The eight agencies of the United States Public Health Service (USPHS) are the major public health component of the U.S. Department of Health and Human Services (USDHHS). The central mission of the PHS is to protect the health of the country's population. The action plan for the PHS has been translated into the main goals of Healthy People 2010: (1) increase quality and years of healthy life, and (2) eliminate health disparities.
In order to achieve these broad goals, Healthy People 2010 includes four broad categories of action: (1) promote healthy behaviors; (2) promote healthy and safe communities; (3) improve systems for personal and public health; and (4) prevent and reduce disease and disorders. Within these four broad categories are twenty-eight priority areas (e.g.. improve the health, fitness, and quality of life of all Americans through the adoption and maintenance of regular, daily physical activity), and within these twenty-eight priority areas are 467 specific objectives. For each of the priority areas, PHS agencies (operating divisions in the USDHHS) are designated to coordinate activities directed toward achieving the objectives. The PHS periodically reviews progress toward achieving the Healthy People objectives.
The PHS administers hundreds of grant-in-aid programs, ranging from grants to support basic laboratory research by investigators in university departments, to block grants to states for support of maternal and child health services. Many of these grant-in-aid programs have a very narrow focus, specifying in some detail the action that must be taken by grantees (e.g., a state agency), while other grants (e.g., the Prevention block grant) permit greater leeway by the grantees. In addition to its hundreds of grant-in-aid programs, the PHS conducts research in its own laboratories, regulates the food, drug, medical device, and cosmetic industries (through the Food and Drug Administration), and directly manages health care and public health programs for the Native American tribes living on reservations and in Alaskan villages.
While the PHS traces its origins to an act "for the relief of sick and disabled seaman" passed by Congress and signed into law by President John Adams in 1798, its modern structure dates to the Public Health Service Act of 1944, as well as to the organization of the Federal Security Agency (FSA) by President Roosevelt in 1939 (when the PHS was moved from the Treasury Department to the FSA), and to the creation of the Department of Health, Education and Welfare (DHEW) in 1953. Following a series of transfers of programs out of DHEW (environmental health in 1970, education in 1980, and social security in 1995), the modern home for the PHS was established. The name of the department was changed to Health and Human Services after the Office of Education was separated to create the Department of Education.
The PHS underwent a series of reorganizations beginning in 1966, which resulted in the assistant secretary for health becoming chief operations officer of the PHS in the early 1970s. During the next several decades there were organizational changes within the USPHS, but the leadership continues to rest with the assistant secretary for health.
The PHS was reorganized by the secretary of Health and Human Services in 1995 with the operating divisions (agencies) reporting to the secretary instead of the assistant secretary for health (who now heads the Staff Office of Public Health and Science). The eight PHS operating agencies are:
- Agency for Toxic Substances and Disease (ATSDR)
- Agency for Healthcare Research and Quality (AHRQ)
- Centers for Disease Control and Prevention (CDC)
- Food and Drug Administration (FDA)
- Health Resources and Services Administration (HRSA)
- Indian Health Service (IHS)
- National Institutes of Health (NIH)
- Substance Abuse and Mental Health Services (SAMHSA)
The assistant secretary for health heads the Office of Public Health and Science and is the senior advisor to the DHHS secretary on health and science. In that position, he or she leads cross cutting between initiatives as identified by the secretary who is now the head of the PHS and directs the activities of the major PHS agencies. The surgeon general reports to the assistant secretary for health and is considered the nation's spokesman on public health issues. Located in the Office of Public Health and Science are important program offices supporting the work of the assistant secretary of health and coordinating USDHHS programs such as the National AIDS Program Office, the Office of International Health, the Office of Emergency Preparedness, the Office of Women's Health, the Office of Minority Health, the Office of Disease Prevention and Health Promotion, the National Vaccine Program Office, and the President's Council on Physical Fitness and Sports. It should be noted that the Public Health Service has commissioned officers (physicians, dentists, nurses, engineers) assigned to all the PHS operating agencies. The functions of the PHS operating divisions are described below.
