SIC 9431
ADMINISTRATION OF PUBLIC HEALTH PROGRAMS

This category includes government establishments primarily engaged in planning, administration, and coordination of public health programs and services, including environmental health activities, mental health, categorical health programs (e.g., cancer control, communicable disease control, maternity, child health), health statistics, and immunization services.

NAICS Code(s)

923120 (Administration of Public Health Programs)

The U.S. public health system consists of programs administered by federal, state, and local government agencies; voluntary health care and research associations, such as the American Red Cross and the American Cancer Society; and professional associations, such as the American Medical Association and American Dental Association. Although several agencies of the federal government had responsibility for aspects of public health, the U.S. Department of Health and Human Services (DDHS) is the principal federal health agency.

Organization and Structure

The Department of Health and Human Services (DHHS) oversees most of the U.S. government's health programs. It is headed by the Secretary of Health and Human Services, a cabinet-level position appointed by the president and confirmed by the Senate. The surgeon general, the chief medical officer, and various agency heads report to the secretary. In 2003 the department employed 65,500 people and had a budget of $502 billion. These numbers both increased from 1999, when the Department employed 59,800 workers and had a budget of $387 billion. DHHS' operations are divided between Public Health Operating Divisions, which include much of what was formerly the Public Health Service, and Human Services Operating Divisions, which include Medicare, Medicaid, and the Administration for Children and Families. The human services divisions are discussed in greater detail under SIC 9441: Administration of Social, Human Resource, and Income Maintenance Programs.

Major divisions of the DHHS include the National Institutes of Health, the Food and Drug Administration, the Centers for Disease Control, the Substance Abuse and Mental Health Services Administration, the Health Resources and Services Administration, the Agency for Toxic Substances and Disease Registry, the Indian Health Service, and the Agency for Healthcare Research and Quality.

The National Institutes of Health (NIH). This top-level agency includes National Cancer Institute; the National Eye Institute; the National Heart, Lung, and Blood Institute; the National Human Genome Research Institute; the National Institute on Aging; the National Institute on Alcohol Abuse and Alcoholism; the National Institute of Allergy and Infectious Diseases; the National Institute of Arthritis and Musculoskeletal and Skin Diseases; the National Institute of Biomedical Imaging and Bioengineering; the National Institute of Child Health and Human Development; the National Institute on Deafness and Other Communication Disorders; the National Institute of Dental and Craniofacial Research; the National Institute of Diabetes and Digestive and Kidney Diseases; the National Institute on Drug Abuse; the National Institute of Environmental Health Sciences; the National Institute of General Medical Sciences; the National Institute of Mental Health; and a number of others. Almost all of the NIH institutes and research centers are located in Bethesda, Maryland. In 2003, the NIH had 17,693 employees, including roughly 4,500 scientists and medical personnel, and a budget of $27.2 billion.

Food and Drug Administration (FDA). The FDA is responsible for enforcing the Food, Drug, and Cosmetic Act of 1938 and the Drug Amendments Act of 1962, which were designed to ensure the purity of food products and the safety and effectiveness of drugs, cosmetics, and therapeutic devices. The FDA inspects all food and drug manufacturing facilities, enforces sanitary standards at restaurants and other public eating places, establishes labeling requirements for food and drugs, and reviews test results on all drugs before they are approved for use in the United States. The FDA had more than 10,479 employees in 2003, including roughly 2,000 scientists and 1,000 inspectors and investigators. The FDA's 2003 budget totaled $1.7 billion.

Centers for Disease Control (CDC). The CDC, located in Atlanta, Georgia, maintains records on the incidence of disease and provides information to health agencies worldwide. The agency also investigates the causes and works with state health care agencies to control the outbreak of diseases and administers the U.S. quarantine program at ports of entry. The CDC includes the Center for Chronic Disease Prevention and Health Promotion; the Center for Environmental Health and Injury Control; the Center for Infectious Diseases; the Center for Prevention Services; the National Center for Health Statistics; and the National Institute for Occupational Safety and Health. The CDC also administers the Agency for Toxic Substances and Disease Registry, which was established in 1980 by the Comprehensive Environmental Response, Compensation, and Liability Act to clean up hazardous waste sites. The Public Health Service is responsible for identifying the health risks involved with toxic wastes and developing ways to lessen the danger of working with hazardous substances. In 2003 the CDC employed a workforce of 8,668 people and had a budget of $6.8 billion.

Substance Abuse and Mental Health Services Administration. Created in 1992, the Substance Abuse and Mental Health Services Administration is responsible for developing substance abuse treatment and prevention programs in conjunction with state and local agencies, as well as programs to promote mental health. The division also supports efforts to develop local mental health facilities by providing leadership and federal grants. Approximately 588 persons staffed the agency in 2003 with a budget of $3.2 billion.

