[House Hearing, 108 Congress]
[From the U.S. Government Publishing Office]





 SERVING THE UNDERSERVED IN THE 21ST CENTURY: THE NEED FOR A STRONGER, 
        MORE RESPONSIVE PUBLIC HEALTH SERVICE COMMISSIONED CORPS

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

                                HEARING

                               before the

                              COMMITTEE ON
                           GOVERNMENT REFORM

                        HOUSE OF REPRESENTATIVES

                      ONE HUNDRED EIGHTH CONGRESS

                             FIRST SESSION

                               __________

                            OCOTBER 30, 2003

                               __________

                           Serial No. 108-108

                               __________

       Printed for the use of the Committee on Government Reform


  Available via the World Wide Web: http://www.gpo.gov/congress/house
                      http://www.house.gov/reform


                                 ______

92-128              U.S. GOVERNMENT PRINTING OFFICE
                            WASHINGTON : 2003
____________________________________________________________________________
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                     COMMITTEE ON GOVERNMENT REFORM

                     TOM DAVIS, Virginia, Chairman
DAN BURTON, Indiana                  HENRY A. WAXMAN, California
CHRISTOPHER SHAYS, Connecticut       TOM LANTOS, California
ILEANA ROS-LEHTINEN, Florida         MAJOR R. OWENS, New York
JOHN M. McHUGH, New York             EDOLPHUS TOWNS, New York
JOHN L. MICA, Florida                PAUL E. KANJORSKI, Pennsylvania
MARK E. SOUDER, Indiana              CAROLYN B. MALONEY, New York
STEVEN C. LaTOURETTE, Ohio           ELIJAH E. CUMMINGS, Maryland
DOUG OSE, California                 DENNIS J. KUCINICH, Ohio
RON LEWIS, Kentucky                  DANNY K. DAVIS, Illinois
JO ANN DAVIS, Virginia               JOHN F. TIERNEY, Massachusetts
TODD RUSSELL PLATTS, Pennsylvania    WM. LACY CLAY, Missouri
CHRIS CANNON, Utah                   DIANE E. WATSON, California
ADAM H. PUTNAM, Florida              STEPHEN F. LYNCH, Massachusetts
EDWARD L. SCHROCK, Virginia          CHRIS VAN HOLLEN, Maryland
JOHN J. DUNCAN, Jr., Tennessee       LINDA T. SANCHEZ, California
JOHN SULLIVAN, Oklahoma              C.A. ``DUTCH'' RUPPERSBERGER, 
NATHAN DEAL, Georgia                     Maryland
CANDICE S. MILLER, Michigan          ELEANOR HOLMES NORTON, District of 
TIM MURPHY, Pennsylvania                 Columbia
MICHAEL R. TURNER, Ohio              JIM COOPER, Tennessee
JOHN R. CARTER, Texas                CHRIS BELL, Texas
WILLIAM J. JANKLOW, South Dakota                 ------
MARSHA BLACKBURN, Tennessee          BERNARD SANDERS, Vermont 
                                         (Independent)

                       Peter Sirh, Staff Director
                 Melissa Wojciak, Deputy Staff Director
                      Rob Borden, Parliamentarian
                       Teresa Austin, Chief Clerk
              Philip M. Schiliro, Minority Staff Director


                            C O N T E N T S

                              ----------                              
                                                                   Page
Hearing held on October 30, 2003.................................     1
Statement of:
    Carmona, Vice Admiral Richard H., U.S. Surgeon General.......    22
    Koop, Dr. C. Everett, former U.S. Surgeon General; Dr. Julius 
      B. Richmond, former Assistant Secretary for Health and 
      former U.S. Surgeon General; and Captain Gerard M. Farrell, 
      Executive Director, Commissioned Officers Association of 
      the U.S. Public Health Service.............................    49
Letters, statements, etc., submitted for the record by:
    Carmona, Vice Admiral Richard H., U.S. Surgeon General, 
      prepared statement of......................................    26
    Davis, Chairman Tom, a Representative in Congress from the 
      State of Virginia, prepared statement of...................     4
    Farrell, Captain Gerard M., Executive Director, Commissioned 
      Officers Association of the U.S. Public Health Service, 
      prepared statement of......................................    70
    Koop, Dr. C. Everett, former U.S. Surgeon General, prepared 
      statement of...............................................    52
    Maloney, Hon. Carolyn B., a Representative in Congress from 
      the State of New York, prepared statement of...............   106
    Richmond, Dr. Julius B., former Assistant Secretary for 
      Health and former U.S. Surgeon General, prepared statement 
      of.........................................................    65
    Waxman, Hon. Henry A., a Representative in Congress from the 
      State of California:
        Letter dated August 11, 2003.............................     7
        Prepared statement of....................................    17
        Prepared statement of Charles LeBaron....................    14

 
 SERVING THE UNDERSERVED IN THE 21ST CENTURY: THE NEED FOR A STRONGER, 
        MORE RESPONSIVE PUBLIC HEALTH SERVICE COMMISSIONED CORPS

                              ----------                              


                       THURSDAY, OCTOBER 30, 2003

                          House of Representatives,
                            Committee on Government Reform,
                                                    Washington, DC.
    The committee met, pursuant to notice, at 10:15 a.m., in 
room 2154, Rayburn House office Building, Hon. Tom Davis of 
Virginia (chairman of the committee) presiding.
    Present: Representatives Mr. Davis of Virginia, Shays, Ose, 
Lewis, Mrs. Davis of Virginia, Duncan, Janklow, Waxman, 
Maloney, Kucinich, Tierney, Clay, Watson, Van Hollen, 
Ruppersberger, and Norton.
    Staff present: David Marin, director of communications; 
Susie Schulte, professional staff member; Teresa Austin, chief 
clerk; Brien Beattie, deputy clerk; Corinne Zaccagnini, chief 
information officer; Leneal Scott, computer systems manager; 
Phil Schiliro, minority staff director; Phil Barnett, minority 
chief counsel; Karen Lightfoot, minority communications 
director and senior policy advisor; Sarah Despres, minority 
counsel; Josh Sharfstein, minority professional staff member; 
Earley Green, minority chief clerk; Jean Gosa, minority 
assistant clerk; and Cecelia Morton, minority office manager.
    Chairman Tom Davis. The hearing will come to order. I want 
to welcome everybody to today's oversight hearing on the 
Department of Health and Human Services' proposed 
transformation of the U.S. Public Health Service Commissioned 
Corps. In light of new and emerging threats to our Nation's 
public health, this hearing will focus on proposed improvements 
to make the Commissioned Corps a more readily deployable force 
to respond quickly and effectively to emergency health needs 
around the country.
    We are slated to have a journal vote at 10:30, so we'll 
move through opening statements, get the statements here and 
get in as much questioning as we can and then take it from 
there. Sometimes they end up not having the votes, but I just 
want to explain, if we have that, we'll recess, go over and 
vote and then come back.
    The Commissioned Corps is one of the seven uniformed 
services of the United States. It is comprised of highly 
trained and mobile health professionals who carry out programs 
to promote good health and understand and prevent diseases and 
injury, assure safe and effective drugs and medical devices, 
deliver health services to Federal beneficiaries and supply 
health expertise in time of war or other national or 
international emergencies. Corps officers have been providing 
health care to American citizens for over 200 years and are 
constantly adapting to changing demands and new challenges in 
the public health field.
    However, currently the Commissioned Corps is underutilized 
and underdeveloped. As a result of this, HHS intends to 
strengthen the public health infrastructure by transforming the 
Corps to meet the challenges of the 21st century. The rationale 
behind the proposed transformation is deeply rooted in new 
emerging threats facing the country. If the United States 
continues to face uncertain threats, including possible 
terrorist attacks and infectious diseases, it's critical that 
the Secretary has well trained medical professionals who can 
respond immediately and appropriately to an emergency need. 
These proposed changes are essential to improving our Nation's 
public health and ensuring that the Commissioned Corps will be 
an effective and efficient force of health care professionals.
    There are three main principles guiding the transformation 
proposal. The first is to expand and enhance the Commissioned 
Corps. The second initiative aims to improve and expand 
training and deployability of commissioned officers to areas 
where primary care services are lacking. The third initiative 
will improve the Commissioned Corps management and development 
structure.
    Under the proposal, the Commissioned Corps' size, structure 
and response capabilities will evolve into a more accessible 
team of health care and public health professionals. The Corps 
will remain committed to traditional public health needs, 
including providing health care to underserved areas around the 
country, supporting the expansion of community health centers 
and strengthening the health care safety net for all Americans. 
These functions will be balanced with emergency response 
efforts to create a better equipped and more effective 
Commissioned Corps.
    In closing, I think it's important to note these ideas for 
reorganization are not novel concepts. Deployability and 
fitness standards for Corps officers date back well over 100 
years. Ultimately, the Commissioned Corps needs to be 
strengthened and its mission broadened to include traditional 
and evolving needs in the public health field. With these 
changes, the Commissioned Corps will be better equipped to 
protect, promote and advance our Nation's public health.
    I understand that some of our witnesses this morning will 
express concerns about specific elements of the transformation 
plan and we welcome their comments. I look forward to a 
constructive dialog on these concerns. I know we all share the 
same goal at the end of the day, and that's a Commissioned 
Corps dedicated to and prepared for emerging 21st century 
challenges and needs.
    We have a great selection of witnesses to provide testimony 
this morning. Surgeon General Carmona is here to provide the 
committee with an overview of the Commissioned Corps, and 
detail the need for reorganization of the Corps. Joining us on 
our second panel will be former Surgeon General Dr. C. Everett 
Koop, who will offer his opinions on the transformation policy. 
Former Assistant Secretary for Health and former U.S. Surgeon 
General Dr. Julius Richmond will also provide the committee 
with his expertise in the area of public health. And finally, 
Captain Gerard Farrell, executive director of the Commissioned 
Officers Association will offer the perspective of officers in 
the Commissioned Corps.
    [The prepared statement of Chairman Tom Davis follows:]

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    Chairman Tom Davis. I now recognize the distinguished 
ranking member, Mr. Waxman, for an opening statement.
    Mr. Waxman. Thank you very much, Mr. Chairman.
    I want to thank Chairman Davis for agreeing to my request 
to hold this hearing today on the future of the Commissioned 
Corps of the Public Health Service. A bipartisan hearing on 
this issue is fitting. As administrations and Congresses have 
come and gone, the Commissioned Corps has steadily advanced 
public health for more than 100 years, saving millions of lives 
in the United States and around the world.
    It's easy to overlook the critical contributions of the 
Commissioned Corps to our Nation's health and safety. 
Commissioned Corps officers review drug applications at the 
FDA, search for breakthrough cures at NIH, and staff the front 
lines of response to public health emergencies. The Corps 
responded to the disaster at the Three Mile Island nuclear 
plant in 1979, the measles outbreak of the late 1980's, and the 
emergence of SARS earlier this year. To date, the more than 
6,000 members of the Corps fulfill critical functions in more 
than 20 science-based agencies and offices.
    Today's hearing will focus on a plan proposed by Secretary 
Tommy Thompson to transform the Commissioned Corps. The plan 
has two main goals: to increase the preparedness of the United 
States for a public health emergency and to improve care for 
the medically underserved. Both of these goals are critically 
important, and there is widespread support for modernization of 
the Corps. The question we face is not whether the Corps should 
be altered to meet today's challenges, but how and by what 
process. Details matter. Unfortunately, the details of the plan 
put forth by Secretary Thompson have serious flaws.
    I have written to Secretary Thompson expressing my concerns 
about the proposed transformation plan. The problems with his 
plan include the new physical fitness and deployment 
requirements that could drive many experienced and dedicated 
scientists and other health professionals out of public 
service. That's one big problem. The plan also leaves the 
Surgeon General with too little management authority over the 
Corps. I ask, Mr. Chairman, that the letter I wrote to 
Secretary Thompson be included in the record.
    Chairman Tom Davis. Without objection, so ordered.
    [The information referred to follows:]

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    Mr. Waxman. In fact, the current administration proposal 
has so many problems that it has raised serious concerns among 
those who should be its stronger supporters. For example, 
Commissioner Mark McClelland of the Food and Drug 
Administration has written to Secretary Thompson that the 
physical fitness standards could drive ``extremely talented and 
committed officers'' out of public service. Dr. Elias Zerhouni 
is the Director of the National Institutes of Health, where 
more than 400 officers serve in many leadership roles. Dr. 
Zerhouni told me at a recent Energy and Commerce Committee 
hearing that he has serious concerns about Secretary Thompson's 
proposal. He testified that he was willing to share a letter 
that he wrote to the Secretary about these concerns with the 
committee. I'm disappointed that the Department has blocked him 
from doing so.
    Public health experts at the Centers for Disease Control 
and Prevention have also voiced serious concerns. According to 
a senior CDC bioterrorism expert, Dr. Charles LeBaron, this 
proposal could undermine public health preparedness. Dr. 
LeBaron is concerned that by emphasizing deployment and 
physical fitness, the transformation plan will produce a Corps 
that is long on mobility but short on expertise. Dr. LeBaron 
asks, if a dirty bomb were to explode in the United States, 
``would the Nation be better served and defended by experts in 
radiation or by a collection of persons whose primary 
credentials lie with the number of situps they could perform 
and their ability to align the seams of their upper and lower 
garments?'' I ask that his written comments on the proposed 
transformation plan be included in the record.
    Chairman Tom Davis. Without objection, so ordered.
    [The information referred to follows:]

