I can only describe our command-center, windows pc-based, “let’s find a connection with some bandwidth” way of merging data and connecting to the outside world as cumbersome, unreliable, slow and practically useless in a field environment. Despite our best efforts to make it work, it never does.

Why cumbersome: because of firewalls and access; if we glom off of a host network at whatever facility we have at the command center, there are concerns that our connections will compromise the network. The connections require IT officers. Access is often limited to a few PC’s (which are not connected to a cloud-based server anyway) that are controlled by command staff. Data collected on these PC’s are not distributed. If you need application A and it’s on computer B; you have to wait for your turn on computer B. If you are working on a word document to do a status update, you just took one of the few available connections to the internet away from everyone.

Why unreliable: Who is to say that wherever we deploy there will be a network at the command center? Wi-Fi and cellular connections are not guaranteed.

Why slow: The more PC’s connected to the network, the slower it performs.

Why practically useless: Because of time and distance. If you are not at the command center, you still need to collect data, merge the data centrally, and write status updates.

Waiting to do all these things at the command center, especially if you have to key-in the data, is a waste of time and a major cause for 18 and 20-hour days.

What is the solution?

Health and Human Services Secretary Kathleen Sebelius had it only partially right when she started a Health Data Initiative http://ping.fm/Um6EU recently, aimed toward distributing health data via a HHS Health Data Community Dataset. She left out one of the most important users of such a system: the “Deployment” community within DHHS.

I can think of a number of ways products from Google, Apple, and Microsoft could be used, with available apps, to collect cloud-based data. But none of these ways is comprehensive, none accomplish the mission securely enough and allow only government to “own” the data. Getting everyone on the same app looks impossible to me without some leadership at HHS.

I’ll suggest the need here. We need an app that:

Allows a secure connection to HHS with an app that requires PIN access by the user. That way unauthorized access to the app is minimized if the host device is lost.

Sends data to HHS servers that are mirrored (the databases are redundant and distributed geographically) to prevent data loss.

Runs on multiple platforms (iOS, Android and Windows Mobile) so anyone with a smartphone in the field can use cellular networks to upload and download data.

Allows the user to send status updates (text reports) to the “cloud” where command staff can edit and forward to OFRD and others.

Allows easy design of data collection forms that can be designed and saved in the “cloud”.

Contains all ICS dataforms so the ICS systems can be leveraged right at the start (T-cards, Safety, Procurement, etc.).

Allows wireless printing at the command center.
Contains useful information resources for hazard assessment.

Contains ready-made forms for patient ID and check-in, triage, hazard assessment.

Allows data download to a central PC by Wi-Fi or cable when cloud-based data management is not available.

Allows data from forms to be sent to a cloud in a database that is set up by the user and can be shared by anyone with the form.

Has a permission-based system that secures databases and forms as read-only, write-only, or read-write.

Allows data and forms to be downloaded in commonly used .pdf and .csv formats.

Leverages the mapping and geotagging capabilities of smartphones.

Works with tablets too. We can stop hauling around bulky laptops and start using Wi-Fi capable tablets. If field personnel also have a 3G/4G tablet, all the better!

Allows us to send distributed alerts to all users in the field.

Cost savings seem to me to be self-evident, and all of this seems in the realm of capability, right now. Tablets and phones are cheap compared to a laptop. They are easy to use, and come ready for wi-fi connection. Many phones and tablets can actually double as wireless hot-spots, allowing users to set up a mini-net work anywhere they can find decent bandwidth.

Here’s the reality; most of us use our personal phones and laptops in a deployment anyway. We can’t get serious work done without them. If we knew we could get reimbursed some nominal amount for using our data bandwidth through our smartphones and tablets, I’m certain we would. I’m certain most of us wouldn’t be bothered at all by contributing a tiny bit of our personal data plans to a deployment. We would gladly contribute our communication hardware rather than use the old command-center, pc-based networks that never, ever work, and have become a major impediment to doing our job in a digital world.

Secretary Sebelius, Assistant Secretary Koh, Surgeon General Benjamin, our HHS IT people, can you make this app?

The reason I bring these classic environmental pieces together is the availability of information that refutes the safety and utility of what I call the “Public Health Commons”. The Public Health Commons are distributed systems, typically government-run and funded, that we share as a common resource. Lets take two examples: water fluoridation and vaccinations. These have been staples of public health practice for decades. It’s not that debate over fluoridation or vaccine safety shouldn’t exist, it should. But the debates should be addressed by public health officials whose education and training influence their decisions.

