Meeting the Health Needs of the Nation

The Public Health Service has a rich history that dates back more than 200 years. In 1798, President John Adams signed the act of Congress giving rise to the Marine Hospital Service. This service was directed to care for the needs of merchant seamen, who often returned from sea with illnesses that threatened their health and the health of their families and communities.

The Marine Hospital Service later became the Public Health Service in 1912. Under the leadership of Supervising Surgeon John Maynard Woodworth, MHS was reorganized along military lines to be a mobile force of professionals subject to reassignment to meet the needs of the Service. In 1889, Congress formally authorized the Commissioned Corps of the U.S. Public Health Service.

Since its inception, the Commissioned Corps has had as its central organizing principles the protection and improvement of the health of the nation. Under normal circumstances, officers of the Corps practice their professional, biomedical and public health skills. At the same time, they are ready to be mobilized as individual officers who respond in large units to emergent situations, or as the entire Corps to serve in one of the armed forces, as directed by the President.

Corps officers are assigned to PHS agencies and to a number of agencies outside PHS, including the Bureau of Prisons, U. S. Coast Guard, Environmental Protection Agency, Health Care Financing Administration, and the Commission on Mental Health of the District of Columbia.

The principal missions of the Corps fall into three broad categories: essential public health and science, military augmentation, and emergency response. Each mission has its own set of demands for health expertise.

Essential Public Health and Science

PHS commissioned officers are key personnel in helping to achieve the public health and science goals of the operating divisions within the Department of Health and Human Services (DHHS). In day-to-day responsibilities, commissioned officers practice their respective skills in laboratories, community clinics, public health facilities, public health departments and other components of the government's public health and science enterprise.

The Corps plays a critical part in lessening the health-care burden of the nation by providing direct health care to the underserved and other federal beneficiaries through the Indian Health Service, the National Health Service Corps, the Coast Guard, the Bureau of Prisons, the Immigration and Naturalization Service, and the U. S. Marshals Service. It is estimated that nearly 95 percent of the Indian Health Service's dentists, engineers, sanitarians, pharmacists, physical therapists, optometrists, and podiatrists are commissioned officers.

Commissioned officers also provide technical assistance to state and local public health departments and provide preventive and public health services (including environmental health and engineering) in remote locations.

One of the major public health activities the Corps is engaged in is the Healthy People Initiative, which was started in 1979 by Dr. Julius Richmond, with the release of a Surgeon General's Report, Healthy People. That report laid the groundwork for Healthy People 1990, which was followed by Healthy People 2000: National Health Promotion and Disease Prevention Objective.

Healthy People 2010 contains broad-reaching national health goals for the new decade and will serve as the basis for the development of state and community plans. Healthy People 2010 has 28 focus areas, or chapters, and 467 objectives and is centered around two major goals.

The first goal is to increase the number of years and quality of a healthy life, a goal developed in response to America's rapidly aging population. In the last century, we gained 30 years of life expectancy. In 1900, life expectancy was about 47 years; in 2000, it was 77 years and rising. In addition, 35 million people in this country are over 65, and the fastest growing age group is over 85 years of age. This trend dictates that the emphasis must be on increasing both years and quality of life, paying careful attention to such areas as Alzheimer's, arthritis, osteoporosis, the management of chronic pain, and the aggressive diagnosis and treatment of depression in the elderly.

The second goal is to eliminate disparities in health among different racial and ethnic groups. It addresses the rapid population shifts that are occurring in this country as we become increasingly more diverse. These shifts will place increasing demands on our health-care system if we do not address them.

This goal grew out of President Clinton's "Race Initiative." During a commencement speech at the University of California at San Diego, he noted that diversity was one of our greatest assets in America and that we should be a model for other countries to follow. He later asked each Cabinet head to develop some strategy for supporting the Race Initiative. We followed through in DHHS with the Initiative to Eliminate Racial and Ethnic Disparities in Health. Some weeks later, President Clinton issued a radio address where he directed me, as the surgeon general and assistant secretary for health, to provide leadership on the assignment to continue improving the nation's health overall as we worked to close the gaps.