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    Mr. Waxman. I requested that Dr. LeBaron testify, and 
Chairman Davis invited him to this hearing. Unfortunately, the 
Department has said it would only let him testify as a private 
citizen, without his uniform and at his own expense.
    Others who should support the plan to improve the 
Commissioned Corps include former leaders of the Corps. I have 
heard from several former Surgeons General and former Assistant 
Secretaries of Health. These distinguished public servants, two 
of whom are here today, are concerned that the transformation 
plan leaves the current Surgeon General with very little 
authority over the Corps. They believe that a splintered Corps 
management system threatens to undermine recruitment, morale 
and effectiveness.
    A transformation plan should also be supported by 
commissioned officers themselves. In that regard, we will have 
the opportunity today to hear from Gerald Farrell of the 
Commissioned Officers Association, which represents 70 percent 
of active members of the Commissioned Corps. He has previously 
said that the proposal appears ``crafted to destroy Corps 
morale'' and ``drive officers out of Government service.''
    A Corps reorganization plan requires the complete support 
of the current Surgeon General, who is the historic leader of 
the Corps. I welcome Vice Admiral Dr. Richard Carmona to this 
hearing. I hope this is an opportunity for him to speak frankly 
about what changes are needed to the Secretary's original 
proposals.
    Let me conclude with an observation. There is simply too 
much at stake for a major Corps transformation to be bungled. I 
have spent my career in Congress fighting to expand access to 
care for the underserved and to improve our public health 
system. I would love to see a Commissioned Corps for the 21st 
century that is even more involved in these longstanding 
concerns. But if there is so much opposition among those who 
should be supporting this proposal, then it is time to take a 
step back. HHS should develop a clear process to make sure any 
changes to the Corps achieve their intended goals.
    I want to thank you, Mr. Chairman, for holding this 
hearing, and the witnesses for coming, and I look forward to 
their testimony.
    [The prepared statement of Hon. Henry A. Waxman follows:]

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    Chairman Tom Davis. Thank you very much. Are there any 
other Members who wish to make opening statements? Hearing and 
seeing none, we have Vice Admiral Richard Carmona here. Would 
you rise with me, and I'm going to swear you in, it's our 
committee tradition.
    [Witness sworn.]
    Chairman Tom Davis. Thank you very much. We're pleased to 
have you with us. We have a light in front that will go orange 
after 4 minutes, red after 5. If you need to go over a little 
bit, do it, but your entire statement is in the record, and 
we'll base our questions on that. We're looking for votes in 
about 15 minutes. We may be able to get through questions and 
get out of here if we do it quickly.

  STATEMENT OF VICE ADMIRAL RICHARD H. CARMONA, U.S. SURGEON 
                            GENERAL

    Admiral Carmona. Thanks for the opportunity for allowing me 
to come before you today. Secretary Thompson sends his 
greetings but also his regrets that he cannot be here today.
    I appreciate the opportunity to address the Committee on 
Government Reform about the administration's efforts to 
transform the Public Health Service Commissioned Corps into a 
more mobile and responsive national resource for meeting some 
of our Nation's most important public health challenges. I am 
particularly pleased to have this opportunity to describe to 
you and the members of the committee the Department's vision of 
the transformation, to delve into the overall objectives and to 
clear up any of the misconceptions about the transformation and 
what it is and what it is not.
    I want to start my prepared statement with a clear message: 
the Public Health Service Commissioned Corps has a long and 
proud history. I am proud of its service to this country and 
the officers who serve in the Corps are justly proud of their 
accomplishments. I have pride in the achievements of people 
such as Rear Admiral Craig Vanderwagen, whom Secretary Thompson 
deployed from the Indian Health Service to Iraq. There is no 
better way to illustrate his service than to quote from his 
recent e-mail message back to us. He wrote: ``The Ministry of 
Health in Iraq has some marvelous professionals who are very 
happy to have the opportunity to do good things for their 
country after years of neglect. We will build a primary care 
system that has not existed here before to complement the 
improvements in public health systems. I am happy to be here 
and growing immensely in this environment and thankful every 
day for the opportunity to be part of this.''
    I applaud the work of commissioned officers like Captain 
Ken Martinez of the National Institutes for Occupational 
Health, a component of CDC and Commander Tim Cote of the Food 
and Drug Administration. Captain Martinez, an engineer who 
works in the field of industrial hygiene, was among the 
officers responding to the anthrax release on Capitol Hill. He 
was deployed from CDC and served 24/7 for several weeks. 
Commander Cote, who is currently the Chief of Therapeutics and 
Blood Safety at the Center for Biologics at the FDA, not only 
served during the anthrax release, when he was assigned to the 
NIH, but also volunteered to deploy for duty in Iraq. It is the 
dedication of individuals like Commander Cote, Captain Martinez 
and Rear Admiral Vanderwagen that exemplifies the best of the 
Corps, past, present, but more importantly, future.
    While the Corps has responded well during many public 
health emergencies, including most prominently the September 
11th attack and the anthrax release on October 15th, Secretary 
Thompson and I believe that our capabilities will have to be 
broader, our resources deeper, and our flexibility enhanced if 
we are going to be ready to address the needs of our citizens 
when they are faced with future national emergencies. We need 
to be ready should local and State public health resources be 
overwhelmed by urgent public health needs, whether engendered 
by a terrorist attack, a natural disaster such as a significant 
earthquake, or a nationwide disease threat, such as would be 
created by an influenza pandemic. In fact, during the past few 
weeks, in preparation for and in response to the havoc created 
by Hurricane Isabel, Secretary Thompson deployed 176 
commissioned officers to several communities, to seven State 
emergency operations centers and to six State health 
departments. These officers served with distinction and I am 
proud of what they have accomplished.
    In addition to addressing public health emergencies, 
ongoing Corps deployments across the country are essential to 
protect public health. For example, the Indian Health Service 
is facing both significant recruiting problems and a large 
number of vacancies, half of them for nurses, in providing care 
for our American Indian and Alaska Native populations. 
Similarly, the President and the Secretary, from the beginning 
of this administration, have recognized that we need thousands 
of health care professionals to overcome shortages in health 
centers and National Health Service Corps placement sites where 
recruitment efforts have fallen short of expectations.
    Secretary Thompson and I are equally concerned that we do 
not have a sufficiently large force, appropriately trained, 
suitably experienced, and readily deployable to address special 
needs, such as the critical issue of childhood immunization. 
Across our Nation, there are urban and rural areas where the 
percentage of children unprotected from critical diseases is a 
serious concern to us all. Further, we need to strengthen our 
national prevention effort. For example, early diagnosis of 
diabetes is important, particularly among some of the most 
needy members of our society. That public health professionals 
are attuned to the early signs of diabetes is crucial to 
controlling the progress of that disease, as well as 
controlling the cost of treatment and more serious conditions 
connected with progression of the disease. Another example is 
the need to respond to the difficult health care issues we face 
along the southwest border. The fact of the matter is that when 
it comes to national resources to address urgent and unexpected 
national public health demands such as these, there are too few 
readily accessible public health professionals at our disposal 
to deploy as needed.
    Over the past several decades, ever since the public 
service hospital system was disbanded, the management of the 
Corps has become more and more decentralized and the structure 
of the Corps less and less distinguishable from the Civil 
Service. The requirements that were placed on the department 
during the events of September 11th and the anthrax attack 
underscore the importance of the Public Health Service 
Commissioned Corps, as well as the need for more direct 
responsibility exercised by the Secretary. Therefore, the 
Secretary has asked his principal health official, the 
Assistant Secretary for Health, to be responsible for policy 
and oversight of the Corps and the Surgeon General to implement 
these policies and be responsible for the operation of the 
Commissioned Corps.
    To strengthen our Corps and broaden its mission to include 
new dimensions that are clearly necessary, we need to revamp 
and strengthen our recruitment efforts, use our promotion 
systems to reinforce and reward the best of qualities of a 
truly national, mobile public health force, bring our 
administrative management systems into the 21st century, and 
adapt the best DOD personnel practices for use in managing the 
Public Health Service Commissioned Corps.
    For years, authority has existed in the Public Health 
Service Act to appoint warrant officers as part of the 
professional Public Health Service Commissioned Corps. 
Secretary Thompson now needs to use the authority to expand the 
capacity of the Commissioned Corps. We need to be able to 
access the clinical resources of registered associate degree-
trained nurses that every State recognizes and licenses to 
provide clinical nursing services. Appointing them as warrant 
officers permits us to expand the service delivery capacity of 
the Corps. At the same time, we want to give them access to the 
education that would be required if they wanted to be 
commissioned officers after receiving a bachelor's degree in 
nursing. Likewise, we want to use the rank structure to add 
other members of the health care team such as laboratory 
assistants, physical therapy assistants and paramedics.
    As part of this effort and at the direction of Secretary 
Thompson, I am already strengthening our Basic Officer Training 
Course to ensure that newly recruited officers are fully aware 
of our readiness standards and deployment systems when they 
first enter on duty. Also, as part of the transformation of the 
Corps, Secretary Thompson and I believe we should explore ways 
to strengthen and expand our reserves as a readily available 
source of additional officers, should we be required to respond 
to public health emergencies and other urgent requirements that 
exceed our active duty capacities. Therefore, the Secretary has 
asked me, working with the Assistant Secretary of Health, to 
look into options for that aspect of the transformation. 
Growing and maintaining a healthy, robust reserve could be 
instrumental in the pursuit of easing the maldistribution of 
public health professionals, without significantly adding to 
the size of the Federal payroll. These public health 
professional reservists could practice their professions within 
their communities all across the Nation and strengthen the 
capacity to respond to emergencies at a local level without the 
need for massive relocation of people and assets in times of an 
emergency.
    There are several other reforms that we are developing as 
part of the transformation initiative. I have mentioned reforms 
directly affecting the lives of officers currently serving in 
the Corps. The continued dedication and commitment of 
commissioned officers to the public health of this Nation is 
very important to both the Secretary and me. We will move to 
strengthen the development of those members of the Commissioned 
Corps who have devoted their careers to research in public 
health by establishing more formally structured career tracks. 
They will provide officers with clear growth opportunities to 
which they can aspire.
    Our Nation asks much of these dedicated individuals, many 
of whom could migrate to the more lucrative private sector. 
Instead, these dedicated officers choose to serve in the Corps 
to the benefit of the entire Nation. In the past, the mission 
statement of the Commissioned Corps has been tailored to focus 
on supporting the activities of agencies that comprise the 
Department of Health and Human Services. Secretary Thompson and 
I believe that we need to revise that statement to better 
emphasize all of the values that have long been part of the 
Commissioned Corps: to protect, promote and advance the public 
health, science, and security of the Nation, domestically and 
globally, as America's uniformed service of uniquely qualified 
health professionals.
    Because much has been speculated about the impact of this 
transformation on existing officers and the potential for 
disruption of their service, I want to conclude and emphasize 
what the transformation is not. Much information has been 
printed and, contrary to characterizations in the media and 
misconceptions elsewhere that have caused concern among 
officers, I would like to make two points. First with regard to 
deployment of officers, any deployments undertaken will be 
congruent with an officer's skills, competencies and physical 
capabilities. To be clear, sending officers such as bench 
scientists, FDA regulatory specialists or epidemiologists from 
CDC to achieve mission objectives that are not consistent with 
their specific training and physical capabilities makes no 
sense. The transformation contemplates no such thing.
    Second, with regard to promotion standards, no system will 
be adopted that places undue demands on an officer with regard 
to training or physical strength. In fact, the three-tiered 
readiness standards we are proposing will impose no new 
physical fitness standards at the basic level through the 
calendar year 2004, and will establish, as other uniformed 
services do, a medical waiver provision. There will be phased-
in incentives for officers to seek higher levels of training 
and deployment capability, but no officer will be disadvantaged 
for promotion by physical fitness standards in the 2004 
promotion cycle.
    Mr. Chairman, for over 200 years, the U.S. Public Health 
Service Commissioned Corps has served our country well. But 
today, faced with new challenges and new threats, 
transformation of the Commissioned Corps is a necessity. As 
envisioned, the transformed Corps will provide this and future 
Presidents with a more highly trained, capable and mobile cadre 
of public health professionals. We can accomplish this without 
disadvantaging any current members of the Corps, and we can 
accomplish this within the limits provided us by Congress for 
the size of the Commissioned Corps.
    Mr. Chairman, that concludes my statement and I am ready to 
respond to any questions you may have. Thank you, sir.
    [The prepared statement of Admiral Carmona follows:]