The other dimension to the Public Health Commons is “government-run and funded”. As they say, all politics are local. As the people of Pinellas County, Florida found out when the Public Health Commons was dealt a blow by four of seven county commissioners who voted to discontinue fluoridation.

This is where Silent Spring and the Tragedy of the Commons link. From The Tragedy; “Ruin is the destination toward which all men rush, each pursuing his own best interest in a society that believes in the freedom of the commons. Freedom in a commons brings ruin to all” and “The individual benefits as an individual from his ability to deny the truth even though society as a whole, of which he is a part, suffers”.

The commissioners who discontinued fluoridation were not presented with compelling scientific evidence that fluoridation is a significant public health risk. Even if they were, did they then consult with the scientists at CDC who endorse the practice? Did they work with the EPA to determine if Pinellas County had set its fluoride concentration to recommended limits? In an action I equate to the Tragedy of the Commons, the four commissioners were convinced that they alone had the perspective necessary to affix a tag to The Public Health Commons. The tag reads “DANGER – Big Government, Less Freedom, Socialism At Work”.

Shutting down programs because of the distributed benefit is bad enough. To hide behind this agenda, they can cite studies and quote experts that provide them with political cover. This has been done before, to state with certainty that vaccines are dangerous, fluoridation is linked to disease, thus the risk outweighs the benefit. Scientists know there is a difference between a rigorous study, designed with statistical power and an opinion piece or speculation. Some decisions are harder than others as the evidence is not always clear. But it is irresponsible as an elected official to quote a study or two, quote an opposing view, mix in a little government oppression, add a pinch of loss of freedom, a drop of paranoia, generalize for 5 minutes and half-bake for an hour before you are ready to influence the Public Health Commons, right there from your County Commissioner’s seat, and affect the health of thousands. It’s not your job to ignore the public health professionals at CDC and EPA, because they just don’t share your “rational self-interest”.

Until Silent Spring was pubished, few were paying attention to the bio-accumulation of pesticides. It took the deaths of birds to see the cause and effect. It took an observant scientist to ring the alarm. Fortunately, big government stepped in and began to regulate DDT. Now, states require pesticide applicators to be licensed and certain pesticides, including DDT, have been banned. The EPA is involved in regulating the pesticide industry; the CDC really does know a thing or two about toxicology and public health practice. But if your not going to listen to them about fluoridation, I’m not sure DDT and a Silent Spring couldn’t make a comeback. Is the Public Health Commons awaiting its depletion?

When a population as large as that affected by this decision can lose ground in the Public Health Commons so easily, this Pinellas County decision should serve as a wake-up call to public health officials that your hard work, your education, and your training mean nothing to those who have a “rational self-interest” in ignoring your expertise. Don’t stand for it. Present your case to the public loudly and clearly; enable them to take back their lost piece of the Public Health Commons.

Sadly, some officers are walking around thinking they have no rights to even talk about anything having to do with public office, or public officials, or politics. This issue has been around for decades, and guidance on these matters is not hard to find. The only question I have is… do we fall under the Hatch Act or not? Apparently, we had policy that cited the Hatch Act at one time, but that policy does not appear to be in effect any longer; CC23–Staffing, Subchapter CC23.5.8 which states ” The officer shall not engage in any political activities prohibited to Federal employees under 5 U.S.C. 7321 et seq. (the former Hatch Political Activity Act). Later, the policy mentions 5 U.S.C. 7324 too. That’s not a whole lot to really sink your teeth into, and it’s wrong anyway.

So, let’s say for the sake of argument that the Hatch Act doesn’t apply for two reasons: 1) our policy is no longer in effect, and 2) we are a uniformed service, therefore the Hatch Act does not apply to us as Federal Employees. You can find that we are not defined as Employees under the Hatch Act under 5 CFR 734.101: Employee means any individual (other than the President, Vice President, or a member of the uniformed services) …

Ok, so now we basically have no policy on political activity of our own that applies to us as uniformed service members. So, let’s do what we do and borrow something. Let’s borrow Department of Defense Directive 1344.10.

