PO -T

ORIGINAL

PUBLIC HEALTH SERVICE UPDATE

BY

Cm EVERETT KOOP, MD

SURGEON GENERAL

      AND

DEPUTY ASSISTANT SECRETARY FOR HEALTH
    U,S, PUBLIC HEALTH SERVICE
U&DEPARTMENT OF HEALTH AND HUMAN SERVICES

PRESENTED TO THE S~RD INTERAGENCY INSTITUTE FOR
     FEDERAL HEALTH CARE EXECUTIVES

         SToLOUIS, MISSOURI

         SEPTEMBER 23, 1983


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(GREETINGS TO HOSTS, GUESTS)

  IT'S A PLEASURE TO BE HERE AGAIN TO REPRESENT THE U.S. PUBLIC
HEALTH SERVICE AT THIS INTERAGENCY INSTITUTE, I MUST COrjFESS THAT
ONE OF THE NICEST ASPECTS OF MY JOB AS SURGEON GENERAL HAS BEEN TO
GET TO KNOW THE HEALTH AND MEDICAL EXECUTIVES ELSEWHERE IN
GOVERNMENT AND TO WORK CLOSELY 1JITH THEM AND THEIR STAFFS, THEY ARE
AN EXTRAORDINARY COMMUNITY OF DEDICATED PUBLIC SERVANTS, IT'S BEEN
A A SOURCE OF GREAT DELIGHT TO MEET THEM AND KNOW THEM AND SOURCE OF
PRIDE TO SERVE ALONGSIDE THEM.

  THIS MORNING, DRUING MY FEW MINUTES AT THE MICROPHONE, I WANT TO
GIVE YOU AN IDEA OF THE MISSION OF THE PUBLIC HEALTH SERVICE AND A
SENSE OF THE WAY IT IS ORGANIZED TO CARRY OUT THAT MISSION, I WANT
TO TALK A BIT ABOUT HOW WE FUNCTION TODAY, HOW WE DID SOME THINGS IN
PRIOR DAYS, AND FINALLY, I'LL MAKE A FEW EDUCATED GUESSES AS TO HOW
THE P.H.S, MIGHT LOOK Al'dD FUNCTION IN THE FUTURE,

  I KI1OW YOU'VE BEEN ABSORBING VAST AMOUNTS OF INFORMATION SINCE
YOU'VE BEEN HERE, SO I WILL TRY TO BE BRIEF,


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  FIRST, YOU OUGHT TO KNOW THAT THE "PUBLIC HEALTH SERVICE" IS NOT

A SINGLE ORGANIZATION WITH BUREAUS, DIVISIONS, AND BRANCHES, IT

MIGHT BETTER BE THOUGHT OF AS A "FEDERATION" OF FIVE INDIVIDUAL

AGENCIES, EACH WITH ITS OWN SPECIAL SPHERE OF EXPERTISE, ITS OWN

CONSTITUENCIES, AND ITS OWN UNIQUE RECORD OF CONTRIBUTIONS TO THE

PUBLIC HEALTH OF THIS COUNTRY.

  THERE IS ALSO AN OFFICE OF THE ASSISTANT SECRETARY FOR HEALTH,

THAT POSITION IS NOW HELD BY DR. EDWARD Nm BRANDT, JR. THIS PERSON

IS THE CHIEF HEALTH ADVISOR TO THE SECRETARY OF OUR DEPARTMENT OF

HEALTH AND HUMAN SERVICES AND, IN OUR CABINET SYSTEM OF GOVERNMENT,

HE IS THE COUNTRY'S HIGHEST RANKING HEALTH OFFICER,

  THE ASSISTANT SECRETARY ENGAGES IN MOST OF THE PUBLIC AND

POLITICAL DIALOGUE REGARDING NATIONAL HEALTH POLICIES AND PROGRAMS,

BUT IN MANY ISSUES AFFECTING THE PUBLIC HEALTH, THE SURGEON GENERAL

BECOMES THE GOVERNMENT'S PRINCIPLE COMMUNICATOR, I'VE DONE THAT ON

A NUMBER OF ISSUES, SUCH AS ORGAN TRANSPLANTS, THE SO-CALLED "BABY
DOE" AND "KATIE BECKET" I-SSUES, AND THE PROBLEM OF PERSONAL AND