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    Chairman Tom Davis. Thank you very much. I have to tell 
you, before this I knew very little about it. This has not been 
a subject in my years that I've spent much time on. I know Mr. 
Waxman has spent a lot of time with this, so I'm learning my 
way through.
    What distinguishes the Commissioned Corps from the Civil 
Service?
    Admiral Carmona. We are in uniform, sir. We are one of the 
seven uniformed services of the United States. Our function, 
our mission, as I stated, is to protect and advance the health 
of the Nation. As you know now, with the threats upon us, that 
has really increased somewhat to be more of a global 
responsibility. As you see, we have officers in Iraq helping to 
rebuild the Health Ministry.
    Chairman Tom Davis. Being uniformed gives your superiors 
more ability to direct than civil servants, too, doesn't it? 
Isn't there more flexibility to direct the uniformed personnel?
    Admiral Carmona. Yes, sir, I think that is one element, 
just as our sister services, that it allows the leadership to 
direct those assets where they may be needed.
    Chairman Tom Davis. OK. Secretary Thompson claimed in his 
announcement of the plan back in July that it would give the 
Surgeon General more authority over the Commissioned Corps than 
ever before. Do you agree that your position will receive added 
responsibility?
    Admiral Carmona. Sir, based on the plan that the Secretary 
has put forward, I think the Surgeon General will have 
unprecedented authority for the operations of the Public Health 
Service Commissioned Corps on a day to day basis. Working in 
concert with the Assistant Secretary and the Secretary who will 
develop the policy for administering the Corps, and in effect, 
the direction to the Surgeon General as to how to operate the 
Corps on a day to day basis.
    Chairman Tom Davis. How do you interact, under the new 
management structure, how does it work with the Assistant 
Secretary for Health? Can you walk me through the new versus 
old, if there is a difference?
    Admiral Carmona. The way the system is proposed to be set 
up, sir, is that the Assistant Secretary, being the Secretary's 
chief deputy for public health matters, oversees the Office of 
Public Health and Science. The Surgeon General reports through 
the Assistant Secretary to the Secretary, and the Secretary, by 
delegation, delegates to the Assistant Secretary certain 
authority to generate policies and oversee the Commissioned 
Corps. In addition, I will have certain delegated authorities 
to operate the Corps on a day to day basis.
    Chairman Tom Davis. OK. We learned after September 11, the 
anthrax scare, SARS, and other recent public health 
emergencies, that solid coordination between Federal, State, 
and local levels is key to handling emerging public health 
threats. We had testimony here last week on the Post Office, 
where some of the advice that was given, frankly, wasn't the 
right advice, it was something that was newly handled by CDC 
and the Postal Service. How will the new transformation improve 
coordination between Federal, State and local levels? Is that 
one of the goals of this, to improve that?
    Admiral Carmona. We are working on improving this right now 
through our Assistant Secretary for Public Health and Emergency 
Preparedness, where we have Corps officers, CDC, NIH, we're 
really all partners in this preparedness. The threats that were 
thrust upon us on September 11 and then on October 15 are very 
new. Having to revitalize, reorganize ourEMS systems from the 
local to the State to the Federal level so that we have a 
seamless system that's able to deal with all hazards, that 
includes the every day things--the hurricanes, the earthquakes, 
the fires in California that are being experienced now--as well 
as the new threats where, quite frankly, who could have 
expected that planes would have been characterized as weapons, 
or pathogens characterized as weapons? It's a very new world, 
but I think we're making significant progress in moving in that 
direction.
    Chairman Tom Davis. What's the communication been like? As 
this plan was being developed, what was the communication like 
from the bottom up ranks? Were there meetings and solicitations 
of ideas, or did this come in basically a top-down 
reorganization?
    Admiral Carmona. I don't think it was a top-down, sir. I 
think what occurred, and I will state that, prior to my 
becoming Surgeon General, this was an issue for the Secretary 
that he was bringing forward. In fact, as I went through my 
interviews, I was questioned about the Public Health Service 
structure, what I saw as the future of the Public Health 
Service, if I was in that position, how I would lead the Corps 
in this transformation. So it predated me.
    Chairman Tom Davis. Right.
    Admiral Carmona. When I came in, there was already a 
structure in place by the Acting Surgeon General, who is my 
deputy now, who had formed committees to begin to discuss 
information within the troops and begin a dialog that would 
move up and down the chain of command on how the transformation 
should go forward.
    Chairman Tom Davis. Has the dialog been satisfactory from 
your perspective?
    Admiral Carmona. The dialog has been a good one. It's been 
a vigorous one. There have been, as you can imagine, as many 
opinions as we have officers. So as you all in Congress have to 
deal with thousands of constituents who see the world 
differently, we have to work hard to develop a consensus and 
try and accommodate all of the input.
    Chairman Tom Davis. Thank you. Mr. Waxman.
    Mr. Waxman. Thank you, Mr. Chairman.
    Admiral Carmona, I want to welcome you to our hearing 
today.
    Admiral Carmona. Thank you, sir.
    Mr. Waxman. To followup on that point about how this plan 
was put together, the Surgeon General is the historic leader of 
the Commissioned Corps. Were you the main author of the plan?
    Admiral Carmona. I think it was a team that put together 
the plan, sir. I could not take credit for it. It was all of us 
who worked on it.
    Mr. Waxman. When it was announced on July 3, had you 
personally reviewed the plan and signed off with your approval?
    Admiral Carmona. The announcement that the Secretary 
brought forth on July 3rd I was fully aware of and fully 
supportive of. In his statement that was delivered, if that's 
what you mean, on July 3rd, yes, sir. I had seen that and was 
fully supportive of his vision to transform the Corps.
    Mr. Waxman. We know that FDA's Commissioner McClelland has 
written to the Secretary, critical of some parts of the 
proposal. And I heard from NIH Director Zerhouni who also had 
serious concerns about the plan. How is it that this plan was 
produced without finding some basic agreement with the 
directors of these critical public health agencies which employ 
hundreds of Corps officers?
    Admiral Carmona. Sir, if I might, I'm not sure that it was 
so much criticism as, for instance in Dr. McClelland's case, 
whom I was in contact with continually, as well as Dr. Zerhouni 
and Dr. Gerberding, who are my peers, he asked for input from 
his troops as to what the issues are. In fact, he assigned me 
two senior officers of our Commissioned Corps to work with me 
in getting that information. I viewed his letter more as a 
synthesis of the input he got that was then transferred to us 
to take appropriate action on. So we welcomed his input, as we 
did Dr. Zerhouni's and Dr. Gerberding's.
    Mr. Waxman. I think they're reflecting a lot of unhappiness 
with members of the Corps, and I'm sure you've heard from 
people in the Corps as well, the draft proposal establishes 
universal fitness standards for all Commissioned Corps 
officers. Those who don't meet the standards would lose 
promotions and face dismissal from the Corps. I wrote to the 
Secretary in August that this could prompt an exodus of 
expertise from science-based agencies.
    Can you explain how the proposed physical fitness 
standards, which include a minimum number of pushups, are 
relevant to experienced officers who are world class scientists 
or expert drug reviewers?
    Admiral Carmona. Yes, sir, I'd be happy to and I appreciate 
your asking the question, because certainly that's been the 
crux of some of the misconceptions. The proposal as we put it 
forth has a three-tiered system. In fact, only if you're going 
to be in the upper tiers, the advanced tier, where you'd have 
some more stringent physical requirements, would you be doing 
anything like pushups or timed runs. So the entry level or 
basic level really is for any one of our officers. Basically, 
it consists of a current physical exam on file that you're 
healthy, that you've got your vaccinations up to date, that 
you've got your basic CPR card on file, and the online modules 
of education that will bring you up to speed, so to speak, on 
emergency deployments and how our system works.
    So in fact, there really is no intent to affect the 
officers as far as losing ability for promotion or for an 
exodus from the Corps. In fact, it allows the officers to 
gravitate to the level based on their skills, competencies and 
what they do, using the example of that lab researcher that you 
alluded to. There would be no intent to deploy that person to 
an environment that they could not work in. However, prior to 
September 11, or October 15, we never expected we'd have to 
deploy a lab scientist some place to figure out some complex 
issue, as we did with anthrax, for instance.
    Mr. Waxman. Before you get into that, you're suggesting the 
policy is different than what I read in the draft proposal. 
Have there been changes in the draft proposal? For example, I 
wrote to Secretary Thompson and I asked him what will happen if 
an officer cannot meet the fitness standards, for example, the 
weight limits or physical fitness requirements. Will promotions 
be withheld or not? And it seems to me that the answer I got 
back was, ``Well, there can be a waiver, but still it's in 
place.''
    Admiral Carmona. Sir, if I might, I think that maybe 
there's some confusion with the old Commissioned Corps 
readiness force. That is changing, the concept that the 
Commissioned Corps readiness force was always looked to be 
phased out. We have about 50 percent of our Corps qualified now 
as Commissioned Corps readiness force, which does meet physical 
standards of running or swimming and pushups and things like 
that.
    Mr. Waxman. So only 50 percent has to meet these?
    Admiral Carmona. No, what I'm saying is that was the 
previous system. What we've done now in this proposal is to 
begin to phaseout CCRF where the whole Corps would be looked at 
as a deployable force, but with different standards within the 
Corps: an entry level, a middle level and an advanced level. 
And that entry level is, for instance, let's say a bench 
scientist who's not going to have to go out and do rescues or 
something that's highly physical, but we want to make sure that 
if they had to be deployed, which would be unlikely----
    Mr. Waxman. Is there anything in writing about this?
    Admiral Carmona. Yes, sir.
    Mr. Waxman. Other than the draft statement, draft proposal 
itself?
    Admiral Carmona. We have many things in writing, sir, that 
have been circulated as we were going through the dialog with 
all the authors and staff----
    Mr. Waxman. Well, if there's been some change, I'd like to 
be sure we get it. But let me ask you----
    Admiral Carmona. We'll get with your staff, sir.
    Mr. Waxman. Great. Just one, because my time is up and I 
hope we'll get a second round. You testified about the role of 
the Surgeon General and you say it's unprecedented authority. 
We're going to hear from two former U.S. Surgeons General, Dr. 
C. Everett Koop and Dr. Julius Richmond, both will testify that 
this reorganization plan does not give enough authority to the 
Surgeon General. The plan sets up a new Office of Corps Force 
Management that's responsible for training, recruitment and 
assignment of support, officer support, and the new office is 
separate from the Office of the Surgeon General and reports to 
the Assistant Secretary for Health. You said that you are going 
to have unprecedented authority day to day. But it sounds like 
some of your predecessors are saying when it comes to policy 
and recruitment, you as Surgeon General will have less 
authority than Dr. Koop and Dr. Richmond had. Do you agree with 
that?
    Admiral Carmona. Well, sir, first of all, I certainly 
respect the large shoes I filled following Drs. Richmond and 
Koop, who were certainly role models for all of us. So no 
question, I welcome their input. I have not seen specifically 
what they have said, though. But based on the plan that is 
before us, and understanding the history of the Corps from 
1966, this plan proposes to give the Surgeon General the 
authority to operate and manage the Corps based on policy that 
emanates from the Secretary and the Assistant Secretary.
    Mr. Waxman. But the policy used to emanate from the Surgeon 
General, is that right?
    Admiral Carmona. I think if you go back historically, prior 
to 1966, when there was no ASH and there was a Surgeon General 
that really did both positions, that's a different issue. But I 
think if you look at the history over the last 40 years, the 
Surgeon General has had periods where he was strong and periods 
where he or she was not. I think this plan really does put some 
meat on the bones, so to speak, and gives the Surgeon General 
authority.
    The issue of OCFAM is an interesting one, because I think 
there was a misconception. The Secretary has clarified that. 
OCFAM is a staff or an advisory group that the ASH will have at 
his or her disposal to be policy advisory. They are not going 
to be operating anything. The operation will be delegated to 
the Surgeon General for all functions of the Corps. That would 
include recruitment and that would include personnel functions. 
But the policy that would give instruction to the Surgeon 
General on how to operate the Corps would come from the 
Secretary and the ASH. That's the distinction, sir.
    Mr. Waxman. Well, it's a, it's a distinction that disturbs 
many of us, because we have always seen the Surgeon General as 
the key person, and not the Assistant Secretary for Health. We 
think a lot of your prerogatives and responsibilities are being 
taken away and we don't see that as particularly a good idea. 
But I'll get back to you on the second round.
    Admiral Carmona. Thank you, sir.
    Chairman Tom Davis. Thank you. I'm going to recess the 
hearing. Can you stay with us? We should be back in probably 
20, 25 minutes.
    Admiral Carmona. Yes, sir, thank you very much.
    Chairman Tom Davis. We'll take a break and reconvene in 
about 25 minutes. We have three votes over on the House floor. 
Committee is in recess.
    [Recess.]
    Chairman Tom Davis. The committee will come back to order.
    Mr. Waxman, you are recognized for additional questions.
    Mr. Waxman. Thank you very much, Mr. Chairman.
    Admiral Carmona, you can understand how there's a lot of 
anxiety out there by members of the Corps that they're going to 
have to go and pass some physical fitness test, even though 
they're working in something that has nothing to do with that. 
We'll want to look for some clarification on this whole point, 
because Dr. LeBaron, I mentioned in my opening statement, is a 
CDC bioterrorism expert. He's expressed concern that we're 
going to have a retrogression in our preparedness if we don't 
have the experts needed to lead our emergency response because 