Its says, that there are many things an Armed Service member CAN do:

4.1. General
4.1.1. A member of the Armed Forces on active duty may:
4.1.1.1. Register, vote, and express a personal opinion on political candidates and issues, but not as a representative of the Armed Forces.
4.1.1.2. Promote and encourage others to exercise their voting franchise, if such promotion does not constitute use of their official authority or influence to interfere with the outcome of any election.
4.1.1.3. Join a partisan or nonpartisan political club and attend its meetings when not in uniform, subject to the restrictions of subparagraph 4.1.2.4. (See DoD Instruction 1334.1 (Reference (c).)
4.1.1.4. Serve as an election official, if such service is not as a representative of a partisan political party, does not interfere with the performance of military duties, is performed when not in uniform, and the Secretary concerned has given prior approval. The Secretary concerned may NOT delegate the authority to grant or deny such permission.
4.1.1.5. Sign a petition for a specific legislative action or a petition to place a candidate’s name on an official election ballot, if the signing does not obligate the member to engage in partisan political activity and is done as a private citizen and not as a representative of the Armed Forces.
4.1.1.6. Write a letter to the editor of a newspaper expressing the member’s personal views on public issues or political candidates, if such action is not part of an organized letter writing campaign or a solicitation of votes for or against a political party or partisan political cause or candidate. If the letter identifies the member as on active duty (or if the member is otherwise reasonably identifiable as a member of the Armed Forces), the letter should clearly state that the views expressed are those of the individual only and not those of the Department of Defense (or Department of Homeland Security for members of the Coast Guard).4.1.1.7. Make monetary contributions to a political organization, party, or committee favoring a particular candidate or slate of candidates, subject to the limitations under section
441a of title 2, United States Code (U.S.C.) (Reference (d)); section 607 of title 18, U.S.C. (Reference (e)); and other applicable law.
4.1.1.8. Display a political bumper sticker on the member’s private vehicle.
4.1.1.9. Attend partisan and nonpartisan political fundraising activities, meetings, rallies, debates, conventions, or activities as a spectator when not in uniform and when no inference or appearance of official sponsorship, approval, or endorsement can reasonably be drawn.
4.1.1.10. Participate fully in the Federal Voting Assistance Program.

Its says, that there are many things an Armed Service member can NOT do:

4.1.2. A member of the Armed Forces on active duty shall not:
4.1.2.1. Participate in partisan political fundraising activities (except as permitted in subparagraph 4.1.1.7.), rallies, conventions (including making speeches in the course thereof), management of campaigns, or debates, either on one’s own behalf or on that of another, without respect to uniform or inference or appearance of official sponsorship, approval, or endorsement. Participation includes more than mere attendance as a spectator. (See subparagraph 4.1.1.9.)
4.1.2.2. Use official authority or influence to interfere with an election, affect the course or outcome of an election, solicit votes for a particular candidate or issue, or require or solicit political contributions from others.
4.1.2.3. Allow or cause to be published partisan political articles, letters, or endorsements signed or written by the member that solicits votes for or against a partisan political party, candidate, or cause. This is distinguished from a letter to the editor as permitted under the conditions noted in subparagraph 4.1.1.6.
4.1.2.4. Serve in any official capacity with or be listed as a sponsor of a partisan political club.
4.1.2.5. Speak before a partisan political gathering, including any gathering that promotes a partisan political party, candidate, or cause.
4.1.2.6. Participate in any radio, television, or other program or group discussion as an advocate for or against a partisan political party, candidate, or cause.
4.1.2.7. Conduct a political opinion survey under the auspices of a partisan political club or group or distribute partisan political literature.
4.1.2.8. Perform clerical or other duties for a partisan political committee or candidate during a campaign, on an election day, or after an election day during the process of closing out a campaign.
4.1.2.9. Solicit or otherwise engage in fundraising activities in Federal offices or facilities, including military reservations, for any political cause or candidate.
4.1.2.10. March or ride in a partisan political parade.
4.1.2.11. Display a large political sign, banner, or poster (as distinguished from a bumper sticker) on a private vehicle.
4.1.2.12. Display a partisan political sign, poster, banner, or similar device visible to the public at one’s residence on a military installation, even if that residence is part of a privatized housing development.
4.1.2.13. Participate in any organized effort to provide voters with transportation to the polls if the effort is organized by or associated with a partisan political party, cause, or
candidate.
4.1.2.14. Sell tickets for or otherwise actively promote partisan political dinners and similar fundraising events.
4.1.2.15. Attend partisan political events as an official representative of the Armed Forces, except as a member of a joint Armed Forces color guard at the opening ceremonies of the national conventions of the Republican, Democratic, or other political parties recognized by the Federal Elections Committee or as otherwise authorized by the Secretary concerned.
4.1.2.16. Make a campaign contribution to, or receive or solicit (on one’s own behalf) a campaign contribution from, any other member of the Armed Forces on active duty. Any contributions not prohibited by this subparagraph remain subject to the gift provisions of sections 2635.301-2635.304 of title 5, Code of Federal Regulations (Reference (f)). See subparagraph 4.1.2.1. for general prohibitions on partisan fundraising activity.

