MI!c,tou~' CfUpI.:r II US Public J k~lth Inti"J<tTUI.

t\lf<· Looklllg B,ck

Chapter II

u.s. Public Health

Infrastructure
Looking Back

Public health has been an important concern in the

)olm Adams, lilr
sl'Colld prl!sidt'll/ 4
II,e Ulliled Slalrs.
United Sta tes dating back to the framers of the Constitu-
tion, who envisioned protection and promotion of public
health among the federal government's responsibilities. On
July 16, 1798, President John Adams signed a bill into law
that provided for the care and relief of sick and injured
merCh:llH seamen in American ports. The earliest marine
hospitals we re located :llong the East Coast, with 130ston :lS
the site of the first such f.1.ci lity. They were established later
along ulland waterways, the Great Lakes, and the Gulf and
Pacific Coasts. In 1870, reorganization converted the loose
network o f locally controlled hospitals into a centrally
controlled Marine Hospit:ll Service with its headqu:lrters
in Washington. D.C. The position of supervising surgeon
(late r known as the Surgeon Gt'ne ral) was created to
administer the service. and President Ulysses S. Grant
appointed John Maynard Woodworth :lS the first
supervising surgeon in 1871.

The scope of the Marine Hospital Service's responsibilities

expanded beyond the care of merchant se:lmen in the dosing
decades of the 19th century. beginning with the control of
infectious disease through better sanitation. As a result of its
Firs! SIIpcrt' isill,f{ S/Irgcdll broadelllllg responsibilities, the service's n:ll1le was changed
)0/111 Maynard in 1902 to the Publtc H ealth and M:J.rine Hospital Se rvice .
~M.lodUior/11. [n [9[2, the M:J.rine Hospital Service became known offi-
cially :lS the Public He:J.lth ServIce.

As Elizabeth Fce and Theodore Drown describe in their

article The U,UII!{illed Promise oj Public Heallli: Deja Ilrl All
Oller Agaill, public health in the United States surged as a
necessity-driven response to immedi:lte local Ihreats. The
:ltlthors explain th:lt these "thrc:lts" were closely tied in
the popular imagination to epidcmic disease, and as a con-
scquence, public hcaldl \Vas u nderstood to be the set of
measures undertaken to protect the local popu!:l tion from
,
~, 21 4 ~ ~l.' 't;:~. ('I~'('>r II us Publl, H~,ll{h Illfr"'tTUc{ur~ Lookm;: 1I" k

epidemic disease. J3ased on this definition of public health,

it could be expected that the first local and state health
departments would arise during a yellow fever ou tbreak
that terrified the new na tion between 1793 and 1806. JIl

Yellou) fever epidemic ill Philadelphia, 1793. Carriages mmbled throlli?lt

the streets 10 pic/': lip tile dyill,\! lind the dead,

fact, the first Goard of H ealth was established in Phila-

delphia lt1 1794, followed by 13altimore in [797, BostOn III
1799, Washington , D. c., in 1802, New Orleans in 1804 ,
and New York City in 1805.

... Once the yellow fever outbreak came under control,

public and budgetary support for these newly formed local
,
Once the yellow
boards of health also dimlll ished. Inte rest in public health
fever ou tbreak
remained quiescent until 1830, when N ew York City
came under con~
citizens formed a Civilia n group known as the "sanitary
reformers" in response to a c holera outbreak. T he reform~ trol, public and
budgetary sup port
ers pressured public officials to take their public health
for these newly
responsibilities seriously and improve the city's living
formed local
conditions.
boards of health
Fee and Brown further explalll that from 1857 to 1860 the also diminished.
sanitary reformers held "Sanitary Conventions ." Duritlg the
Civil War, the group persuaded President Abraham Lincoln
to create a Sanitary Commiss ion to investigate conditions
among the Union Forces and take measures to improve
sanitation and health interventions. One of the measures
taken by civilian and military authorities in tesponse to the
Sanitary Commission's pressure was improved sanitation
 :llllong the troops. Another critical measure - educating
officers ,1l1d enlisted men - taught the closely confined
troops about the spread of infectio us diseases and the need
for personal and pllblic hygiene. After the war ended,
Sanitary Commission measures continued ill New York,