Health Resources and Services Administration (HRSA). The HRSA is charged with improving health care services in areas without adequate resources. The agency is responsible for the National Health Service Corps, which recruits and assigns physicians, dentists, and nurses to areas with a shortage of health care professionals. The agency also provides grants for health care education and administers well-child programs through the Bureau of Maternal and Child Health and Resources Development. In 2003 this agency's $7.1 billion budget was implemented by a workforce of 1,937 people.

Indian Health Service (IHS). With 14,961 employees, including roughly 1,270 physicians and dentists and 2,700 nurses, the IHS is responsible for providing health care to more than 1.5 million Native Americans. The IHS has 63 health centers, 44 health stations, 36 hospitals, and 5 residential treatment centers under federal management. In addition, it has 445 health care facilities under the direction of Indian tribes or Alaska Native corporations, including 13 hospitals and 170 Alaskan village clinics. The Bureau of Indian Affairs transferred responsibility for Native American health care to the Public Health Service in 1955. The Indian Health Service was elevated to agency status in 1988. Its 2003 expenditures were budgeted for $3.5 billion.

Agency for Healthcare Research and Quality. Established in 1989, the Agency for Healthcare Research and Quality focuses on improving the quality of patient care. It also assesses new health care technologies, promotes health care services in rural areas, and investigates questions of medical malpractice and liability. This agency employed 294 persons and had a $309 million budget in 2003.

Office of the Assistant Secretary for Health. Several public health programs are conducted by the Office of the Assistant Secretary for Health. These include population research and family planning by the Office of Population Affairs, the promotion of healthy lifestyles by the Office of Disease Prevention and Health Promotion, the President's Council on Physical Fitness and Sports, special health initiatives for minorities, and the National AIDS Program.

Background and Development

Early efforts to provide for the public health in the United States were concerned with quarantine and sanitation. As early as 1795, the governor of New York appealed to the state medical society for help in controlling epidemics. The medical society recommended improving drainage in low-lying areas, collecting refuse from along river banks, controlling the air pollution from slaughter houses and soap factories, and generally cleaning up "the accumulation of filth in the street."

The U.S. Public Health Service traced its beginnings to 1798, when Congress authorized the Marine Hospital Fund for the "care and relief of sick and disabled seamen." The fund was financed by a 20-cents-per-month tax on merchant seamen and administered by the Treasury Department. The first Marine Hospital was established on Castle Island in Boston Harbor in 1799. Other hospitals, often small facilities located in boarding houses, were eventually established in port cities from Newport, Rhode Island, to Charleston, South Carolina. As the nation expanded west, Marine Hospitals also were established in Chicago, Cleveland, New Orleans, and several other cities along the Mississippi and Ohio rivers.

For much of the nineteenth century, the Marine Hospital Fund concerned itself primarily with caring for merchant seamen. It also was poorly managed. By 1869, when the first permanent public health department was created by Massachusetts, only 9 of 31 Marine Hospitals built since 1798 were still in operation. In 1871, Dr. John Maynard Woodworth was appointed to the new position of Supervising Surgeon of the Marine Hospital Service. Woodworth, who envisioned a much broader role than caring for ill seamen, eliminated the patronage system and instituted examinations for all job applicants. Wood-worth also had been General William T. Sherman's chief medical officer during the Civil War and reorganized the Marine Hospital Service along military lines. He gave his "officers" military titles, put them in uniform, and assigned them where they were needed most. In 1873, Woodworth's title was changed to surgeon general.

Meanwhile, the concept of public health developed slowly in the United States. New York, which was struck by an outbreak of yellow fever in 1798, received permission from the state legislature to pass its own health laws and appointed a city health inspector in 1804. But by 1830, only five major cities had established boards of health. In the mid-1840s, New York also became one of the first cities to pass legislation requiring the registration of births and deaths. In 1845, New York City health inspector John C. Grissom published a report entitled "A Brief View of the Sanitary Conditions of the City," in which he found "an immense amount of sickness, physical disability, and premature mortality among the poorer classes." Grissom also concluded "that these are, to a large extent, unnecessary, being in a great degree the results of causes which are removable."

Shattuck Report. When the American Medical Association was founded in 1847, one of its first endeavors was to collect information on sanitary conditions from around the country, which focused attention on the growth of slums in American cities. In 1850, the Massachusetts Sanitary Commission published what became known as the Shattuck Report, written by Lemuel Shattuck, a former teacher and bookseller.

Shattuck revealed the extent of communicable disease, especially among the poor, and recommended establishment of a state board of health and local boards in every community. The Shattuck Report also discussed the need for environmental sanitation, the inspection of food and drugs, well-child programs, vaccination against smallpox, control of air pollution, treatment of alcoholism, and city planning. Although Massachusetts did not implement the Shattuck Report for almost 20 years, it became a blueprint for later public health activities.