FAMILY VIOLENCE AS A GROlJING ISSUE IN AMERICAN PUBLIC HEALTH. I AM

ALSO THE HIGHEST RANKING MEMBER OF THE UNIFORMED P,H,S, COMMISSIONED

CORPS, WHICH IS 5,800-STRONG.  MY RANK IS EQUIVALENT TO VICE ADMIRAL,


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  THE P.H.S. IS A NON-COMBATANT UNIFORMED SERVICE WITH A PROUD
TRADITION THAT REACHES BACK TO 1793 AND THE VERY BEGINNINGS OF
MILITARY MEDICINE IN THE UNITED STATES, OUR MEN AND WOMEN HAVE BEEN
ON ACTIVE DUTY IN ALL THE FAMILIAR "HOT SPOTS" AROUND THE WORLD,
SERVING SIDE BY SIDE WITH OUR COLLEAGUES FROM ALL FOUR SISTER

SERVICES.  WE'VE BEEN IN SOUTHEAST ASIA,,.THE MIDDLE EAST,,,CENTRAL

AMERICA,..AFRICA... WHEREVER AMERICAN INTERESTS HAVE REQUIRED THE
PRESENCE OF THE AMERICAN UNIFORM, YOU WILL FIND CAREER, UNIFORMED
PUBLIC HEALTH PERSONNEL "PULLING DUTY,"

  WE ALSO SERVE IN MANY PLACES WHERE OUR RECORD IN PUBLIC HEALTH
IS RESPECTED AND REQUESTED FOR SOMETIMES VERY COMPLICATED REASONS,
FOR EXAMPLE, A TEAM OF THREE P,H.S, EPIDEMIOLOGISTS WENT TO THE wEST
BANK OF THE JORDAN, AT THE REQUEST OF THE STATE OF ISRAEL, TO
DISCOVER THE CAUSE OF A MYSTERIOUS EPIDEMIC THAT HAD HOPSITALIZED
LARGE NUMBERS OF YOUNG WOMEN FROM THE AREA'S ARAB COMMUNITIES, OUR
TEAM PRESENTED TO THE AUTHORITIES ITS CONCLUSION THAT THE EPIDEMIC
WAS A MASS PSYCHOLOGICAL PHENOMENON, A RARE BUT NOT UNKNOwN EVENT IN

MEDICINE.  YOU MAY REMEMBER READING ABOUT THAT IN THE NEWSPAPERS,


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  I SHOULD ADD THAT 1JHEN THIS REPORT l/AS TAKEN TO THE WORLD HEALTH

ASSEMBLY IN GENEVA, IT WAS GREETED WITH MUCH HOT POLITICAL RHETORIC

FROM MANY THIRD WORLD DELEGATES,  HOWEVER, OUR PEOPLE HAD DONE THEIR

USUAL SOLID JOB OF SCIENTIFIC INQUIRY AND THEIR RESULTS COULD NOT BE

EASILY SMOTHERED, EVEN BY THE HEAVILY ACRIMONIOUS AIR OF GETIEVA,

  CERTAINLY ONE OF THE GREAT TRIUMPHS OF MODERN MEDICAL SCIENCE

HAS BEEN THE VIRTUAL ELIMINATION OF SMALLPOX AS A COMMUNICABLE

DISEASE.  AND ONCE AGAIN, THE PEOPLE WHO HAD BEEN ON THE FRONT LINES

OF THE FIGHT AGAINST SMALLPOX, ma GOUt1CING THROUGH THE VILLAGES AND

SAVANNAHS OF AFRICA AND ASIA AND ADMINISTERING TENS OF THOUSANDS OF

DOSES OF THE SMALLPOX VACCINE. a, liERE CUR P,H,Sm PHYSICIANS, NURSES,

AND SANITATION ENGINEERS,

  P.H.S, PERSGNNEL HAVC ALSO BEEN STATIONED AT POINTS OF EMBARKA-

TION IN SOUTHEAST ASIA,  I TRULY BELIEVE THAT THEIR PROFESSIONAL

COMPETENCE HAS BEEN AMERICA'S BEST DEFENSE AGAINST THE IMPORTATION

OF NEW AND HIGHLY CONTAGIOUS DISEASES, DURING THIS PERIOD WHEN OUR

COUNTRY HAS BEEN CARRY IIJG OUT A HUMANITARIAf4 PROGRAM OF ACCEPTING

REFUGEE "BOAT PEOPLE" FROM THAT PART OF THE 1JORLD. P,H.S, PERSONNEL

HAVE ALSO BEEN CARING FOR THE IHEALTH NEEDS OF CUBAN AND HAITIAN

REFUGEES lJHEN THEY FIRST ARRIVE ON OUR SHORES,


  THE PUBLIC HEALTH SERVICE IS UNIQUELY QUALIFIED TO DO THIS KIND
OF WORK FOR TWO REASONS: ITS HISTORY OF PROFESSIONAL MEDICAL
EXCELLENCE AIjD ITS RECORD AS A CARING AND COMPASSIONATE ORGANIZATION
RIGHT HERE AT HOME,

