Two Centuries of Health Promotion
Protecting and advancing the health of our nation's people and contributing to the delivery of health care world-wide is very important work and the main task of the Public Health Service (PHS). The PHS is a principal part of the Department of Health and Human Services (HHS) and the major health agency of the Federal Government. The PHS has about 5,700 Commissioned Corps officers and 51,000 Civil Service employees. Its budget in 1993 was approximately 17 billion dollars.
In order to fulfill its very broad mission of promoting health in our nation and the world, the PHS has designed programs and created agencies which help control and prevent diseases; conduct and fund biomedical research that will eventually lead to better treatment and prevention of diseases; protect us against unsafe food, drugs, and medical devices; improve mental health and deal with drug and alcohol abuse; expand health resources; and, provide health care to people in medically underserved areas and to those with special needs.
The eight major agencies that make up the PHS and that do this work are the Centers for Disease Control and Prevention (CDC), the Agency for Toxic Substances and Disease Registry (ATSDR), the National Institutes of Health (NIH), the Food and Drug Administration (FDA), the Substance Abuse and Mental Health Services Administration (SAMHSA), the Health Resources and Services Administration (URSA), the Agency for Health Care Policy and Research (AUCPR), and the Indian Health Service (IHS).
The Assistant Secretary for Health, with the assistance of the Surgeon General, heads the PHS, advises the HHS Secretary on health and health-related matters, and directs the activities of the major PHS agencies. Located in the Office of the Assistant Secretary for Health (OASH) are other important programs such as the National AIDS Program Office, the Office of International Health, and the President's Council on Physical Fitness and Sports.
As the PHS gets ready to celebrate its bicentennial in 1998 it has a lot to be proud of. Its history has been one of growth and expansion, of ever-increasing Federal responsibility for health care, and of change in response to the evolving health needs of our nation. This then is the history of the Marine Hospital Service (1798-1902), the Public Health and Marine Hospital Service (1902-1912), and the Public Health Service (1912-present).
The PHS grew out of a need for healthy seamen in our infant republic, which relied so much on the sea for trade and security. These seamen traveled widely, often became sick at sea, and then, away from their homes and families, could not find adequate health care in the port cities they visited or would overburden the meager public hospitals then in existence. Since they came from all the new states and former colonies, and could get sick anywhere, their health care became a national or Federal problem. A loose network of marine hospitals, mainly in port cities, was established by Congress in 1798 to care for these sick and disabled seamen, and was called the Marine Hospital Service (MHS).
The Federal Government had only three executive departments then to administer all Federal programs -- State, Treasury, and War. The MHS was placed under the Revenue Marine Division of the Treasury Department. Funds to pay physicians and build marine hospitals were appropriated by taxing American seamen 20 cents a month. This was one of the first direct taxes enacted by the new republic and the first medical insurance program in the United States. The monies were collected from ship masters by the customs collectors in different U.S. ports.
The President was granted the authority to appoint the directors of these hospitals, but later allowed the customs collectors to do it. The appointments thus became influenced by local politics and practices. Often times hospitals were built to meet political rather than medical needs. Each hospital was managed independently and the Treasury Department had no supervisory mechanism to centralize or coordinate their activity. For example, the report of a Congressional commission formed to investigate the MHS stated in 1851 that the "hospital at Mobile is as distinct and different from that at Norfolk or New Orleans as if it were a hotel and the other a hospital..."
Lack of money, in addition to the lack of any supervisory authority, was another major problem for the MHS. The demand for medical services far exceeded the funds available. For that reason sailors with chronic or incurable conditions were excluded from the hospitals and a four-month limit was placed on hospital care for the rest. Additional funds had to be appropriated constantly from Congress in order to maintain the Service and to build the hospitals. Because of these problems Congress was forced to act and in 1870 reorganized the MUS from a loose network of locally-controlled hospitals to a centrally-controlled national agency with its own administrative staff, administration and headquarters in Washington, D.C.
Through this reorganization, the MHS became a separate bureau of the Treasury Department under the supervision of the Supervising Surgeon, who was appointed by the Secretary of the Treasury. The title of the central administrator was changed to Supervising Surgeon General in 1875 and to Surgeon General in 1902. Additional money to fund the reorganized Service was appropriated by raising the hospital tax on seamen from twenty to forty cents per month. The money collected was deposited in a separate MHS fund.