Metropolitan Board of Health. In 1857, Philadelphia organized a National Quarantine and Sanitary Convention, attended by 73 delegates from nine states. City health officers also met in Baltimore, New York, and Boston over the next three years, but the Civil War interrupted plans for a fifth conference scheduled for Cincinnati in 1861. After the war, the Council of Hygiene and Public Health, formed by a citizens group in New York, published a report on sanitary conditions that shocked the community into action. In 1866, the state legislature created a Metropolitan Board of Health with broad powers to improve sanitary conditions in a four-county area. Members of the board included four physicians who served as sanitary commissioners, the health officer for the port of New York, and four police commissioners.

In A History of Public Health, George Rosen called the Metropolitan Board of Health "a turning point in the history of public health not only in New York City, but in the United States as a whole." Rosen noted that a "change from a haphazard to an efficient administration was as essential to the development of a complicated urban industrial society as the provision of new scientific knowledge. In fact it was the provision of a stable administrative foundation which made it easier to incorporate new scientific knowledge into public health practice."

Although Louisiana established the first state health department in 1855, it was largely ineffective. However, several states soon established boards of health patterned after the New York Metropolitan Board of Health. Massachusetts adopted many of the ideas contained in the earlier Shattuck Report and established a state board of health in 1869. California followed in 1870, the District of Columbia in 1871, Minnesota and Virginia in 1872, Michigan in 1873, Maryland in 1874, Alabama in 1875, Wisconsin in 1876, and Illinois in 1877.

National Board of Health. In 1878, following an outbreak of yellow fever that killed an estimated 14,000 Americans, Congress passed the first Federal Quarantine Act. It assigned responsibility for enforcing port quarantines to the Marine Hospital Service. However, Congress failed to appropriate any money for enforcement and instructed Surgeon General Woodworth not to interfere with state laws.

Meanwhile, the American Public Health Association, founded in 1872, lobbied Congress to create a national health department. In 1879, Congress created a National Board of Health, comprised of nine members appointed by the president, including one each from the Army, Navy, and Marine Hospital Service. Quarantine responsibility was shifted to the National Board of Health, which also began monitoring outbreaks of disease and providing grants for states to create sanitary facilities.

Woodworth died 11 days after passage of the act creating the National Board of Health, which he had bitterly opposed. However, he was succeeded as surgeon general by Dr. John B. Hamilton, who continued the fight. Hamilton repeatedly accused board members of corruption or ineptitude. There also were growing complaints from the states, which felt the board was encroaching on their rights. In 1883, Congress refused to continue funding for the National Board of Health. Responsibility for port quarantines was returned to the Marine Hospital Service, which also was directed to investigate the origin and causes of epidemic diseases. Dr. Joseph J. Kinyuon established the first "laboratory of hygiene," forerunner to the National Institutes of Health, at the Marine Hospital on Staten Island in 1887.

In 1889, following another deadly outbreak of yellow fever in the South, Congress officially created the Commissioned Corps of the Marine Hospital Service, a mobile force of physicians organized along military lines. The surgeon general was to be appointed by the president and confirmed by the Senate. The following year, Congress gave the Marine Hospital Service interstate quarantine authority. In 1891, when Dr. Walter Wyman became surgeon general, the Marine Medical Service had a budget of $600,000 and the Commissioned Corps consisted of 54 medical officers.

U.S. Public Health Service. This service has the responsibility for providing medical examinations to all immigrants. The Quarantine Act of 1893 charged the Marine Hospital Service with refusing admission to the United States to "idiots, insane persons… persons likely to become a public charge, and persons suffering from a loathsome or a dangerous contagious disease."

In 1902, the Marine Hospital Service officially became the Public Health and Marine Hospital Service, reflecting the widening scope of its activities. Forty of the 45 states then had some form of state health department, and the surgeon general also was directed by Congress to convene national conferences on public health annually or "whenever in his opinion the interest of the public health would be promoted by such a conference." Five state health authorities also could require the surgeon general to convene a conference to discuss a public health emergency.

Also in 1902, Congress passed the Biologics Control Act, which made the Public Health and Marine Hospital Service responsible for regulating the transportation and sale of vaccines, serums, or other medical products designed for human use. The Hygienic Laboratory, which had begun the manufacturing of diphtheria antitoxin in 1894, was moved to Washington, D.C., where divisions of chemistry, zoology, and pharmacology were added to its facilities. When Surgeon General Wyman died in 1911, the Public Health and Marine Hospital Service budget was $1.75 million and the Commissioned Corps also had grown to 135 officers.