they couldn't pass the physical fitness exam and do the 
requisite number of pushups.
    We're hearing from people who are very anxious, because if 
they are commissioned officers and they have to leave the Corps 
prior to 20 years of service, they lose all their retirement 
benefits. When you change the promotion and other rules mid-
stream, they're put in a terrible position. I'm sure you can 
understand why so many of these officers are concerned about 
having the rules changed in the middle of their careers. 
They've given a lot to public health and it's imperative to 
avoid mistreating them and draining our science-based agencies 
of expertise.
    I suppose it was a debate within the administration as to 
who's better able to handle the management structure and to set 
the actual policy for the Corps. On the one hand, it could be 
the Assistant Secretary of Health. On the other, it could be 
the Surgeon General. Give me the arguments for both sides, very 
briefly. Why would we want to have that management decision in 
the Assistant Secretary as opposed to the Surgeon General? It 
used to be one person, but now it's two.
    Admiral Carmona. It's a far more complex world now, and 
greater responsibility. But the Secretary encouraged us to have 
a vigorous debate about this issue. Because there is no right 
answer. But we were looking for a logical division of 
responsibility and authority and policy----
    Mr. Waxman. Just give me the argument. If you were 
advancing the argument for giving it to the Assistant Secretary 
of Health, what would you say?
    Admiral Carmona. That the Surgeon General, in being the 
commander of the Corps every day, running the operation for the 
U.S. Public Health Service, as well as being an advisor to the 
President and the Secretary and being on the road quite a bit 
for public health issues around the country if not the world, 
probably has enough to do with just those components, and that 
policy might be much too much. Now, on the other side----
    Mr. Waxman. Give me the argument the other way. Let's say 
you were making the argument, self-interested as it may be, but 
for the institution and the decision in general.
    Admiral Carmona. I never was on a debate team, but I'll 
play the game. [Laughter.]
    The issue of the Surgeon General having it, really, if you 
argued for it, would be that, some would argue that, why would 
you divide management and policy, that they are intricately 
related and that we should probably consider having those 
together. Now, notwithstanding the fact that really the 
Secretary is the one that has the authority for the entire 
Health and Human Services, and delegates that authority for 
certain functions to the ASH or the Surgeon General. So really, 
the ASH doesn't have policy authority unless it's delegated 
from the Secretary.
    Mr. Waxman. OK. You're a combat-decorated Vietnam war 
veteran, aren't you?
    Admiral Carmona. Yes, sir.
    Mr. Waxman. You served in the military?
    Admiral Carmona. Yes, sir.
    Mr. Waxman. As Surgeon General, what's your rank?
    Admiral Carmona. I'm Vice Admiral, 09 pay grade.
    Mr. Waxman. And how many stars are associated with this 
rank?
    Admiral Carmona. That's a three star billet, sir.
    Mr. Waxman. It's my understanding that if an Assistant 
Secretary for Health is a member of the Commissioned Corps and 
is not also the Surgeon General, this person becomes a four 
star general. I also understand that Congress authorized this 
structure at a time when the Assistant Secretary for Health had 
more responsibility than today. Is it typical in other branches 
of the uniformed services that political appointees would be 
put in a uniform and take the rank of a general or admiral?
    Admiral Carmona. Well, sir, it's a good question. The 
system that we are proposing is parallel to that of the 
Department of Defense. My colleagues in the Army, Navy and Air 
Force are also three star billets, so either admiral or 
lieutenant general, vice admiral, lieutenant general at an 09 
level. So Army, Navy, Air Force and myself, we are the four 
Surgeons General, if you will, of the country.
    The Assistant Secretary in the Department of Defense that 
those Surgeons General report to is what you would call a four 
star equivalent, has the authority of a four star general or 
admiral, but doesn't wear the uniform because they are a 
civilian in an assistant secretary position. So your 
distinction between HHS and DOD is correct, that in the past, 
there was a change in statute that allowed for the Assistant 
Secretary to put on the uniform and not just be an equivalent 
of a four star.
    Mr. Waxman. But would you recommend that an assistant 
secretary of health who was a political appointee put on the 
uniform of the Commissioned Corps and become a four star 
admiral over the Surgeon General? And would having too many 
political appointees in uniform pose any danger for the 
professionalism of the Corps?
    Admiral Carmona. That's a very tough question, sir. I've 
been involved in discussions and have had discussions with my 
colleagues at DOD as well as within the Corps and others as to 
should that be more of a DOD type position at Assistant 
Secretary. There are pros and cons, just as there were with the 
issues that you asked me to take both sides of just a moment 
ago.
    I think that when you put a uniform on a person who hasn't 
come up through the ranks or understands, you do put them at a 
disadvantage because there's a certain culture that's 
engendered in that uniform that takes decades to get to. So I 
think that, unknowingly, that person is put at a disadvantage 
with their peers because they're, from everything from not 
being sure how to wear the uniform or salute or what the common 
courtesies are and the culture of the uniform. It makes it very 
difficult. So you'd have to propose an argument that would say, 
well, what is the benefit to putting the uniform on that 
person, rather than just having the equivalent and give them 
all of the graces that go along with the position, so to speak, 
but not the uniform itself.
    Mr. Waxman. Do you feel like you're now becoming a lawyer 
because you're saying on the one hand and then on the other 
hand?
    Admiral Carmona. Almost. A little more practice I'll be OK.
    Mr. Waxman. You're doing a good job.
    One last question I want to ask, and then I know others 
have things they want to pursue. The transformation plan 
proposes to create a warrant officer rank within the Corps to 
hire hundreds of associate nurses. My understanding is that the 
Navy has tried and abandoned this approach and that it's drawn 
criticism from the Chief Nurse Officer. Have you studied the 
experience of associate nurses and other services, and what is 
the logic for not proceeding more slowly with this plan?
    Admiral Carmona. Sir, that's a very good question. It's 
probably best to answer it in terms of why we even considered 
it. As you know, nationally, there's a nursing shortage, 
whether they're associate degree nurses or bachelor-trained 
nurses. It's certainly easier to access the associate degree 
nurses who are in a 2-year program than a 4. Now, I'm a former 
registered nurse. I understand the issues of nursing.
    The reason that the Secretary chose to move in this 
direction was, we have huge unmet needs in the Indian Health 
Service and underserved areas around the country, and nursing 
is one of those biggest needs. So we were looking to be able to 
get nurses at the bedside, in the communities, to serve those 
underserved populations. In fact, I just got an e-mail last 24 
hours, request for nurses specifically in Alaska and the Arctic 
Circle; for nurses to do OB/GYN as well as primary care, 
because the Eskimos have to travel over 500 miles if we can't 
get some people up there to fill the void.
    In your area, sir, we got a request for nurses because of 
the forest fires.
    Mr. Waxman. My question that I don't think you're 
answering, not that you don't have good intentions behind it, 
but there has been an attempt to do this and it didn't succeed. 
My question was, whether anybody studied the experience of 
associate nurses in other services and the fact the Navy tried 
it and abandoned it later should have been some lesson.
    Admiral Carmona. We did, sir, and in answer to your 
question directly, we did study those experiences and spoke to 
our colleagues in the other uniformed services. The driver for 
this was, we still have these huge, unmet needs. We looked at 
it as an opportunity to get nurses on the ground where they 
were needed to serve these underserved populations that are in 
desperate need of care.
    Now, with that, we understand the concerns of all of the 
nursing leadership nationally who said, you know, the bachelor-
trained nurse is more capable, has more experience, has more 
academic background. But why not put those together? And we 
looked at a continuum. So if we bring in associate degree 
nurses and put together an educational program that allows them 
to progress while they're working and become a bachelor trained 
nurse, under the supervision of our bachelor-trained nurses, to 
me that's a win-win situation for the Corps, it's a win-win 
situation for the communities that so desperately need those 
nurses.
    Mr. Waxman. Thank you very much, Mr. Chairman.
    Chairman Tom Davis. Thank you very much. Just a couple of 
last questions. I'll put this under one big question.
    Under the transformation proposal, I just wondered what 
type of emergencies would the Commissioned Corps respond to and 
are you planning on sending any Corps officers to respond to 
the California wildfires?
    Admiral Carmona. Thank you, sir. As I alluded to with Mr. 
Waxman, we just got a request, in fact I brought the e-mail 
with me, from the Red Cross in California to ask us to send 
five public health nurses for a 2-week deployment to assist 
them with public health needs that are being unmet in those 
communities from the fires, and one of our liaison officers for 
our Commissioned Corps readiness force to support them through 
communications and should we need more resources there. We are 
in the process of deploying half a dozen nurses and a 
pharmacist up to the Arctic Circle now, because there are 
10,000 Eskimos who have no care unless we can get those people 
there, because there is such a shortage of nurses and other 
health care professionals.
    These come in on a daily basis from around the country and 
around the world sometimes, like Iraq. We do everything we can 
to meet that unmet need wherever it may be. So we really look 
forward to those opportunities to serve. We have a very robust 
6,000 member Corps. We could probably use more, because 
sometimes we can't meet all the needs. But I'll tell you, we 
look forward to those challenges on a daily basis.
    Chairman Tom Davis. That's why people go into it, to serve.
    Admiral Carmona. They do. We've got the most committed, 
hard working people I've ever worked with in my whole life. 
They subordinate their whole lives to serve others. So we would 
love to take in all the ones that we turn away because we don't 
have the billets for them. But we certainly have opportunities 
for them to serve if we could get them in.
    Chairman Tom Davis. How much larger do you think the Corps 
ought to be to fulfill its mission?
    Admiral Carmona. How much larger should it be? Well, sir, 
to answer that----
    Chairman Tom Davis. I know you're off script here. 
[Laughter.]
    Admiral Carmona. To answer that academically I'd have to 
ask you to give me some time to study it. Because we know that 
we have unmet needs throughout the country. We have community 
health centers where doctors aren't there, nurses aren't there, 
therapists aren't there. There's mental health needs in our 
underserved communities that are unmet. We could certainly look 
at that for you. But just generally, there is a large unmet 
need, as all of you know in this country, that public health 
officers could meet if we had those numbers.
    Chairman Tom Davis. Thank you very much.
    Any other questions? Mr. Van Hollen.
    Mr. Van Hollen. Thank you, Mr. Chairman. Thank you, 
Admiral. I think we all have a great interest in the future 
success of the Corps. It has a long and distinguished history, 
and we're all very interested in making sure that continues and 
we have a big stake in its reorganization. In addition, I also 
have many members of the Corps in my district. I represent a 
district right near our Nation's Capital here in Maryland, and 
many members of the Corps are at the FDA and NIH and other 
Federal agencies in this region.
    I think you would agree, would you not, that it's 
important, whenever you undertake this kind of transformation 
and reorganization, that you get the support, the buy-in in 
this case, of the members of the Commissioned Corps and the 
officers of the Commissioned Corps in order for it to be 
successful in the long run? Would you agree with that?
    Admiral Carmona. Yes, sir.
    Mr. Van Hollen. Are you aware of any surveys that have been 
done to determine whether or not members of the Corps or 
members of the officers in the Corps, what their reaction is to 
this reorganization plan?
    Admiral Carmona. I'm aware of a lot of discussions and 
meetings that have taken place. I work through my colleagues, 
Dr. Zerhouni, Dr. Gerberding, Dr. McClelland, Dr. Duke, all the 
optive and staff within HHS. They then test their people to 
bring back information. I've gone to a number of all-hands 
meetings where I've asked for input from officers and that 
comes in and we take a look and see where the themes are 
developing. So there's been a number of ways that has been 
done. But really the input has come in various forms.
    Mr. Van Hollen. Would you agree that in a particular 
agency, if 72 percent of the members of the officer corps said 
that, as a result of this planned reorganization, they intended 
to leave after 3 years, that would be a problem, I assume?
    Admiral Carmona. Well, I'd certainly, if that was the case, 
I'd want to talk to them, first of all, to make sure that they 
understood what we were doing and that there was no 
misconception, misperception, of what the intent was, and find 
out specifically what are the issues.
    Mr. Van Hollen. Right. Well, I think that, one of the 
problems as I understand in talking to people, is that part of 
the cause for the misunderstanding may be a failure to 
communicate by the Department with members of the Corps. I have 
a survey that was done by the Commissioned Corps officers at 
the CDC, Centers for Disease Control. According to the results 
of that survey, 82 percent of the CDC officers who responded to 
the survey said they were considering leaving the Corps within 
3 years because of the transformation. And of the physicians 
among them, 75 percent of the physicians said that as a result 
of the transformation plan, they were considering leaving the 
Corps. If that were to occur, you would agree that would be a 
significant degradation in the ability of the Corps to do its 
job, would you not?
    Admiral Carmona. Certainly, sir. If I might add, though, 
that as Mr. Waxman alluded to earlier, there were 
misperceptions at the time the survey was done. For instance, 
the physical requirements that people would have to, 
everybody's doing pushups and situps and being trained. That 
wasn't an issue. So when we heard about that, we did everything 
we could to correct those misperceptions that was not the 
intent, that there were three levels of physical ability. I 
think that was the biggest complaint that people pushed back on 
