momentum, maybe 
losing some of the intensity of interest in combatting AIDS, 
and if we do so, we could see another surge of infection?
    Dr. Carmona. Senator, I am equally concerned, and have been 
following the Barcelona meetings that our Secretary is at now 
very closely because that is the latest science and latest 
thoughts on AIDS. This is a global epidemic. It knows no 
borders, and the point that you make is absolutely correct, 
with a large segment of the population not knowing. If you look 
at that just briefly, to describe the demographics, when we 
have AIDS that is in what we might consider a Third World 
country, say, in Africa, we have a population that is largely 
uneducated, that does not read, that lives in small villages. 
So, when they are infected, they have no idea what germs are or 
germ theory, as opposed to an urban area in the United States, 
where there may be geographic areas where there is AIDS 
concentrated and people just do not know because they do not 
get tested, and they ignore the fact that they should be tested 
because they had engaged, for instance, in high-risk 
activities.
    So that you have this wide array of areas in front of you, 
and again this is underscores the need for public health to be 
culturally competent, geographically competent in its 
recommendations because what is going to serve well in Africa, 
the Sahara, South America is not going to work in urban New 
York City or Boston. So the messages we send have to be clear 
and specifically directed at the populations at risk.
    I think the Surgeon General, more than ever, needs to be 
involved in this global epidemic, not just for AIDS, but global 
health because we have borders, and we protect our borders, and 
we deal with domestic preparedness now and national security, 
but disease knows no borders. Those diseases come and go on 
planes, and buses, and migration, and within the economy. So I 
think it is very important that the Surgeon General, with the 
direction of Congress, take a lead in this area to attempt to 
eradicate this epidemic.
    Senator Sessions. A person that is infected can get 
treatment that can help prolong and improve their quality of 
life, particularly pregnant women can avoid transmitting 
disease to their child. In addition to that, we can reduce the 
spread of the disease. So I think we do need to give more 
attention to that. We cannot lose our intensity of interest in 
it, and I am glad to hear you say that.
    Mr. Chairman, my time is about out. I would just say that I 
believe that Dr. Carmona brings a lot of qualities to this 
office that are important at this critical time in our Nation's 
history, and I believe, if confirmed, and I think he will be, 
his abilities will fit in with the challenge we face at this 
time.
    I thank you.
    Dr. Carmona. Thank you, Senator.
    The Chairman. Thank you very much.
    Senator Reed.

                   Opening Statement of Senator Reed

    Senator Reed. Thank you very much, Mr. Chairman. Thank you, 
Dr. Carmona. You are a man of extraordinary talents and 
extraordinary varied experiences. You are also someone with 
great devotion to this country. You have demonstrated in many, 
many ways.
    I, too, read the Los Angeles Times article, and there is 
one issue I would like you to comment upon, and that was an 
anecdote that in 1991 a nurse criticized your professional 
judgment. You, rightly so, I think, pointed out that that 
criticism should have been directed to professional review, and 
then there was a mediation, in which she took a demotion, and 
the agreement was, according to the article, that she would not 
be reported to State authorities, yet she was reported.
    I guess in my mind that raises two management issues, not 
personnel issues in particular, personality issues, but the 
management issue is you have got the reputation of a 
swashbuckler in terms of you will do anything you can to 
protect your patients, and you will fight bureaucrats and 
everyone else, but what happens when someone sort of goes 
around the rules with a patient that you have? The issue of a 
double standard.
    The second one is, if the agreement was not to report to 
State authorities, was there some grudge here or retaliation?
    I raise those issues because you are going to be a manager 
of a major organization of the Federal Government, and you are 
going to have to deal with issues like this each and every day, 
and I want to, for my own view, and I hope for the edification 
of everyone, just get your sense of, you know, is there 
anything there to these concerns, if they are concerns at all?
    Dr. Carmona. Senator, thank you for allowing me to respond 
to those.
    Again, I was disappointed at the coverage, as I stated in 
my earlier remarks.