As a result, we selected six areas to begin our focus: infant mortality, breast and cervical cancer screening and management, cardiovascular disease, diabetes complications, HIV/AIDS, and immunizations. In all of these areas, minorities are lagging sorely behind their white counterparts. Look at these examples

Infant Mortality. (1) A baby born to an African-American mother has more than twice the risk of dying in the first year than a white baby. An American Indian baby is 1.5 times more likely to die. (2) African-American women are nearly four times as likely to die during pregnancy or shortly thereafter as white women.

Cancer. (1) Although the incidence of breast cancer is greater for white women, African-American women are more likely to die from the disease. (2) African-American men under 65 suffer from prostate cancer at nearly twice the rate of whites. (3) Vietnamese women living in this country experience cervical cancer at five times the rate of white women. Hispanic women over 65 have twice the risk. (4) Asian-Americans are 3 to 5 times more likely to die from liver cancer.

Cardiovascular Diabetes. American Indians suffer from diabetes at nearly three times the average rate. For Hispanics, the rate is nearly double that of whites. And African-Americans suffer 70 percent higher rates of diabetes than whites and have the highest death rate.

HIVIAIDS. This disease was first identified in this country in 1981 when it was predominately a disease among white, gay men. However, it has increasingly become a disease of people of color, of women, and of the young.

Immunizations. In adult immunizations, all groups are sorely lagging. For influenza vaccination, only 67 percent of older white persons, 58 percent of elderly Hispanics, and 50 percent of African-American senior citizens reported getting a flu shot. (2) Even fewer people have received the pneumococcal vaccine.

Eliminating disparities is not a zero-sum game. Since 1798 when the Public Health Service was officially established, it has functioned under the premise that to the extent that we care for the needs of the most vulnerable among us, we do the most to protect the health of the nation. It is that understanding that has given way to the conclusion that these disparities cannot be allowed to continue.

When the Healthy People 2010 initiative was launched, the plan included for the first time 10 leading health indicators, comprising 10 areas of health status that were based upon Healthy People 2010 objectives. These new measures will allow Americans to easily assess the overall health of the nation as well as that of their own communities, and make comparisons and improvements over time. They are physical activity, overweight and obesity, tobacco use, substance abuse, responsible sexual behavior, mental health, injury and violence prevention, environmental quality, immunization, and access to health care.

Unlike the objectives that may vary from state to state, community to community, and individual to individual, these Leading Health Indicators are universal. Similar to the nation's leading economic indicators for health, they will serve as the mechanism for monitoring national progress to see how well the country is meeting its goals and objectives.

As surgeon general and leader of the PHS Commissioned Corps, I am applying the principles of Healthy People 2010 and the Leading Health Indicators to improving the health status of all Corps officers. PHS officers not only need to be familiar with the concepts of a healthy lifestyle for their own well-being, but also in their roles as health leaders. My staff has been working with the Army Physical Fitness Research Institute (APFRA) to develop programs for PHS officers that improve their health, energy levels and stamina. APFRA is doing great work in the field of personal wellness, which we are utilizing. Today's work environment, whether it is responding to medical emergencies or long hours in the office, requires sharp minds and healthy bodies, By allowing officers to perform their own health assessments and develop individualized wellness programs, we will have a better Corps.

Military Augmentation

PHS historically has worked with most branches of the armed forces, including the Coast Guard, on various health-related missions. Individual commissioned officers or teams of officers can be assigned or detailed to any branch of the armed forces. Approximately 165 PHS officers currently are assigned to the Coast Guard. PHS officers have recently been detailed to the U.S. Army Medical Research and Material Command and to the Office of the Assistant Secretary of Defense for Health Affairs to work in the TRICARE Management Activity. The President, by Executive Order, can make the PHS Commissioned Corps a branch of the land and naval forces of the United States. This authority was used by Presidents in World Wars I and II and during the Korean War.