  THE PJi,S, HAS BEEN AT THE HEART OF OUR NATIOI'JAL COMMITMENT TO
PROVIDE QUALITY HEALTH CARE TO THE POOR AND THE DISADVANTAGED
CITIZENS OF OUR COUNTRY.  OUR COMI1ISSIONED MEDICAL OFFICERS HAVE
BEEN FOUND IN THE coMriuNITY HEALTH CENTERS 0F 0uR INNER CITY AND

RURAL GHETTOS, IN MIGRANT LABOR CAMPS, IN COAL MINING COUNTRY, AND
ON THE SEACOASTS AND LJATERWAYS OF AMERICA,

  FOR NEARLY 30 YEARS WE tIAVE ALSO STAFFED THE HOSPITALS, CLINICS,
AND HEALTH STATIONS SERVING MORE THAN 200 INDIAN TRIBES AND ALASKAN
NATIVE VILLAGES.  WE GOT THIS ASSIGNllEIlT FROM THE CONGRESS IN 1355,
DURING THE NEXT 25 YEARS, THE MEDICAL PERSONNEL OF THE P,H,S, MERE
PRIMARILY RESPONSIBLE FOR LOWERING THE INFANT MORTALITY RATE FOR
INDIANS FROM 62.7 DEATHS PER 1,000 LIVE BIRTHS DOWN TO ONLY 13.2
DEATHS PER 1,000 NEWBORNS,, ,AN 80 PERCENT DECREASE u  DURING THE SAME
PERIOD, 1955 THROUGH 1980, THE INFANT MORTALITY RATE FOR THE UNITED
STATES AS A WHOLE WAS CUT BY 52 IDERCENT, FROM 26.4 TO 12,6,

  INCIDENTALLY, I'M PLEASED TO REPORT THAT OUR LATEST PROVISIONAL
INFAIIT FIORTALITY RATE FOR THE NATION AS A \JHOLE FOR THE 12 MONTHS
ENDING IN MAY 83 IS NOW DOWN TO 11.0,


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  OF COURSE, No SINGLE GROUP CAN CLAIM ALL THE CREDIT FOR suet

DRAMATIC TURtd OF EVEl4TS,  NEVERTHELESS, THE DEDICATED HARD WORK

THE COMMISSIONED CORPS OF THE PUBLIC HEALTH SERVICE WAS CRUCIAL

THAT ACHIEVEMENT I I4 I ND1 Al4 HEALTH,

-I A

OF

TO

AND I WOULD BE REMISS IF I DID NOT MENTION THE TOP PRIORITY

CHALLENGE FACINI; THE U.S. PUBLIC HEALTH SERVICE TODAY: SOLVING THE

MYSTERY OF AQUIRED IMMUNE DEFICIENCY SYNDROME, OR "AIDS,"

  SINCE JUNE OF 1921, WIiEf4 WE BEGAti TO TRACK THE APPEARANCE OF

"AIDS" IN THE U.S., THE P,H.S, HAS RECEIVED REPORTS OF MORE THAN

2,200 CASES,  OF THAT NUtlBER, THERE HAVE ALREADY BEEN 300 DEATHS,

THERE IS NO KNOWN CURE FOR "AIDS." THE EVIDENCE SO FAR SUGGESTS

THAT A VICTIM HAS PERHAPS TlJO OR THREE YEARS OF LIFE LEFT, ONCE HE

HAS THE DISEASE,  AND I SAY "HE" EECAUSE THREE OF EVERY FOUR CASES

OF "AIDS" OCCUR ItI HOMOSEXUAL OR BISEXUAL !lEtl,

  "AIDS" IS JUST ABOUT THE TOUGHEST MEDICAL MYSTERY TO HAVE BEEN

IiANDilD TO THE P.H.S. TO SOLVE, AtiD THAT INCLUDE'S LEGIONNAIRE'S

DISEASE, TOXIC SHOCK SYNDROME, AND THE TYLENOL TAMPERING SCARE,


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  ALL THIS INFORMATION MAY BE VERY INTERESTING, BUT JUST w IN
THE PUBLIC HEALTH SERVICE DOES lJHAT -- AND HOW? I CAN BEST ANS1JER

THOSE QUESTIONS BY QUICKLY RUNNING THROUGH OUR ORGANIZATION, FIRST,

LET ME START WITH THE 5 P.H.Sa AGENCIES.