    Senator Reed. Right.
    Dr. Carmona. I believe that the whole story was not told. 
There was no retaliation whatsoever, and briefly I will just 
let you know what happened.
    The nurse was reported because it was an act of 
unprofessional conduct that was required to be reported by 
statute. There was never any agreement because I could not make 
such an agreement if it violated statute.
    The nurse had problems--again, and I think I know the case 
you are speaking of----
    Senator Reed. Yes, and we do not have to get into----
    Dr. Carmona. I think the nurse had problems and was not 
able to function in the environment that she was in, in the 
Emergency Department, and, in fact, some of her colleagues no 
longer wanted her to work there because she could not carry her 
own weight. Her boss asked me to take her within the Flight 
Program and the Trauma Program, and we did. She did not work 
out there either, and the staff was very unhappy with her 
because she was undependable, did not provide the services she 
was supposed to. I went to her supervisor and told her, I said, 
``This is unacceptable. You really need to do something else.''
    We worked very hard, followed due process, tried to 
rehabilitate her and did everything we possibly could to 
maintain her as a good employee, but it just did not work, and 
I had to make the best decision for the organization and for 
the patients that we serve, and I did so with a great deal of 
empathy, and compassion, and careful thoughtfulness and working 
through a process that was not reported in that article.
    Senator Reed. Let me ask you another question, which is 
less particularly to your career, and very important to the 
Nation, and that is the incidence of gun violence. One of the 
leading cause of death in this country for people from birth to 
44 is injury, and one of the leading forms of injury is caused 
by firearms. I am told that in 1999, over 28,000 Americans were 
killed by firearms.
    We have just horrendous situations in Rhode Island. We had 
a young man who worked, with a blameless record, at the 
Providence General Printing Plant, walk in one Saturday 
morning, kill a coworker, injure another coworker, drive to a 
suburb, kill another coworker and then take his own life.
    Just this last weekend, a young Marine going up to visit 
his family, on leave from Camp Lejeune, was killed in the rest 
room of a convenience store by someone to take his car. The 
perpetrator drove to his estranged wife's house, invaded the 
house, took hostages, finally killed himself.
    There is a huge epidemic of violence in the country, much 
of it related to firearms. What are you going to do, in your 
preventive capacity, to try to stem this epidemic of firearm 
violence?
    Dr. Carmona. Once again, Senator, thank you for allowing me 
to comment on another issue that is near and dear to my heart.
    As you know, having been a trauma surgeon for many years 
and running a program where I often, on a daily basis, cared 
for gunshot wound victims, and very early on, in a partnership 
with our law enforcement professionals in the community and our 
EMS community in Arizona, in southern Arizona, we started to 
look at this. In fact, our sheriff took a leadership role.
    You know, one of the things I recognized was that, on a 
daily basis, as I was admitting my patients to the Trauma 
Center years ago, two to three out of every four of these 
patients were preventable, some of them were gunshot wounds, 
but what I equally recognized was that the sheriff, for every 
person I put in a hospital bed, was putting somebody in jail. 
So, as he was competing for dollars to get more jails, I was 
competing for dollars to expand the Trauma Center, and I 
recognized this is not going to work. So we started to look at 
avenues for prevention. This is over a decade ago.
    We embarked on a number of programs through education to 
try and not divide the community because, as you know, there is 
already a polar debate about weapons, about what should be 
done, but a strategy to embrace both sides and say what can we 
do to decrease the end result of weapon violence?
    We came upon a program that has really been quite 
successful that was put together by a Florida police officer. 
It is called CARGO, Communities Addressing Responsible Gun 
Ownership, and it embraces both sides of the polar debate 
because it does not take a side on gun ownership, it deals with 
educating the people as to the risk of gun ownership and what 
steps need to be taken if you choose to own one, and actually 
goes through the demographics of suicides, homicides and such, 
and in limited follow-up, we have been able to, I think, show 
that it does have an impact as far as weapon safety, and 
education, and being able to decrease the outcomes that you are 
speaking of.