4.1.3. Commissioned officers shall not use contemptuous words as prohibited by section 888 of Reference (b) or participate in activities proscribed by DoD Directives 5200.2 and 1325.6
(References (g) and (h), respectively).
4.1.4. Subject to any other restrictions in law, a member of the Armed Forces not on active duty may take the actions or participate in the activities permitted in subparagraph 4.1.1., and may take the actions and participate in the activities prohibited in subparagraph 4.1.2, provided the member is not in uniform and does not otherwise act in a manner that could reasonably give rise to the inference or appearance of official sponsorship, approval, or endorsement
4.1.5. Activities not expressly prohibited may be contrary to the spirit and intent of this Directive. Any activity that may be reasonably viewed as directly or indirectly associating the Department of Defense or the Department of Homeland Security (in the case of the Coast Guard) or any component of these Departments with a partisan political activity or is otherwise contrary to the spirit and intention of this Directive shall be avoided

Now, as a USPHS Officer, you can make a choice. You can follow a defunct CC that doesn’t look like it applies anyway because the Hatch Act doesn’t apply to uniformed services, or you can follow the DoD Directive, which doesn’t apply to USPHS Officers either. Now, common sense dictates that you should use the DoD Directive “Political Activities by Members of the Armed Forces” as a guide.

————————————————————————————-
The old Hatch Act Statutes quoted in CC23.5.8:

§ 7321. POLITICAL PARTICIPATION
It is the policy of the Congress that employees should be encouraged to exercise fully, freely, and without fear of penalty or reprisal, and to the extent not expressly prohibited by law, their right to participate or to refrain from participating in the political processes of the Nation.

§ 7324. POLITICAL ACTIVITIES ON DUTY; PROHIBITION

(a) An employee may not engage in political activity—(1) while the employee is on duty;
(2) in any room or building occupied in the discharge of official duties by an individual employed or holding office in the Government of the United States or any agency or instrumentality thereof;
(3) while wearing a uniform or official insignia identifying the office or position of the employee; or
(4) using any vehicle owned or leased by the Government of the United States or any agency or instrumentality thereof.

(b)(1) An employee described in paragraph (2) of this subsection may engage in political activity otherwise prohibited by subsection (a) if the costs associated with that political activity are not paid for by money derived from the Treasury of the United States.
(2) Paragraph (1) applies to an employee—(A) the duties and responsibilities of whose position continue outside normal duty hours and while away from the normal duty post; and
(B) who is—(i) an employee paid from an appropriation for the Executive Office of the President; or
(ii) an employee appointed by the President, by and with the advice and consent of the Senate, whose position is located within the United States, who determines policies to be pursued by the United States in relations with foreign powers or in the nationwide administration of Federal laws

Everywhere I turned in NYC, my eyes met the faces of people who died, posted memorials with a message underneath that simply said “Missing” with a phone number to call. It was my first real exposure to the personal impact of what had happened to thousands. Not a single poster even hinted that the person might be dead.

The smoking, smoldering, acrid pile held another story, another reality. The remains of the structures hung in the air, dust and papers were everywhere, and I knew that those faces were among me as I walked the perimeter of the pile.

We were all stoic, and stunned, and very busy going about our work. I now look back and realize what was done, and what wasn’t done, and why, in the name of public health. It was my first exposure to why Fitzhugh Mullan decided to title his 1989 book “Plagues and Politics: The Story of the United States Public Health Service”.

I emphasize the word politics because we all know how to do our jobs. What you don’t anticipate is the other dimension to your work that is inescapably, and entirely, political.

You have a political fight on your hands the minute you get orders to deploy. Never forget that what we do isn’t just about doing the right thing. It’s about getting everyone on board so you can do the right thing. The fight materializes; will the money, the political will, and the need mesh. It may be slow coming. Time is not your friend. Bring the fight to them. Bring it early and don’t listen when told to wait.

In this day of strained state and federal budgets, lets imagine another 9/11 happens tomorrow. Are you ready for a fight? Are you ready to test your agency heads, are they ready to back up their people? Are you Officers ready and willing to make some noise?

If you think your deployment isn’t about politics, take my advice and stay home. For those of you who deploy; your job is to lay it on the line early and often, and make sure everyone knows what you see with your professional judgment. If you get a whiff of stonewalling, stand up. If the system isn’t working, stand up.

Deployments don’t give you a second chance. Be taller, louder, and repeat your story in multiple directions until either someone with political power listens or tells you no. Don’t take a verbal no either; get it on the record.

Don’t sit at your desk ten years later, giving a lesson learned from 9-11.