  I'LL BEGIN WITH "A," THE ALCOHOL, DRUG ABUSE, AND MENTAL HEALTH

ADMINISTRATION,  I THItlK THE TITLE SAYS IT ALL, THIS AGENCY HAS

THREE NATIONAL INSTITUTES -- GF MENTAL HEALTH, OF DRUG ABUSE, AND OF

ALCOHOLISM Aid;> ALCOHOL ABUSE.  THEY CARRY OUT RESEARCH AND PUBLIC

EDUCATION PROGRAMS AliD, UNTIL RECEtiTLY, THEY ALSO SUPPORTED A NICE

RANGE OF SERVICE DELIVERY PROGRAMS AT THE LOCAL LEVELam.800 MENTAL

HEALTH CENTERS . . ,300 STATE AND LOCAL DRUG ABUSE PROGRAMS. m aAND ABOUT

1,000 LOCAL ALCOHOLISM PROJECTS,  MORE ABOUT THOSE PROJECTS LATER,

  THE FISCAL 1383 APPROPRIATION FOR AmD.A,M,H,A, IS $420 MILLION

DOLLARS,

  NEXT, ARE THE CENTERS FOR DISEASE CONTROL, OR C.D,Cm THE

CENTERS ARE HEADQUARTERED IN ATLANTA AND, AS THE NAME IRPLIES,

THEY'RE COCiCERt;ED PRIMARILY 1JITH CONTROLLING OR PREVENTING

COMMUNICABLE AND VECTOR-BORNE DISEASES, C,D,C,'s MORTALITY AND

MOi(BIDITY lJEEKLY REPORT IS REGARDED AS THE BEST BAROMETER I/E HAVE OF

INFECTIOUS DISEASE ACTIVITY IN THIS COUNTRY,


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  c.D.c.3 HISTORY 1s ROOTED IN THAT STRONG TROPICAL DISEASE FRATERN-

ITY WHO LABORED WITH WILLIAM CRAWFORD GORGAS AND ldALTER REED IN THE
CARIBBEAN, CENTItAL ATJEKICA, AND THE PHILIPPINES. TODAY, THE CENTERS

WORK PRIMARILY THROUGH STATE AND LOCAL HEALTH AUTHORITIES TO CARRY OUT
SUCH ACTIVITIES AS CHILD IMMUNIZATIONS, THE CONTROL OF SEXUALLY TRANS-

MITTED DISEASES, AND THE EPIDEMIOLOGICAL DETECTIVE WORK TO SOLVE THE
MEDICAL MYSTERIES I MENTIOl'iED EARLIER, FOR EXAMPLE, IT IS OUR -- AND

THE COUNTRY'S -- LEAD AGENCY IN THE FIGHT AGAINST "AIDS,"

  CmDmC, PERSOl'jNEL ARE 011 T,D,Y, WITH STATE HEALTH AGENCIES AND ARE

USUALLY THE ONES OVERSEAS WHO SCREEN REFUGEES HEADING THIS WAY, YOU

MIGHT BE INTERESTED TO KfdOCJ THAT THE PUBLIC HEALTH SERVICE IS INVOLVED
IN HEALTH-RELATED TECHNICAL ASSISTANCE AGREEMENTS WITH 3-8, OTHER ti3'

NATIOT4S.  INTERNATIONAL HEALTH HAPPENS TO i3E ONE OF THE SURGEON
GENERAL'S RESPONSIBILITIES, BUT WE USUALLY TURN TO THE CENTERS FOR
DISEASE CONTROL FOR THE PERSONNEL CJHO DO THE ACTUAL WORK IN THE HOST

COUNTRIES.

TtlE c,D,c. BUDGET FOR FISCAL '83 Is $248 MILLION,


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  THE FOOD ArdD DRUG ADMINISTRATION -- OR FmD,A. -- HAS BEEN, FOR MOST