    So, again, my approach would be to try and deal with all 
sides of that debate, of which there are, you know, pretty 
heavy debates, as you know, but bring them together for a 
common purpose, and that is to make our community safer, and I 
think that is accomplishable, and I think it can be done from 
the Office of the Surgeon General, as a spokesperson, with the 
Congress empowering the Surgeon General to do so.
    Senator Reed. Dr. Carmona, the Surgeon General has, and it 
has been referred to several times, the bully pulpit in terms 
of health care policy in the United States. So your vigorous 
advocacy for many issues is going to be looked for by this 
committee.
    Thank you.
    The Chairman. Thank you.
    On the questions of prevention and guns, we have probably 
12 children that die every single day from gunshots, and what 
can be done in the areas, particularly with regards to 
children? If you could do that, I mean, if you are able to save 
one life, it is a major step. But it isn't unreasonable to 
think that you could reduce those numbers in terms of children 
and cut that list in half, and the number of children that you 
would save would be very impressive. We want to work with you 
in those areas of prevention and also in terms of the whole 
issue of weapons in the hands of people that shouldn't have 
them.
    Let me just go back, if I could--you have been very patient 
with our committee, but I would like to just go back and cover 
a few of these topics in a bit more detail, first on tobacco.
    First, I am going to ask whether you agree that nicotine is 
addictive and that tobacco use is the leading cause of 
preventable death and disease in America and, third, that the 
tobacco industry targets children with the advertising.
    Dr. Carmona. Senator Kennedy, I think there is no doubt 
that those statements are true.
    The Chairman. I am sure that you know that every year more 
American children die from tobacco-related diseases than from 
AIDS, car accidents, murders, and suicides combined, and 90 
percent of the smokers start before the age of 19. Past 
Surgeons General have released vitally important studies of 
tobacco, most recently a report on its impact on women's 
health. So do you intend to make tobacco a priority? And, if 
so, do you have anything specific in mind?
    Dr. Carmona. Mr. Chairman, thank you once again for 
allowing me to comment on this important topic. As I said 
earlier, I think that tobacco is one of the largest health 
hazards that our society faces, especially our children and our 
adolescents. As you have pointed out, the big risk is when they 
get started and they get hooked, and it is tough to get them 
off it. So as I pointed out earlier, with the help of Congress 
and the fellow leadership within our health system--that is, at 
CDC and NIH--to be able to bring the best science forward, the 
best programs forward, that are targeted specifically for at-
risk populations, because an adult population who you want to 
intervene as smokers needs a different message than those that 
are children, than those that might be on an Indian 
reservation, than those that may be in an inner-city 
underserved area. We have to develop these culturally competent 
messages, deliver them, possibly by role models, the people 
that they watch and look for, the singers, the dancers, the 
people that the kids look up to, to make them understand that 
this is not a good thing to do.
    You know, I guess I would make my commitment to you, 
Senator, that I will strive in everything I do to work with the 
Congress to make sure that we have a significant impact in the 
reduction of tobacco use in our children as well as adults.
    The Chairman. Well, we will look forward to working with 
you on that as well as these other issues.
    I note that the State of Arizona has been a leader in the 
tobacco prevention and control program. CDC has given a great 
deal of technical assistance to other States to try to 
replicate Arizona's success. It is the work of States like 
Arizona that led Dr. Satcher to believe that we could actually 
cut smoking rates in half through comprehensive State-based 
prevention and control programs.
    Would you like to see CDC continue its efforts to assist 
the States like Arizona and work towards reducing the 
consumption rate, smoking rate for children as well?
    Dr. Carmona. Mr. Chairman, I think it is absolutely 
essential that not only CDC but any other Federal assets we 
have that can weigh in on this through providing good science 
and programmatic guidance, we need to bring all our forces to 
bear to have an impact on this epidemic.
    The Chairman. On HIV and AIDS, with no cure, prevention of 
HIV is a critical component to fighting AIDS and HIV infection. 