, Chicago and Massachusetts, creating a record of success

(or the first effective boards of health. ~ I3y the 18705,
most ll1;ljor cities had instituted some (orm of public
By the 1870s, health organiz;ltion.
most major cities
h:ld Illstituted Adv:lllClllg III 11lSto ry to the New Deal years in the 1930s
some form of and, ag;liIl. visi ting the Public H ealth Service, as it became
public health known in 1912. Congress heeded President Fr:ll1klin
orgalllzauoll. R.oosevelt and, in response to the Great Depression, created
th ... wclf:lrc sra re. Thl" Public H ealth Service benefited from
support in Congress ;lI1d expanded greatly during the New
Deal years. With the Soci:J.1 Security Act of 1935, Congress
established soci:ll in5ur:J.tlce :J.nd c:lsh :J.ssist:lnce programs
that Improved the public's he:llth by e]]Suring income

PrI·siril'lll nouscvclt s(\!.lIi/lX lir(· Sl(i,,/ Srmrily Art.

security for groups at greater risk of poverty :lnd disease.

Much bter, in 1965, Congress enacted t he McdiC:J.re :J.nd
Medicaid prog rams. expanding soc ial insurance. Medicare
and Medicaid broadened significantly the role tbat the
federal government plays in addressing he:J.lth care issues
for the needy.
216 .\1,k'I<>"'" ('h.'ptcr II Us Puhllc He,lth Jnt,."tru,tun· L{l"k",1': JlJ,k

The consolidation of the modern federal public health

establishment came in the mid-20th century. In 1930, the
Ransdell Act established the National Institutes of Health,
which have evolved into the current well-funded engine
for biomedical research and t raining throughout the United
States. In 1946, the Centers for Disease Control (known as
t he CDC) was formed from the Office of Malaria Control
in Wa r Areas and became part of the Public H ealth Service,
significantly expanding the federa l governmem's public
health responsibilities.

In 1953, the federal public health and social welfare func-

tions were consolidated into aile cabinet-level de pa rtment,
the Department of Health, Edu cation and Welfare. T his
new department housed virtually all of the federal agencies
with public health responsibilities that had evolved since
th e Civil War, in cluding the M edicare and Medicaid pro-
grams. [n 1979, when a new Department of Education
was formed, the newly named Department of H ealth and
Human ServIces (D H H S) became the home of federal
health and so ci al services prog rams.

Today the nation's public heal th systcm is a complex net-

work of people, systems and organizations working at th e
local, state and national levels. ~ The U.S. public health
syste m is distinct from other parts of the health care system
,
in two key respects: its primary emphasis is preventing dis- The U.S. public
ease and disabili ty, and it focuses a ll population rather than heal th system is
individual health. distinct from
other parts of the
Uoth th e public and private sectors play important roles in health care system
public health. The nation is served by more than 3,000 in two key
county and city health departments, 3,000 local boards of respects: its pri~
health, 59 state and territorial health departments, and mary emphasis is
marc thall 160.000 public and private laboratories. A se ri es preventing disease
of fede ral health and envIronm ental agencies set national and disability, and
standards and provide funding, training, sc ientific guidance it foc uses on pop~
and technical support. ulation rather
t han individual
Hospitals, clinics, managed care organizations, civ ic and
health.
voluntee r groups, and national associations suppOrt the
work of local, state and federal public health agencies. The
associations include the National Association of County
and Ci ty Health Offic ials (NACCHO), the Association
of Sta te and Territorial Health Offic ials (ASTHO), the
Association of Public H ealth Laboratories (A PH L), the
 National Association of Local l30ards of Health (NAL I3 0 1-l),
the Council of State :ll1d Tcr r itori:tl Epide miologists (CST E)
and the American Public H ealth Association (APHA).

Although these components :lTe numerous, the public

health infrastructure is but one piece of a larger public
ht'alth system. T he syStem depends on three interrelated
components: the capacity and COlnpetcncy of the work~
force, information and data systems, and organization;!]
cap:lcity. Deficiencies in one area can have a r ipple effect
throughollt the entire public health system.

