Controlling a pandemic like Covid-19 requires both the intervention of government agencies and changes in the lives of ordinary Americans.
One thing the federal government should do, but hasn’t, is fully deploy the U.S. Public Health Service Commissioned Corps (USPHS). Not only can the Corps support health systems in rapidly scaling medical care, it can also advise state governments on the judicious use of state police powers to help slow the spread of the virus and limit economic damage.
The Corps is the world’s only national uniformed service devoted to protecting, promoting, and advancing the health and safety of a nation. It has more than 6,300 officers — physicians, nurses, pharmacists, engineers, and more. Under normal circumstances, the Corps’ commissioned officers work side by side with their civilian counterparts in all aspects of public health at government agencies, from direct patient care to providing policy and administrative services.
Since 9/11, the Corps has placed special emphasis on training its officers as America’s Health Responders for man-made and natural disasters, including epidemics and pandemics. Organized as nimble teams, USPHS Rapid Deployment Forces work in concert with Disaster Medical Assistance Teams as well as other resources.
More than 2,400 USPHS officers were deployed to the Gulf region in response to Hurricanes Katrina and Rita in 2005, where they helped rebuild devastated health systems, conducted disease surveillance, and provided needed clinical care. The USPHS has also used these skills abroad, including commanding and staffing a medical unit in Liberia to fight the deadly 2014-2015 Ebola outbreak.
So far, the USPHS has deployed more than 1,000 officers to support Covid-19 activities abroad, assisting the government of Japan. Domestically, it dispatched a Rapid Deployment Team to Kirkland, Wash., following the deadly outbreak in a nursing home.
The USPHS has also announced plans to deploy 10 to 12 clinical strike teams to care for 300 to 500 patients each.
But that does not engage the full force of the Corps. Now is the time for the Trump administration to fully activate and deploy the USPHS to help Americans, given dire predictions of a ventilator shortage in New York City, Boston health care workers recycling face masks, and total economic costs estimated in the trillions of dollars.
USPHS officers can manage logistical challenges arising from an increased need for medical care. They are experienced in coordinating rapid construction of field hospitals to increase bed capacity and assisting with rapid organization of supply chains to help procure personal protective equipment from routine and unorthodox sources to address supply shortages. Theresa Cullen, a former one-star rear admiral in the USPHS, told us that as part of the Hurricane Rita response, a Disaster Medical Assistance Team worked with the community in Waco, Texas, to turn a Walmart into an emergency shelter in just a few hours and cared for hundreds of hurricane victims.
Facing difficult ethical dilemmas such as mandatory “do not resuscitate” orders, USPHS officers, who are dual trained in clinical medicine and epidemiology and driven by a public service mission, can advise health system leaders on balancing individual rights and the need to protect the public health.
The role of state police powers
America’s system of federalism generally places the responsibility for making and implementing public health decisions in the hands of local and state officials. The 10th Amendment to the U.S. Constitution reserves police power, including public health police power, to the states. States, therefore, are obligated to use police powers to protect the public interest, which includes public health as disease outbreaks and epidemics can be directly controlled through targeted societal interventions.
Governors, mayors, and state and local public health officials responsible for disease surveillance within their borders must then judiciously exercise their wide-ranging police powers in this crisis. Police power can include mandatory quarantine of those with suspected or confirmed disease, as well as enforcing sheltering in place, social distancing, travel restrictions, and the closing of businesses and public spaces.
The deployment of these powers must balance the protection of civil rights with the protection of the public health and adhere to six key principles:
- Interventions should be evidence-based and grounded in scientific knowledge, not political considerations.
- Health officials should make individualized risk assessments demonstrating a significant risk to the public.
- Coercive measures should be proportionate to the threat faced.
- There should be no less restrictive alternatives to accomplish public health objectives.
- Individuals subject to deprivation of liberty should be afforded due process, including impartial hearings.
- Government should ensure fair and equal treatment, avoiding stigma or discrimination against individual groups.
USPHS officers are uniquely qualified to help state and local officials follow these principles as they take action. Corps members can make individualized risk assessments and identify the least-restrictive alternative to achieve public health objectives, ensuring judicious use of state police powers. As officers sworn to protect the Constitution, they can advocate for fair and equal treatment of all persons. USPHS officers can liaise in real time with policymakers and politicians to provide them with the evidence-based and action ready options.
The need for an ‘after action review’
Once the pandemic is under control, Congress should review the government’s response to the virus given the scope of the Covid-19 outbreak and the depth of its impact on American life. Similar to the 9/11 Commission, a Covid-19 commission should include an interdisciplinary team of physicians, lawyers, scientists, business leaders, communication and policy experts, and academics. Such a commission can play a critical role in evaluating and identifying actions that can be used to inform playbooks for future responses to public health emergencies.
Both the USPHS and the Centers for Disease Control and Prevention should be front and center among the items the commission should examine. Policymakers can assist with determining the USPHS’ core peacetime mission and its appropriate evolution as a uniformed service during times of crisis, in addition to creating sustainable funding models. Early CDC challenges with frontline staff in managing the initial outbreak suggest longstanding organizational challenges for how the CDC surveys and plans for pandemics, highlighting the need for agency reform. Americans, affected in their daily and economic lives by the deployment of state public health police powers, should be informed how local and state officials make these decisions.
Dealing with pandemics requires action, unity, and introspection. Now is the time for action and unity, even as we begin to plan for the future.
Andrew B. Meshnick is a medical student at the Georgetown University School of Medicine. Brian J. Miller, M.D., is a physician in Washington, D.C., who is currently working in a coronavirus screening clinic and an adjunct associate professor at UNC Kenan-Flagler Business School. Boris D. Lushniak, M.D., served as acting surgeon general from 2013 to 2014. He was the commander of the USPHS Monrovia Medical Unit in Liberia, and is now the dean of the University of Maryland School of Public Health.