There's already a strong push to create a unified military medical command at the same level as transportation, special operations, or other four-star functional, as opposed to regional, commands. The Walter Reed fiasco needs to be addressed as a part of this, not on its own.

As a resource, there is also the Commissioned Corps of the Public Health Service (PHS), with the US Surgeon General also having three-star rank, and the Assistant Secretary of HHS for Health having four-star protocol rank. PHS officers often serve in Veterans Affairs (VA) medical slots and sometimes military ones.

Rehabilitation needs a higher visibility within both DoD and DVA. It is a distinct medical specialty with its own certification.

Right now, each military service has a three-star Surgeon General. Among the deputies in each service is a two-star director of nursing. I would propose the following:

Military

1. Create a specified military medical command, headed by a four-star physician. There will be physician deputies, probably drawn from the existing service Surgeons General, that watch over specialized service-specific functions, such as being sure a doctor assigned to a submarine is qualified in underwater medicine, rather than a pure flight surgeon*.
2. Actively consider creating an Undersecretary/Assistant Secretary of Defense for Health, with equivalent rank to the head of health for DVA. Do not restrict this position to being civilian only; a military or PHS officer could hold it.

3. Three-star Deputy Surgeon General for Rehabilitation, which could be a physician or nurse, responsible for two areas:

   ***Rehabilitation of military personnel who intend to go back on active duty.

   ***Coordinating transfer of permanently unable to serve personnel to Department of Veterans Affairs responsibility

4. Three-star Director of Nursing in the Military Health Command.

Veterans Affairs

[Reporting to the Undersecretary are the Deputy Undersecretary for Health and the Associate Deputy Director for Health, who must be physicians. There may be up to eight Assistant Undersecretaries, plus Medical Directors who must be physicians or dentists.]

(5) A Director of Nursing Service, who shall be a qualified registered nurse and who shall be responsible to, and report directly to, the Under Secretary for Health for the operation of the Nursing Service.

(6) A Director of Pharmacy Service, a Director of Dietetic Service, a Director of Podiatric Service, and a Director of Optometric Service, who shall be responsible to the Under Secretary for Health for the operation of their respective Services.

I recommend:

1. Designate an Assistant Secretary for Rehabilitation, preferably a physician certified in physical & rehabilitation medicine, to coordinate the VA role in short- and long-term rehabilitation.
2. Strengthen the Inspector General function, including a physician or nurse deputy for quality.

*I do know one physician qualified in both aerospace and diving medicine, who tells me this is more common than people think.

--

Howard

*equal opportunity offense to both extremes*

"Those who cannot remember the past are condemned to repeat it" [George Santayana]

While it is not practiced in all of Africa, the various forms of what is called "female circumcision" is more appropriately called "female genital mutilation." I will never forget the screams of a woman, heard through an ER room door, of a brief attempt to do a pelvic examination on a woman who had had an unqualified person, among other things, sew shut most of the vaginal opening. Mercifully, a more experienced physician quickly intervened, and the rest of the examination was performed in the operating room, under general anesthesia.

In contrast, male circumcision, of the Western sort removing the prepuce, is relatively rare among non-Muslims. Many in the West still consider this a mutilation. When confronting the problem of HIV/AIDS in Africa, however, the issue becomes more difficult.

As reported in the February 24 issue of Lancet, summarized in Medpage Today (may need registration), :

The publication of two large African studies in the Feb. 24 issue of The Lancet brings to three the major trials that have found male circumcision helps prevent HIV.

All three were halted early after data monitoring committees found a significant benefit for the circumcised men.

* Circumcision Halves Risk of Heterosexual HIV Transmission;

* Male Circumcision Equal to Vaccine in Preventing HIV Infection

Although there had been questions about the methods used in the first study -- of 3,274 men in South Africa -- the latest trials confirm the early results:

* In 2,784 men ages 18 to 24 in Kisumu, Kenya, researchers found the two-year HIV incidence was 2.1% in the circumcised men and 4.2% among controls -- a difference that was statistically significant at P=0.0065.

* The risk reduction in the Kenyan trial was 53%.

* In 4,996 men ages 15 to 49 in the rural Rakai district of Uganda, researchers found a two-year HIV incidence of 0.66 cases per 100 person-years in circumcised men and 1.33 cases per 100 person-years among controls, which was significant at P=0.006.

* The risk reduction in Uganda was 51%.

The South African study, by comparison, showed a risk reduction of 60%.

I have no simple conclusions here, but, with increasing American involvement in Africa as well as worldwide efforts at HIV reduction, this may be worth discussing. One issue is whether the legitimate concern over female genital mutilation (e.g., infibulation) should apply to male circumcision (i.e., removal of the prepuce).