There are 40,000 new infections each year in our Nation, and 
prevention methods that are scientifically proven effective 
obviously must be employed. Will you ensure that as Surgeon 
General you will use scientifically proven methods to reduce 
new infections in accordance with the CDC's 5-year plan?
    Dr. Carmona. Mr. Chairman, once again, absolutely I would 
do that, and I would look on my colleagues in all disciplines, 
and what I would hope to do is to be able to establish new 
networks, you know, locally, within our Federal Government, 
through HCFA, CDC, NIH, HRSA, Indian Health Service, SAMHSA, 
but also expand out, UNICEF, the World Health Organization, 
because this is a global epidemic, and it ultimately will 
affect us even across our borders.
    So I think that it is vital that we establish these new 
networks and bring all of the forces that can weigh in on this 
positively to bear so that we have positive outcomes that you 
and I and the Congress desire.
    The Chairman. The HIV/AIDS epidemic has hit our communities 
of color disproportionately hard. Latinos make up 19 percent of 
the new HIV infections, the largest emerging minority community 
in this country. African Americans are 12 percent of our 
population. They make up 38 percent of all the AIDS cases. What 
would you do as Surgeon General to dispel the stigma of HIV and 
AIDS, including HIV testing, in our communities of color?
    Dr. Carmona. Well, as outlined in the CDC plan, Mr. 
Chairman, working with the communities to develop culturally 
and geographically competence messages. I mean, I have said 
that many times this morning, but they really have to be made 
specifically, and I have learned that so much in, you know, my 
own background where I grew up and understanding the Hispanic 
culture, to working with Native Americans today and working 
very often in underserved areas, understanding the unique needs 
and unique messages that need to be sent to our citizens so 
that they can be helped.
    From prevention and care, you know, the Surgeon General 
needs to keep this issue on the forefront, on the front of that 
bully pulpit, with the help of Congress, and continually drive 
this message home. We need to be able to, in the public eye, 
demonstrate that this is a public health issue. It should be 
devoid of any social stigma. It is a public health issue that 
affects all segments of our population, and it is a global 
health issue that has huge economic and health consequences.
    So that is the message I would continue to deliver, and it 
is devoid of any social stigmata.
    The Chairman. Just last week, the Journal of the American 
Medical Society published a study of the stark disparities in 
health care that Hispanic and Latino children receive in our 
country. Let me quote the study from Dr. Glen Flores of Boston 
Medical Center:

          Compared with whites and African Americans, Hispanic children 
        are much more likely to have no health insurance, drop out of 
        school, have no regular doctor, to have cavities, to attempt 
        suicide if they are a girl, or to be obese if they are a boy.

    If confirmed, you would be the second Surgeon General of 
Hispanic heritage in our history. What would you do to change 
this unacceptable situation?
    Dr. Carmona. Mr. Chairman, one of the assets I have is 
probably starting off with some credibility with my fellow 
Hispanics. I have lived in the inner city. I have lived in 
underserved areas. I have received care in public facilities as 
a child, so I know what it is like. I know the stigma of being 
poor in the inner city.
    As you know, there is a direct relationship with education, 
with literacy, with employment, with salary as it relates to 
all of these risk factors. So there is a wide range of 
interventions that we can move forward on that include 
education, that include job programs, that include empowering 
these communities to understand what the issues are and making 
them stronger.
    I see the job of the Surgeon General as one of educating 
and empowering so that the communities can take charge of their 
own destiny, and that is what I would hope to accomplish.
    The Chairman. Well, that is going to be enormously 
important because what is happening, the Hispanics generally, 
the people of color, they are falling further and further 
behind.
    Just quickly, and I am not going to get into all of this, 
diabetes, we met a few months ago and you spoke eloquently 
about your commitment to increase national fitness and 
preventing diabetes. I know Secretary Thompson has made 
diabetes a high priority of his own. Now nearly one in five 
Americans have this devastating disease, and there are 
approximately 16 million Americans with diabetes, almost a 
third of whom are unaware that they have the disease.
