Public Health Service Update
By C. Everett Koop, M.D.
Surgeon General and Deputy Assistant Secretary for Health
U.S. Public Health Service
U.S. Department of Health and Human Services
Presented to the 63rd Interagency Institute for Federal Healthcare Executives
St. Louis, Missouri
September 23, 1983
(Greetings to hosts, guests)
It's a pleasure to be here again to represent the US Public Health Service at this interagency institute. I must confess that one of the nicest aspects of my job as Surgeon General has been to get to know the health and medical executives elsewhere in government and to work closely with them and their staffs. They are an extraordinary community of dedicated public servants. It's been a source of great delight to meet them and know them in source of pride to serve alongside them.
This morning, during my few minutes at the microphone, I want to give you an idea of the mission of the Public Health Service and a sense of the way it is organized to carry out that mission. I want to talk a bit about how we function today, how we did some things in prior days, and finally, I'll make a few educated guesses as to how the PHS might look and function in the future.
I know you've been absorbing vast amounts of information since you've been here, so I will try to be brief.
First, you ought to know that the "Public Health Service" is not a single organization with bureaus, divisions, and branches. It might better be thought of as a "federation" of five individual agencies, each with its own special sphere of expertise, its own constituencies, and its unique record of contributions to the public health of this country.
There is also an Office of the Assistant Secretary for Health. That position is now held by Dr. Edward N. Brandt, Jr. This person is the chief health advisor to the secretary of our Department of Health and Human Services and, in our cabinet system of government, he is the country's highest-ranking health officer.
The assistant secretary engages in most of the public and political dialogue regarding national health policies and programs. But in many issues affecting the public health, the Surgeon General becomes the government's principal communicator. I've done that on a number of issues, such as organ transplants, the so-called "Baby Doe" and "Katie Becket" issues, and the problem of personal and family violence as a growing issue in American public health. I am also the highest-ranking member of the uniformed PHS Commissioned Corps, which is 5,800 strong. My rank is equivalent to Vice Admiral.
The PHS is a noncombatant uniformed service with a proud tradition that reaches back to 1798 and the very beginnings of military medicine in the United States. Our men and women have been on active duty and all the familiar "hot spots" around the world, serving side-by-side with our colleagues from all four sister services. We've been in Southeast Asia . . . the Middle East . . . Central America . . . Africa . . . wherever American interests have required the presence of the American uniform, you will find career, uniformed public health personnel "pulling duty."
We also serve in many places where our record in public health is respected and requested for sometimes very complicated reasons. For example, a team of three PHS epidemiologists went to the West Bank of the Jordan, at the request of the State of Israel, to discover the cause of a mysterious epidemic that had hospitalized large numbers of young women from the area's Arab communities. Our team presented to the authorities its conclusion that the epidemic was a mass psychological phenomenon, a rare but not unknown event in medicine. You may remember reading about that in the newspapers.
I should add that when this report was taken to the World Health Assembly in Geneva, it was greeted with much hot political rhetoric from many Third World delegates. However, our people had done their usual solid job of scientific inquiry and their results could not be easily smothered, even by the heavily acrimonious air of Geneva.
Certainly one of the great triumphs of modern medical science has been the virtual elimination of smallpox as a communicable disease. And once again, the people who would been on the front lines of the fight against smallpox . . . bouncing through the villages and savannas of Africa and Asia and administering tens of thousands of doses of the smallpox vaccine . . . were our PHS physicians, nurses, and sanitation engineers.
PHS personnel have also been stationed at points of embarkation in Southeast Asia. I truly believe that their professional competence has been America's best defense against the importation of new and highly contagious diseases during this period when our country has been carrying out a humanitarian program of accepting refugee "boat people" from that part of the world. PHS personnel have also been caring for the health needs of Cuban and Haitian refugees when they first arrive on our shores.
The public health service is uniquely qualified to do this kind of work for two reasons: its history of professional medical excellence and its record as a caring and compassionate organization right here at home.
The PHS has been at the heart of our national commitment to provide quality health care to the poor and the disadvantaged citizens of our country. Our commissioned medical officers have been found in the community health centers of our inner-city and rural ghettos, in migrant labor camps, in coal mining country, and on the seacoasts and waterways of America.
For nearly 30 years we have also staffed the hospitals, clinics, and health stations serving more than 200 Indian tribes and Alaskan Native villages. We got this assignment from the Congress in 1955. During the next 25 years, the medical personnel of the PHS were primarily responsible for lowering the infant mortality rate for Indians from 62.7 deaths per 1,000 live births down to only 13.2 deaths per 1,000 newborns . . . an 80 percent decrease. During the same period, 1955 through 1980, the infant mortality rate for the United States as a whole was cut by 52 percent, from 26.4 to 12.6.
Incidentally, I'm pleased to report that our latest provisional infant mortality rate for the nation as a whole for the 12 months ending in May 83 is now down to 11.0.
Of course, no single group can claim all the credit for such a dramatic turn of events. Nevertheless, the dedicated hard work of the Commissioned Corps of the Public Health Service was crucial to that achievement in Indian health.