Taxing seamen to fund the MHS was abolished in 1884. From 1884 to 1906 the cost of maintaining the marine hospitals was paid from the proceeds of a tonnage tax on vessels entering the United States, and from 1906 to 1981, when the Public Health Service hospitals were closed, by direct appropriations from Congress.
The 1870 reorganization also changed the general character of the Service. It became national in scope and military in outlook and organization. Medical officers, called surgeons, were required to pass entrance examinations and wear uniforms. In 1889, when the Commissioned Corps was formally recognized by legislative action, the medical officers were given titles and pay corresponding to Army and Navy grades. Physicians who passed the examinations were appointed to the general service, rather than to a particular hospital, and were assigned wherever needed. The goal was to create a professional, mobile, health corps, free as possible from political favoritism and patronage, and able to deal with the new health needs of a rapidly growing and industrializing nation.
Epidemics of contagious diseases, such as small pox, yellow fever, and cholera, had devastating effects throughout the 19th century. They killed many people, spread panic and fear, disrupted government, and caused Congress to enact laws to stop their importation and spread. As a result of these new laws, the functions of the MHS were expanded greatly beyond the medical relief of the sick seamen to include the supervision of national quarantine (ship inspection and disinfection), the medical inspection of immigrants, the prevention of interstate spread of disease, and general investigations in the field of public health, such as that of yellow fever epidemics.
To help diagnose infectious diseases among passengers of incoming ships, the MUS established in 1887 a small bacteriology laboratory, called the Hygienic Laboratory, at the marine hospital on Staten Island, New York. That laboratory later moved to Washington, D.C., and became the National Institutes of Health, the largest biomedical research organization in the world.
To better consolidate these increased functions of the MHS, including medical research, and give them legal powers, Congress passed an act in 1902 which expanded the scientific research work at the Hygienic Laboratory and gave it a definite budget. The bill also required the Surgeon General to organize annual conferences of local and national health officials in order to coordinate better state and national public health activities, and changed the name of the MHS to the Public Health and Marine Hospital Services (PHMHS) to reflect its broader scope.
The PHMHS was not the only government agency engaged in health-related work. The enforcement of the pure food and drugs law, passed in 1906, was placed in the hands of the Bureau of Chemistry of the Department of Agriculture. The Federal inspection of meats entering interstate commerce, also mandated by law in 1906, was done by the Bureau of Animal Industry of the Department of Agriculture. The Bureau of the Census was authorized in 1902 to collect vital statistics -- data relating to health and disease from around the country.
Efforts were made during the early decades of the 20th century by both political parties and by people inside and outside of government concerned with the nation's health to combine public health-related work being done by various Federal agencies, but they were unsuccessful in Congress. The act of August 14, 1912 changed the name of the PHMHS to the Public Health Service and further broadened its powers by authorizing investigations into human diseases (such as, tuberculosis, hookworm, malaria, and leprosy), sanitation, water supplies and sewage disposal, but went no further.
Real consolidation began in June 1939, when the PHS was transferred by President Franklin D. Roosevelt to the newly created Federal Security Agency (FSA), which combined a number of New Deal government agencies and services related to health, education, and welfare. Over 140 years of association between the PHS and the Treasury Department came to an end. All of the laws affecting the functions of the services were also consolidated for the first time in the Public Health Services Act of 1944.
The FSA was a noncabinet-level agency whose programs grew to such size and scope that, in 1953, President Eisenhower submitted a reorganization plan to Congress which called for the dissolution of the FSA and the transfer of all its responsibilities to a newly created Department of Health, Education, and Welfare (HEW). A major objective of this reorganization was to ensure that the important areas of health, education, and social security be represented in the President's cabinet. In 1979, HEW's educational tasks were transferred to the new Department of Education and the remaining divisions of HEW were reorganized as the Department of Health and Human Services (HHS).
Throughout all of these reorganizations which have shaped, defined, and established the PHS in its present place in the Federal Government, and which have spanned nearly two centuries, the PHS has never lost sight of its primary goal -- providing health care for those with special needs. From the care of sick and disabled sailors the PHS has extended its activities to other groups with special needs (such as, the American Indians, the Alaska Natives, migrant workers, Federal prisoners, and refugees), and to the nation as a whole.
The duties and functions of the PHS have expanded to include disease control and prevention, biomedical research, regulation of food and drugs, mental health and drug abuse, health care delivery, and international health. These six themes provide the organizational structure for the images of the PHS that follow.