The Public Health and Marine Hospital Service officially became the Public Health Service in 1912, when Congress extended its authority to "investigate the diseases of man and conditions influencing the propagation and spread thereof, including sanitation and sewage and the pollution either directly or indirectly of the navigable streams and lakes of the United States." Dr. Rupert Blue, who directed the agency's efforts to eradicate plague in San Francisco following the earthquake of 1906, became surgeon general. That same year saw the founding of the National Organization of Public Health Nursing.

World War I. On April 2, 1917, President Woodrow Wilson asked Congress to declare war on Germany. The following day, he issued an executive order making the Public Health Service part of the U.S. military. By that fall, more than half a million men were drafted and sent to makeshift training camps. The Public Health Service was set to work ensuring sanitary conditions, including drinking water and waste disposal.

The Public Health Service was also charged with controlling the spread of venereal disease among servicemen, which included treating infected prostitutes. In 1918, the Army Appropriation Act established a division of venereal disease within the Public Health Service with a budget of $2 million.

In 1918, following an outbreak of "Spanish influenza" that eventually spread to 46 states and killed half a million Americans, Congress created a Reserve Corps that allowed the Public Health Service to recruit health professionals other than physicians for emergency duty. More than 2,000 doctors, nurses, and clerks were recruited to the Public Health Service during the epidemic.

Federal Security Agency. The Federal Security Agency became responsible for the care of returning soldiers, and by 1921 the agency operated 62 hospitals. But in 1922, Congress established the Veteran's Bureau, later to become the Department of Veteran Affairs, which took over all but 24 Marine Service hospitals. The 1920s also saw new attempts to consolidate government services into a national department of health. However, Surgeon General Hugh S. Cumming opposed the move, which he believed would diminish the role of the Public Health Service, and the efforts failed.

In 1930, Congress passed two acts that would significantly affect public health administration in the United States. The first was the Parker Act, named for New York Congressman James S. Parker, which authorized the Public Health Service to recruit sanitary engineers, pharmacists, and dentists for the Commissioned Corps. The second was the Ransdell Act, named for Louisiana Senator Joseph Ransdell, which created an expanded National Institute of Health within the Public Health Service in place of the Hygienic Laboratory.

The Public Health Service continued to expand under President Franklin D. Roosevelt, whose New Deal programs included the Social Security Act, passed in 1935, which provided federal grants for states to develop public health programs in addition to benefits for retired workers. In 1936, the Public Health Service received applications for funds from every state, which ultimately led to the creation of the Division of State Relations.

In 1937, Congress passed the National Cancer Act, which created the National Cancer Institute. In addition to setting up laboratories within the Public Health Service, the National Cancer Institute awarded research grants to individuals and nongovernmental institutions, establishing a pattern for federal support of biomedical research. In 1938, Congress passed the Venereal Disease Control Act, which for the first time charged the Public Health Service with eradicating specific diseases.

In 1939, Roosevelt issued an executive order that brought the Public Health Service under the administration of the newly created Federal Security Agency, along with the Civilian Conservation Corps, National Youth Administration, Office of Education, U.S. Employment Service, and Social Security Board. The Food and Drug Administration was added in 1940.

World War II. At the start of World War II, Public Health Service officers were assigned to each of the Army Service Commands to oversee sanitary conditions. The Public Health Service also coordinated state emergency medical services, including a nationwide network of 300 hospitals to treat casualties, and commissioned officers served in war zones with the U.S. Coast Guard from 1941 to 1945. In 1942, the Public Health Service created the Office of Malaria Control in War Areas, based in Atlanta, which attempted to control the spread of disease in Southern states and the Caribbean by eradicating mosquito larvae and draining swamps. By 1943, the Office of Malaria Control, which extended its scope to include typhus, employed 4,300 people, including 300 commissioned officers. Between 1940 and 1945, the Public Health Service doubled in size, to 16,000 employees, while the Commissioned Corps quadrupled to 2,600 officers, two-thirds of whom were in the Reserve Corps.

As the war wound down, Congress began to enact legislation that would shape the future of the Public Health Service, beginning with the Public Health Service Act of 1944, which consolidated and revised most of the legislation then relating to the Public Health Service. The act also realigned the Public Health Service into four divisions: the Office of the Surgeon General, the Bureau of Medical Services, the Bureau of State Services, and the National Institute of Health. In 1946, the Office of Malaria Control became the Communicable Disease Center under the Bureau of State Services. The Public Health Service also assumed responsibility for national vital statistics, which had been a function of the Census Bureau.

A critical shortage of health care facilities after the war also led to creation of the National Hospital Survey and Construction Program in 1946, which provided grants for construction of state-run hospitals and positioned the Public Health Service as the lead agency in the planning, design, and operation of medical facilities. Between 1947 and 1971, the Public Health Service disbursed $3.7 billion in state grants, accounting for about 10 percent of all hospital construction in the United States. Under the National Mental Health Act, also passed in 1946, the Public Health Service established a broad program of grants for research, training, and creation of mental health services.