that: ``Whoa, I'm a researcher, I shouldn't have to run miles 
and do pushups and situps.'' That wasn't the issue. I'm not 
sure how that got out there, but we've done everything we can 
to correct that misperception. Certainly, once the appropriate 
information is out, I'd love to see a survey done, once 
corrected, if that was still the opinion.
    Mr. Van Hollen. Well, 70 percent of the commissioned 
officers, I understand, are members of the Commissioned 
Officers Association. So would you agree it's a representative 
body, a body that represents them?
    Admiral Carmona. Yes, sir.
    Mr. Van Hollen. Don't you think it would be important to 
consult with them in coming up with this reorganization plan?
    Admiral Carmona. Well, as far as I know, I've spoken to Mr. 
Farrell many times, and the leadership, and I was not present 
at meetings, but I am told that there were two meetings with 
the commissioned officer directors, the COA director and 
leadership at HHS. But I was out of town those times and I 
don't know about those discussions.
    Mr. Van Hollen. Well, Mr. Farrell is here, but I just 
happened to see the October issue of the Commissioned Officers 
Association newsletter, this month's issue. In it, he says, 
``Over the last several weeks, I have presented COA's views on 
the transformation process in many different places. Capitol 
Hill, OMB, various journalists and to several COA branches. 
Interestingly, the one place I have not been invited to present 
our views is DHHS.''
    Now, if that's the case, and according to his testimony it 
seems to be, doesn't that suggest a very serious problem in how 
this plan was put together in the first place? You mentioned, 
what you're saying is confusion that hopefully we can sort out 
today. But it sounds to me like a lot of the confusion resulted 
from a failure to approach this reorganization in a way that 
makes sense, which is going to talk to the people who would be 
most affected. Doesn't that seem to--would you agree with that?
    Admiral Carmona. No, sir, respectfully I wouldn't in this 
case. I do agree with you that there has been some confusion 
and misperception. I have great respect for Mr. Farrell and the 
COA, I'm a member and have had many discussions with them over 
time. But there's a lot of venues to get to our officers. COA 
of course is a leadership group that is involved with our 
officers. But we've gone through the optive, the stafftivs, 
we've met with the leadership at CDC, NIH, FDA, SAHMSA. So it's 
not any one point of contact, it's multiple points of contact. 
And, certainly, I know personally, I rely on Mr. Farrell for 
input when I have questions, when I'm trying to learn the 
culture of the Corps and maybe the best course of action. He's 
got a little historical perspective that I don't have, and he's 
provided me great information since I've been in this position, 
which is only about 15 months.
    Mr. Van Hollen. Well, just in closing, Mr. Chairman, I 
think the results of the CDC survey where you've got 80 percent 
of the people surveyed suggesting they would leave the Corps as 
a result of this reorganization within 3 years and Mr. 
Farrell's statements that he has not really been included with 
respect to DHHS, thinking in this, suggests to me that if it's 
a question of confusion as opposed to significant substantive 
issues, then that confusion has clearly resulted from a failure 
to consult broadly with the people who would be most affected.
    Thank you very much, Mr. Chairman.
    Chairman Tom Davis. Thank you. Mr. Shays.
    Mr. Shays. Thank you, Mr. Chairman. Thank you very much.
    I don't know whether to call you General or Admiral, so I'm 
going to call you Doctor. [Laughter.]
    Doctor, what makes the Corps unique?
    Admiral Carmona. I think the most unique aspect of the 
Corps is that we are a uniformed service of health 
professionals, unlike any other service in the world, that 
provides for the needs of public health to the United States 
and the globe now, on a daily basis, but also has the ability 
to respond to any contingencies that arise as far as 
emergencies.
    Mr. Shays. I see it as, you don't follow the standard 40 
hour work week.
    Admiral Carmona. No, sir.
    Mr. Shays. You have that military kind of ethos, in a way. 
And it seems to me that if you are not fulfilling your unique 
responsibility then you need to say, ``we need to change.'' It 
strikes me that change is going to make some people think, 
``Maybe this isn't the organization I want to be in.'' But if 
you're like any other health care organization in the country, 
there's really no point in your existing. That's kind of how I 
react. Obviously you want to interact with your employees and 
your employees need to buy into this organization. But if some 
people leave, that to me is not necessarily a bad sign. It's 
just a sign that they don't want to be part of what is unique 
about the Corps.
    What are the new public health threats? I wasn't responding 
to my colleague from Maryland, it was something I wanted to say 
beforehand. Because I do think if you have a large number, it 
does say, ``Hey, we're not communicating well, and we need 
to.'' But what are the new public health threats, and how are 
you responding to these new public health care threats?
    Admiral Carmona. The U.S. Public Health Service really is 
that anonymous backbone for public health in the United States. 
So when you turn on the water, when you take your medications, 
we all take for granted that those things are safe. But it's 
because we have this very robust public health service at FDA, 
CDC, NIH that does the research, does the work there.
    The new threats really that are upon us began on September 
11, because, prior to that, we characterized the emergencies we 
responded to as all hazards, hurricanes, earthquakes, and other 
types of disasters--chemical spills and so on--where we would 
assist communities in mitigating and recovering from disasters. 
But since September 11, we're dealing with issues of planes and 
weapons and pathogens as weapons, so it's an entirely new 
world. But the expertise that we have in the U.S. Public Health 
Service is very adaptable to those new threats. And whether 
it's bioterrorism or conventional weapons of mass destruction, 
that is bombs and bullets and fires and explosions, we are 
prepared to work with our colleagues throughout the country to 
be able to make our country a healthier and safer environment 
for all.
    Mr. Shays. Someone sitting at this exact desk a few years 
ago, in one of my hearings on national security, a doctor of a 
noted major medical magazine, said his biggest fear was that a 
small group of dedicated scientists could create an altered 
biological agent that could wipe out humanity as we know it. 
This wasn't someone on the extremes, this was a pretty Main 
Street kind of personality and organization. Do you think that 
statement is worth being concerned about?
    Admiral Carmona. Absolutely, sir. We on a daily basis have 
intel briefings and look at the potential threats around the 
world. Certainly the bio threat is a very real one, from 
naturally mutating organisms as well as purposely creating 
mutations that could be more virulent. So we are very 
concerned.
    Mr. Shays. Former Speaker Gingrich believes that 
bioterrorism is the greatest threat that we face. My 
subcommittee is concerned about botulinum toxins, more so than 
even smallpox and so on. Is this something that you have 
focused any attention on?
    Admiral Carmona. Our officers at CDC and NIH, you bet, 
would be doing the research on that, to develop appropriate 
mechanisms to respond should that occur. But botulinum toxin is 
a very real threat, especially as it relates to the food 
supply, its ability to be disseminated easily. So we are 
concerned about that, and there is active research going on 
right now.
    Mr. Shays. As we speak, we don't really have a vaccine 
against it?
    Admiral Carmona. No, sir.
    Mr. Shays. Which to me, Mr. Chairman, raises some gigantic 
concerns.
    I want to conclude, because I know that we also have former 
Surgeons General. I just want to say that I view you as the 
chief spokesperson for health needs and health concerns. I 
believe that office is, and I believe in some ways there's 
almost been an attempt to downgrade the office. You are a moral 
authority that has to speak out. My view is that you sometimes 
may have to speak out when no one else in the administration 
agrees with you. I hope that you feel that you have that duty, 
because I believe you do.
    Admiral Carmona. I agree with you, sir, I do feel I have 
that duty. A day doesn't go by that I don't get up and really 
understand that term when people say the weight of the world is 
on your shoulders. I understand the immense responsibility I 
have and I take it very seriously. Thank you for your comments, 
sir.
    Mr. Shays. Thank you. Thank you, Mr. Chairman.
    Chairman Tom Davis. Thank you. We have another panel to get 
to, but I want to make sure if Members have questions they have 
an opportunity to ask them. Are there any other questions? Mr. 
Tierney.
    Mr. Tierney. Just quickly, Admiral, thank you. Can you give 
us in 25 words or less what's the rationale for the Service 
being a uniformed service as opposed to a civil organization?
    Admiral Carmona. Twenty-five words or less. Well, 
professionalism, visibility, mobility, all of the issues we 
spoke a little bit earlier in some of the questions that I was 
posed. But not dissimilar from our sister uniformed services, 
that there is a command and control structure, there's an 
authority. And just like the Army and the Navy and the Air 
Force who have specific missions that they are tasked with, the 
U.S. Public Health Service also has those missions. We are 
proud to be seen as a uniformed, visibly fit, mobile service.
    Mr. Tierney. Would you not function as well as a civil 
organization as opposed to military?
    Admiral Carmona. I think it would be much more difficult to 
do it as a civil servant, sir.
    Mr. Tierney. Because?
    Admiral Carmona. Well, because you wouldn't have the 
control of the troops, you wouldn't have the training, you 
wouldn't have a lot of the constraints of a uniformed service. 
As Congressman Shays just said, it's not a 40 hour week for us. 
We typically put in 60, 70, 80 hours a week, and we don't count 
the clock when we're deployed and we have to take care of those 
in underserved communities.
    Mr. Tierney. I notice that amongst your physicians you have 
dieticians also serving in your force.
    Admiral Carmona. Yes.
    Mr. Tierney. And we're talking about serving the 
underserved. What prospect if any does this reorganization have 
for any plans that you might have for addressing the issue of 
obesity as a national health concern, particularly amongst the 
underserved?
    Admiral Carmona. I am so happy you asked that question, 
because it is something that Secretary Thompson is passionate 
about, as I am. It is the fastest growing epidemic we have in 
this country, with 9 million children being obese or 
overweight, two-thirds of the American public being overweight 
or obese, huge costs, $117 billion a year. What we want to do 
is to be able to use this force for those reasons, to get out 
there and deal with this public health issue through education, 
through intervention. Our officers at NIH and CDC are doing 
research on it. It's a very big team approach. But we're 
already out there doing this.
    Mr. Tierney. Are you going to make that a focal point of 
your----
    Admiral Carmona. It already has been, sir, as far as 
prevention. Prevention is one of the focal points of my 
portfolio as assigned by the President and the Secretary. And 
obesity is probably the key element within prevention right 
now.
    Mr. Tierney. Thank you very much. I yield back, Mr. 
Chairman.
    Chairman Tom Davis. Thank you, Mr. Tierney. The gentleman 
from Missouri.
    Mr. Clay. Just two quick questions.
    Chairman Tom Davis. Sure.
    Mr. Clay. Thank you, Surgeon General Carmona, for being 
here. Good to see you again.
    Tell me, what efforts are being made to recruit and train 
minority applicants wishing to become commissioned public 
health service officers?
    Admiral Carmona. As part of our transformation, we're 
looking at a scholarship program which we would like Congress 
to be involved in, where we would work with Congress to have 
Congressmen select worthy young men and women who could come 
into the Public Health Service and serve. We certainly would 
hope that would include a robust portion of underserved 
minorities, Native Americans, Black, Hispanic, etc. Because we 
recognized that, in fact, we need to have a more robust work 
force.
    Now, with that said, of all the uniformed services, about a 
third of our officers identify themselves already as minority. 
So we are very proud of what we have achieved with diversity 
within our ranks already. But we don't want to stop there. We 
want more.
    Mr. Clay. I'd be interested in hearing more about the 
program that you want to develop.
    Let me also ask you, what do you and Secretary Thompson 
envision to be the cost of the proposed transformation or 
reorganization plan, and how long will the implementation take?
    Admiral Carmona. The entire transformation is still being 
worked on, sir, as far as the specific details. Part of it, 
we're doing as much as we can through policy and just 
administrative changes within the Corps, which really there is 
very little cost associated with that, it's just a 
reorganization. Some of the issues that in the future we would 
like to bring before Congress as far as having an academy, 
having additional resources allocated to train minority 
doctors, nurses, dieticians, and others, have career pathways, 
we would like to engage in a discussion with Congress and other 
leadership to answer those questions because we feel that it 
will help us to meet the unmet need in many, many underserved 
populations in this country.
    Mr. Clay. OK, I thank you for your responses. Thank you, 
Mr. Chairman.
    Chairman Tom Davis. Thank you. Any other questions?
    Admiral, General, Doctor, nurse, I'm not sure what to call 
you--[laughter]--you've requited yourself well. Thank you very 
much. We appreciate your being here, and we'll take a 2-minute 
recess and get our next panel up. Thank you very much.
    Admiral Carmona. Thank you, Mr. Chairman. Thank you all.
    [Recess.]
    Chairman Tom Davis. Our next panel is a very distinguished 
panel; Dr. C. Everett Koop, who was U.S. Surgeon General from 
1981 to 1989; Dr. Julius Richmond, who was Surgeon General from 
1977 to 1981 and professor emeritus at the Harvard School of 
Public Health; and Captain Gerard Farrell, who is executive 
director of the Commissioned Officers Association.
    It's our policy to swear you in, so if you would just rise 
with me and raise your right hands.
    [Witnesses sworn.]
    Chairman Tom Davis. Thank you very much.
    You know the rules, the light will turn orange after 4 
minutes and red after 5. You don't need to read your entire 
statement, because it's already in the record. You can 
highlight it. But we'll be generous, whatever you need to get 
your points across, and then we'll move to questions. I just 
want to thank all of you for being here. This is a really 
important issue that has not been highlighted at the 
congressional level much. We're very interested in your 
comments and your taking the time to be with us today. I'll 
start with Dr. Koop and move this way. Dr. Koop, thank you very 
much for being here.