With military components reporting shortfalls of health-care professionals, there has been a renewed interest in tapping into the approximately 2,500 Inactive Reserve PHS officers for short tours of duty in Department of Defense branches. The FY01 National Defense Authorization Act, under section 755, authorizes the Secretary of the Army and the Secretary of Health and Human Services to enter into an agreement to conduct a program under which officers of the PHS Inactive Reserve component may be detailed to augment the Army Medical Department, subject to existing legislative authorities. This provision also requires the Secretary of the Army, in consultation with the DHHS Secretary, to review existing legislative authorities and report to the Senate and House Committees on Armed Services no later than 1 March 2001 on the findings of this review and any recommendations necessary to permit enhanced augmentation by the PHS.

Staff from the respective PHS and Army surgeon general offices have met to discuss the process for Inactive PHS officers to activate for short tours with the Army. Although there may be some barriers to overcome before a full-fledged program is established, PHS is optimistic that the interim deployment of a small number of PHS officers to the Army will assist PHS in establishing the foundation for a PHS Ready Reserve Corps, which is being planned. The Ready Reserve Corps would be a subset of the Inactive Reserve component that is in a higher state of readiness to deploy to disaster sites and for other surge needs.

Emergency Response

The Office of Emergency Preparedness (OEP) administers programs using an all-volunteer force located in every state in the nation. Individuals who may be called include 1,400 active-duty officers who are members of the Commissioned Corps Readiness Force (CCRF), 7,000 active-duty, Civil Service, and civilian members of the National Disaster Medical System (NDMS), and many thousand individuals who are members of the Metropolitan Medical Response System in 72 cities across the country.

In the past 18 months, PHS commissioned officers have deployed as members of the CCRF and Disaster Medical Assistance Teams (DMATs) to a wide variety of assignments. Deployments typically fall into one of three categories:

* Providing support to the local medical and health-care system overwhelmed by a disaster. This includes scenarios such as the activations for the California wildfires, Oklahoma tornadoes, and hurricanes Denny and Floyd. Although acts of nature are non-discriminatory, it is often the most disadvantaged people who suffer the greatest in a disaster, i.e., those without health and property who are more likely to live in substandard housing in flood plains, and communities lacking strong public health infrastructure.

For example, the community of Princeville, N.C., which was almost entirely destroyed by Hurricane Floyd, was a poor community, predominately African-American, with a high percentage of subsidized housing and virtually no industry. PHS commissioned officers, working through their various DHHS agencies and OEP, were onsite assisting in the disaster response and recovery. This-included providing health care to residents requiring special medical needs, crisis counseling, mortuary support, and animal control. They provided assessments of public health needs for disease and injury surveillance to the state, including environmental safety concerns, such as safe drinking water and food safety.

* Providing support to special population groups. Examples of this support are activations for Operation Provide Refuge at Ft. Dix, N.J., and for assisting illegal aliens from China who were sent to Tinian and Guatemala. Each of these events has focused our attention on the vulnerability of those fleeing war in their homeland, or attempting to enter our country illegally.

During Operation Provide Refuge, more than 4,000 Kosovars were received at Ft. Dix over a two-month period. During this time, 150 PHS officers provided medical and mental health care to people who had been victims of the worst inhumanity of war. Our involvement in Operation Provide Refuge can only be described as one of the finest hours in the history of the Public Health Service.

Other activations, such as addressing the acute nursing shortage in Kotzebue, Alaska, at the Maniilaq Health Center, or the Hoopa, Calif., wildfires, were a response to specific tribal requests for support.

* Planning and preparedness activities for chemical, biological, and radiological mass casualty events. Recent deployments of commissioned officers to large public events--such as the International Monetary Fund Meeting in Washington, D.C., the national political conventions, and the NATO Summit--have consisted of two separate but related roles. In each of these settings, CCRF not only provided health care to agents and bomb-sniffing dogs from the U.S. Secret Service during the long hot days, they also were pre-positioned in case there was a weapons of mass destruction (WMD) event. Officers from the Food and Drug Administration were available to monitor any food-related concerns surrounding the event.