Health, Education, and Welfare. The research facility founded as the Hygiene Laboratory in 1887 became the National Institutes of Health in 1948 with creation of the National Heart Institute, National Institute of Dental Research, National Microbiological Institute (which would become the National Institute of Allergy and Infectious Diseases in 1955), and Experimental Biology and Medical Institute (which would be absorbed into the National Institute of Arthritis and Metabolic Disease in 1950). Other institutes of health would be created later, beginning with the National Institute of Mental Health in 1949 and concluding with the National Institute on Aging in 1974.

In the late 1940s, the Hoover Commission on Executive Reorganization also recommended creation of a Cabinet-level department for education and welfare. But it was not until 1953 that newly elected President Dwight D. Eisenhower created the Department of Health, Education, and Welfare (HEW) by executive order. The new department, which would become the Department of Health and Human Services in 1979 with the creation of the Department of Education, assumed all functions of the Federal Security Agency. Oveta Culp Hobby was appointed secretary of HEW, but administration of the Public Health Service remained with the surgeon general.

The Public Health Service faced a major crisis soon after the reorganization. In 1955, Surgeon General Leonard Scheele endorsed a new vaccine for polio developed by Dr. Jonas Salk, and HEW issued licenses to six pharmaceutical companies to begin distribution. Within two weeks, there were reports from across the country that vaccinated children were developing full-blown polio. Scheele issued a statement calling for a halt to all vaccinations while the vaccine was reexamined. The problem was quickly traced to one pharmaceutical company, but more than 70 children contracted polio from the vaccine and 11 died. Secretary Hobby and her special assistant for medical affairs resigned two months later.

Despite the polio scare, the Public Health Service continued to expand beginning in 1955, when the Bureau of Indian Affairs (BIA) in the U.S. Department of Interior transferred responsibility for Indian health care programs. Federal health care for Native Americans had begun in the early nineteenth century with Army doctors attempting to contain smallpox and other contagious diseases among tribes living near military posts. Originally part of the War Department, the BIA was transferred to the Department of the Interior in 1849, with the first federal hospital for Indians built in Oklahoma in the 1880s. By the mid-1950s, the BIA operated 48 hospitals and was responsible for the health of more than half a million Indians and Alaska natives.

The Armed Forces Medical Library, later known as the National Library of Medicine, became part of the Public Health Service in 1956. Further expansions came with the Community Health Services and Facilities Act of 1961, the Vaccination Assistance Act and the Health Professionals Education Act of 1963, and the Nurse Training Act of 1964—each of which directed the Public Health Service to provide financial or research support for state health care programs.

Smoking. In the mid-1950s, the Public Health Service, the American Cancer Society, and the American Heart Association formed a panel to study the effect of smoking on health. In 1956, Surgeon General Leroy Burney wrote an obscure article for the Journal of the American Medical Association that concluded, "The weight of evidence at present implicates smoking as the principal etiological factor in the increased incidence of lung cancer."

In 1964 HEW published the results of a two-year study, entitled "Smoking and Health: Report of the Advisory Committee to the Surgeon General of the Public Health Service," that reaffirmed the earlier conclusion. Dr. Terry Luther, who succeeded Burney, declared, "Cigarette smoking is causally related to lung cancer in men. The magnitude of the effect of cigarette smoking far outweighs all other factors. The data for women, though less extensive, point in the same direction."

Based on the Public Health Service report, Congress passed legislation in 1966 that required a warning label on all cigarette packaging. Cigarette ads were banned from radio and television in 1971, and cigarette companies were required to include a health warning in advertising in 1972.

Reorganization. After Lyndon Johnson became president in 1963, he presented Congress with a far-reaching program of social reform that included major health-related legislation. In 1965, Congress passed laws that expanded the role of the Public Health Service in the fight against heart disease, the care of migrant workers, the vaccination of children, and local health care planning. However, the most significant health care legislation, Medicare and Medicaid, did not involve the Public Health Service, which viewed the programs as medical insurance rather than the provision of health care.

In 1965 John Gardner became secretary of HEW and transferred the surgeon general's statutory authority to himself, although Dr. William Stewart, who had succeeded Terry as surgeon general, continued as head of the agency. Then in 1968, Wilbur Cohen replaced Gardner and initiated another reorganization. He created three agencies within the Public Health Service: the National Institutes of Health, the Food and Drug Administration, and the Health Services and Mental Health Administration. Cohen also assigned administrative responsibility to Dr. Philip Lee, then the assistant secretary for health and scientific affairs. The surgeon general was relegated to deputy administrator.