Why did I refuse to make one investment in a gadget yet willingly made another investment in a vehicle? Because a gadget is obsolete in matter of months. Because a vehicle is incredibly complex and is expected to last for years.

There is a fair comparison here to people and public health. Someone is willing, at a high price, to give you the peace of mind that your health care needs are covered over a certain term. If you break, they will pay to fix… you. Most people don’t cash in, but when they do, the repair is expensive.

But what about the long-term? Well, my car manufacturer is no dummy. They want my car serviced in the shop at certain intervals; oil changed, filter changed, lube, battery check, belts checked, and they keep an eye on certain items that they know will fail eventually… like my timing belt. Pay to get the service done or when you have a systems failure, they can refuse to honor the warranty, on the grounds that you didn’t maintain your vehicle according to their plan.

So, public health service is like maintaining an entire country; it’s complex. NOT just in the sense that when you break you can and will be fixed…at an extremely high cost without insurance, and at a high cost with insurance. Some people think that public health is simply fixing broken things…broken people. There’s a lot of honor and glory in fixing a broken body, neglected as it may be. You can study the rates at which people break. You can predict when and where they are most likely to break. You can certainly point, with a great deal of pride, to the many grateful people you’ve brought back to health after neglect, injury, misfortune or disaster.

But… there is a hidden investment that gets few if any honors and only glory among peers. Lives saved, life prolonged, quality of life improved, IQ points gained, misery avoided, productivity achieved, costs avoided… simply by making an investment in prevention. We didn’t do microsurgery to repair the hand. We knew that the occupation was dangerous so we guarded the machine. We didn’t diagnose and treat dysentery. We applied simple food safety practices that kept the food at the right temperature and forced removal of tainted food from the market. We didn’t treat lung cancer with the latest advances in chemotherapy. We figured out how to get you to stop smoking. We pulled the radon from your home. We didn’t institutionalize you. We treated your mental illness and depression before you harmed yourself and others. We didn’t take your x-ray, dilate your pupil, take a blood sample, or test your hearing after years of damaging exposures; we knew your bones would become brittle if we didn’t stop an exposure to a hazard at work, we knew your radiation exposure would cause cataracts and skin cancer, we knew your band saw would make you deaf in five years, we knew your chronic inflammation was due to your water quality.

These are but a tiny, tiny, fraction of the examples that make up preventive medicine expertise vested (and invested) in the Commissioned Corps. Hitting on all cylinders, the Corps serves as a dedicated group of professionals not unique in individual capabilities; it is unique in its body of knowledge; its public health diversity, its ready application to virtually any public health problem. At its core, Commissioned Officers represent a reserve of astounding diversity in public health preventive medicine and clinical practice. The Corps represents a diversity of training, education, and experience that is on tap anytime, anywhere, anyplace. It can be used for immediate public health “repairs” and for longer term public health goals. Most importantly, it has been called upon rarely, because some leaders think that public health service is merely fixing what is broken in the body. It is not.

The worst consequence of any public health threat is manifest not only in what is repaired in the human body. The worst consequence is to not take both the necessary holistic prevention and clinical public health approach and leverage a Commissioned Corps with that unique capability. Give us a call, we are always willing and eager to repeat history by putting the “service” back in public health.

I also get that little fish live and die by forces that are beyond their control. Stock and housing markets swing and crash. Timing it wrong can ruin you. Saving money all your life still isn’t enough when you’re only getting a 1% return. Beating cancer means you are now an insurance risk. Going bankrupt means you are an employment risk. Dying from disease not only kills you, it wipes out all the money you might have passed down to your kids. Mental illness is treated in the emergency room or on the streets. Many people are one flat tire, one mortgage payment, one missed insurance premium from going without the essentials. Working 3 part time jobs means no benefits and less liability to your employers. But, you are told the American dream is still within your reach, all you have to do is work hard and reach for the stars.

America is full of contrasts, as are many countries where the ultra-wealthy live a stones throw from the impoverished. My United States went into trillions of dollars of debt and bankrupted the futures of millions upon millions of its citizens for the sake of buying things most of us never needed in the first place. What we really needed were great roads and schools, clean air and water, a real energy policy that started when our President talked about it 30 years ago, health and mental health care for those in need, living wages. I remember when I was a little kid in grade school; every morning we stood and looked at our flag and said the Pledge of Allegiance to the Flag. “…one nation, under god, indivisible, with justice and liberty for all” I said, my hand over my heart. Back then I had no idea how the meanings of those words would become the contrasts that divide the way my classmates and I would see the world 40 years later.