Agency for Toxic Substances and Disease Registry (ATSDR). The ATSDR performs specific public health functions concerning hazardous substances in the environment. This agency works to prevent exposure and to minimize adverse health effects associated with waste management emergencies and pollution by hazardous substances. The agency goals are to identify people at risk of exposure to hazardous substances, evaluate the degree of risk due to the presence of toxic agents in the environment, and prevent or mitigate adverse human health outcomes.
Agency for Healthcare Research and Quality (AHRQ). Established in 1999 by Congress from its predecessor agency, the Agency for Health Care Policy and Research, the AHQR focuses on quality of care and medical care outcomes, rather than the health system and health care policy. The agency is responsible for conducting and sponsoring research to enhance the quality, appropriateness, and effectiveness of health care services. In general, the primary aims of the AHRQ are to support research designed to improve the quality of health care, reduce its cost, and broaden access to essential services.
Centers for Disease Control and Prevention (CDC). The CDC acts as the lead PHS agency relating to the surveillance and identification of disease through epidemiological and laboratory investigations, and it is the primary agency administering grants to support public health programs, such as HIV/AIDS (human immunodeficiency virus/acquired immunodeficiency syndrome), sexually transmitted diseases (STDs), injury protection, immunization, and cancer screening, in DHHS. The CDC is composed of eleven major operating components. These include three program offices, Epidemiology, International Health, and Public Health Practice, and eight centers, Immunization, Chronic Disease Prevention and Health Promotion, Prevention of Infectious Diseases, Injury Prevention and Control, HIV and STD Prevention, Health Statistics, Environmental Health, and the National Institute for Occupational Safety and Health (NIOSH). With its headquarters in Atlanta, Georgia, it has personnel abroad and on local, state, and federal levels of public health to facilitate data collection, analysis and program implementation. In addition to controlling the introduction and spread of disease in the United States, the CDC provides assistance to other countries and international health organizations.
Food and Drug Administration (FDA). The FDA is charged with administering the Federal Food, Drug, and Cosmetic Act and several related public health laws. New medical devices, experimental drugs, biologics, cosmetics, food additives, and food labels are some of the everyday items under FDA scrutiny. The FDA, in cooperation with the United States Department of Agriculture, is the primary federal agency responsible for food safety. It must assure the safety of all imported goods (e.g., fruit and vegetables) as well as domestically produced foods, except meat and poultry. The FDA also protects the nation's food supply indirectly by monitoring the type of food given to livestock. The United States Department of Agriculture is responsible for meat and poultry safety.
Health Resources and Services Administration (HRSA). The HRSA is a large and complex agency with three major bureaus that administer numerous categorical grant-in-aid programs to the states. The HRSA attempts to improve access to medical care for the indigent, uninsured, rural residents, and other special-need populations. HRSA promotes quality health care to underserved populations with policies that range from training of minority primary-care physicians to the resources related to health care for federal prisoners. It is the agency responsible for providing health professions education programs to meet national needs. The National Health Service Corps Program is one such program sponsored by HRSA that aims to direct health care personnel to underserved areas. The HRSA supports community health centers and funds the Ryan White CARE (Comprehensive AIDS Resources Emergency) Act for people living with HIV/AIDS. Though it works to improve the resources for maternal and child health, and establishes policies in cooperation with the private sector, including policy for allocation of organ, bone, and tissue transplants.
Indian Health Service (IHS). Article I, Section 8 of the U.S. Constitution is the original legal basis for the federal government's responsibility to provide health services to American Indians and Alaskan Natives. The structure of the IHS has been shaped by numerous treaties, laws, Supreme Court decisions, and executive orders since the ratification of the Constitution. The goals of the IHS have been to ensure that comprehensive, culturally acceptable personal and public health services are available and accessible to all American Indian and Alaskan Native people. Because of limited resources, the hospitals, clinics, and public health programs of the IHS primarily serve Indian reservations and Eskimo villages. Currently more than half of all American Indians do not reside on reservations and are not eligible for these direct services provided by IHS. In recent years the IHS worked closely with tribes to transfer program management to the tribes. Limited funding by Congress has slowed this process. Currently, the IHS provides care for approximately 1.5 million Native Americans and Alaskan Natives in thirty-four different states. Depending on the resources available, the IHS attempts to provide a full range of preventive, primary medical care (hospital and ambulatory care), community health, alcohol programs, and rehabilitative services. The IHS contracts with non-HIS providers such as individual physicians, state and local public health agencies or tribunal health institutions when the agency's facilities, resources, or highly specialized medical services are not available.