The changes continued after Richard Nixon was elected president in 1968. In 1969, Secretary of HEW Robert Finch appointed Dr. Jesse Steinfeld to be surgeon general, over the protests of many in the administration who thought the job should be left vacant. When Elliot Richardson replaced Finch in 1971, he appointed a committee chaired by former undersecretary of HEW John Perkins to study the future of the Commissioned Corps. The committee concluded that the Commissioned Corps should be replaced by a civil service career system for health care professionals and that the position of surgeon general should be eliminated. The recommendation was never carried out, but the position of surgeon general was left unfilled for four years after Steinfeld resigned in 1973. The deputy surgeon general, Dr. S. Paul Ehrlich, Jr., fulfilled the ceremonial duties of the surgeon general until 1977.

Despite the controversy surrounding the role of the surgeon general, the Public Health Service expanded under the Nixon administration. In 1970, Congress passed the Occupational Safety and Health Act, which created the Occupational Safety and Health Administration (OSHA) within the Department of Labor to establish and enforce workplace health and safety standards. In addition, the law created a National Institute for Occupational Safety and Health under the Public Health Service to study the causes of employee illnesses and accidents. Also in 1970, the Public Health Service established the Institute on Alcohol Abuse and Alcoholism and the National Health Service Corps, which recruited health care professionals for rural areas of the country with a critical shortage of health care services.

Tuskegee Project. The Public Health Service faced another controversy in 1972, when a former venereal disease program worker raised questions of ethics and racial prejudice in the Tuskegee syphilis project. In the early 1930s, the Public Health Service, the Macon County, Alabama, Health Department, and the Tuskegee Institute began studying syphilis in a group of black patients. They continued the study without medical intervention for almost 40 years, despite the fact that penicillin had proved effective against syphilis in the 1940s. The Center for Disease Control attempted to defend the study by claiming that penicillin sometimes led to adverse reactions in patients with advanced cases of syphilis. However, a medical review panel dismissed the claim and called for an immediate end to the project. The government later paid $10 million in out-of-court settlements to survivors of the program and families of those who had died.

Following revelations about the Tuskegee Project, the Public Health Service underwent another reorganization in 1973, when five operational level agencies were created under the Office of the Assistant Secretary for Health. The Centers for Disease Control was established as a separate agency, along with the Health Resources Administration, the Health Services Administration, the Food and Drug Administration, and the National Institutes of Health. A sixth agency, the Alcohol, Drug Abuse, and Mental Health Administration, was created in 1974. The name was later changed to the Substance Abuse and Mental Health Services Administration.

Swine Flu. Late in 1975, four Army recruits fell ill with a new strain of influenza, dubbed "swine flu," that was believed related to the pandemic Spanish influenza of 1918 that killed more than half a million Americans. The swine flu virus was isolated in 1976, and the Public Health Service began preparing for a nationwide immunization program that fall. When more than 200 people came down with a respiratory illness after attending an American Legion convention in Philadelphia, the immunization program was put into effect. Almost 50 million Americans were inoculated between October and the middle of December.

However, by November there were also hundreds of reports of a rare condition known as Guillain-Barre Syndrome, which left its victims paralyzed. Horribly, the cause was traced to the swine flu vaccine. Moreover, researchers had proved that the "Legionnaires disease" was not swine flu, and there had not been any reports of swine flu in the United States since the four recruits had become ill a year earlier. The Public Health Service announced suspension of the immunization program on December 16, 1976. More than 1,000 people eventually developed Guillain-Barre Syndrome and the government paid more than $84 million in liability claims.

Healthy People. In 1977, President Jimmy Carter appointed Joseph Califano as secretary of HEW. Califano then recruited Dr. Julius Richmond, the first director of Project Head Start, as Assistant Secretary for Health. However, Richmond agreed to serve only if he also was appointed surgeon general, thus filling the vacancy that had existed since 1973 and avoiding the ambiguity of who ran the Public Health Service.

Richmond established an Office of Disease Prevention and Health Promotion to launch what he called a "second health revolution" that would address the issues of smoking, drinking, nutrition, sedentary living, and poor safety practices. In 1979, the Office of Disease Prevention and Health Promotion published "The Surgeon General's Report on Health Promotion and Disease Prevention."

The report, which became known as "Healthy People," established goals for 1990 that included a 35 percent reduction in infant mortality, a 20 percent reduction in mortality among all age groups, and a 20 percent reduction in the number of days of illness among the elderly. In the forward, Califano said, "You, the individual, can do more for your own health and well-being than any doctor, any hospital, any drug, any exotic medical device." A companion report, "Objectives for the Nation," was published in 1980 and established specific targets by age group for several health categories.

During the 1980s, the Public Health Service continued to report that people were not adopting healthier lifestyles, and in 1990, the Office of Disease Prevention and Health Promotion extended its target date another decade with the publication of "Healthy People 2000: National Health Promotion and Disease Prevention Objectives." The American Public Health Association published a guide, "Eleven Steps to a Healthy Community," to assist states in achieving the "Healthy People 2000" objectives, and in 1993 reported that 41 states had adopted its model program.