And I would be remiss if I did not mention the top priority challenge facing the US Public Health Service today: solving the mystery of acquired immune deficiency syndrome, or "AIDS."
Since June of 1981, when we began to track the parents of "AIDS" in the U.S., the PHS has received reports of more than 2,200 cases. Of that number, they have already been 900 deaths. There is no known cure for "AIDS." The evidence so far suggests that a victim has perhaps two or three years of life left, once he has the disease. And I say "he" because three of every four cases of "AIDS" occur in homosexual or bisexual men.
"AIDS" is just about the toughest medical mystery to have been handed to the PHS to solve, and that includes Legionnaire's Disease, Toxic Shock Syndrome, and the Tylenol tampering scare.
All this information may be very interesting, but just who in the public health service does what -- and how? I can best answer those questions by quickly running through our organization. First, let me start with the five PHS agencies.
I'll begin with "A," the Alcohol, Drug Abuse, and Mental Health Administration. I think the title says it all. This agency has three national institutes -- of mental health, of drug abuse, and of alcoholism and alcohol abuse. They carry out research and public education programs and, until recently, they also supported a wide range of service delivery programs at the local level . . . 800 mental health centers . . . 300 state and local drug abuse programs . . . and about 1,000 local alcoholism projects. More about those projects later.
The fiscal 1983 appropriation for ADAMHA is $420 million dollars.
Next, are the Centers for Disease Control, or CDC. The centers are headquartered in Atlanta and, as the name implies, they're concerned primarily with controlling or preventing communicable and vector-borne diseases. CDC's Mortality and Morbidity Weekly Report is regarded as the best barometer we have of infectious disease activity in this country.
CDC's history is rooted in that strong tropical disease fraternity who labored with William Crawford Gorgas and Walter Reed in the Caribbean, Central America, and the Philippines. Today, the centers work primarily through state and local health authorities to carry out such activities as child immunizations, the control of sexually transmitted diseases, and the epidemiological detective work to solve the medical mysteries I mentioned earlier. For example, it is our -- and the country's -- lead agency in the fight against "AIDS."
CDC personnel are on TDY with state health agencies and are usually the ones overseas who screen refugees heading this way. You might be interested to know that the Public Health Service is involved in health-related technical assistance agreements with over 30 other nations. International health happens to be one of the Surgeon General's responsibilities, but we usually turn to the Centers for Disease Control for the personnel who do the actual work in the host countries.
The CDC budget for fiscal '83 is $248 million.
The Food and Drug Administration -- or FDA -- has been, for most of its 77 years, one of the most widely publicized, loved, and hated agencies of government. The two watchwords of its law, safety and efficacy, make the FDA the arbitrator of public health in the marketplace of drugs, vaccines, medical devices, health supplies, radiological gear, and certain health and medical practices, such as nutrition and diet counseling, prescription drug advertising, drug prescribing, and antenatal fetal diagnosis.
The FDA's budget for fiscal '83 is $367 million. That's really not much money, considering that the mission of the FDA, which is to regulate about $465 billion worth of American commerce, more than 100 times the FDA's budget.
The Health Resources and Services Administration is concerned with a variety of programs. Let me go through them quickly with you.
First, in sheer size and impact, is the Maternal and Child Health Program -- running at a level of $373 million this fiscal year.
Next would be the education and training of health professionals: physicians, dentists, nurses, therapists, technicians, and many others. The major component of this program, the National Health Services Corps, assigns 2,500 health personnel -- physicians, nurses, and dentists fresh out of graduate school -- to deliver medical care in underserved areas. This is how many young health professionals repay the government for their student loans.
A third program has been the building and maintaining of America's hospitals. This is known as the Hill-Burton program, named for its congressional sponsors back in 1946. It was a vital program, since we had done very little about hospitals on the home front during World War II, and a great many new things had happened in medicine as a result of things we learned as part of our war effort. It has been a very successful program -- so much so that we apparently now have about 100,000 surplus hospital beds, a very costly business for the nation.
The Health Resources and Services Administration is PHS agency that is actually delivered -- directly or through third parties -- a variety of health services to certain special populations: American Indians and Alaska natives, migrant workers, federal employees, coal miners, and people living in medically underserved or unserved areas.
Until recently merchant seamen, bargemen, canallers, riverboaters, and federal retirees were also included; they receive their care through eight Public Health Service Hospitals and 27 clinics -- all that remained of the once extensive network of "Marine Hospitals" begun by President John Adams in 1798. The only hospitals the PHS still runs at the National Center for Hansen's Disease -- a world famous Leprosarium -- in Carville, Louisiana, St. Elizabeths Hospital for the mentally ill on the outskirts of Washington, DC, and, as I mentioned a moment ago, the Indian Health Service System of 48 hospitals and 120 clinics.
The Health Resources and Services Administration has a fiscal '83 appropriation of $1.2 billion.
The agency with the largest appropriation to the National Institutes of Health. Its budget for fiscal 1983 is $4 billion.