OF ITS 77 YEARS, ONE OF THE MOST WIDELY PUBLICIZED, LOVED, AND HATED

AGENCIES OF GOVERNMENT,  THE TlJO 1JATCHCdORDS OF ITS LAlJ, SAFETY AND

EFFICACY, MAKE THE F,D.A. THE ARBITER OF PUBLIC HEALTH IN THE MARKET-

PLACE OF DRUGS, VACCINES, MEDICAL DEVICES, HEALTH SUPPLIES, RADIO-

LOGICAL GEAR, AND CERTAIN HEALTH AND MEDICAL PRACTICES, SUCH AS

NUTRITION AND DIET CGUNSELI/i'G, PRESCRIPTION DRUG ADVERTISING, DRUG

PRESCRIBING, AND ANTENATAL FETAL DIAGNOSIS,

  THE F,D,A,'s BUDGET FOR FISCAL '83 IS $3G7 MILLION. THAT'S REALLY

NOT MUCH MONEY, CONSIDERING THAT THE MISSION OF THE F,D,A,, WHICH IS

TO REGULATE ABOUT $465 BILLION WORTH OF AMERICAN COMMERCE, MORE THAN

100 TIMES THE F,DmA.'S BUDGET,

  THE HEALTH RESOURCES AND SERVICES ADMINISTRATION IS CONCERNED WITH

A VARIETY OF PROGRAMS,  LET ME GO THROUGH THEM QUICKLY WITH YOU,

     9   FIRST, 111 SHEER SIZE AND IMPACT, IS THE MATERNAL AND CHILD

HEALTH PROGRAM -- RUNNING AT A LEVEL OF $373 MILLION THIS FISCAL YEAR,


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     0   r4EXT WOULD BE THE EDUCATION AND TRAINING OF HEALTH PROFES-
SIONALS: PHYSICIANS, DENTISTS, NURSES, THERAPISTS, TECHNICIANS, AND

MANY OTHERS,  THE MAJOR COMPONENT OF THIS PROGRAM, THE NATIONAL HEALT
SERVICE CORPS, ASSIGNS 2,500 HEALTH PERSONTJEL -- PHYSICIANS, NURSES,
AND DENTISTS FRESH OUT OF GRADUATE SCHOOL -- TO DELIVER MEDICAL CARE

IT4 UNDERSERVED AREAS,  THIS IS HOW k1ANY YOUNG HEALTH PROFESSIONALS
REPAY THE GOVERNMENT FOR THEIR STUDENT LOANS.

'H

     9   A THIRD PROGRAIl HAS BEEI THE BUILDING AND MAINTAINING OF

AMERICA'S HOSPITALS,  THIS IS KNOWN AS THE HILL-BURTON PROGRAM, NAMED
FOR ITS CONGRESSIONAL SPONSORS BACK IN 134, IT WAS A VITAL PROGRAM,
SINCE WE HAD DONE VERY LITTLE ABOUT HOSPITALS 0N THE HOME FRONT DURING
WORLD WAR II, AND A GREAT MANY NElJ THINGS HAD HAPPENED IN MEDICINE AS
A RESULT OF THINGS WE LEARNED AS PART OF OUR WAR EFFORT,  IT HAS BEEN

A VERY SUCCESSFUL PROGRAM -- SO T.lUCH SO THAT WE APPARENTLY NOW HAVE
ABOUT 100,000 SURPLUS HOSPITAL BEDS, A VERY COSTLY BUSINESS FOR THE

NATION.

  THE HEALTH RESOURCES AND SERVICES ADMINISTRATION IS THE P.H.S.
AGENCY THAT HAS ACTUALLY DELIVERED -- DIRECTLY OR THROUGH THIRD PARTIES
-- A VARIETY OF HEALTH SERVICES TO CERTAIN SPECIAL POPULATIONS:
AMERICAN INDIANS AND ALASKAN NATIVES, MIGRANT ldORKERS, FEDERAL

EMPLOYEES, COAL MINERS, AND PEOPLE LIVING IN MEDICALLY UNDERSERVED OR

UNSERVED AREAS,


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  UNTIL RECENTLY MERCHANT SEAMEN, BARGEMEN, CANALLERS, RIVERBOATERS,

ATID FEDERAL RETIREES WERE ALSO INCLUDED: THEY RECEIVED THEIR CARE

THROUGH EIGHT PUBLIC HEALTH SERVICE HOSPITALS AND 27 CLINICS -- ALL

THAT REilAINED OF THE ONCE EXTENSIVE TiETWORK OF "MARINE HOSPITALS"

BEGUN BY PRESIDENT JOHN ADAMS IN 1795. THE ONLY HOSPITALS THE P,H,S,

STILL RUfdS ARC THE NATIONAL CENTER FOR HANSEN'S DISEASE -- A WORLD

FAMOUS LEPROSARIUM -- IN CARVILLE, LOUISIANA, ST. ELIzABETHs HOSPITAL

FOR THE !`lEtiTALLY ILL Oid THE OUTSKIRTS OF WASHINGTON, D.C., AND, AS I

MENTIONED A MOMENT AGO, THE INDIAN HEATH SERVICE SYSTEM OF 48 HOSPITALS

AriD 120 CLIFIICS,

  THE HEALTH RESOURCES AI"4D SERVICES ADMINISTRATION tiAS A FISCAL '83

APPROPRIATION OF $1.2 BILLION.

