Public Health Service Evolves to Meet Nation's Needs

[February 1, 2006, AJHP News]

Donna Young

BETHESDA, MD, 14 January 2006—Exploring through boxes and files of historical documents at the U.S. National Archives and Records Administration's Washington National Records Center in Suitland, Maryland, is a passion for Captain Robert E. Pittman, principal pharmacy consultant for the Indian Health Service (IHS).

"It's like a treasure hunt," he gleefully said.

Over the past six years, Pittman has spent many hours of his free time at the National Archives identifying and photocopying hundreds of records in compiling a history of pharmacists serving in the U.S. Public Health Service (PHS) Commissioned Corps—the federal government's nonmilitary, uniformed force of health care professionals.

"I periodically would take a day off and go down there and hunt and see what I could find and bring back several hundred xeroxed pages and try to sort through it," said Pittman, a 21-year PHS veteran who's "always had an interest" in history.

PHS, known originally as the Marine Hospital Service, was established under the Department of the Treasury in 1798 to provide health care services to merchant seamen in U.S. seaport communities.

An old hospital in Ferry Point, Virginia, served as the first Marine Hospital in 1801, Pittman said, adding that the program constructed its first new facility in 1804 at Boston Harbor in Charlestown, Massachusetts.

In 1871, he said, physician–pharmacist John M. Woodworth was appointed the lead medical officer over the Marine Hospital Service and was named the nation's first Supervising Surgeon—known today as the Surgeon General.

In the program's early days, Pittman noted, the hiring of personnel for the hospital system was based more on "who you knew" rather than a person's skills or training.

"People were hiring their friends and family . . . and the merchant seamen were complaining that they weren't getting the quality of care they wanted," he said.

So Woodworth, recognizing the importance of having professionally trained health care practitioners at the Marine Hospitals, quickly set out to structure the program along the lines of a military system, Pittman said.

Congress formally authorized the Commissioned Corps in 1889, he said. However, the program initially commissioned only physicians as officers.

While pharmacists were the only other professionally trained practitioners employed by the program in 1889, Pittman noted, it took another 41 years before federal lawmakers mandated under the Parker Act of 1930 that pharmacists be granted commissions.

"Unfortunately for pharmacy, they had enough civilian pharmacists that they could bring in that they didn't choose to use the commission for pharmacists until the 1930 order," he said.

On July 23, 1930, Edgar B. Scott, who joined PHS in 1896, and Edwin M. Holt, who joined in 1900, became the first two pharmacists to be commissioned as officers in the corps. Holt was also the first PHS Commissioned Corps pharmacist to be detailed to the Office of Indian Affairs in the U.S. Department of the Interior.

Another eight pharmacists were commissioned in September 1930.

A wider scope. To help meet the nation's growing public health demands, the government expanded the role of the Marine Hospital Service and changed the program's name—first to the Public Health and Marine Hospital Service in 1902, and finally to the U.S. Public Health Service in 1912—to reflect the service's broadened functions.

During the immigration boom at the beginning of the 20th century, one of PHS's major roles was providing medical examinations to immigrants entering the United States, Pittman said.

Pharmacists were stationed at the immigration inspection center at New York's Ellis Island and insular quarantine stations in Hawaii, Puerto Rico, and the Philippines, he noted. They also served at the U.S. Leprosy Investigation Station at Kalawao on the Hawaiian island of Molokai.

The vital role that PHS practitioners played in the nation's health became even more evident when an influenza pandemic spread worldwide in 1918, Pittman declared.

That year, he said, Congress created a reserve component for PHS, similar to the U.S. military's National Guard, which gave the program the ability to recruit health care practitioners for short-term needs.

Today, Pittman said, PHS uses its reserve component as mostly a recruitment tool for practitioners who are undecided about staying in the program throughout their professional career.

As part of PHS's broadening role in the early 1900s, the government began detailing pharmacists and other practitioners to various federal agencies, including the National Hygienic Laboratory in Washington, D.C.—the predecessor of the National Institutes of Health (NIH).

Milton W. Skolaut, a former president of the American Society of Health-System Pharmacists (ASHP), was the first commissioned PHS pharmacist assigned to NIH, Pittman noted, adding that Skolaut became the agency's first director of pharmacy services at the NIH Clinical Center in 1952.

Another former ASHP president, George F. Archambault, in 1947 became the first commissioned pharmacist appointed as pharmacy branch chief of PHS's Division of Hospitals. He was later appointed pharmacy liaison to the Surgeon General—now called the chief pharmacist officer.

Today, PHS pharmacists work in several federal agencies, including IHS—where Pittman is detailed—the U.S. Coast Guard, the Federal Bureau of Prisons, the U.S. Immigration and Customs Enforcement, the Centers for Disease Control and Prevention (CDC), and FDA.