No matter. How you see the world and how it really is depends on where you look from and whether or not you have your eyes open. Which leads me to this summer as our USPHS Tier I and II teams complete missions in rural Kentucky, and RAM (Remote Area Medical) sets up shop nearby to give basic free medical care to the laid off and underemployed. I understand how serving these people is not big business. It’s not something we have wanted to go trillions of dollars in debt for, because those trillions would be, by now, doing the type of work that doesn’t generate the next industrial park, or hedge fund, or too big to fail business. No, that money would have kept a superpower from being humiliated because RAM, which was founded to provide medical care to the impoverished in other nations, found it necessary to set up permanent shop in Kentucky to serve the United States of my Pledge of Allegiance.

Now, here’s where beliefs come into play. What is unacceptable harm or risk, and what creates societal dysfunction? Who gets to decide? At what level are these decisions made; at the local, state or federal level? Who has to pay to mitigate risks?

Everyone has a different algorithm that pops out the right answer for them. Since it appears this country is constantly locked in conflict clouded by pundits, “truthiness”, non-participatory democracy, and finger-pointing, I thought I might as well add my biases to the blog.

First, laws create a framework for making sure people are punished for imposing unacceptable risk or harm to others. When people see that freedom to create havoc goes unpunished, it destabilizes society. Laws must be not only on the books, they must be enforced to have any societal benefit. Mindless slashing of taxes, closing of agencies, all in the name of a less is more belief system, ultimately destabilizes a legal framework put in place to protect all citizens. When laws are dismantled, unenforced, there are winners and there are losers. Few seem to understand what they gain versus what they lose.

Second, a functional society depends on due process. Due process is achieved when local, state, or federal programs are in place. So, if you are being victimized by a dysfunctional society, you can actually take your grievance to some authority who will fix the problem. But again, mindless slashing of taxes and closing of agencies in the name of a less is more belief system, ends up harming those who cannot afford due process without a program in place.

My contention is dismantling enforcement of laws so that the powerful (either physically powerful or economically powerful) have less accountability is a fools reward to anyone who thinks freedom means less government and not enough tax revenue to enforce the law. My contention is dismantling programs that allow people a means of due process is a fool’s reward, for exactly the same reasons.

I’m convinced beliefs have supplanted reason in this country. Many people in this world hunger for a sense of freedom and function for their societies. If they only had a framework of laws, a way to fairly and dependably enforce those laws to achieve balance, and programs that give them a sense of due process, they would gladly die for that system. We see people, now, who struggle to achieve what we have in the U.S., while I watch people in this country who struggle to dismantle that very same system.

It’s often said that you don’t know what you’ve got until it is gone. If your beliefs are so strong that you are willing to risk lawlessness and societal dysfunction, loss of accountability and due process, then I suggest that you move somewhere where you understand what you gain and what you lose without imposing those losses and gains on everyone else. On the other hand, you could just stay right here and simply learn to compromise and learn to frame freedom in terms that don’t impose your beliefs on everyone. What a great idea for a country.

In the coming months, the protests against the universal healthcare plan under the Obama administration will focus on universal healthcare as a sort of abomination of democracy, a socialist plot to transfer wealth from those who can afford health insurance to those who cannot, an unconstitutional requirement, an interference in the fair workings of capitalism. Yet, if the profit motive were shifted in favor of business’s model to provide health care to those who have the least and most difficulty in paying, then somehow everything would be OK (for example, the prison model, where health care is essentially a basic right with costs built into a business plan).

But the system doesn’t work that way outside the prison walls, because risk and ability to pay are added to the equation. The business models show costs cannot be controlled without pooling risk. Allowing the sickest or poorest into a pool drives up costs and eats into profits. So, the sickest and poorest are excluded until they get health care in the emergency rooms of public hospitals, often too late, without the preventive care that would have helped to keep them out of the emergency room in the first place. Ultimately, the taxpayers and insurance pools pay this cost anyway in the form of higher taxes and premiums, but this method does not erode the balance sheet of the businesses that provide health care insurance. Costs can always be passed on in the form of higher premiums.

So we have two healthcare delivery models. One is a tax-payer supported prison model, where the risk pool is the population itself, the delivery of healthcare is a basic right, and the prison business essentially controls healthcare delivery costs to preserve its bottom line. The other delivery model outside of prison is full of risk pools, some in and some out of the pool, where healthcare is not a basic right, and costs for care of those who are outside of the risk pool are passed on to taxpayers with little to no incentive for the insurance business to control costs in any way other than to keep excluding the sickest and least able to pay from joining the risk pools. Where you would rather be depends on your circumstances, but the more humane system seems to be within the prison walls.