AIDS. In 1981, doctors in the United States began reporting a strange new disease that left healthy young men susceptible to a variety of rare infections and cancers. In 1982, the Centers for Disease Control gave the disease a name, acquired immune deficiency syndrome (AIDS), after discovering that it weakened the body's disease-fighting immune system. In 1983, the Public Health Service issued its first set of guidelines on AIDS prevention, which urged high-risk individuals to change their sexual practices and refrain from donating blood. In 1986, Koop released a more controversial report, much of which he wrote himself, urging sex education beginning in grade school and the use of condoms. He also denounced the notion of quarantines and called for tolerance.

Meanwhile, other agencies within the Public Health Service also became involved in the campaign against AIDS. In 1985, the Centers for Disease Control announced that it was safe for children with the disease to attend school; however, it recommended precautions for younger children who might be more likely to bite or scratch each other. The Food and Drug Administration also approved a test to screen for AIDS among blood donors and announced that the nation's blood supply was again safe.

Then in 1988, Koop took the dramatic step of writing and mailing an eight-page brochure on AIDS, "Understanding AIDS," to all 107 million households in the United States—the largest public health educational campaign ever. In 1988, the Public Health Service also established the National AIDS Program to provide support and coordination for federal, local, and private-sector efforts. During Koop's tenure as surgeon general, he also issued the first surgeon general's report on the health hazards of smokeless tobacco and assumed formal command of the Commissioned Corps, then with 5,500 uniformed officers. The Public Health Service also closed the last of the Marine Hospitals and assumed responsibility for health aspects of the toxic waste clean-up program known as Superfund.

Further controversies with subsequent Clinton administration nominees left the surgeon general's post vacant for more than two years. Shalala and Lee retained their posts in Clinton's second term.

As the century came to a close, it was easy, by funding and media coverage alone, to identify the most pressing public health issues: AIDS, tobacco-related disease and morbidity, food safety, and (more diffusely) the ability of the United States to respond to disease brought into the country from foreign sources. The World Health Organization had reported increases in infectious diseases, including a resurgence of tuberculosis, and U.S. pharmaceutical companies tried to keep pace with antimicrobials intended to defeat new strains of "superbugs," a term applied to mutated viruses and bacterium that are resistant to conventional treatments.

A 1998 report from the CDC indicated that there were approximately 400,000 tobacco-use related deaths per year in the United States alone. The 1999 class-action settlements with tobacco companies were allocated among federal and state agencies to assist in treatment and education programs to address this problem. The 1998 "Fen Phen" scare, as well as illnesses and deaths reportedly connected to contaminated herbal sprouts and pet chews (pig ears and animal hooves), were addressed by the FDA. The FDA also released statements in 1999 proposing new rules regarding nutrition labeling on food products and the safe handling of eggs and egg products. In September 1999 the FDA issued a statement identifying a potential link between incidence of Down Syndrome and low maternal levels of folic acid.

Current Conditions

During the early 2000s, a number of new public health threats emerged. Among these were heightened risks of bioterrorism, including the use of diseases like anthrax and smallpox as weapons. Other potential public bioterror threats included exposure to radiation, botulism, the plague, sarin nerve gas, sulfur mustard (mustard gas), ricin, and VX. In addition to bioterrorism were the spread of West Nile virus, as well as a new illness called severe acute respiratory syndrome (SARS).

An increased concern about biological weapons emerged in the wake of the terrorist attacks that were made against the United States on September 11, 2001. Following the tragic events of that day, mail tainted with deadly anthrax bacteria was circulated in the postal system, causing several deaths. According to the CDC, anthrax "is an acute infectious disease caused by the spore-forming bacterium Bacillus anthracis. Anthrax most commonly occurs in wild and domestic lower vertebrates (cattle, sheep, goats, camels, antelopes, and other herbivores), but it can also occur in humans when they are exposed to infected animals or tissue from infected animals."

Following the discovery of contaminated mail, U.S. government agencies responded in a variety of ways. The CDC began communicating information to the public about cross-contamination and the appropriate way to handle mail. In addition to basic information about anthrax, the CDC provided information about exposure, symptoms, diagnosis, testing, and screening. It also discussed the difference between symptoms of anthrax exposure and the flu and implications for pregnant women and workers, and provided information about the antibiotic Cipro, which was used in treatment. The U.S. Postal Service responded by implementing a number of security measures, including electron-beam irradiation for sanitizing mail in select locations. The organization also purchased nearly 90 million pairs of rubber gloves, as well as 5 million facemasks to safeguard its employee base. To protect postal customers, some 145 million postcards were sent to U.S. residents that provided explanations about what to do with suspicious items received via U.S. mail.