National Institutes of Health (NIH). Headquartered in Bethesda, Maryland, the NIH is composed of twenty-seven separate institutes and centers, including the National Institute of Environmental Health Sciences, located in North Carolina. The mission of the NIH is to fund biomedical research in its own laboratories, and in universities, hospitals, private research institutions, and private industry, to develop new knowledge that can potentially improve the health of the population, the quality of medical care, and the understanding of disease processes. The research at NIH is focused primarily in basic biomedical and clinical research.
Substance Abuse and Mental Health Services Administration (SAMHSA). SAMHSA was created in 1995, when the Alcohol, Drug Abuse, and Mental Health Administration (ADAMHA), created in 1973, was broken up and its research function transferred to NIH in three categorical divisions: Drug Abuse (NIDA), Alcohol Abuse and Alcoholism (NIAAA), and Mental Health (NIMH). The services programs (grant-in-aid program) was transferred to the newly created SAMHSA. The mission of SAMHSA is to improve the quality and availability of prevention, treatment, and rehabilitation services for persons suffering from alcoholism, substance abuse, and mental illness. SAMHSA's Center for Mental Health Services, Center for Substance Abuse Prevention, and Center for Substance Abuse Treatment work together and with other government and private organizations to build the infrastructure that facilitate community prevention and treatment. The agency funds programs and conducts its own studies and studies in conjunction with the NIH and other agencies, to improve treatment methods. SAMHSA provides its services primarily through block grants and contracts with state health agencies, in order to help reduce illness, death, disability, and cost to society caused by substance abuse and mental illness.
Currently, specific challenges facing the PHS include the threat of bioterrorism, the global HIV/AIDS epidemic, and assuring safety of the blood and food supply. Major problems and challenges include:
- Applying the growing body of knowledge of the multiple determinants of health of populations, including health behaviors, human biology, the physical environment, the socioeconomic environment, and health care, to federal and state health policies and programs.
- Continuing to support advances in science and technology, including those in biomedical research, social and behavioral sciences, computer science and informatics, nanotechnology, and other areas.
- Developing the potential of the National Health Information Infrastructure (NHII), based on the Internet and the World Wide Web, to foster connectivity among the parties invoked in achieving healthier communities, improving patient safety, improving quality of health care, and contributing more directly to the health of individuals.
- Respondent to the changing nature of the health problems in the United States, including the increased burden of chronic illness; sociobehavioral health problems (e.g., substance abuse, violence); the aging of the population; the increasing diversity of the population; the growing disparities in health status related to race; ethnicity and socioeconomic status; and the threats posed by infectious diseases.
- Addressing the problems created at the state and local level by the current proliferation of categorical public health programs designed to deal with specific diseases, specific services, specific populations, specific providers, specific locations, or other categories.
- Responding to the increasing importance of global health issues as country boundaries become more permeable to disease and as global markets determine the safety of food and the availability, quality and cost of pharmaceuticals, blood and medical devices.
The performance and impact of the U.S. health system (including both medical care and public health) in this complex environment can be significantly improved if a comprehensive strategy to promote public health is developed with leadership by the U.S. Public Health Service, and if supported with the necessary investments.
(SEE ALSO: Agency for Healthcare Research and Quality; Block Grants for Public Health; Centers for Disease Control and Prevention; Food and Drug Administration; Health Resources and Services Administration; Healthy People 2010; National Institutes of Health; United States Department of Health and Human Services [USDHHS])
— PHILIP R. LEE; BRIAN PUSKAS; ANNE M. POR