Downtime. By the 1980s, most of PHS's hospitals had been taken over by the Veterans Administration or shuttered, and the Reagan administration began a movement to downsize the Commissioned Corps, Pittman said.

Many officers who were set to retire in a few years were forced to take early retirement, he said, while younger officers who had been with PHS for only a few years were laid off from their jobs.

The number of pharmacist officers dropped from over 580 in 1981 to just over 450 in 1983, Pittman said.

There was even some debate about disbanding PHS altogether, he lamented.

A revitalization. But in 1987, Surgeon General C. Everett Koop, recognizing the nation's need for a strong public health service, initiated a campaign to revitalize the Commissioned Corps, Pittman said.

Koop called for PHS officers to always wear their uniforms while on duty—a practice that had gone by the wayside during the 1970s—to "reemphasize that we were a uniformed service" and to present a more formal appearance to the public, Pittman said.

The revitalization effort also helped underline PHS's mission to provide health care services to underserved populations, he said.

The Commissioned Corps focused again on providing training and a career path for practitioners, Pittman noted, adding that Koop led the charge to recruit more women, minorities, and other underrepresented groups.

By the mid-1990s, PHS had over 750 commissioned pharmacists in the corps. Today, Pittman said, of the more than 6000 Commissioned Corps officers, nearly 1000 are pharmacists.

PHS also has about 350 civil service pharmacists, he added.

Serving in times of war and disaster. Although PHS is a nonmilitary service, Pittman said, the Commissioned Corps has twice been declared part of the U.S. military under a presidential wartime order in the nation's history.

The first time, he said, was in 1917 during World War I. The second time was during World War II, Pittman said, adding that the second order was not lifted until 1952 during the Korean War.

Most recently, officers have been deployed overseas to help provide medical services to military personnel in Iraq and Afghanistan. PHS officers also provided medical support to the military during the Vietnam War.

Commissioned Corps officers do not take for granted the fact that they could be militarized if a need arises, Pittman affirmed.

"We hope that those events don't occur, but we have that capability," he said.

PHS officers also assist other U.S. agencies in providing medical and humanitarian services to residents of war-torn or disaster-stricken countries, Pittman noted.

But it has been the recent disasters at home that have kept the Commissioned Corps busier than it has been in modern history, he proclaimed.

PHS deployed about 2600 officers, including about 400 pharmacists, to the Gulf Coast to assist victims of hurricanes Katrina, Rita, and Wilma in 2005, Pittman said, adding that Commissioned Corps officers have continued into 2006 to provide care to residents of Louisiana.

PHS pharmacist officers deployed to the Gulf Coast provided clinical services, vaccinated patients, helped to augment staff in hospitals in areas affected by the storms, interacted with state and local officials, and played leadership roles, according to Rear Admiral John T. Babb, a pharmacist and director of the Surgeon General's Office of Force Readiness and Deployment.

Babb has also recently served as the acting chief pharmacist officer for PHS following the retirement in July 2005 of Rear Admiral Richard S. Walling, who served as chief pharmacist from July 2001 through June 2005. Walling served in that job simultaneously with his position as the director of the Americas and Middle East regions for the Department of Health and Human Services (HHS) Office of Global Health Affairs.

Future challenges. PHS garnered many valuable lessons from the 2005 hurricanes, Pittman said. Most notably, while the Commissioned Corps is well suited to quickly respond to a large-scale disaster, a sustained effort is difficult for a force whose members have regular day-to-day jobs working at federal agencies, like FDA and CDC, which cannot afford to have their workers gone for long periods of time.

Most Commissioned Corps deployments are for two weeks, he noted. Yet the need for public health workers in the Gulf Coast may continue throughout this year—causing a possible strain on federal agencies if PHS officers are asked to deploy several times, he said.

A potential influenza pandemic in the next few years, Pittman worried, could stretch the Commissioned Corps beyond its abilities.

"We can send folks to [aid victims of] hurricanes and those kinds of things for short periods of time," he said, "but we don't have the surge capacity . . . to sustain a one- or two-year deployment of a large number of folks" that might be required to respond to an influenza pandemic.

HHS has been discussing how to address the Commissioned Corps' lack of surge capacity with various members of Congress to find a solution, Pittman said.

The hurricanes and preparation for an influenza pandemic have also emphasized the need for PHS to have practitioners trained in current clinical skills, he said.

"You can't just say 'I've worked in the office at FDA for 25 years and now I'm going to go out and provide patient care.' It doesn't work," Pittman said.

The Commissioned Corps is considering how it can provide an adequate amount of clinical experience to PHS officers who do not work in a clinical environment to keep those practitioners' skills up-to-date, he said.

While the Commissioned Corps has undergone many changes throughout its history, Pittman said, the next few years will be a time of "transformation to meet the needs of the 21st century."

"It's an ever-evolving and ever-changing kind of system that responds to public needs," he said.