The Centers for Disease Control and Prevention monitored well over 100,000 hospitalizations and emergency room visits before, during and after the convention in order to determine if any pattern developed that could be traced to a WMD event. Emergency coordinators from four PHS regional offices were on site to supplement the resources of other federal, state and local public health entities. A recent planned event that required this level of deployment was the Presidential Inauguration in Washington, D.C. in January 2001.

The Public Health Service Nobel Training Center in Anniston, Ala., is involved in training CCRF, DMAT and NDMS personnel to support the health-care needs of the American people during a chemical, biological or radiological event. In fact, the first class of 90 individuals was recently completed, and will serve as a template for future training.

The Office of Emergency Preparedness is also charged with assisting local governments to plan, develop, equip and identify the training requirements for a Metropolitan Medical Response System (MMRS) as the principal resource in planning and responding to the health and medical consequences of a nuclear, biological or chemical terrorist incident. There are currently 72 cities that are participating as MMRS sites, with plans to increase this number to 122 by 2002.

Future Plans

In recent years, Public Health Service operating divisions have continued to evolve, and the responsibilities of the PHS have increased to include:

* Expanding research into the cause, treatment, control and prevention of disease.

* Increasing emphasis on non-infectious diseases such as: cancer and heart disease.

* Supplying health-professional assistance to local, state, national and international health organizations to cope with special health needs and challenges.

* Furthering programs to treat mental illness more effectively, to promote better mental health, and to combat drug abuse, alcoholism and other health hazards.

* Expanding food and drug programs to safeguard the public's health.

* Strengthening communicable disease control at home and abroad.

* Leading the National Health Service Corps to assign health professionals to isolated communities where there is no health care.

* Expanding medical, dental, and public and environmental health programs for Alaskan Natives and American Indians.

* Expanding efforts to achieve a smoke-free society.

* Mobilizing Acquired Immune Deficiency Syndrome (AIDS) research and focusing on AIDS education and prevention.

In response to increasing responsibilities, the Public Health Service has grown from a small nucleus of health professionals 200 years ago to more than 50,000 professional, technical and support personnel in Civil Service, and 5,800 officers of the Commissioned Corps, working in a wide variety of health programs.

The success of these programs hinges on the readiness of a cadre of specially trained and dedicated career men and women whose central mission is to protect and improve the health of the nation. The Commissioned Corps is strategically positioned to carry out that mission today and in the future.

ADM David Satcher, USPHS, is the surgeon general of the United States and also serves as the assistant secretary for health, Department of Health and Human Services. He was appointed to these positions 13 February 1998. Admiral Satcher received a baccalaureate degree from Morehouse College in Atlanta, Ga., in 1963, and his M.D. and Ph.D. degrees from Case Western Reserve University in Cleveland, Ohio, in 1970. From 1982-1993, Admiral Satcher served as president of Meharry Medical College, Nashville, Tenn. In 1993, he was appointed director of the Centers for Disease Control and Prevention, a component of the Public Health Service, in Atlanta. In that capacity, Satcher directed national health promotion and disease prevention programs. He is also a member of the Reserve Officers Association (ROA). Admiral Satcher's spouse is Nola Satcher and he has four children.

January 2001: Commissioned Corps Bulletin

Surgeon General's Column

"May you live in interesting times."

Chinese saying

Indeed, these are interesting times. We have survived a new year, a new century, and a new millennium, and, as if that were not enough, we have witnessed a presidential election unlike anything since Thomas Jefferson was elected President in 1800 or Rutherford Hayes in 1876. Both elections were "interesting," to say the least, and sparked a great deal of controversy in their own right, easily rivaling what we just witnessed. Perhaps the most noticeable difference is that the citizens of that day lacked the benefit of having CNN and MSNBC telling them how interesting it was!