Wor kforce Capaci ty an d Competency

Workforce capacity and competency refers to the expt'rtise

, of professionals who work in federal, state and local public

health agencies to protect the public's health. ~ The
govcrnmcntal portion of the pubhc health workforce
T he gove rn mental incltldes 448,754 profess ionals deployed at the local, st:J.te
portion of the and n:J.tionallevels. At the local level, public he:J.llh workers
public health are found in local health :J.genc ies and in pr ivate and non-
workforce profit o rganiz:J.tiolis concerned with the public's hC:J.lth.
includes 448,754
professionals The most com mOil professiollal disciplines withill the
deployed at the U.S. public health workforce are nurses. phys icians.
local, state and environmental specialists, laboratorians, health educators,
national levels. disease investigato rs, outreach workers and manage rs.
Public health also includes dentists, soc ial workers, 1ll1tri-
tionists, anthropologists, psycholog ists, econom ists, political
scientists, engineers, information technology specialists,
public heal th infol'maticians, epidemiolog ists, biostatisticiallS
and lawye rs. Any professional whose primary fUllctioll is to
improve health can be considered part of the public health
workforce. However, it is wo rke rs in official public health
agencies who are on the front lines in t racking disease
trends, implementing comlllunitywide health pro motion
and disease-prevention programs, and responding to
emerg ing threats and outbreaks.

T he fedetal government has traditionally supponed a var i-

ety of programs to enhance public health workforce capac-
ity. For example, grant programs at the H ealth Resources
and Services Administration (HRSA) are devoted to public
hcalth professional developmcnt and tt aini ng. Over the
last decade, CDC has also provided valuable ttaining
opportun ities for state and loc:J.l public health le:J.ders and
'., 218 ' Mlle'toll~' Ch"pt~r 11 US Public Health lnfra>trtl(tllf<· · L""km.l: Uark .• ' '. . , • '>-., •
• • , ... _. • ' , • J • :J,

professionals. In addition, state and local health departments

are actively developing ways to strengthen their public
hea lth workforce. For example, New Jersey established
credentials and competency-based training requirements
for public hea lth workers . In Pennsylvania, the Allegheny
County Health Deparnne m joined the University of
Pittsburgh Cemer for Publi c H ea lth Practi ce to create a
partnershIp for faculty and workforce developmcnt. Pri va te
foundations also help build workforce c:1pacity by provid-
ing grants to schools of public he:11th. funding ed ucation
and training opportunities :It the st:lte and loctl level, sup-
porting research and sponso ring national co nfercilctes.

Desp ite efforts to grow th e workforce cap:1ci ty of the

nation, there is a gap betwecn the increasing demands
placed on th e dedicated public health workforce and the
growing complexity of dise:lse patter ns, interventions, p:lrt-
nerships, technology, tools and training necessary to meet
the demands. There are 448,254 public health workers
in th e United States, according to U.S. Department of
L:lbor statistics from 2004, compared with 490,000 lawyte rs,
532,740 bank tellers, :llld 2,026,000 fast food workers. [n
setting a public health goal to improve the public health
workforce ~ by the year 20[0, the federal gove rnment
calls for each C01l1111t111ity to be served by :I "fully trained,
,
culturally competent publ ic healrh rcam, rep rese nting the ... by the year
optima! mix of professional disciplines." 2010, the federal
government calls
Surve illance and Information Systems for each commu-
nity to be served
The delivery of effective public health services depends on by a " fully
timely and rdiabl e infor1l1atio11 :lnd data, Perhaps perceived trained , cultur:llly
as not as exciting:ls other publi c health discip lin es, survetl- competent public
lance :lnd information systems are nonetheless the heart of health team, rep-
public health planning and interventions. Th ese tools help resenting the
to monitor disease and enable efficient comlllUlliC:lt ioll optimal ll11X of
among public :lnd printe health organiz:ltions, the media professional disci-
and th e publi c. They also Illake it possible for health profes- plines."
sionals to diagnose the he:llth of populations, distribute
reso urces to the right locations, and alert the publi c abOllt
public health issues and threats.

The ongoing sysrc1l1:1tic co llection, analysis and inter-

pre tation of health-related data is c:llled "surveill:lTlce."
Surveillance systems provide data on illness, disability :lnd
death from acute and chronic cond itions; on injuries; on
 219

