The National Disaster Medical System, the nation’s medical rapid response force has beginnings in the mid 1986 as a small civilian division of the Uniformed Public Health Service in conjunction with the U.S. Department of Health, Washington, D.C. office. From those humble beginnings, NDMS has expanded to a nationwide program with volunteer reservists in almost all 50 states. Thirty-five person to 105 person teams exist nation wide. Sixteen of these teams can be “out the door” in two hours and on the ground providing emergency medical support for devastated communities within hours of an event. Additional teams can deploy within 24 hours and a support staff of thousands provide resupply and replacement personnel for extended missions such as the hurricane season of 2004 or Katrina, Rita and Wilma in 2005.NDMS has served in terrorism related disasters as well at the Murrah Federal Building, the World Trade Center, the Pentagon and other events. NDMS is the nation’s “ready team” deploying on a stand by basis at events of national significance including the Presidential Inauguration, the rededication of the Statue of Liberty, the Republican and Democratic National Conventions and even at the Super Bowl.So why can nobody find NDMS a permanent home?Many thought that the Public Health Service was the perfect place for NDMS. However the Public Health Service is just that a public health service. Their role is in disease surveillance, vaccination programs, disease prevention and community health. They are not a response agency. They do not move with the speed required to mount a disaster response. They are public health doctors, an epidemiologist more at home in a laboratory or in an office setting than in a field tent or the belly of a rescue helicopter. Public health as a profession and as individual public health professionals are the best people suited for the work that they do. They are detail oriented, idealistic and dedicated to doing the most good for everybody. Unfortunately, these are not the characteristics of a field responder.NDMS was next moved following the events of September 11, 2001. With the formation of the Department of Homeland Security and the consolidation of so many government agencies to that new department. NDMS was inexplicably placed under the auspices of FEMA!The Federal Emergency Management Agency (FEMA) is a planning and recovery organization. Staffed primarily by former law enforcement and fire department commanders as well as experienced and highly trained emergency management professionals, FEMA best roles are in community disaster planning and preparedness and in providing for community recovery. It however must be noted that there is no response role in that definition. Even those in charge in FEMA admit they have no idea what to do with medical people and NDMS is all medical people. The excellent response to the hurricane season of 2004 gave tremendous encouragement to those in Congress and in the Department of Homeland Security who placed NDMS under FEMA. The integrated response and recovery phases exemplified how these two disaster phases can overlap and the ability to integrate services and serve the public well. 2005 was another matter. The debacle that was the response to Katrina pointed out the need for a true response agency separate and apart from a planning and recovery division. Discussions began almost immediately of disbanding FEMA or breaking it into two or more agencies. Fortunately, cool heads prevailed and the understanding that recovery is a nature part of planning ensured that FEMA would continue to exist and do the job for which they are so well suited for the foreseeable future. It also resulted in another transfer of the NDMS system.Those of us in NDMS had hoped at this point that after close work with the Coast Guard, a Homeland Security based response oriented organization with limited civilian medical capabilities, would be our new home. It seemed only natural to put field response medical personnel with field response rescue personnel. Coast Guard has its own medical corp that cares for its own people. They understand the needs of medical people of medical response in adverse circumstances. Coast Guard has its own medical first response rescue personnel in the form of rescue swimmers and even paramedic level trained medics so they understand the unique needs of medical first responders. It seems like a perfect fit.Unfortunately, in the vagaries that define Washington decisions, NDMS was effective January 1, 2007 moved back to the Department of Health and Human Services (formerly known as the U.S. Public Health Service). The reason given to NDMS members was that it was that the Department of Health and Human Services is charged under the National Response Plan with preparation and response to pandemic flu.Let’s get real!The National Response Plan enumerates 16 possible disasters for which the Department of Homeland Security and the U.S. government has greatest concern. Only one of these falls within the prevue of the U.S. Public Health Service. Pandemic flues occur once every 91 years and while we are at the beginning of the “window of opportunity” for this next pandemic. There will be little that a field response service can do. The pandemic when it strikes will strike simultaneously across the nation. Local professionals such as those who make up the volunteer reservists of the NDMS system will be needed in their local communities. The Centers for Disease Control and the Secretary for the Department of Health and Human Services have already said that those individuals will remain in their local communities to ensure that local health care is not compromised to any greater degree than necessary anywhere in the country in order to provide services to some other portion of the country. In other words, NDMS has no role in the current pandemic flu response plan.Even accepting on face value the reasoning for the most recent transfer of the National Disaster Medical System from the Department of Homeland Security to the Department of Health and Human Services as valid, by 2013 the pandemic will have struck. This is a mathematical certainty based on several centuries of experience with this type of pandemic disease.Will that mean that NDMS will be moved again?Will NDMS find a permanent home more suited to its unique role in disaster response and recovery?Again, NDMS will fall victim to the vagaries of Washington decision making. Unfortunately for the National Disaster Medical System and the vulnerable citizens whom these fine professionals have dedicated their lives to serving, NDMS itself has stayed so far out of the limelight that few if any people will even notice the next time that their services are hampered by poor management or supervisors who do not even know what to do with medical people.