    We have been developing comprehensive legislation to better 
prevent, treat, and hopefully cure diabetes, and we have worked 
with the CDC, with the NIH, and with patients on this 
legislation. We already have strong bipartisan interest, and we 
want to work with you. Will you work with us to try and see if 
we can't gain the administration's support?
    Dr. Carmona. Senator, not only am I willing, but I am eager 
to take on this project with the Congress to be able to make 
significant change. This is another one of those epidemic-
proportion diseases that has a huge impact on quality of life 
and cost of care and one that we can intervene relatively 
easily in prevention practices.
    The Chairman. Vaccines. The country has made tremendous 
progress in immunizing rates for children up to 2 years old. 
They stand at 90 percent or higher for most childhood diseases. 
There are still troubling disparities between immunization 
rates in non-white communities. Will you help and work with us 
in trying to zero out those differences and ensure all children 
have access to the vital vaccines that they need?
    Dr. Carmona. Mr. Chairman, again, not only am I willing to, 
I am eager to follow your lead. You have clearly been one of 
the strongest proponents in our Nation for the safety and care 
of our children, and I could only hope to be able to work with 
you and address these issues and follow your lead, sir.
    The Chairman. Well, there are also growing rumors, which do 
not hold up under scrutiny, that childhood vaccines are unsafe, 
can cause autism or multiple sclerosis. More and more parents 
are thinking twice before immunizing their children against 
dangerous diseases. So this is an important area for education 
of the public about the safety of vaccines and immunizing 
children, and this will be something you will be interested in?
    Dr. Carmona. Absolutely, Mr. Chairman. I think, again, that 
that is--in my opening statement and throughout the meeting 
today, I have pointed out that I think a very important 
function of the Surgeon General, as the people's doctor, is to 
be able to bring the latest science from the bench to the 
bedside and be able to articulate it to families and their 
practitioners so that they can make timely, well-informed 
decisions. This falls into that category.
    The Chairman. The adult immunizations haven't received the 
attention and resources they deserve. We have 50,000 adults die 
each year from vaccine-preventable diseases or their 
complications. So this is certainly an area that we need to 
give attention to.
    I haven't mentioned asthma, the growth of asthma. The 
number of deaths from asthma has doubled in the last 5 to 7 
years. As the father of chronic asthmatic child who happens now 
to be in Congress----
    [Laughter.]
    It is a devastating disease. There were several times when 
he was really very close to not making it, and we were 
fortunate to have at the Children's Hospital in Boston some 
experimental drugs that really--actually, I am convinced saved 
his life. But this has been an expanding problem for children, 
particularly in the inner cities, and I hope you will work with 
us on this area as well.
    Dr. Carmona. Mr. Chairman, absolutely, I share your passion 
for protecting our children. Clearly, the issue of asthma is 
increasing and it is multi-factorial. Some of it is 
environmental. Some of it is psychogenic. But, clearly, our 
underserved populations also are disproportionately affected 
because of the environmental factors in some of the areas that 
they live and issues that you are well aware of, I know. But I 
look forward to being able to work with you for the betterment 
of our children.
    The Chairman. I was interested in your opening comments 
about the programs you set up on mental health after September 
11th. We had a very interesting hearing in this committee room 
about the impact on children, particularly on the children. At 
the time of the terrible tragedy, so many of the children went 
home and turned on the television and saw the collapse of the 
towers repeated hour after hour after hour, thinking those 
were, many of them, new circumstances coming. When you have the 
children in New York, and particularly the children of those 
that were tragically lost, and the fire fighters' and rescue 
workers' children obviously first come to mind. But the impact 
that has on children across the country is something that we 
are going to live with, are living with, but it is something 
that we should not forget.
    I was interested that you developed a program for mental 
health and just what the impact was going to be out in Arizona. 