person:ll environment and Occup:lt i on~t1 risk f:lc tors; on

preve ntive :l11d tTC:ltlllent services; :llld on program costs.
Data from these systcms can assist prevention efforts by
functioning as early-warning signals for new and emerging
conditions. Data systems also t:1c ili tate pl:l11ning, as public
health agencies use data on disease prevalence to develop
prevention programs.
, ~ Although federal agenc ies take the lead in collecting
national public health data, they represc nt only a fraction of
Although federal the many necessary partners that collect, analyze and trans-
agencies take the late these d:ua. Programs III each area collect inform:nion
lead in collecti ng from local communities. Other d:lta-collection systems
national public depend lIpon the participation of private citizens nation-
health data, they wide. Still other systcms rely on the administrative records
represent only a and Surveys of public and private health care organizations.
fraction of the
many necessary Despite advances in technology. many loca l health depart-
partn ers that co l- ments still lack access to basic information-system capabil i-
lect, analyze and ties. Access is critied becausc st:ltC and local public he3lth
translate these department stam need the Internet 3nd other elt-ctronic
data. illfof11l3 tioll systems to pe rform their job fun ctions effec-
tively. Similarly, it is essential that staff be tra ined ro use
these systems . 111 1999, to address this issue. the CDC part-
nered with local and state health agencies, as well as nation-
al public he:llth organizations, to develop the Health Alert
N etwork (HAN),:l natio nwide, integrated information 3nd
comm uni cati on system cap:lble of distributing he:llth :lIens,
prevention guide hn es and other information. In 2000, the
CDC laullched 3nother program, the Nltioll:J1 Electronic
Di sease Surveillance System , to provide n:ltionaJ st:lndards,
specifications,3nd workin g prototypes so that infor1l13tion
collected by loc31 health departments can be used to detect
:tlld m3nage outbreaks th at affect more than one 3rea.

Orga nizational Capacity

Org:lnizational ca pacity is the structure and mechanisms 0 11
which a functioning public health system relies - its facili-
ties, laborarories and fin:lncing mechanisms. In order to
perform activities 3nd provide services that safeguard the
health of 3 community, public health departments and lab-
oratories must have modern t:1Cilities, adequ3te financing,
sli ccessful partnerships with institutions in both th e pllblic
and private sec[Q r, properly tr:tined persollnel and up- ro-
date information systems.
220 M,Ie'tOn<" Ch'pl<r II us I'lIbh~ fleahh fllfrmfllcllIrc Looking B.\ck

In 1998 and 2000, studies performed by the University

of North Carolina and the CDC's National Public
Health Performance Standards Program measured health
department performance. ... Both studies revealed that
the state public health systems have half or less of the
,
organizational capacity t hey need to optimally perform ... state public
esse ntial public health services. The ave rage performance health systems
score fo r local public health departments was slightly high- have half or less
er than for state public health systems. [n part, the cumula- of the o rganiza-
tive result of budget cutS, lack of staff t raining and outmod- tional capac ity
ed information systems and laboratories, these scores also they need to opti-
renect the growing demands on the public health system. mally perform
The public health infrastructure has had trouble keeping essential public
pace with the demands for performance. health services.

On twO occasions, in 1988 and 2002, the Institute of

Medicine (10M) addressed public health infrastructure in
twO 10M reports. [n the 1988 report, titled The Frllure oj
Public Healtll, 10M presented proposals for ensuring that
public health se rvice programs would be effective and
efficient enough to deal not only with curren t challenges
but future cnses as wcll. The report identified the core
func tions of public health: assessmen t, policy development
and assurance of essential health se rvices. It also recom-
mended the ma nncr in whic h the performance of these
core functions be divided among federal, state and local
leve ls. The subseque nt 2002 10M report, titled The FH/rrrc
(1ftllc Pllblic~ Health ill tire 21st Celltury, reviewed the nation's
public health capabilities and recommended a comprehen-
sive framework for involving publ ic health age ncies with
multiple partners in both the public and private sectors to
create a more integrated public health system. Among the
2002 10M report's recomme ndations for this integrated
public health synem were the following:

• Adopt a population health approac h that cons iders

mul tiple determinants of health.

• Strengthen government's public health functions, the

backbone of the public heal th system.

• Develop new partners across sectors, reqmrmg

accountability in the process.

• Make decisions based on evidence.

'. • '. 221

• Enhance cOllltllunication within this expanded public

health system. D

Essentia,1 Public H eal th Functions*

1. Monitor health sta tus to identify community health

problems.

2. Diagnose and investigate health problem s and

health hazards in the community.

3. Inform, cd uca te and empowe r peopl e about hea lth

Issues.

4. Mobilize community partnerships to identify and

solve health problems.

5. Develop poli cies and plans that support individual

and commUf1lty health efforts.

6, Enforce laws and regulations that protect health and

cnsu re safety.

7 . Link people to needed personal health services and

assure the provision of health ca re \Vhen it is o ther-
w ise unavailable.

8 . A,sure a compctcilt public health and personal

health care \Vorkforce.

9. Evaluate the effectiveness, accessibi lity. and quality

of personal and population-based health services.

10, Research new insights and innovative solutions to

health problems.