STATEMENTS OF DR. C. EVERETT KOOP, FORMER U.S. SURGEON GENERAL; 
 DR. JULIUS B. RICHMOND, FORMER ASSISTANT SECRETARY FOR HEALTH 
AND FORMER U.S. SURGEON GENERAL; AND CAPTAIN GERARD M. FARRELL, 
 EXECUTIVE DIRECTOR, COMMISSIONED OFFICERS ASSOCIATION OF THE 
                   U.S. PUBLIC HEALTH SERVICE

    Dr. Koop. Thank you, sir. I will, because of the 
constraints of time, skip the niceties of introduction and ask 
you to refer to my prepared remarks.
    I would like to say that I support Secretary Thompson's 
vision and initiative in recognizing the need for improvement 
in the Corps. The concerns I have are much more to do with 
organization and process, not the overall goal of strengthening 
the Corps.
    I am the only living person who was Surgeon General and 
leader of the Public Health Service Commissioned Corps under 
two organizational concepts. One system worked well, but the 
other was inefficient, tied the hands of willing, competent 
experts and initiatives were stifled by bureaucrats with no 
real solutions. This system undermined the morale of the Corps.
    The following changes I believe are important, sir. The 
Surgeon General and his staff must have complete and direct 
control over all aspects of the day to day administration, 
management and operation of the Corps. This is the system which 
worked after my revitalization of the Corps in 1987. The Corps 
needs to better define requirements, including personnel 
requirements--no small task. The Corps will then be able to 
move forward with its overall recruiting and assignment 
strategy.
    The growing need for the Corps to respond to emergency 
situations demands some sort of a robust, ready reserve 
component, similar to the reserve components of the other 
uniformed services. The key to emergency response is the 
training, organization and exercising of the response force, 
well in advance of the emergency. This will require much 
thought before instituting change, as well as evaluation of 
trial and error, then reevaluation and, of course, funding.
    Efforts to improve professionalism should include a 
continuum of educational opportunities from pre-commissioning 
through indoctrination through executive level management, 
administration, leadership and even officership for those 
selected for flag rank. The Corps has functioned best, in my 
opinion, when officers were rotated every 3 years through, say, 
Indian Health Service, Bureau of Prisons, public health service 
agencies, and then a period of refreshment in one of the public 
health service hospitals. The hospitals, except for those in 
the Indian Health Service, were closed in 1981, which severely 
impacted the opportunities to educate and re-educate our 
officers. There must be some alternate plan, which would 
include bioterrorism updates.
    My concerns are that the plans do not support the important 
changes just mentioned. The system that did not work well for 
me was when personnel management of Corps officers was 
separated from control or direction by the Surgeon General. The 
new system I devised worked well. But in 1995, to my dismay, 
personnel management functions were moved again, this time 
under the HHS Assistant Secretary for Administration and 
Management. As a result, the Corps experienced difficulties in 
the recruiting and placement of officers, and has continued 
until very recently to slowly grow smaller. Hardly the system 
that would foster the desired increase in the size of the 
Corps.
    We do not need a new office for day to day management and 
operation which reports to the Assistant Secretary for Health 
on a co-equal basis with the Surgeon General. What then would 
be the role of the Surgeon General for leadership of the Corps, 
which is really one of the principal functions for which he is 
nominated in the first place and then confirmed by the Senate? 
And leaving compensation and medical affairs under the 
authority of still another assistant secretary will add 
confusion and inefficiency where least needed.
    The plans also appear to devalue the role of Corps officers 
in fundamental public health roles: research laboratory work, 
regulation activities. Clinical health care for underserved 
populations is not the only aspect of public health. Equally 
important is the work conducted by Corps officers in 
institutions like CDC, NIH, FDA. Let me remind you that the 
world relies on the standards of FDA, the NIH is the premiere 
source of medical research on this planet, and the CDC is 
preeminent in international health.
    In the Department rush to fix one problem, they might well 
create two more if the process is not engineered critically. 
Mission drives requirements, tempered by resources. Then, after 
that, plans are developed to match resources against 
prioritized requirements. It appears to me we are beginning 
with the plans first.
    Our public health infrastructure is not able to respond to 
the threat of bioterrorism. There are insufficient health care 
providers for some underserved communities, and improvements to 
our research capabilities are demanded by new diseases such as 
SARS. I would argue for an increased role for the Corps and the 
Surgeon General in leading the public health infrastructure at 
all levels. The Corps' role in emergency preparedness and 
response, especially organizational issues, should be carefully 
evaluated, as should be the relationship of the Corps and the 
Office of the Surgeon General to the new Department of Homeland 
Security.
    In increasing the mobility of the Corps in emergent 
response, remember that these highly trained and experienced 
health professionals have day jobs. Their day jobs are 
critically important, whether they are clinicians on a remote 
Indian reservation or in Federal prison, or assigned as an 
epidemiologist or researcher at CDC. You cannot routinely 
deploy the only pharmacist on a reservation or in a prison 
without a plan for substitution.
    Also, the lifelong researcher at CDC may not be the ideal 
choice to respond to an emergent situation where trauma skills 
will be the primary need. New responsibilities for the Corps 
must be carefully balanced against the still important role of 
the Corps in traditional areas of public health. This can only 
be successfully accomplished by using a strategic planning 
process which is organized, inclusive and based upon data. My 
impression of the current process is that none of these exist.
    The Surgeon General is clearly recognized as the top public 
health professional in the country. The Office of the Surgeon 
General ought to be empowered to take charge of the 
infrastructure and develop the changes necessary to make it 
better. The Commissioned Corps is one logical tool already in 
place at the Surgeon General's disposal to make this happen. To 
do less, sir, I think, unnecessarily risks the public health of 
this great Nation. Thank you.
    [The prepared statement of Dr. Koop follows:]