But the idea that it isn't only the children in the particular 
region but children outside as well that have been impacted is 
something that is very important to understand, and I was glad 
you referenced that.
    Dr. Carmona. Thank you, Mr. Chairman. It was something that 
we needed in our community and actually obviously was needed in 
the rest of the community. Nobody could anticipate those type 
of events, and it wasn't just our children. But we realized 
that most of our communities on a daily basis, patients don't 
have ready access to mental health needs. As you know, 
approximately 20, 25 percent of individuals on a daily basis 
who require mental health input can't get it, don't have 
access.
    We recognize that after September 11th, after the first 
week of watching those planes hit those buildings a hundred 
times, that we are going to have a lot of post-traumatic stress 
disorder, and our children couldn't handled it as well as our 
adults, and we rapidly put together a great team that was able 
to address those issues for our community. So thank you for 
mentioning that, Senator.
    The Chairman. And you mentioned mental health. This is 
something we are very committed to. You have members--Senator 
Wellstone particularly is a leader, and Senator Domenici, and 
we have to address this issue. We just touched on the substance 
abuse and alcohol abuse, and working with the agencies in 
making sure that they have the high priority in terms of 
investments in SAMHSA. We want to work with you in these areas 
as well.
    So we have a very full agenda, but I think anyone that has 
listened to your responses to these questions, and particularly 
in the wide range of public health matters, has to be impressed 
that you--as well as in the whole range of bioterrorism issues 
which my other colleagues raised and which I am very interested 
in, your background and experience and knowledge about these 
areas is certainly very, very impressive.
    We want to thank you very much for your appearance here 
this morning. We are grateful for your answers. It is my 
intention, since we just came from the recess of the 4th, to 
leave the record open for the next 2 days for questions and 
then to close down the record, and we will move expeditiously 
on your nomination in our committee. I am confident you will be 
confirmed.
    Dr. Carmona. Thank you, Senator.
    [The prepared statement of Dr. Carmona follows:]

              Prepared Statement of Richard Carmona, M.D.

    Chairman Kennedy, Ranking Member Gregg, distinguished members of 
the committee, guests and staff, I am profoundly humbled and honored to 
come before you to be considered for this prestigious appointment as 
the U.S. Surgeon General. Three and a half months ago, I began an 
unanticipated and uncharted journey into the unknown when I was 
nominated by President Bush to be the next U.S. Surgeon General. I am 
still numbed and in disbelief at this extraordinary honor. No one could 
possibly anticipate this unique calling in their life, especially me. 
For in each successive milestone in my life, I have always felt quite 
blessed that I had achieved more than anyone in my family and more than 
I had ever dreamed. From meager beginnings to dropping out of high 
school and finally finding significant life direction from my first 
real employer, the U.S. Army and my then newly adopted family, the U.S. 
Army Special Forces. There I was continually tested, challenged and 
held accountable as I developed essential survival skills that allowed 
me to survive not only in combat, but also equally important . . . 
prepared me for the battlefields of life. Courage, honesty, dedication, 
integrity and sometimes most important of all, tenacity are some of 
those essential tools that were transferable to the ``real world'' as I 
embarked on life. I have been privileged to serve the public in many 
capacities my entire life. From being a lifeguard at a public beach 
through being a soldier, medic, nurse, police officer, physician and 
surgeon, professor, researcher, public health officer, public health 
system CEO and community leader . . . there is no greater endeavor than 
to serve ones fellow man. Now I may have the ultimate opportunity for 
public service before me . . . United States Surgeon General. . . The 
``Top Doc,'' the ``Peoples Doctor,'' . . . This really is a surreal 
experience. As I related to my young, very inquisitive daughter, it is 
as if the fairy godmother reached out and touched me and, cast me in 
the best Disney movie ever made!
    For many years some had wondered about my apparently disjointed 
career paths; military and police special operations, emergency 
preparedness and management, search and rescue, paramedicine, medicine, 
trauma surgery, public health and teaching. However, to me they were 
always complimentary in regards to protecting the public's health, 
safety and welfare. Then came ``9/11'' and my 5 decades of careers 
suddenly all merged and took on a new and even more significant meaning 
as Homeland Defense and Domestic Preparedness became household words.