  THE AGENCY WITH TtIE LARGEST APPROPRIATION IS THE NATIONAL

INSTITUTES OF HEALTH.  ITS BUDGET FOR FISCAL 1983 IS $4 BILLION

  THE 11 INSTITUTES THAT ARE THE N.1.H. SUPPORT ABOUT lG,OOO EXTRA-

t',lURAL RESEARCH PROJECTS AT ANY ONE TIME. N.ImH. ALSO CARRIES OUT SOME

2,000 INTRAMURAL PROJECTS EACH YEAR,  SINCE 1337, WHEN THE NATIONAL

CANCER INSTITUTE WAS ESTABLISHED, THE NmInHn HAS SUPPORTED THE WORK OF

IlORE THAiI GO NOBEL LAURZATES II'd MEDICI1JE, PHYSICS, AND CHEMISTRY, OR

ABOUT 1 OUT OF EVERY G WIt'dNERS IN THOSE PRIZE CATEGORIES.


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  THAT, BRIEFLY, IS A "SNAPSHOT," SO TO SPEAK, OF THE 5 P.H.S.

AGENCIES.

  THE FINAL MAJOR ORGANIZATIONAL UIjIT WITHIN P.H.S. IS THE OFFICE OF
THE ASSISTANT SECRETARY FOR HEALTH, WITHIN THIS OFFICE ARE SUCH
ACTIVITIES AS DISEASE PREVENTION AND HEALTH PROMOTION, ANTI-SMOKING,
SUPPORT FOR HmM.O,'s, ADOLESCENT PREGNANCY PROGRAMS, PHYSICAL FITNESS
AND SPORTS MEDICINE, AI"jD STAFF ACTIVITIES SUCH AS PERSONNEL, PLANNING
AND EVALUATION, MANAGEMENT AND BUDGET, PERSONNEL, AND SO ON,

  THE O,A,SmH, BUDGET THIS YEAR IS $185 BILLION, BUT OVER 80
PERCENT OF THAT IS EARMARKED FOR THE FUNDING OF FOUR BLOCK GRANTS,
AND THAT LEADS ME TO SOME COMMENTS ABOUT THE CHANGES THAT HAVE TAKEN
PLACE AND PROBABLY WILL CONTINUE TO PLACE IN THE PUBLIC HEALTH SERVICE,

  THE GROWTH OF THE P.H.S. DURING THE PAST 20 YEARS HAS BEEN THE
RESULT MAINLY OF NEW AND EXPANDING CATEGORICAL GRANT PROGRAMS, AT THE
TIME PRESIDENT REAGAN WAS INAUGURATED, IN JArjUARY 1981, THE EXECUTIVE
BRANCH WAS FUNDING AND OPERATING 534 CATEGORICAL GRANT-IN-AID PROGRAMS,
ONE-SEVENTH OF THOSE -- 74, TO BE EXACT -- WERE IN P,H,S,


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  THE ADMINISTRATION SAID THAT IT \JAS TIME FOR THE FEDERAL GOVERNMENT

TO GET OUT OF THE BUSINESS OF DELIVERING HEALTH SERVICES, EITHER

DIRECTLY OR BY PROXY THROUGH GRANTEES AND CONTRACTORS, IT HAD BECOME

TOO COSTLY, TOO UNWIELDY, AND NOT AS EFFECTIVE AS ADVERTISED. HANDING

OVER THOSE FEDERAL PROGRAMS TO STATE AND TERRITORIAL HEALTH AUTHORITIES

SEEMED TO BE PREFERABLE,  BUNDLING THEM INTO BLOCKS, WITH AS FEW

STRINGS AS POSSIBLE, WAS TO BE THE METHOD.