The 11 institutes that are the NIH support about 16,000 extramural research projects at any one time. NIH also carries out some 2,000 intramural projects each year. Since 1937, with the National Cancer Institute was established, the NIH has supported the work of more than 60 Nobel laureate in medicine, physics, and chemistry, or about 1 out of every 6 winners in those prize categories.
That, briefly is a "snapshot," so to speak, of the 5 PHS agencies.
The final major organizational unit within the PHS is the Office of the Assistant Secretary for Health. Within this office are such activities as disease prevention and health promotion, anti-smoking, support for HMOs, adolescent pregnancy programs, physical fitness and sports medicine, and staff activities such as personnel, planning and evaluation, management and budget, personnel, and so on.
The OASH budget this year is $1.5 billion. But over 80 percent of that is earmarked for the funding of four block grants. And that leads me to some comments about the changes that have taken place and probably will continue to change in the Public Health Service.
The growth of the PHS during the past 20 years has been a result mainly of new and expanding categorical grant programs. At the time President Reagan was inaugurated, in January 1981, the executive branch was funding and operating 534 categorical grant-in-aid programs. One-seventh of those -- 74, to be exact -- were in PHS.
The administration said that it was time for the federal government to get out of the business of delivering health services, either directly or by proxy through grantees and contractors. It had become too costly, too unwieldy, and not as effective as advertised. Handing over those federal programs to state and territorial health authorities seemed to be preferable. Bundling them into blocks, with as few strings as possible, was to be the method.
President Reagan proposed -- and Congress approved -- the notion of grouping many similar categorical grant-in-aid programs into a series of block grants to the states: one for preventive services, another for the ADAMHA projects, and a third for maternal and child health. Congress authorized and funded these three as of August 1981.
A fourth "primary care" block grant is principally concerned with community health centers. As the law now reads, the PHS still directly funds most of the 530 or so community health centers around the country, but each state has the option to take over the centers within its own borders. So far, all but West Virginia and the Virgin Islands have declined the offer.
However, the president still hopes that Congress will not leave this is a state option but will revise the law to give control of these important projects to the states and localities where the people are actually served.
The results of the block grant approach is a new division of labor within PHS. One task is simply to administer the fiscal arrangements for the blocks. That can be done with a relatively small staff at the Assistant Secretary's level. The other task is to provide the states with any technical assistance they might need or in other ways be helpful to state program people at their request. This also requires fewer federal personnel in smaller PHS agencies.
The president hopes that the block grant approach, in addition to breathing new life into American Federalism, will also tend to reduce the growth rate of federal health funding, which has grown 14-fold in the past 15 years. Health has been the fastest-growing line item in the federal budget. When the president looks for "targets of opportunity" for cooling down the federal budget, what better place could he choose to start than the nation's health budget?
But even that is an oversimplification. Some health agencies may get reduced funding, but some health functions will require -- and will receive -- more money. This is clearly the case in research.
Only the federal government can assemble the extraordinary resources personnel, money, facilities, and time to . . .
Unlock the genetic code . . .
Identify the fundamental mechanisms of human immunology . . .
Develop monoclonal hybridoma technology . . .
And, of course, keep up the battle to conquer the major killers in society: heart disease, cancer, and stroke.
The NIH research budget for fiscal 1983 is $3.7 billion or $337 million higher than last year's budget. The same is true for ADAMHA. While that agency has actually had a drop in its overall total, ADAMHA has nevertheless had a net increase of $27.3 million this year to support behavioral research. So, in both absolute and relative terms, the research activity will continue to become central to the life of the PHS in the future.
In what other ways of the PHS change? I think we will be returning to what had once been our traditional role of partner . . . of equal among equals . . . with colleagues in health and medical care at other levels of government in and private non-profit and four-profit organizations.
With a reduced federal presence, we believe the more initiatives for improved health and medical care will originate elsewhere, outside Washington. The opportunities will certainly still be there. The federal contribution will tend to be more substantive -- again, reflecting its research strengths -- or facilitative as, for example, the negotiator among competing health interests, and purposive, in the way it performs as steward of the national health agenda.
There has also been another change. The gray federal health structure was built to deliver health services. It was predicated on the traditional practice of medicine and that was essentially curative and reparative medicine. It was also largely post-facto medicine: that is, we treated people after a disease arrived or disabling event occurred.
But one of the things we've learned from research and experience is that the most effective tool we have two improve health status is prevention, combined with health promotion. There would never have been enough money in the world to care for all the children and adults struck down by polio, diphtheria, measles, and typhus. Therefore, we had to come up with new vaccines and a program of mass immunization. Similarly, there's not enough money in the world to take care of all current and future heart disease, cancer, and stroke victims. Therefore, we must convince people to quit smoking.
The logic of this is so overwhelming that the prevention of disease and disability in the promotion of good health and well-being are now the keystones of national health policy.
One of the most exciting developments in the years ahead, therefore, will be the maturing of this concept as the foundation of American public health policy and practice. Enriching this process will be an important function of the federal health enterprise, whether by its research or its public education programs.
I hope this brief overview has helped you get some perspective on where the US Public Health Service is and where it seems to be heading. We've come a very long way over the past 185 years. We believe will enjoy a journey every bit as exciting during the next 185.
Thank you.