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    Chairman Tom Davis. Thank you, Dr. Koop.
    Dr. Richmond, thanks for being with us.
    Dr. Richmond. Thank you very much, Mr. Chairman.
    I do want to express my appreciation to you, Mr. Chairman 
and to Congressman Waxman and the other members of the 
committee for your interest in this very important topic, which 
is so important, as Dr. Koop and Dr. Carmona have already 
indicated, to the health of our people. I'll make my comments 
relatively informal and, I hope, quite brief, so that we will 
have maximum time for questions, Mr. Chairman.
    I want to say at the outset that I think it is important 
not alone to have this hearing but, I would hope, Mr. Chairman, 
that this committee would continue its interest in this matter. 
I come currently from an academic community, and in our 
academic community, oversight committees become extremely 
important for our functioning. Committees, essentially from the 
outside, and I view the role of this committee as an oversight 
committee, and I think having to answer your questions is 
extremely important in terms of our pursuing the best pathways 
to the Nation's health.
    As you've already heard from Dr. Carmona, in the context of 
history, we have great reason to be proud of the record of the 
U.S. Public Health Service and Commissioned Corps in responding 
to emergencies which threaten the health of our people. History 
tells us that this response to health emergencies has always 
been full and effective. I have never known a situation where 
that has not been true. But this reflects the matter of 
constant training for emergency preparedness. Let me just give 
some brief illustrations, Mr. Chairman. First, on September 11, 
2001, I think it's very significant that, of all of the Federal 
officials, Secretary Thompson was the first one to go on 
national television after the crisis of that day to point out 
that the Public Health Service had already responded by sending 
support to the State and local health officials in New York 
City. Again, that was not fortuitous, that was because of the 
emergency preparedness of the Corps.
    Let me just very briefly illustrate some anecdotal evidence 
of the responsiveness of the Corps that I had personal 
experience with when I was Surgeon General and Assistant 
Secretary. One, the Mariel boat refugees arriving on our shores 
from Cuba, hundreds of them, when Mr. Castro emptied his jails 
and prisons and sent those people to our shores. Within hours, 
our Public Health Service officers prepared the way for the 
appropriate dealing with that situation. That had to go on for 
an extended period of time.
    Comparably, the Southeast Asian crisis of that time, in the 
late 1970's, when the boat people of Southeast Asia were in 
refugee camps in Asia and were being brought to this country to 
relieve the pressures on the camps over there, some were found 
to have tuberculosis. In consultation with the Secretary of HHS 
at that time, we agreed that the best policy would be to screen 
the refugees before they came. She asked me, Madam Secretary 
Harris, she said, ``Well, how long will it take for you to get 
people over there?'' I said, ``Within 24 hours,'' and that's 
when our staff members from CDC appeared in Southeast Asia to 
do the screening.
    But perhaps most significantly, Mr. Chairman, was the Three 
Mile Island nuclear plant disaster when, as we know, near 
Harrisburg, there was a great threat of a nuclear reactor plant 
disaster. This was prior to any experience with Chernobyl. 
Nobody knew what was going to happen. We needed instant 
response. Our CDC officers were on the scene within a matter of 
hours and stayed there, and I might say in a very courageous 
way at great risk to themselves, because no one could predict 
what would happen. Fortunately, that pressure chamber never 
exploded. But the CDC staff gathered data, and to this day 
collect epidemiologic data so that we can learn from that 
experience.
    I mention these events because these responses are not 
fortuitous. They result from cultivating a corps of highly 
competent professionals. I can't over-emphasize that, and Dr. 
Koop has emphasized it as well as Dr. Carmona. But the 
competence of these professionals is engendered in the agencies 
in which, to use the modern parlance, they are embedded, the 
NIH, the CDC, HRSA, the FDA. This is where their professional 
work and their professional competence is developed.
    Now, what is combined with this high degree of professional 
competence is the matter of flexibility. Effective responses 
develop out of flexibility. No set of regulations, however well 
intended, including those for the proposed transformation, can 
replace the need for a high degree of flexibility.
    So Mr. Chairman, my concerns over what I know about the 
proposed transformation are the following. The Surgeon General 
and the agency heads should constitute a governing council, as 
they now functionally do, for the deployment of officers. They 
would act in concert with the Surgeon General. The current 
proposals do not take into account the concerns of the 
leadership of the Public Health Service agencies and the need 
to maintain our public health infrastructure, particularly at 
the Federal level.
    I think it's extremely important that we recognize that 
there has been an erosion, as an Institute of Medicine report 
not too long ago indicated, of our public health infrastructure 
at the State and local level. But it also can be eroded at the 
Federal level if we don't take cognizance of the importance of 
maintaining the important functions of those agencies. And Dr. 
Koop has said very eloquently how important that is.
    Second, the Surgeon General should unequivocally be the 
leader of the Corps, including, I would say, Mr. Chairman, its 
planning, policy and management functions. The Corps is not so 
large that one commanding officer can't incorporate the 
direction of all of these functions. It violates any sound 
principles of management to propose, for an example, an Office 
of Commissioned Corps Force Management to assume functions that 
the Surgeon General has had and has executed effectively 
historically.
    Last, I would say, Mr. Chairman, flexibility should prevail 
in the evaluation and assignment of officers. This should 
prevail as well in the physical fitness requirements. The 
important issue is whether an officer can perform assigned 
duties. Parenthetically, I would add that I served for 4 years 
in World War II as a flight surgeon. Had we held to arbitrary 
standards, we would have lost much very valuable person power. 
And I could illustrate with many examples.
    So in summary, Mr. Chairman, it's not that I am opposed to 
change. We can always do better. And in Dr. Koop's day, I would 
recall for you that we engaged in a revitalization of the 
Corps. But we didn't have to reorganize the Corps to revitalize 
it and enhance its functions. So our past performance is due to 
the sound organizational structure and, in my view, the 
leadership which the Corps has had. We should enhance its 
efforts and not engage in changes which might well impair its 
efforts by creating new problems. In other words, we must be 
aware of, particularly, unintended consequences.
    Thank you very much, Mr. Chairman.
    [The prepared statement of Dr. Richmond follows:]

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    Chairman Tom Davis. Thank you very much.
    We have 7 minutes left on our vote on the floor. Here's 
what I think I'd like to do if it's all right with you. Recess 
it now, we just have two quick votes, we'll get there for the 
end of one, the beginning of another. Then Mr. Waxman and I at 
a minimum will be back here to hear from you, Captain Farrell, 
and then we'll go to questions. Is that all right? Then I will 
recess the meeting and we will reconvene within the next 15 
minutes. Thank you.
    [Recess.]
    Chairman Tom Davis. The committee will come back to order. 
Thanks for being with us and thanks for being patient.
    Captain Farrell. Mr. Chairman, the Commissioned Officers 
Association of the U.S. Public Health Service appreciates your 
interest in the important contributions to the health of the 
Nation by the Commissioned Corps of the U.S. Public Health 
Service. In the Corps' long and distinguished history to the 
service of the Nation, its role in defending and advancing the 
public health has never been more important than today, given 
the evolving and emerging new threats we face to public health.
    COA represents the interests, as you know, of some 7,000 
active duty, retired and reserve officers of the Commissioned 
Corps. Seventy percent of active duty officers are COA members. 
Our constituents are the officers who will be charged with 
implementing the changes to the Corps. We believe, therefore, 
that they also have a role to play in developing what those 
changes will be.
    COA supports what is best for the Nation's public health, a 
most fundamental component of our national security. The threat 
of biological weapons in the war against terrorism demands an 
army of public health warriors to provide leadership in the 
Nation's public health defense. Leadership for the Corps and 
the Nation's public health community is and ought to be 
provided by the U.S. Surgeon General.
    Along with improvements in emergency response, we must not 
forsake more traditional public health roles, however: 
research, laboratory and regulatory work. The Commissioned 
Corps has many strengths. Among those are its adaptability, its 
diversity, its cross-cutting relationships in public health, 
the dedication, commitment, and professionalism of its officer 
corps. But there is always room for improvement.
    We therefore fully support the Department of Health and 
Human Services' strategic plan which calls for an expanded, 
enhanced and fully deployable Commissioned Corps, and we 
applaud Secretary Thompson's initiative to transform the Corps. 
Specifically, our association supports the restoration of 
authority over and responsibility for the Corps to the Office 
of the Surgeon General. This includes full budgetary and 
manpower authority. We support the implementation of a force 
requirements and management system, which is billet-based and 
resourced similar to the other uniformed services. We support 
an overall recruitment and assignment strategy, based on the 
validated requirements. These will lead to a fully deployable 
Corps, consistent with the needs and requirements of the 
operating divisions, agencies and departments in which officers 
are assigned. It will also lead to a robust, ready reserve. We 
support initiatives to expand the size of the Corps and enhance 
its readiness capability, consistent with the Corps' mission 
and the goal of increased professionalism. Finally, we support 
improvements in ongoing education, including the establishment 
of a public health service academy designed to increase the 
Corps' professionalism.
    We were very interested to hear Admiral Carmona's testimony 
earlier, because much of what the Admiral has discussed today 
is new. But our specific concerns with the organizational 
structure and planning process as we have understood them up to 
this point lead us to believe that they were not designed to, 
perhaps, but might undermine, the ability of the Corps to 
attain the goals that we all agree upon. As we understood the 
plan to be conceived, and according to its written record, it 
would effectively sideline the Office of the Surgeon General 
and marginalize any relationship between that office and the 
Corps it is supposed to lead. It further fragments the Corps 
when just the opposite is needed.
    The Department's approach applied new roles and missions 
for the Corps, but does not specifically address them. Nor does 
the plan address existing roles and missions for the Corps, 
which seem to be devalued. Force-shaping policies have been 
introduced with no attempt to define the requirement to which 
the force is being shaped. The new policies, since they were 
decided without input from the operating divisions and 
agencies, including the non-HHS agencies where officers are 
assigned, have created a situation where officers are less 
likely to be employed in these vital public health institutions 
in the future.
    The proposal to recruit 2 year degree nurses as warrant 
officers, as has already been discussed, has raised significant 
concerns in the public health community. Adequate funding for 
the transformation and its effective implementation does not 
appear to have been considered.
    Corps officers look to the Surgeon General for leadership, 
just as members of the other uniformed services look to their 
respective service chiefs. In the present environment and under 
the proposed plans to transform the Corps, the Surgeon General 
is being prevented from exercising any meaningful leadership 
authority over the Corps. This situation contravenes the intent 
of the President in nominating him and the Senate in confirming 
him.
    The unfortunate result of a poorly planned and communicated 
transformation is an alarming degradation of morale in the 
Commissioned Corps. We have received hundreds of comments from 
our members expressing their alarm and concern over the process 
and direction of transformation. One Corps officer, an 
eminently qualified medical epidemiologist assigned to CDC 
wrote, ``In general, the leadership of CDC's disease 
recognition and response teams has been staffed through the 
Commissioned Corps. The transformation of the Corps would 
appear to systematically disassemble such expert teams.''
    Our recommendations are simple and straightforward. We 
would like to see this committee, in collaboration with the 
committees of jurisdiction in the House and Senate, take 
appropriate action to ensure that the planning process used by 
the Department is similar to that in use at the Centers for 
Disease Control and Prevention, where they have a futures 
initiative in place. Specifically, we urge a planning process 
which includes, at a minimum, input and participation of all 
Health and Human Services operating divisions and non-
departmental agencies, a process that is open and transparent 
throughout.
    We would recommend a process which begins with the 
validation of the mission of the Corps and a set of core values 
to guide the way. The validated mission becomes the basis for 
and drives end strength requirements, recruiting plans and 
policies, training requirements, assignment, including 
deployability policies, promotion plans,and policies. In short, 
mission requirements shape the force. Requirements for Corps 
officers at the Federal, State and local levels of public 
health infrastructure must also be included.
    We recommend establishing a billet-based system of 
requirements identification with the active participation of 
all affected operating divisions, departments, and agencies 
where Corps officers are assigned. This should include 
establishing requirements for a ready reserve component.
    We recommend delaying implementation of the force shaping 
policies, including new promotion policies, until the profile 
of the future Corps can be defined by the requirements-based 
force management system previously discussed. We believe that 
it is important to confirm the role of the Office of the 
Surgeon General in providing direct leadership, policy 
administration, management, and operational control, including 
budgetary and personnel management for the Commissioned Corps. 
We recommend identification by the Department and appropriation 
by the Congress of funding to implement the key provisions of a 
transformed Corps, including its expansion where needed, a 
ready reserve component, and a training academy with 
scholarship opportunities.
    Finally, we recommend clarification of the Surgeon 
General's role in regard to emergency preparedness within the 
Department. This is consistent with the Surgeon General's role 
in public health, especially as envisioned by the Department in 
the transformation process thus far.
    Once again, sir, the Commissioned Officers Association very 
much appreciates this opportunity to submit our views, and we 
look forward to addressing further details of these and other 
issues with you and the committee staff, and in the future, to 
working with the Department on these important issues. Thank 
you, Mr. Chairman.
    [The prepared statement of Mr. Farrell follows:]