    Ironic as it may seem, I believe it was best summed up by one of 
our former county supervisors who was quoted in the press as saying, 
``Rich didn't know it, but he has been training his whole life for this 
job,'' (U.S. Surgeon General)! Over the last several months after my 
nomination, I have had the opportunity and privilege to return to 
Washington frequently as I met many of you and others to prepare for 
this day. My perception of the awesomeness of our leadership and 
government has not lessened on any of my subsequent trips, but has 
rather heightened. Every trip here, I feel like a very fortunate 
tourist who has been afforded the opportunity to witness the workings 
of the greatest government and country in the world. As I made my 
rounds on ``the Hill'' and had the privilege to meet many of you, I 
gained a better understanding of the enormous responsibility of the 
position of the United States Surgeon General. I was absolutely 
overwhelmed by your hospitality, candor, graciousness and the passion 
by which you and your colleagues described your areas of interest and 
concerns relating to the health, safety and welfare of our citizens. 
Among our many discussions, a common thread emerged. . . . Prevention, 
whether the issue was counter terrorism, global health, AIDS, quality 
of health care, asthma, substance abuse, or childhood obesity. . . . 
Maintaining health and wellness and preventing disease and injury was 
the highest priority for all of you, as I am happy to say it is for me.
    Of necessity, and by the direction of the President and the 
Secretary, the role of the United States Surgeon General has broadened 
significantly from that of the traditional public health 
responsibilities to now include the expanded leadership role as part of 
the team ``addressing'' homeland defense and domestic preparedness. A 
significant part of this new preparedness endeavor is to build, 
strengthen and expand the Commissioned Corps of the United States 
Public Health Service. These are our unsung heroes, domestic warriors 
who on a daily basis during peace and war are responsible for the 
Nations public health. They can be found working in numerous essential 
capacities nationally, such as researchers at NIH and CDC, clinicians 
at the Federal prisons and the U.S. Coast Guard and within the Indian 
Health Service, just to name a few of their many areas of 
responsibility. More recently they have been highly visible in our 
National Office of Emergency Preparedness and in our Disaster Medical 
Assistance Teams and the National Disaster Medical System.
    The events of ``9/11'' have thrust the new millennium upon us. 
Never before has the potential role of the United States Surgeon 
General been so essential to the President, the Congress and the 
public. As the national leader and spokesperson for health issues as 
well as the advisor to the President and Secretary, the Surgeon General 
has the opportunity to bring the best scientific information forward 
and articulate clearly and concisely complex evidence based science 
that has the ability to improve the health, safety and welfare of our 
citizens. From our brave first responders to mothers and fathers 
throughout America, we need the ability to deliver timely, uniform, 
user friendly information that will empower the receiver to take 
appropriate individual or collective action in daily activities that 
effect individual and public health, as well as during catastrophic 
emergencies such as hurricanes, floods, disasters and events such as 
``9/11.'' In our ``all hazards'' approach, the public is an essential 
component of our team as are our first responders.
    I also recognize that my ultimate success as Surgeon General will 
be co-dependent on the team I am on and the networks I can establish 
and work with to effect change. To that end, I also know that I must 
work diligently in order to establish my credibility with the Congress 
and other--leaders. I will therefore strive to become your consultant, 
ally and spokesperson as you attempt to navigate the sometimes rough 
seas of health and public policy development in serving our Nation.
    Once again in my life I find myself in the enviable position of 
having exceeded my dreams. My goal now is simply to serve you and the 
public in an exemplary fashion so that my legacy would be that my 
presence made a significant difference for our country.
    Thank you very much for the privilege of coming before you to have 
my nomination considered.

    The Chairman. The committee stands in recess.
    [Whereupon, at 11:41 a.m., the committee was adjourned.]
  

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