| Home > Events > 2nd National Symposium > Bruce Lawlor Department of Defense: Supporting the Health Care System
Major General Bruce Lawlor Good afternoon, ladies and gentlemen. I'd first of all like to thank Johns Hopkins for inviting me here to speak. I want you to know I make this presentation with some trepidation. Everybody else on this panel has got an M.D. after their name, and I'm up here as a simple soldier. I'd like to tell you though that before I came to the Joint Task Force, I was at the Pentagon, and for those of you who are at the Pentagon, you know today that there's a great deal of construction going on out there. They're basically gutting the building, revising it, revamping it, a tremendous construction project, and I had a great deal to do with that. About a year ago when I was there, I was walking down the stairways, and there was a bottle there, and I thought, "Well, someone's going to get hurt," and so I picked that bottle up and out popped a genie. (Laughter.) The genie looked at me, and this being an era of constrained resources, said to me, "I'm going to give you one wish." (Laughter.) And I looked around at this ratty, old Pentagon building that was built in a hurry in about six months during the war, World War II, and I said, "You know, you have a tremendous number of Americans working here doing tremendous work for the country, sacrificing, working long hours, trying to protect our liberties and our freedoms. Why don't you, Mr. Genie, build a new, revised Pentagon? Make this place a decent place to work." And the genie looked at me and he said, "Are you nuts?" (Laughter.) MAJ.GEN. LAWLOR: He said, "Do you realize the amount of the environmental impact statement that will have to be written, the amount of money that the Congress is going to have to appropriate, the technological and engineering feat that this would require?" And I confess I thought about that a little bit, and it was kind of overpowering, and so I said to the genie, I said, "Well, okay. Instead of that, why don't you make me an interesting and dynamic public speaker?" And the genie says, "We can take this probably and do it in sections, and we can get the Congress" -- (Laughter and applause.) MAJ.GEN. LAWLOR: So with that preface, let me move quickly through some thoughts that I would like to offer for your consideration. I'd like to talk a little bit about who we are as a Joint Task Force, and then give you some thoughts about some of the things that we're thinking about and hopefully invite you to think about them with us. I command a Joint Task Force that's stationed at Fort Monroe, which means that it is composed of Army, Navy, Marine Corps, Naval personnel. I have some Coast Guard personnel. We have some police officers that work with us. Admiral Knouss has been kind enough to help us out with one of his people. And what we do is we think about this problem all the time. I mean that's the only mission we have is to think about how would we as a defense organization, as a Department of Defense, try to assist state and locals if we were asked to do so and we were given or ordered to be in support of another lead federal agency. Now, it's been discussed as I've been here today the federal response plan, in which there are 12 emergency support functions that have to be performed in the event of a disaster. My organization has the mission from the DOD perspective of trying to support every one of those 12 organizations if they need us, and so really what we do is we try to think about ways that we can take DOD assets and, based upon the requirements that other federal agencies identify for us, we try to see if we can help and fill those requirements. We adhere very carefully to five principles that the Secretary of Defense has promulgated, and I'd like to mention them briefly for you because I think they're very important, and it helps to focus what we do in people's minds. The first is that we are always in support of another lead federal agency. The Department of Defense is not in charge at an incident site. We are not in charge, frankly, of anything at the incident site. We will take instructions from the lead federal agency. In most cases it will be the Federal Emergency Management Agency or it can be the Department of Health or Health and Human Services. We will take our instructions from them in terms of what we are to do and the priorities that we are to do them in. And so we are never in charge of anything within the United States. And part of the reasons for this is that we believe that the use of federal forces, federal troops within the United States is a very serious thing, and these principles that we adhere to are designed to insure that it is done only with the greatest of care. The second thing that we have working for us is a very shortened chain of command. I report to the Commander in Chief of Joint Forces Command, a four-star General Kernan, and he in turn reports directly to the Secretary of Defense, and what that means is that we have civilian oversight very closely watching everything we do. Within the Secretary of Defense's Office, there has been a special office created, an Assistant to the Secretary of Defense for Civil Support, headed up by Ms. Pam Burkowski, and her job is to provide day-to-day supervision and oversight of everything we do, and that includes procedures and plans and actual operations. Thirdly is that we have been specifically charged to conduct all of our operations in conformity with state, local, and federal law. Now, that seems like it's obvious. It seemed obvious to me when I first got this job. It seemed obvious to many