The U.S. Public Health Service (USPHS) has a long, unique and distinguished history as a uniformed service. While most of its people today belong to the agency’s civil-service component – more than 50,000 employees, serving in the Department of Health and Human Services’ (HHS) operational divisions, and overseen by the Assistant Secretary for Health (ASH) – the USPHS is remarkable for the distinction of having one of the nation’s seven uniformed services, the Public Health Service Commissioned Corps. More than 6,700 health professionals today make up the Commissioned Corps, a mobile, duty-bound group of health officers willing to go anywhere, at any time, to meet the nation’s most urgent public health needs. As an organization with deep historical roots, the Commissioned Corps has been instrumental in shaping the look and feel of public health in today’s United States.
The ancestry of the Public Health Service dates to a time before the existence of the modern concept of “public health,” when the United States was dependent on maritime trade for economic and national security.
Most Americans recognize the military branches of service, along with the Coast Guard, as “uniformed service components” of their government, but many are unaware of the nation’s army of “health soldiers,” who wear military-style uniforms, submit themselves to compulsory service, and are promoted in a rank system identical to the Navy’s. In order to understand how such an organization came into being, and how it continues to flourish today, it is important to understand the history and tradition that have shaped the Public Health Service for more than 200 years.
Safeguarding a Nation
The ancestry of the Public Health Service dates to a time before the existence of the modern concept of “public health,” when the United States was dependent on maritime trade for economic and national security. It originated not as an agency designed specifically to encompass public health, but as a means of addressing outbreaks caused by merchant seamen who brought diseases into American ports. These seamen were a burden on public hospital capacity and threatened the health of the population. In 1788, the First U.S. Congress appointed a committee to consider “a bill or bills to establish hospitals for sick and disabled seamen.” This required medical personnel at that time to assess, and in many cases quarantine, ships entering American harbors.
In July 1798, a law was passed creating an entitlement to public care for merchant seamen – the Marine Hospital Fund – and hospitals were built or endowed at various port cities along the Atlantic Seaboard. As the nation expanded west, facilities were set up at river and Great Lakes ports, and eventually on the Gulf and Pacific coasts as well.
The administration of this fund was usually overseen by local customs collectors and politicians, who tended to lobby hard for public funds to establish a hospital, and then hand out sinecures as soon as a contract was won. As a result, the quality of care varied greatly from place to place, and by 1849, the marine hospitals had become something of an embarrassment. An investigative commission recommended that a chief surgeon, attached to the Treasury Department, should be appointed to oversee the administration of the program. After the Civil War, this recommendation began to turn the corrupt Marine Hospital Fund into the disciplined, forward-thinking agency that would become the Public Health Service.
If any one person could be called the “father of the Public Health Service,” it would be the first Supervising Surgeon of the Marine Hospital Service, John Maynard Woodworth, who promptly cleaned house after his 1871 appointment. He shut down poorly performing facilities, improved contract and outpatient care, and published candid annual reports. He was also the architect of the Commissioned Corps. The spoils system that had helped ruin the hospitals, along with the notoriously scandal-ridden Grant administration under which the system operated, made Woodworth determined to find a purely merit-based method for tenure and promotion within the ranks of the service. As the former Chief Medical Officer for Gen. William T. Sherman, Woodworth borrowed the only reliable template he could find – the military model. In 1873, his own title was changed to Supervising Surgeon General, and from then on all applicants to the service were subject to entrance examinations. Appointments were made to the “general service” only, as opposed to specific (i.e., more desirable) locations. Woodworth put his newly commissioned officers into uniforms.
Woodworth’s transformation of the service’s physicians into a mobile, professional corps of uniformed officers stands today as a remarkable feat of administrative reform, achieved a full decade before the 1883 Civil Service Act was passed to stem government corruption. His reforms were made law in 1889, when Congress made the Marine Hospital Service, and its system of appointment and promotion, a formal fixture in the federal public health system.
The formal establishment of the Commissioned Corps came at a critical time. The late 19th century was an era of immense progress in understanding infectious agents, and the Public Health Service was at the forefront of efforts to fight diseases that had long been seasonal killers: typhoid, malaria, cholera, tuberculosis, and others. Not long after passage of the 1889 law, the service’s Hygienic Laboratory – predecessor of the National Institutes of Health (NIH) – opened in one room of the Marine Hospital on Staten Island, where it was positioned to investigate the illnesses of immigrants and seamen. Within a few years of its founding, the Hygienic Laboratory was producing therapeutic sera and antitoxins, and training scientists from state health agencies in their use. The laboratory proved so successful – and so necessary to the service’s new research function – that, in 1904, it was moved to its own specially designed headquarters in Washington, D.C. By 1912, the agency’s expanded roles in public health – including its newly acquired quarantine authority, its research functions, and its disease control responsibilities – had become so important that Congress passed a law changing its name to the Public Health Service.
War Comes to the PHS
Like much of the nation, the Public Health Service was caught off guard by the United States’ 1917 entry into World War I. President Woodrow Wilson promptly militarized the service, many of whose officers were then detailed to the Army or Navy. The military draft – which totaled 3 million men by war’s end – created new challenges for the service, with overcrowded military posts providing staging areas for diseases such as typhoid fever and malaria. The war coincided with one of the worst epidemics in its history, the influenza outbreak of 1918-1919, which eventually claimed the lives of half a million Americans. The epidemic drew 64 officers – nearly a third of the Commissioned Corps – to work on fighting the disease, while the service hired an additional 2,000 doctors, nurses, and other civil servants for influenza duty.
The service’s survival of the war years, and the ensuing demands of veterans on the system, left it forever transformed. Nurses, in particular, had taken on a key role in PHS programs, staffing the service’s most important hospitals and clinics. Like all health professionals other than physicians, however, nurses could only be employed as civil servants in the Public Health Service. Under the pressures of war, Congress had passed temporary legislation allowing some health professionals to be commissioned as Reserve officers, but most PHS health professionals, and the host of support personnel needed to carry out its programs, were civil service employees. By 1925, the Public Health Service’s 4,672 employees included 182 regular service officers. While the Commissioned Corps still provided the leadership, the PHS had become much larger and more broad based than the small, elite corps of Marine Hospital physician-officers that had spawned the service more than a century earlier. In 1930, these changes in the service were finally accommodated in a law authorizing regular corps commissions for dentists, pharmacists, sanitary engineers, and Hygienic Laboratory scientists at the level of division director. The legislation also gave the Surgeon General tremendous latitude in assigning personnel to other agencies, including the newly created Bureau of Prisons, and tied the pay of Commissioned Corps officers to those of the Army.