Healthcare for society at large should work somewhat like a prison. If we are a collective citizen group (We the People), then let us spread the risk to the entire population, instead of pooling the risk. Healthcare should not be debated in terms of whether or not the constitution supports it; it is a basic human need. In as much as defense of the country with a strong military is a basic societal need, preservation of the strength of the country in the form of healthcare is a basic societal need.

Some want to frame health care for our fellow citizens as a game of survival of the fittest, where the weakest of us (financially) should be left to die. To help those people, we drive our society into a sort of socialism when we see each other’s health as a collective responsibility. I believe this argument is weak.

Our people are our resource. You need look no farther than the beginning words of the constitution to see that the framers of this country saw “We the People” as empowering. They founded this country to get away from a society where the norm is an “us vs. them” caste society where taxation is without representation. I believe if we are going to be taxed and if we are going to pay higher and higher premiums to pay rising healthcare costs, we should have a say in how the insurance and healthcare industries conduct business. Continuing the status quo will continue to erode our society, balloon our taxes and eat into the overall economy. I believe our nation was founded on precepts of compassion and goodwill toward man (however convoluted those precepts were at the time). Compassion and goodwill are not the precepts of untethered capitalism. At times, our lawmakers need to step in to act for our country as a whole, and particularly for those who do not have a loud, media-driven voice.

I do not want to live in a us-vs.-them United States, where class warfare, anti-governent sentiment, constitutional arguments, and demonization of the poor creates a slippery slope that slides us down to paranoia and hate. I do want to live in a society that believes that healthcare for our citizens is a collective responsibility, a basic right of life, and a way to preserve the resource that is “We the People”. Preserving our collective health is as much a benefit as not despoiling our land or waterways, air, parks or other resources. The movement toward universal healthcare is a vital link that breaks the chain of poverty and preserves our society and economy. We should be fully engaged in lifting each other up, spreading our health care risk among the whole population, and avoiding continuous cycles of economic chaos caused by unaffordable health care and ever rising costs.

Spreading risk also means spreading costs, and giving the people a legislative voice in their country’s future physical and economic strength. We’ve poured, and continue to pour, billions and billions of red ink into supporting one of the most innovative military-industrial complexes in the world. Our legislators put us in massive debt to support it without raising a red-ink protest. Ostensively because the military was an accepted means of preserving our nation’s health and wealth, and the military-industrial complex helped each state’s tax base and job pool.

Can we slow that military-industrial economy just a bit to work on the equally important healthcare-industrial complex? We should learn from other societies, that our people constitutes our greatest asset, our greatest resource. Universal healthcare helps people to break out of a prison of pooled risk where too much risk is avoided to preserve a bottom line, and spreads the risk that balances those who currently need healthcare and those who do not. By spreading risk, costs per capita go down, not up. Costs cannot be as easily transferred to higher taxes and premiums, therefore an incentive to control costs is created, without being borne by those rejected from the risk pool. We don’t need to fear from the economic impact of adding “risky” people to a pooled risk group of the entire population.

Our people are our resource, wealth-building in the healthcare-industrial complex is not more important than the health of our society as a whole. Spreading risk is in line with the concept of “We the People” and not the antithesis of the Constitution. Rather, it is a thesis of the Constitution, that collectively we are the nation’s asset, resource, and founding father’s contrast and answer to concentrated wealth and power.

Speaking of promotions, we understand that next year’s promotions will be competitive through all the ranks in the Regular Corps. Promotions are tied to multiple aspects; probationary periods, competitiveness, and long term tracking of performance. The problem we see is how the new COER scores and the desired “leveling” of COER scores meshes with officer to officer comparisons at promotion boards. Anticipate wide differences in COER scores among individuals, between OPDIVs, and officer’s new and old COER scores. We see this as an opportunity that has been created to weed out poor performers, and perhaps unfairly handicap high performers who fall victim to local or OPDIV policies regarding COER scoring. While leveling of the scores is a desirable goal to help identify the highest performers, the leveling must be consistently applied across the Corps. We see no evidence that such leveling, and the training that needs to be provided to supervisors and reviewers, has or will occur. It is certainly too late to roll out such training now. Many OPDIVs will choose to play it safe and not risk handicapping officers by experimenting with normalized COER scores.

The long awaited and overdue Management review is with the ASH, the Mission review is nearing completion. All of these reviews are complicated by the fact that the direction the Corps takes impacts more than officers themselves. It must be aligned with short and long term DHHS and Administration objectives. The greatest cause for concern is the recent exit of senior career flags, the lack of permanent appointments in key positions (Deputy SG, Chief of Staff, OCCO) and what we understand is a lack of input solicited from senior career officers that guide both policy and Management/Mission reviews.