Americans until about two weeks ago when we learned about Palm Beach in Florida, and now we understand that sometimes it is more complex to try to figure out just what the rules of the game are because there are state rules and there are local rules and there are federal rules, and someone has to make the decision on how to integrate all of those rules. So we do that. The third thing that the Secretary has stated is that the primary mission of the Department of Defense is to fight and win the nation's wars, and what that really means is that we are not reorganizing ourselves in order to accept this particular mission. What we do is we look at the existing capabilities within the department, the war fight capabilities, if you will, and try to tailor them so that they will assist if we are asked to do so. And the final thing that we're doing at the JTF based on the Secretary's guidance is to involve the National Guard in the forefront of the DOD's response efforts because they are connected to the states and to the communities. So that's a little bit about who we are and what we're doing. And now I'd like to talk a little bit about the bioterrorism problem and give you some thoughts that we see from our perspective. How you define this problem is very important because the definition of the problem oftentimes will set the parameters of your solutions, and we think that perhaps defining the problem as a medical problem or even a public health problem may not be the best solution because there are a variety of areas that impact this response as we see it and as we see ourselves involved in it. Now, first of course is the medical response, and you've all heard about the overwhelming requirement for assistance in the event of a catastrophic CBRNE, chemical, biological, radiological and nuclear high yield explosive incident within the United States. DOD can help, but in order to help, we have to be careful in terms of our planning or you will find that the assistance that we can provide will not be as immediate as you would like to see it and may not be in the quantity that you like to see it, and there are three reasons for that, and I'll talk about them very briefly. The first is the force structure itself. The Department of Defense has been going through a downsizing exercise since about 1990. To give you an idea, to tell you about the Army which is what I know the best, since approximately 1990 the Army has been reduced by 40 percent, and so the force structure itself is no longer there. And what has happened is because the primary mission of the Army and all the services is to fight and win the nation's war, there has been a focus to make sure that the tip of the spear is sharp, and in order to do that, sometimes you sacrifice some of the support requirements or the supporting units that you have, and unfortunately those supporting units are the very units that probably would be needed in the event of one of these domestic incidents. And so many of our hospitals are now clinics, and many of our clinics no longer exist. We rely extensively on the civilian medical community for health care throughout the military, and those assets simply are not deployable. So that's one of the issues. More importantly though is the issue of our culture. Our medical system is designed to establish medical facilities at the edge of the battlefield and then echelon their way to the rear areas with each succeeding echelon providing more definitive care, and our strategy has always been to stabilize and evacuate. I think Admiral Knouss talked about it, to take the patient away from the danger area and transport him or her to some area some distance away in order to provide definitive care. That is contrary to what we are thinking about here. Here we're talking about the need to bring medical care, definitive medical care, to the actual incident site, to the danger zone, and that's contrary to the way DOD does business.And so we're rethinking that process. How do we go about doing that? And trying to figure out how we organize ourselves. The final reason is our force structure. Our force structure is designed to operate in a very austere environment and to be self-sufficient, and so what you get when you get an Army mobile surgical hospital, for example, is a series of skills, skill sets, doctors of different kinds having different types of degrees and skills, nursing with different skills. You also get the infrastructure that's needed to support that facility because the unit is designed not to operate in the suburbs of Cleveland or Baltimore or Los Angeles, wherever. The unit is designed to operate in the austere environment like the Saudi desert. And so when I ship one of those units somewhere, I'm not shipping just people and medicines. I'm shipping beds, blankets, medical equipment, the kitchens, all of the facilities that's needed to support this unit in an austere environment. And so how do we look at this? We think that perhaps a way to approach it is that we need to start defining the type of care that's needed over time as the crisis develops. What is the type of care that the health care community prognosticates that we're going to be required at certain times as the crisis develops and winds down? And then once we've made that decision, we need to begin to look at what are the specific kinds of skill sets that you need and medicines that you require, and let's bring those skill sets and medicines to the site without moving the rest of the infrastructure. I can move knowledge, and I can move medicines a heck of a lot faster than I can move cots and kitchen equipment. It takes