There's another reason we can lay claim to the fact that these are interesting times. In the three years since I have served as Surgeon General and Assistant Secretary for Health, we have published four Surgeon General's Reports on major public health issues confronting the nation: suicide, mental health, oral health, and tobacco cessation. Surgeon General's Reports have a longstanding tradition of being trusted, respected and highly regarded by the American people because they bring the best available science to bear on some of our most challenging health problems. While they are not policy documents, they do have clear policy implications, and we have been careful to point out the disparities, barriers to access and global implications of each public health issue within each report.

In June 1999, we responded to the pleas of some of our nation's silent sufferers and released the first-ever Surgeon Generals Call to Action to Prevent Suicide. When we released the Call to Action, we stated unequivocally that suicide is a serious public health problem. Most people don't realize that suicide is much more common than homicide. For every two homicides, there are three suicides. More than 30,000 people die each year in this country as a result of suicide--that's 81 people each day. It's the eighth leading cause of mortality and the third leading cause of death among young people age 15 to 24. Suicide is a serious complication of mental illness. In fact, 80 to 90 percent of people who commit suicide are suffering from a mental illness. Very soon, we will release a National Strategy for Suicide Prevention.

In December 1999, we released Mental Health: A Report of the Surgeon General. No other issue to cross my desk has struck such a chord with the American people as mental health. In this landmark report, we pointed out that mental health is fundamental to overall health and personal well-being. We also stated that mental disorders are real and that in the United States, one in five persons suffers from a mental disorder each year. The good news in the report is that mental disorders can be correctly diagnosed and treated. In fact, the last 25 years there has been a scientific revolution that has revealed excellent treatments for mental illnesses. We estimate that 80 to 90 percent of mental disorders are treatable and can return people to productive lives and positive relationships. The bad news is that fewer than half of those people who experience a mental illness each year seek treatment because of stigma.

Our work in mental health is far from over. We are working on several fronts to eliminate the stigma associated with mental illness. We are planning to release the following supplements to the Mental Health Report: Culture, Race and Ethnicity, Youth Violence Prevention, and Children's Mental Health.

In May 2000 we published Oral Health in America: A Report of the Surgeon General. In that report, we noted major problems with access that began with lack of health insurance but went far beyond that. Even when comprehensive dental coverage is available through states, use of dental care is low. We have found people tend to pose two major reasons for not visiting the dentist: denial that a problem exists and cost. The latest report by the Department's inspector general revealed serious shortcomings in Medicaid dental programs in the United States and that the level of reimbursement from Medicaid is a major concern.

We must also address issues surrounding socioeconomic status, such as education, income, and housing. Some poor children and some nursing-home residents have limited access to oral health care. Among all predisposing and enabling variables, low educational level has often been found to have the strongest and most consistent association with tooth loss, We must eliminate discrimination in quality by professionals.

In August 2000, we published the Surgeon Ceneral's Report on Reducing Tobacco Use. While there have been more Surgeon General's Reports on tobacco than any other topic, this report marked the first time we ever provided an in-depth analysis of the various methods to reduce tobacco on all major frontsueducational, clinical, regulatory, economic, and comprehensive.

Smoking remains the leading cause of preventable death in this country. Today, nearly one-quarter of U.S. adults and onethird of U.S. teens continue to smoke, and in recent years, we have witnessed an increase in smoking rates among college students. That's why we believe that efforts should focus on promoting quitting among adults and youth smokers; preventing young people from ever starting to smoke; and protecting citizens from second-hand smoke.

Perhaps by the time you read this, we will have released the Surgeon General's Call to Action on Sexual Health. We hope that, among other things, it will spark a national dialogue on sexual health that is long overdue. More on that next month.

Until then, may you continue to live in interesting times!

COPYRIGHT 2001 Reserve Officers Association of the United States
COPYRIGHT 2004 Gale Group