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    Chairman Tom Davis. Thank you very much.
    Captain Farrell, do you feel you've been involved in the 
process to date? Have you shared these views with the people 
that are putting this reorganization together?
    Captain Farrell. We've done our best to do that, sir. I 
have had, as Admiral Carmona mentioned, two meetings, one 
several months ago with the then-Department Chief of Staff 
where we discussed very specifically the organizational issue. 
Unfortunately, that gentleman left office a week later, and 
we're not aware of any follow-through.
    About 2 months ago, I was able to meet with the Acting 
Assistant Secretary for Health, Cristina Beato. But we 
discussed mostly issues relative to the Association and not 
anything substantive relative to the issues regarding 
transformation. Subsequent to that meeting, I have offered on 
three occasions my services or the services of our association 
to the Department and we have been rebuffed on all three of 
those occasions, sir.
    Chairman Tom Davis. Rebuffed meaning?
    Captain Farrell. No answer at all.
    Chairman Tom Davis. ``Don't call us, we'll call you,'' that 
kind of thing?
    Captain Farrell. Yes, sir.
    Chairman Tom Davis. So what's the morale of the men and 
women that you represent at this point?
    Captain Farrell. Pretty poor, sir. The one survey that was 
referred to earlier, they were able to use some metrics to 
define a 50 percent degradation in morale at their particular 
agency. I would say from the tenor of the input that I get from 
our members there is considerable concern about not so much 
that the Corps is being transformed, but that they may be asked 
in the transformation to take on additional requirements and 
obligations without the support structures being put in place 
to enable them to do that, both in terms of fulfilling their 
jobs in the agencies in which they work and in their ability to 
take care of their families if they're going to be deployed 
more often.
    Chairman Tom Davis. Thank you.
    Dr. Koop, thank you for your testimony as well. Ordinarily, 
you noted, the mission drives the requirements, tempered by 
resources. Are you concerned that in this case, maybe the 
process is going to drive the mission?
    Dr. Koop. I think it might be that way. Certainly, I think 
that the direction that we usually take when we undertake 
something like a transformation that's contemplated here, the 
cart now seems to be before the horse.
    Chairman Tom Davis. One of the concerns that this committee 
constantly has is that Government becomes too bureaucratic and 
process-driven instead of mission-driven. One of our goals is 
to try to get out there and be able to be more mission-driven. 
I think the jury is still out on what the ultimate plan is 
going to be here. But I think I hear loud and clear your 
concerns and the concerns of Dr. Richmond in terms of the way 
this has unfolded to date.
    Dr. Koop. Well, this 100 year-old organization has been 
evolving for a long time. I think the two functioning words 
that make it possible are flexibility, as Dr. Richmond said, 
but also appropriateness. I think proper leadership of the 
Corps, using those two guidelines, can accomplish a lot of 
things without having a tremendous reorganization, which is 
causing a lot of the disruption of morale and planning of many 
of the members of the Corps.
    Chairman Tom Davis. Unlike a lot of organizations, this 
organization is driven by its membership, by its employees, 
because they are technical and they are professional. 
Recruiting and retaining them is critical. That's not true 
everywhere. But it's certainly true in this particular case. I 
know Mr. Waxman shares my concern here that this is an area 
where you talk about larger reserves and continuing to track 
top-quality people who are service-driven people. But we cannot 
allow a diminution in the morale at this point. I think that 
could have ramifications down the road. It's tough to get good 
people.
    Dr. Koop. It's comforting to hear you say that.
    Chairman Tom Davis. It's always tough to get good people. 
And I'm not just saying that we can't move ahead with 
transformation, but I think, at this point, we don't have, 
we're not sure exactly, from my perspective, we don't even have 
all the information we've requested, I think. And I'm still 
trying to get comfortable with it, and if the workers are still 
getting comfortable with it, that gives us some concern.
    I am going to turn the gavel over to Mr. Shays, but I'm 
going to recognize Mr. Waxman. And let me just say to all of 
you, thank you very much for being here. This has been very 
useful to us.
    Mr. Waxman. Thank you very much, Mr. Chairman. Well, what 
we seem to see here is a reorganization where all the people 
who should have been consulted weren't consulted. And from what 
I hear from you, Captain Farrell, you don't feel that your 
members of the Corps were really brought into the development 
of this reorganization plan. That's one reason they don't feel 
comfortable with it. And second, they don't feel comfortable 
with it because they feel that their careers are going to be 
jeopardized, all the service may be lost in terms of their 
pension if they're forced to do things that were never expected 
of them in the past. Is that right?
    Captain Farrell. That's true, sir. One of the issues is 
that many of these officers joined the Corps under a different 
set of circumstances and a different set of rules. And there is 
no provision, at least as we understand it, for grandfathering 
the new rules. We don't really object to changing the rules as 
long as the people who joined the Corps under a different set 
of circumstances and understandings are somehow protected, 
don't lose their retirement benefits and their ability to 
continue to serve with the distinction that they have already 
exhibited.
    As far as our participation in the planning process, it's 
not just the fact that we have been, I'll use the words shut 
out, but even those elements within the Corps itself that have 
been asked to provide input seem to have been ignored. For 
example, the Department convened a distinguished panel of Corps 
officers to look at promotion policies and make 
recommendations. Yet when the revised promotion policies were 
published at the end of August, the officers who served on that 
panel were not able to discern any of their input having any 
effect on the proposed new policies.
    Mr. Waxman. One of the cries from members of the Corps is 
that they're going to have to go through this physical fitness 
standard that many of them won't be able to meet. Even though 
that's not required of them in their day-to-day activities, 
they feel they'll have to leave the Corps. Dr. Carmona gave us 
some assurance today, and we'll look forward to some written 
assurance as well, that the interpretation of the proposal that 
all of us have seen is not going to be quite as we have read 
it.
    Have you been told that those physical fitness standards 
are going to be revised, and have you seen any of the 
revisions?
    Captain Farrell. No, sir. Most of what Admiral Carmona was 
reporting on this morning was news to me, and represents a 
completely different plan from the one that I've had the 
ability to examine thus far.
    Mr. Waxman. Well, it's critically important for HHS to 
followup today's testimony with a clear and detailed policy 
that provides the assurances to people that they're not going 
to be put through some mindless set of tests on how many 
pushups they can do when that has nothing to do with their 
expertise. We wouldn't want to lose their expertise.
    Captain Farrell. No, sir.
    Mr. Waxman. And have people who do good physical routines 
but don't have the expertise that's going to be required, as we 
heard from Dr. LeBaron, to deal with bioterrorism or at the FDA 
to deal with drugs, or CDC with other public health matters.
    Dr. Koop, in the 1980's you were the representation to 
everybody of public health, and you spoke the truth whether it 
was tobacco or AIDS. You represented the service and dedication 
of the Commissioned Corps. You've raised a couple issues about 
this transformation plan. One is that the Surgeon General 
should be the leader. Do you feel that the changes that are 
being talked about to either take away the powers of the 
Surgeon General, give them to the Assistant Secretary of 
Health, or to split the authority makes any sense?
    Dr. Koop. I've never been asked to testify, Mr. Waxman, 
with so little real knowledge. A lot of the things that I have 
behind me are hearsay. And I have to say what Mr. Farrell has 
just said, and that is, what I heard from Dr. Carmona is not 
what I knew up until yesterday. So there seem to have been some 
major changes. But the way I saw it, I would say that the 
Surgeon General's powers had been emasculated. To have him co-
equal with a Department that knows nothing about what he is 
supposed to be doing and reporting to somebody who is in a 
different division of HHS seems to me ridiculous.
    Mr. Waxman. Well, I didn't get assurances from his 
testimony this morning that was changed. I thought he gave a 
good face to it by saying how the Surgeon General would deal 
with the day-to-day activities. But it sounded like the 
policies were no longer going to be the Surgeon General's 
policies, they were going to come from elsewhere.
    Dr. Koop. As I heard Dr. Carmona, I thought he was 
separating policy from day-to-day activity, but you can't.
    Mr. Waxman. And Dr. Richmond, do you also agree with that 
position? You were Surgeon General and Assistant Secretary of 
Health.
    Dr. Richmond. Yes. In my testimony I focused particularly 
on the importance of the Surgeon General having responsibility 
for the policy and management of the Corps. Now, that of course 
is under the rubric of the Secretary of the Department's 
overall responsibility. But having said that, all of the policy 
development and the management of the Corps, and particularly I 
would emphasize, Mr. Waxman, the extremely important functions 
of relating to the agencies where the professional expertise of 
the officers keeps being renewed. This is why we're the envy of 
all of the countries of the world and that's why we're often 
drawn upon, particularly our capacities in CDC, by countries 
all over the world, because of this matrix that we have of 
professional competence in the agencies and the Commissioned 
Corps and the Surgeon General as its commanding officer. That 
delicate balance, I think, should not be impaired. The minute 
one goes down the path of separating policy from management in 
an organization of that size, I think, is an invitation to 
disaster.
    Mr. Waxman. Just one last question, I'll ask Dr. Koop, and 
Dr. Richmond, I want you to respond. You can look at the Corps 
as having to respond to a medical emergency, and that's 
important. But also what's important is the idea of having 
Commissioned Corps officers serve in agencies like FDA, NIH and 
CDC. These are science-based agencies and they're critical to 
the overall mission of the Corps. Is that your view, and do you 
feel that there's some suggestion people ought to be only in a 
medical response team and not the other side?
    Dr. Koop. That's where I stress flexibility and 
appropriateness, because the individual officer is sometimes 
caught between the demands of a medical emergency which require 
a Corps response and his day-to-day activities as well as 
responsibility to the agency where hi serves.
    I'd like to call attention to one other thing I think Mr. 
Tierney mentioned: the difference between the civil service 
response to an emergency and the Commissioned Corps. It's 
another anecdote that was mentioned in part by Dr. Richmond 
just a minute ago. That is, when Castro did dump a lot of 
people on our shores from his prisons and his insane asylums 
and so forth, the Governor of Florida called Secretary Harris 
for help. She issued an immediate request to the civil servants 
in HHS to respond to that emergency, and not one person 
volunteered. When she inquired why, they said, ``It's not my 
job description.'' In desperation, she turned to the Surgeon 
General, who said, ``Go,'' and 268 people went and served 
between 2 weeks and 2 years at that very onerous job of sorting 
out those people which, you'll remember, ended in separating 
6,000 criminally insane people from other refugees.
    Mr. Waxman. All three of you made excellent points, and I'm 
persuaded by the testimony today that everybody we've heard 
from, and the Secretary himself, has the same goal in mind, 
making sure that we have a Commissioned Corps that serves the 
best interests of the public health and needs of the American 
people. I just wish the Department had gone through a process 
where everybody's views might have been sorted through and 
digested and there could have been a greater consensus for the 
proposal. But it's not too late. And I hope this hearing will 
produce that kind of dynamic that I think is essential to 
getting a win-win for everybody, not something where people 
fear a plan and may find themselves with no other choice but to 
leave. Because, as Congressman Van Hollen pointed out, in that 
survey, if we have 70 or 80 percent of people leaving the 
Corps, leaving the Centers for Disease Control and Prevention, 
it's not in their interest and it's certainly not in our 
interest to have that happen.
    I thank the three of you for coming and I appreciate your 
contribution today. I hope as a result of this hearing we can 
get to a good result for everybody.
    Mr. Shays [assuming Chair]. I thank the gentleman.
    In my previous life chairing--I chair now the National 
Security Subcommittee--I used to oversee the Departments of 
Health, HHS, CDC, and so on, in the 4-years that I chaired that 
subcommittee. I developed a tremendous appreciation for our 
health care institutions and all the folks associated with it.
    I'm struck with this basic belief, that I think the 
administration has a lot of very intelligent people working for 
it, and I sense there are probably a lot of good ideas in this 
reorganization. But the one criticism that seems to be not just 
unique to HHS and so on has been the desire sometimes to just 
mandate without involving the employees. So what could 
potentially be really good ideas aren't bought into by the 
employees. And frankly, the administration's desire just 
sometimes not to disclose stuff to Congress and so on, it's an 
Achilles heel in my judgment. It's a view that I have that goes 
not just in health care but in a lot of others.
    So I take that general bias, so it's very easy for me to 
accept, Captain, your criticism of this process, because we've 
heard it before in so many different ways. But having said 
that, it doesn't mean the ideas are wrong or the effort is 
wrong. And I'd like to ask you first, Dr. Koop, in your 
testimony, you stated that the Corps, to reach its full 
potential, the Surgeon General must have complete and direct 
control over all aspects of the day-to-day administration, 
management, and operation of the Corps. I'd like you to tell me 
what this means. Every manager wants to have as much control, 
but are you saying that it needs to be more complete and more 
direct over everything as opposed to some other type of 
management of individuals? And if so, why?
    Dr. Koop. The essential thing has been mentioned in several 
ways, and that is that every officer has two obligations: that 
to the agency which employs him for his day job, where he has 
many obligations, and when emergencies arise, he has the 
obligation to respond as a member of the Corps. And that's why 
I said that, at the present time, the flexibility and the 
appropriateness which guide the council that makes these 
decisions makes it more than just a one-man decision. It isn't 
that the Surgeon General is a dictator, but he is the 
orchestrator of a very highly-tuned group of experts, all of 
whom have a very definite understanding of their 
responsibilities, both to emergencies and to the day-by-day 
situations that occur; they vary from agency to agency.
    In my day, high on the table of organization, I reported 
directly to the Assistant Secretary of Health. But that did not 
mean that I didn't consult almost every day with the agency 
heads, and it didn't mean that I bypassed the Assistant 
Secretary and spent a lot of time with Otis Bowen on the 
discussion of policy. So it was a collegial atmosphere, which 
is one of the things that always was attractive about the 
Corps. Nevertheless, the Corps itself and the agency heads 
looked for direction to the Surgeon General.
    Mr. Shays. Dr. Richmond, would you amplify on anything? 
Would you disagree with anything?
    Dr. Richmond. No, I think Dr. Koop has put this very well. 
But I would also emphasize, just in terms of management 
principles, one cannot have a Corps which brings together 
professional expertise as well as preparedness issues without 
having clear lines of command and authority. I think anything 
that creates any degree of ambiguity about the Surgeon 
General's capacity to be the commanding officer would be a step 
backward.
    Mr. Shays. So when I intuitively look at people in uniform 
and see ranks, the analogy is much closer to the military than 
it would be to so-called civilian life?
    Dr. Richmond. Yes, and I think the uniformed service 
component sort of exemplifies that. And I think that the 
differentiation in part from the military is this professional 
expertise that exists in the Corps. That can't be constantly 
renewed and reinvigorated without these officers being in the 
operating agencies where the professional skills and 
developments are, as I indicated earlier, bringing the 
resources of NIH, FDA, CDC, and all of the others, HRSA, to 
bear on the problems. If we don't have that constant 
refreshing, professionally, of these officers by virtue of 
their placement there, they won't have the competence really to 
do the job in emergency preparedness that we hope they have.
    Mr. Shays. So putting in my words, qualification to the 
pure military model is that a lot of those in the Corps are 
highly educated, part of a profession of doctors who basically 
you then say somehow modifies this concept of pure military.
    Dr. Richmond. That's correct.
    Mr. Shays. It implies to me there has to be more 
consultation and so on. But you still want lines of authority 
and so on. Is that what you're saying?
    Dr. Richmond. That's exactly right.
    Mr. Shays. Dr. Koop.
    Dr. Koop. That's correct, because the command and control 
aspect that the military uses so well is what separates us from 
a civilian organization.
    Mr. Shays. Otherwise, you might as well not exist.
    Captain Farrell, anything you would disagree with, or how 
would you amplify it or where would you put your emphasis?
    Captain Farrell. No, sir, I think that both Dr. Koop and 
Dr. Richmond both can say it far more eloquently than I can. 
The model that the Corps likes to look at is the military 
model. And that is in terms of organization and operation. But 
they don't execute it the way the military does, because 
they'll never be able to, because their mission is different.
    What the uniformed service brings to the Corps probably 
more than anything else is the perception that very uniform 
conveys. Because what that uniform conveys is a perception of 
order, a sense of disciplined organization, it brings with it 
identity, a sense of purpose, and a commitment and a 
confidence, not so much a confidence in the people wearing the 
uniform, but in the confidence of the general public and those 
who adopt the uniform and wear it. There have been countless 
surveys over the past number of years that ask the general 
public, ``What is the institution in the country that you have 
the most confidence in?'' They list them, they are judges or 
clergy or whatever. Uniformed services consistently rank in the 
top three. That is something that I think is essential in 
health.
    Mr. Shays. You put the emphasis slightly differently. I 
don't mean to be splitting hairs, but I'd like the two Surgeons 
General to respond. You said what made it different, I was 
inferring that the difference was the education of the 
individuals and the focus on the individuals. You put the focus 
on the mission. Is this a difference without a meaning? Are 
they one and the same, Dr. Richmond or Dr. Koop?
    Dr. Koop. I don't think there's a gap in what we're 
thinking. The mission of the military is much more focused. 
That of the Public Health Service is very diffuse. And I think 
there's another thing that may sound silly to bring up, but of 
all the uniformed services in this country, we are the only one 
that is unarmed, also the only one that doesn't go by the 
principles of the Uniform Code of Military Justice. So we have 
certain flexibility in our ranks that the Army, Navy and the 
Air Force cannot exert.
    Mr. Shays. Can an employee within the Corps be ordered to 
go into harm's way like they can be in the military? If there's 
an epidemic somewhere, can you basically, as the Surgeon 
General, basically say, you need to go there, your life is 
somewhat in danger but that goes with the uniform?
    Dr. Koop. That goes with the uniform. The difference comes 
where, if he says, ``I'm not going,'' the Surgeon General 
doesn't have the right to court martial him.
    Mr. Shays. No firing squads?
    Dr. Koop. Not yet. [Laughter.]
    Dr. Richmond. Mr. Chairman, I don't think there is a 
difference between mission and the other issues we're talking 
about. But our mission is to promote the public's health. And 
the difference is that we have to have professional skills in 
order to do that, not just military skills.
    Mr. Shays. This may seem a little trite, but it does 
interest me, because uniforms are worn. I'd love to know what 
the policy of yours, Dr. Koop, and Dr. Richmond were, if 
someone was, when would they be required to wear a uniform if 
at all? If they worked for the CDC or NIH, would they be in 
uniform? Tell me how you sorted that out. Was that up to each 
individual to decide?
    Dr. Koop. When I came, the rule was you had to wear your 
uniform at least 1 day a week. I decided, we had several things 
that happened to us that really lowered morale right after I 
got here. One was that the administration closed all the public 
health service hospitals. Morale was very low. We lost our 
educational component. I announced to the troops that if they 
wore their uniform, they'd see that they had a lot of friends 
suffering the same way. And I tried to stress the wearing of 
the uniform more and more.
    Then when the day came for the revitalization, we had a 
problem in the Corps that we inherited from the Vietnam war. As 
you'll recall, if one volunteered for the Public Health Service 
at the time of the draft, they were exempt from the draft. We 
got a number of people who joined the Public Health Service for 
reasons other than pursuing public health. And we were very 
unhappy to have the military refer to these people as the 
``Yellow Berets,'' and they were a relatively incorrigible 
group that did not like the military discipline. They are the 
first people that I was anxious to do something about. 
Revitalization was geared in such a way that would make life 
very uncomfortable for these people and we lost 400 of them 
almost immediately. So one of the rules was----
    Mr. Shays. And that didn't disappoint you?
    Dr. Koop. Not one bit. After that, I would say that 
gradually, the uniform became something that was worn more and 
more, and we had very few officers at the time I left in 1989 
that spurned the uniform for reasons that were never made 
clear.
    Mr. Shays. Interesting. Dr. Richmond, talk to me about the 
uniform, and also Captain Farrell. I just want to know, what 
role does the uniform play?
    Dr. Richmond. I think Dr. Koop has spoken to this point. I 
think it's an important morale issue. It gives the group a 
sense of identity. I think it conveys important messages to the 
public about the commitment. We haven't talked all that much 
about what the Commissioned Corps means.
    Mr. Shays. I'd be happy to have you tell me.
    Dr. Richmond. When people enter the Corps, they really have 
made a commitment. That really includes, as you suggested, Mr. 
Chairman, being ordered into harm's way. That is part of the 
oath that they take. So it does provide a sense of identity, 
and to the public, it certainly communicates the sense of 
commitment that people in the Corps have.
    Captain Farrell. I would agree with all that, Mr. Chairman. 
The uniform brings a sense of identity, a sense of shared 
common purpose, unity of purpose. It brings tremendous 
visibility.
    To go back to your earlier question, the decision about 
uniform policy is essentially today left to the individual 
agencies in which Corps officers are assigned. For instance, in 
the Bureau of Prisons, officers that are assigned there are 
required to wear their uniforms. It is a matter of being able 
to sort out who are the good guys and who are the bad in the 
prison. In Indian Health Service, you will find that most of 
the officers wear their uniform most of the time. Just 
recently, within the past month, Commissioner McClellan at FDA 
issued an edict that from, I guess it was the beginning of 
October, henceforth, all FDA commissioned officers will wear 
their uniform every day. That is something that we support, 
because we think the uniform adds a tremendous amount to this 
shared sense of purpose.
    Mr. Shays. Thank you. It looks like your oath is the same 
as the oath of Congress for the most part?
    Captain Farrell. That may be true. The oath is the same, 
exactly the same as the other uniformed services.
    Mr. Shays. Right. It also says, ``I will support and defend 
the Constitution against all enemies, foreign and domestic, 
that I will bear true faith and allegiance to the same, that I 
take this obligation freely, without any mental reservation or 
purpose of evasion, that I will well and faithfully discharge 
the duties of the office for which I am about to enter, so help 
me God.'' And then an affidavit as to service: ``I am willing 
to serve in any area or position wherever the exigencies of the 
service may recall.'' And another affidavit as to striking 
against the Federal Government: ``I am not participating in any 
strike against the Government of the United States or any 
agency thereof, and I will not so participate while an employee 
of the Government of the United States or any agency thereof.'' 
It's a fairly clear statement.
    Before we adjourn this hearing, what would you like to put 
on the record? Whatever you'd like, I'd like you to put it on 
the record, however long you'd like to take to do that. Dr. 
Koop, is there anything that you would like to put on the 
record?
    Dr. Koop. No, as I've said, when you've been chairman of 
the committees before, sir, there are a lot of things you can 
do that we can't do. And I think that the guidance from your 
committee as to how this particular transformation should have 
been done is not too late to correct. I think corrected, and 
following the things you've heard from all of the witnesses 
here, it can be done in such a way that we get the kind of a 
Corps we want that doesn't change its character, but does put 
responsibility and leadership where it belongs.
    Mr. Shays. I know that Mr. Davis tends to followup on this, 
with the very good staff that we have. So that will be done.
    Dr. Koop. Good.
    Mr. Shays. Dr. Richmond.
    Dr. Richmond. I would just reinforce that notion that this 
have continuity, and certainly, we admire the interest that the 
committee members have demonstrated.
    But I think the central message that I would like to leave 
is that the Surgeon General needs to be the commanding officer 
of the Corps, and that needs to be very clear.
    Mr. Shays. Free from politics.
    Dr. Richmond. Including policy, yes. With the oversight of 
the Secretary.
    Mr. Shays. Right, but I'm saying free from politics, the 
ability to say what needs to be said when it needs to be said. 
The irony is that when you have a Surgeon General that does 
that, he or she is a credit to the administration, besides 
protecting the health and welfare of all Americans. They also 
in a very real way give credibility to the administration when 
they do that, whatever administration.
    It's a comfort to those of us who aren't in the health 
field to know that if something needs to be said, we know one 
person will do that, and that's the Surgeon General, that they 
will say whatever needs to be said. That's essential. I was 
under the reign of Dr. Koop, and I just appreciated it so much, 
Dr. Koop. I never felt that you would be reluctant to say what 
needed to be said. You found a gentle way to say it in most 
cases, but you said it.
    Captain Farrell, is there anything you would like to put on 
the record?
    Captain Farrell. Sir, I'd just like to add that our 
association I think is encouraged and heartened by what we've 
heard here today, and we certainly appreciate the committee's 
interest. I would agree with Dr. Koop and Dr. Richmond that the 
important thing here now is to follow through and to make sure 
that the changes that are apparently taking place and the 
details of the transformation plan are actually carried out, 
put in writing for us all to see so we can evaluate and make 
sure that the plan is moving in the direction that the Corps 
officers will be able to fully support.
    Mr. Shays. Thank you all very much. With that, we'll 
adjourn this hearing. Thank you.
    [Whereupon, at 1:05 p.m., the committee was adjourned, to 
reconvene at the call of the Chair.]
    [The prepared statement of Hon. Carolyn B. Maloney and 
additional information submitted for the hearing record 
follow:]

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