literally days to move and set up an Army facility, whereas it takes hours to move some personnel and some medicines. And so we're looking at conversion models where we can take what we have by way of medical care and use the existing infrastructures within the communities, hopefully located somewhere very near an existing hospital because we believe that people are going to self-evacuate to the places they know. So if we can somehow figure out a way to use existing facilities on the ground at the hospital site or near the hospital site to bring our care, we think we can respond quite rapidly. Another area that I would ask you to think about, and I'll close this down quickly, is the psychological impact that a CVRNE event will have in the Untied States. Recently the Journal of the American Medical Association had a series of articles that talked about the kinds of things in America that people are expected to experience if one of these events occur, and it sort of has a scale of greater need or greater problems for us. We talk about helplessness and hopelessness, and then it starts to change, and you see anger. You see panic. You see violence. You see riot, and the problem becomes in order to provide definitive health care, in order to bring these services to a community, we first have to stabilize the community itself. So I'd ask you to think about as you think about the entire medical care problem, to think about stabilizing the psychological environment within the community because for us to do our jobs, for the community to do its job, we first have to make sure that we have a safe environment in which to deliver these services. So that is an important issue. Finally, let me talk to you a little bit about the political issues that we see because they are very, very important and very critical to us as folks that are attempting to assist. We're not going to make any of these decisions, but we need to have these decisions made by our political leadership. And one of the things that we have seen in the exercises that we've been a part of is a noticeable lack of participation in some cases by the political leadership in the really important decisions that have to be made. For example, limited medicines. Who gets it? What's the priority? How are you going to put a program on the ground that will be understandable and that will not cause the very kinds of psychological problems that we're concerned about occurring in one of these incidents? It's a prioritization issue. Who gets the shots, which is another way of saying who doesn't get them? And that's very important. Which parts of the city will we first be directed to try to provide care for? We've run some exercises where you begin to see natural divisions begin to emerge, rich versus poor, black versus white, and these are the kinds of difficult, difficult political decisions that we have to begin to decide how we're going to handle. The care of our deceased. How do we care for large numbers of deceased? We've been looking at this. One of the things that we know within DOD is that we no longer have the capacity to provide that kind of service because that, too, has been downsized, and so how do we, if we are confronted with the death, let's say, of five, 6,000 people, how do we process that? How do we process the remains in a way that's dignified and respectful? That's not an easy decision because it not only is a decision in terms of priority, it's a decision that involves religious beliefs, the beliefs concerning evidentiary collection, licensing problems, and it's a very difficult issue that we need to also address. The final thing I'd like to talk to you about, and I'll leave you with this thought, is the issue of quarantine. We hear a lot about the question of quarantine, and we think that's also a health care issue that the health care community really needs to think about because quarantine in our judgment -- and we've looked at that -- has an enormous number of problems associated with it because once you isolate a person, you have assumed responsibility for that person's care and feeding and warmth and shelter, and all of the things that that person is required to have in order to survive. And I would leave you finally with my friend Bubba. Now, I love Bubba. Bubba is in my imagination a hard working American, loves his family, loves his country, loves his God, and he'll give you the shirt of his back. He'll do anything he can to help, and Bubba has an ambulance, and that ambulance is a Ford F-150, and Bubba is going to do what he needs to do to help his family and to help other people. And so when you talk about quarantine, think about Bubba and think about how far you're willing to go and who's going to enforce it because it is not a role for the Department of Defense to be doing quarantine enforcement. And the last time that I know of that quarantine was done in this kind of a situation was in Yugoslavia where the only effective way to quarantine their folks was to take over hotels and put barbed wire around them and have the military enforce it. And I have to tell you that's not the American way of doing business. And so let me leave you with this thought. I try not to be a Chicken Little because I really don't believe in Chicken Little. This is a wonderful country. We have enormous wealth. We have great capacity. We have dedicated health care professionals, dedicated medical people, and we're going to get through this thing, just like we've gotten through every other challenge in the last 225 years. We'll get through this one. Thank you.
(Applause.)
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