  PRESIDENT REAGAN PROPOSED -- AND CONGRESS APPROVED -- THE NOTION

OF GROUPIHG MANY SIMILAR CATEGORICAL GRANT-IN-AID PROGRAMS INTO A

SERIES OF BLOCK GRANTS TO THE STATES: ONE FOR PREVENTIVE SERVICES,

ANOTHER FOR THE A,D,AaMmH,Aa PROJECTS, AND A THIRD FOR MATERNAL AND

CHILD HEALTH,  CONGRESS AUTHORIZED AND FUNDED THESE THREE AS OF AUGUST

1981,

  A FOURTH "PRIMARY CARE" BLOCK GRANT IS PRINCIPALLY CONCERNED WITH

COMMUNITY HEALTH CENTERS.  AS THE LAW Now READS, THE P,H,~, STILL

DIRECTLY FUfdDS MOST OF THE 530 OR SO COMMUNITY HEALTH CENTERS AROUND

THE COUNTRY, BUT EACH STATE HAS THE OPTION TO TAKE OVER THE CENTERS IN

WITHIN ITS OWll BORDERS,  SO FAR, ALL BUT \JEST VIRGINIA AND THE VIRGIN

ISLANDS HAVE DECLIfjED THE OFFER.


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  HOWEVER, THE PRESIDENT STILL HOPES THAT CONGRESS WILL NOT LEAVE

THIS AS A STATE OPTION BUT WILL REVISE THE LAW TO GIVE CONTROL OF

THESE IMPORTANT PROJECTS TO THE STATES AND LOCALITIES CJHERE THE PEOPLE

ARE ACTUALLY SERVED.

  THE RESULT OF THE BLOCK GRANT APPROACH IS A NEW DIVISION OF LABOR

WITHIN P.H,Sm  ONE TASK IS SIMPLY TO ADMINISTER THE FISCAL ARRANGEMENTS

FOR THE BLOCKS.  THAT CAN BE DONE WITH A RELATIVELY SMALL STAFF AT THE

ASSISTANT SECRETARY'S LEVEL'   THE OTHER TASK IS TO PROVIDE THE STATES

1JITH ANY TECHtiICAL ASSISTANCE THEY MIGHT NEED OR IN OTHER WAYS BE HELP-

FUL TO STATE PROGRAM PEOPLE AT THEIR REQUEST, THIS ALSO REQUIRES FEWER

FEDERAL PERSONNEL IN SMALLER P .ti,S. AGEUCIES.

  THE PRESIDENT HOPES THAT THE BLOCK GRANT APPROACH, IN ADDITION TO

BREATHING NEW LIFE INTO AMERICAN FEDERALISM, WILL ALSO TEND TO REDUCE

THE GROWTH RATE OF FEDERAL HEALTH FUNDING, WHICH HAS GROWN 14-FOLD IN

THE PAST 15 YEARS,  HEALTH HAS BEEN THE FASTEST GROWING LINE ITEM IN

THE FEDERAL BUDGET.  WHEN THE PRESIDENT LOOKS FOR "TARGETS OF

OPPORTUNITY" FOR COOLING DOWN THE FEDERAL BUDGET, WHAT BETTER PLACE

COULD HE CHOOSE TO START THAN THE NATIOTJ'S HEALTH BUDGET?


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  BUT EVEN THAT IS AN OVERSIMPLIFICATIONS SOME HEALTH AGENCIES MAY
GET REDUCED FUNDING, BUT SOME HEALTH FUNCTIONS WILL REQUIRE -- AND

WILL RECEIVE -- MORE MONEY.  THIS IS CLEARLY THE CASE IN RESEARCH,

  ONLY THE FEDERAL GOVERNMENT CAN ASSEMBLE THE EXTRAORDINARY
RESOURCES OF PERSONNEL, MONEY, FACILITIES, AND TIME TO,,,

UNLOCK THE GENETIC CODE,,,

IDENTIFY THE FUNDAMETJTAL MECHAr4ISMS OF HUMAN IMMUNOLOGY,, ,

DEVELOP MONOCLOI'1AL HYBRIDOMA TECHNOLOGY.. .

AND, OF COURSE, KEEP UP THE BATTLE To CONQUER THE MAJOR KILLERS IN
SOCIETY: HEART DISEASE, CANCER, AND STROKE,

  THE N,I,H. RESEARCH BUDGET FOR FISCAL 1983 IS $3,7 BILLION OR $337
MILLION HIGHER THAN LAST YEAR'S BUDGET, THE SAME IS TRUE FOR

A,D.A,M.H.A.  WHILE THAT AGENCY HAS ACTUALLY HAD A DROP IN ITS OVERALL
TOTAL, A.D.A.M.H.A. HAS 14EVERTHELESS HAD A NET INCREASE OF $27.3
MILLIGN THIS YEAR TO SUPPORT BEHAVIORAL RESEARCH' SO, 114 BOTH
ABSOLUTE AND IN RELATIVE TERMS, THE RESEARCH ACTIVITY WILL CONTINUE TO
BECOME CENTRAL TO THE LIFE OF THE P,H'S, IN THE FUTURE,


