The Public Health Service’s role continued to expand in the interwar years, undertaking chronic disease research at the National Institutes of Health. The service was aligned by President Franklin Roosevelt with several other agencies under the umbrella of the newly created Federal Security Agency – predecessor of the future Department of Health, Education, and Welfare (HEW). This officially transferred the Public Health Service out of the Treasury Department, where it had resided since its creation, but had little effect on the service’s activities.
Ultimately, the expansion of PHS programs and personnel throughout World War II brought about organizational changes that the service’s leadership had been seeking for years.
The PHS was again militarized when the United States entered World War II in 1941, and eight Commissioned Corps officers lost their lives in the conflict. Toward the end of the war, PHS officers helped lead the United Nations’ disease prevention and medical programs in European and Middle Eastern refugee camps. Ultimately, the expansion of PHS programs and personnel throughout World War II brought about organizational changes that the service’s leadership had been seeking for years. These changes were formalized in the Public Health Service Act of 1944, which further broadened the Commissioned Corps by authorizing commissions for nurses, scientists, dieticians, physical therapists, and sanitarians. As a whole, the Commissioned Corps quadrupled in size during the war, while the size of the PHS as a whole doubled. These numbers held fast, even as the nation demobilized from war. The makeup of the Commissioned Corps had changed dramatically: two-thirds of Corps officers were reserve officers, half were non-physicians, and a quarter were women.
The Public Health Service Act also divided the agency into three bureaus – State Services, Medical Services, and the NIH – that would carry out its separate operational missions. In 1953, when President Dwight D. Eisenhower elevated the Federal Security Agency to cabinet status as HEW, he made few organizational changes to the PHS. The authorities of the Surgeon General remained intact – a detail that later HEW secretaries – who had, after all, the authority to appoint or fire surgeons general in the new department – considered an oversight.
The 1960s, an era when public and environmental health moved to the forefront of national issues, was ironically a time when the very existence of the Public Health Service became threatened.
In 1955 – after years of lobbying by Commissioned Corps officers who believed Native Americans would never receive the kind of care they needed while the Indian health program was just one of many missions under the Bureau of Indian Affairs – the Indian Health Service (IHS) program was transferred to the Public Health Service. Today, the IHS remains one of PHS’ most important program areas, employing roughly a third of the corps’ officers.
The Commissioned Corps’ New Frontier
The 1960s, an era when public and environmental health moved to the forefront of national issues, was ironically a time when the very existence of the Public Health Service became threatened. The many social reforms undertaken by Presidents John F. Kennedy and Lyndon B. Johnson during these years included a number of health-related programs, which doubled the PHS budget between 1963 and 1968. The additional programs and responsibilities required unprecedented knowledge and expertise from the service’s leaders, and the amount of financial and political capital spent on the Public Health Service presented the tradition-bound Commissioned Corps with a dilemma.
An organization designed to be immune from politics, the Commissioned Corps was now being called upon to be more responsive to the policies of elected leaders. The Corps had become accustomed to promoting its own leaders from within, and this tradition had always been a hallmark of its professionalism. But in such a progressive era, this tradition couldn’t continue. At the time of the Johnson administration – despite the fact that 80 percent of PHS employees were civilians – no civil servant had ever run a bureau in the service.
The result of this crisis was one of the most dramatic renewals in agency history, completed to a large extent by 1968. The reorganization transferred responsibility for directing the PHS from the Surgeon General to the Assistant Secretary for Health (ASH), a political appointee. Although the Assistant Secretary could – and has on occasion – come from the ranks of the Commissioned Corps, this has not typically been the case. The Surgeon General, no longer the administrator of the Public Health Service, became largely an adviser and public spokesperson for health-related issues after 1968. The reform was seen by most Corps officers as a “demotion” for the Surgeon General, marking the first time that a noncareer official had become the nation’s top health officer. Today, the Surgeon General provides operational command of the Commissioned Corps under the supervision of the ASH.
Many within the PHS were disheartened by the dramatic 1968 overhaul, but the advent of political leadership, an expanded scope of responsibility, and a status beyond its marine hospital heritage actually enabled the service to thrive. Its budget, programs (the Food and Drug Administration was added to the service under the 1968 reform), and personnel continued a trend of steady growth – a trend that continued even after the service transferred its programs in air pollution, solid waste, pesticides, and drinking water to the newly created Environmental Protection Agency in 1970.
The Surgeon General of the Reagan administration, C. Everett Koop, with his high-profile positions on tobacco use, AIDS, organ transplants, and disabled rights, gained the Surgeon General’s office more respect and prominence than ever before.
Another legislative landmark for the Public Health Service was the Omnibus Budget Reconciliation Act of 1981 (OBRA ’81), which, among many health-related provisions, ended the health care entitlement for merchant seamen and closed the remaining PHS hospitals. Suddenly, the agency’s original reason for existing had disappeared. OBRA ’81 left the PHS a much leaner organization overall, but its six operational divisions – with a looming AIDS crisis (which made reforms to the FDA’s drug approval process increasingly urgent), responsibility for the health implications of Superfund site cleanups, and new agency status for the Indian Health Service – still had plenty of work to do.
The Surgeon General of the Reagan administration, C. Everett Koop, with his high-profile positions on tobacco use, AIDS, organ transplants, and disabled rights, gained the Surgeon General’s office more respect and prominence than ever before. In particular, his 1986 report on AIDS was a candid, articulate, and nonjudgemental look at the escalating health crisis. The report’s recommendations for sex education and condom use sparked a political firestorm – and demonstrated that the office could be, unlike those of many bureaucratic appointees, above politics.
Today’s Commissioned Corps
The Public Health Service today remains a component of the Department of Health and Human Services, renamed in 1980 after the creation of a separate Department of Education. A major reorganization in 1995 once again changed PHS’ leadership structure, leaving the agency just as important but less discrete as a “health agency” – the eight HHS agency heads now report directly to the Secretary, rather than to the ASH. In the HHS bureaucracy, the Assistant Secretary is still one notch above the Surgeon General, technically holding the rank of four-star Admiral (the Surgeon General is technically a three-star Admiral). The ASH oversees 12 core public health offices – including the Office of the Surgeon General and the U.S. Public Health Service Commissioned Corps – as well as 10 regional health offices across the nation and 10 presidential and secretarial advisory committees.