The Health Sciences track of the PPACA is delayed due to lack of funding. The federal budget is a political football, especially unfunded PPACA programs. This is a vital tool for recruiting that will require a champion. Hopefully COA is lining up support. In addition, the Ready Reserve is also in funding limbo. The concept of the USPHSRR is a short-tour force for deployment or backfilling deployed Regular Corps officers. These RR officers are anticipated to be readiness standard qualified. We anticipate officers removed from the IRC (because the law no longer supports an IRC) will be allowed to re-apply to the Ready Reserve Corps when the time comes.

Lastly, we understand that uniform changes are still being debated by an active Uniform Advisory Committee.

So things are happening; some good, some bad (retirements of key officers), and some frankly disturbing (new COER roll-out). But know this; the Corps, if properly funded, will probably emerge stronger and more aligned with the nation’s overall health care initiatives. Even if funding doesn’t materialize, many barriers to the Corps’ overall growth have been lifted. Domestic and international needs for Corps officers have never been greater. The Corps has survived and endured in spite of riding a sine wave of change, year after year, administration after administration. What is important is that career officers continue to prove to OPDIVs that hiring Corps Officers is a wise choice and an investment, that career officers with vision and enthusiasm seek out senior positions, that career officers actively seek to guide and advise appointees, that we don’t lose the type of unit cohesion we are building in Tier teams, that we invest in our junior officers, and finally, we communicate with officers early and often.

It appears that VADM Benjamin has heard from the CPO’s recently and she has finally issued a long-awaited communication that explains that she has been busy increasing her visibility as SG. Well, better late than never, I guess. It seems to me a short communicative email could have been sent much earlier. I hope our SG understands that she is leading a uniformed service and needs to communicate much more often. Her email is reassuring and promises a formal status report regarding the transformation, and leadership selections that will create a “high performance, efficient, and innovative team.” She is promising a shake-up of sorts that will result in “openness, good communication, and quality service to you and the public.”

I think our career officers have been heard, and I hope our expectations of transparency will be met. Stay tuned!

Meanwhile, Smart Power, and the programs and money to support it, is being lobbied by organizations that believe that President Obama’s $58.8 Billion request for the International Affairs Budget should be fully funded to develop civilian-led tools of development and diplomacy. What is Smart Power? Retired military leaders express to congress the need for Smart Power as Veterans for Smarter Power, part of the U.S. Global Leadership Coalition of businesses and Non-Governmental Organizations (NGO’s) who believe as former Surgeon General VADM Carmona did in this speech that power should be leveraged for humanitarian, public health missions.

I certainly see the logic in that as combat operations end in Iraq, and operations continue in Afghanistan, with much focus of the military on helping establish workable public infrastructures in those countries, including public health systems. The DoD, USPHS, Coast Guard and 20 NGO’s have contributed to the 2010 humanitarian missions in flood-stricken Pakistan, and major humanitarian and civic assistance missions in the Pacific, Latin America and the Caribbean. All evidence that Smart Power is on the move, but is it on the move for the Commissioned Corps of the USPHS?

Recently the Dept. of State started to manage a new Civilian Response Corps which provides civilian federal employees with the funding, training and equipment to deploy rapidly world-wide to provide “reconstruction and stabilization assistance to countries in crisis or emerging from conflict.” HHS is hiring 5 new employees for the ACTIVE Civilian Response Corps A (CRC-A) who would deploy within 48 hours anywhere in the world to support the mission and 40 existing HHS employees for the STANDBY Civilian Response Corps (CRC-S) who would augment the CRC-A by deploying for up to three months to provide specialized services as part of the whole of government response.

While international responses for humanitarian missions and disaster response plays to Smart Power, does our domestic response network seem to play 2nd fiddle? The USPHS could have used funding to respond to domestic disasters with the HAMR teams. But the funding never materialized, and our Tier Teams do what they can with very limited funding.

As U.S. Coast Guard’s ADM Thad Allen recently commented in an NPR interview, there has to be unity of effort to coordinate and focus the energy and the efforts of government with all of the millions of people who want to do something in the wake of any disaster.

Hopefully our leadership and particularly our new Surgeon General, as mired as they are in the aftermath of the PPACA, transformation, and reorganization, has a short and long term plan of action to ensure a Smart Power role exists for the Commissioned Corps of the USPHS, both domestically and internationally.

(See the blog for active links at http://ping.fm/Bwj0t)