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  IN WHAT OTHER WAYS WILL THE P,HmS, CHANGE? I THINK WE WILL BE

RETURNING TO WHAT HAD ONCE BEEN OUR TRADITIONAL ROLE OF PARTNER,, ,OF

EQUAL AMONG EQUALS.. . WITH COLLEAGUES IN HEALTH AND MEDICAL CARE AT

OTHER LEVELS OF GOVERNMENT AND IN PRIVATE NON-PROFIT AND FOR-PROFIT

ORGANIZATIONS.

  WITH A REDUCED FEDERAL PRESENCE, WE BELIEVE THAT MORE INITIATIVES

FOR IMPROVED HEALTH AND MEDICAL CARE WILL ORIGINATE ELSEWHERE, OUTSIDE

WASINGTON,  THE OPPORTUNITIES WILL CERTAINLY STILL BE THERE, THE

FEDERAL CONTRIBUTION WILL TEND TO BE MORE SUBSTANTIVE -- AGAIt4,

REFLECTING ITS RESEARCH STRENGTHS -- OR FACILITATIVE AS, FOR EXAMPLE,

THE NEGOTIATOR AMONG COMPETING HEALTH INTERESTS, AND PURPOSIVE, IN THE
WAY IT PERFORMS AS STEWARD OF THE NATIONAL HEALTH AGENDA.

  THERE HAS ALSO BEEN ANOTHER CHANGE. THE GREAT FEDERAL HEALTH
STRUCTURE CJAS BUILT TO DELIVER HEALTH SERVICES, IT WAS PREDICATED ON
THE TRADITIONAL PRACTICE OF blEDICINE AND THAT WAS ESSENTIALLY CURATIVE

AND REPARATIVE MEDICINE.  IT WAS ALSO LARGELY POST-FACTO MEDICINE:

THAT IS, WE TREATED PEOPLE AFTER A DISEASE ARRIVED OR A DISABLING

EVENT OCCURRED,


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  BUT ONE OF THE THINGS WE'VE LEARNED FROM RESEARCH AND EXPERIENCE

IS THAT THE MOST EFFECTIVE TOOL WE HAVE TO IMPROVE HEALTH STATUS IS

PREVEliTIOli, COMBINED WITH HEALTH PROMOTION. THERE WOULD NEVER HAVE

BEEN ENOUGH MONEY IN THE WORLD TO CARE FOR ALL THE CHILDREN AND ADULTS

STRUCK DOWN BY POLIO, DIPHTHERIA, MEASLES, AND TYPHUS, THEREFORE, WE

HAD TO COME UP WITH NEW VACCINES AND A PROGRAM OF MASS IMMUNIZATION,

SIMILALRLY, THERE'S [JOT ENOUGH MONEY IN THE lJORLD TO TAKE CARE OF ALL

CURRENT AND FUTURE HEART DISEASE, CANCER, AND STROKE VICTIMS, THERE-

FORE, THERE WE MUST CONVINCE PEOPLE TO QUIT SMOKING.

  THE LOGIC OF THIS IS SO OVERWHELMING THAT THE PREVENTION OF DISEASE

AND DISABILITY AND THE PROMOTION OF GOOD HEALTH AND WELL-BEING ARE NOW

THE KEYSTONES OF NATIONAL HEALTH POLICY.

  ONE OF THE MOST EXCITING DEVELOPMENTS IN THE YEARS AHEAD, THERE-

FGRE, WILL BE THE MATURING OF THIS CONCEPT AS THE FOUNDATION OF

AMERICAN PUBLIC HEALTH POLICY AND PRACTICE. ENRICHING THIS PROCESS

WILL BE AN IMPORTANT FUNCTION OF THE FEDERAL HEALTH ENTERPRISE,

WHETHER BY ITS RESEARCH OR ITS PUBLIC EDUCATION PROGRAMS,


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  I HOPE THIS BRIEF OVERVIEW HAS HELPED you GET soriE PERSPECTIVE or{
WHERE THE U.S. PUBLIC HEALTH SERVICE IS AND WHERE IT SEEMS TO BE
HEADIFIG,  WE'VE COPIE A VERY LONG WAY OVER THE PAST 185 YEARS. WE
BELIEVE WE'LL ErlJOY A JOURNEY EVERY BIT AS EXCITING DURING THE NEXT
185,

THANK YOU,

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