As described by the CDC, smallpox is "an acute, contagious, and sometimes fatal disease caused by the variola virus (an orthopox virus), and marked by fever and a distinctive progressive skin rash." Although smallpox was considered eradicated in 1980 because of successful campaigns to vaccinate the population, the disease remained in storage in select locations and reemerged as a potential bioterrorism threat during the early 2000s. To prepare for a possible attack, the CDC requested that the U.S. government develop a program to protect the public. This plan included "preparedness teams" consisting of public health and health care employees. The government facilitated production of smallpox vaccine and began vaccinating these individuals in preparation for an outbreak. As of February 2003, the CDC indicated that enough vaccine existed "to vaccinate everyone who would need it in the event of an emergency."

West Nile virus, West Nile fever, and West Nile encephalitis are related conditions that affect humans, as well as a number of other animals including birds and horses. The virus, which is transmitted by mosquitoes, was first discovered in the eastern United States in the summer of 1999. According to the CDC, "West Nile virus is a flavivirus commonly found in Africa, West Asia, and the Middle East. It is closely related to St. Louis encephalitis virus found in the United States…. West Nile fever is a case of mild disease in people, characterized by flu-like symptoms. West Nile fever typically lasts only a few days and does not appear to cause any long-term health effects. More severe disease due to a person being infected with this virus can be West Nile encephalitis, West Nile meningitis or West Nile meningoencephalitis. Encephalitis refers to an inflammation of the brain, meningitis is an inflammation of the membrane around the brain and the spinal cord, and meningoencephalitis refers to inflammation of the brain and the membrane surrounding it." Although the CDC stressed that the chance of humans becoming infected with West Nile virus is low, the center indicated that the avoidance of mosquito bites was the best means of prevention. In addition, it encouraged citizens to report potentially infected dead birds to local and state authorities.

One final threat public health officials faced in the early 2000s came from a new respiratory illness called severe acute respiratory syndrome (SARS), caused by the SARS coronavirus (SARS Co-V). In 2003, outbreaks of this illness occurred in Asia, Europe, and North America. The World Health Organization identified the SARS outbreak in southern China in March 2003. Since then, the disease was believed to have spread via international travel. By May of 2003, USA Today reported that more than 8,000 possible cases had been identified across the globe, resulting in nearly 685 deaths. In North America, the SARS outbreak occurred in the Canadian city of Toronto, where nearly 350 people were infected and almost 25 people died. In addition to presenting challenges for travelers and public health officials, SARS also impacted the world economy by affecting activities like business travel and tourism.

In response to SARS, the CDC communicated constantly with public health officials across the globe, including the World Health Organization. It also took very specific measures to address the emergence of this new public health threat. These included the provision of some 300 medical experts to address SARS, including scientists and medical officers who helped to conduct investigations in the United States and other countries; activation of a 24-hour Emergency Operations Center; issuing alerts for travelers; and conducting lab tests on specimens from infected individuals.

Further Reading

"1999 Food & Nutrition FDA Press Releases & Fact Sheets," 12 November 1999. Available from http://vm.cfsan.fda.gov/lrd/press.html .

Centers for Disease Control and Prevention. "Anthrax: Frequently Asked Questions." 26 May 2003. Available from http://www.bt.cdc.gov/agent/anthrax/faq/index.asp .

——. "Basic Information about SARS." 8 May 2003. Available from http://www.cdc.gov .

——. "Smallpox Questions and Answers: The Disease and the Vaccine." 31 March 2003. Available from http://www.bt.cdc.gov/agent/smallpox/overview/faq.asp .

——. "West Nile Virus Basics." 26 May 2003. Available from http://www.cdc.gov .

"House and Senate Negotiators Shape a Bill to Increase NIH Funds." The Chronicle of Higher Education, 29 October 1999.

Manning, Anita. "SARS Epidemic Grows More Puzzling." USA Today, 1 May 2003.

Mullan, Fitzhugh. Plagues and Politics; The Story of the United States Public Health Service. New York: Basic Books, 1989.

"State-Specific Prevalence Among Adults of Current Smoking and Smokeless Tobacco Use." Journal of the American Medical Association, 6 January 1999.

"Stopping Microbial Killers." The Futurist, June-July 1998.

U.S. Department of Health and Human Services. "HHS: What We Do." Washington, DC: 2003. Available from http://www.hhs.gov .

U.S. Postal Service. "USPS Loses $303 Million in 2Q: Sept. 11 Assaults, Anthrax Attacks Upped Losses $123 Million More Than Expected." Traffic World, 28 October 2002.

Woodyard, Chris, and Barbara De Lollis. "Vacationers Say There's No Place Like Home." USA Today, 23 May 2003.