' I'rom <he I'"bhe H~,hh I'"n "noll! l'roJec< (1994_1999). d"ec<ed by " S<ecron!:
Co"'n"tt~c eI,,,,,,,, by the A$$""'" SccrC<1ry of He,hh .nd Smgcon Gener;1l wnh
th. p.rtiripJnon of CDC ond 0 hO$1 of pllhlic hClhh '1Io<:i,"ions. fo""d~non$ .""
<>'1:>1"""0"'.
Case Study
The Creation of CDC
The Communicable Disease Center (CDC) opened in
the old Office of Mabria Control in War Areas in Atlanta,
Georg ia, on Ju ly I, 1946. As a part of the U.S. Public
Hea lth Service, the original C D C mission was to work
with state and local health offic ials in the fi ght :tgainst
malaria, then sti li prevalent in several Somhern states,
as well as typhus and other comlllunicable diseases. Its
fOllndcr,Josepb W. Mountin, MD, a visio nary public

Dr.JM(!plr Mouutiu, thirdfrolll Ip. men;".!! with CDC s/affrr.<.

health leader, had high hopes for this small and compara-
tively insi gnificant branch of the Publi c Health Service.
Dr. M OlitHin received his medical degree from Marquette
University in Milwaukee, Wisconsin, in 1914. H e bcg:lIl h is
ca reer with the Public Health Service durmg World War I
working in sanitation in the temporary living quarters
specially built by the U.S. Army for soldiers in military
arC:lS throughout the United States. In his distinguished
C:lrecr with the Publi c H e:lh h Service, Motlntin became
widely known as the f:1ther of many servIce progr:lms.
In bte Novembe r 1951, he was appointed to the post of
bureau c hi ef with the r:lnk of Assistant Surgeon General.
MOllntin died ullcxpectedly the following YC:lr at the
Naval M edic:l1 Cclltcr in Octhesda .
During the first years of CDC, medical epidemiologists
were scarce. It was nor umil 1949 that Dr. Al exander
Langmuir, now known as rhe f:1 th er of infectious disease
epidemiology, arrived to head th e epidemiology branch. He
launched the first-(:ver disease survei llan ce program and
co nfirm ed hi s sllspicions tbat malaria co ntrol. the largest
part of rhe C D C budget, had lon g since become unn eces-
sary. Subsequently, disease sur vei ll:l.1l ce becal1lt" the corn er-
stone o f C D C "s mission of service and. in time, ch:mged
the practice of public health . Langmuir was C D C's chief
epidemiologist from 1949 to 1970 . He spellt the rest of
hi s life teachin g at Harvard Medi ca l School and at Johns
H opkins, where he had earned his degree in public ht"alth .
In 1993. he died of kidney cancer at the age of83.

Wo rld events also had an impact on C D C 's miss ion. III

1950, the start of the Korean War gave illlpetus to creat ing
the Epidemi c Intelligen ce Service (E1S). With th e threa t of
biological warf:1re looming, Langmuir wanted to train epi -
demiologists to detect new emergin g agents and at the
sa m e time gua rd against cO lllmon threa ts to public health.
In 1955, CDC broadened its focu s to includ e poliomyelitis
(po li o) and established the Polio Surveillance Unit.

Two major health crises in th e mid- 1950s ccmented

CDC's crcdibility and long-term su rvival. In 1955, after
poli o :lppea red in ch ildren who had received the Salk

Arr El5 ojjiCl'r usiu,(! rir(' muscle eva/ualiou leSlj.rr polio.

vacci ne, o nly rece ntly approved , CD C stopped the

national inoculation prog r:llll. The cases were traced to
contam inated vaccine from a laboratory in California;
once the probl em was corrected, the inoculation program
resum ed. at least for first- and seco nd-graders. Two years
later, surveillance traced the co urse of a massive influ enza
epidemic. From data gathered in 1957 and subsequl:!lt years,
national guidelines for influen za vaccine were developed.

In the 1950s and 19605, C DC grew by acquisition. The

vc nereal disease program came to Atlanta in 1957 and
with it, the first Publi c Health Advisors. The tuberculosis
and immunization programs we re moved under C D C's
"umbrella" in 1960; and in 1961 , CDC took over publica-
tion of th e Morbidit), alld Mortalit), Weekly R ep(lrl (MM WR).
The MMWR, whi ch lists important data on deaths and
certain diseases from every state every week, is still pub -
lished evcry wcek and is considered an essential publi c
health too!' The Foreign Qu:nantine Service, one of the
oldest and mOst prenigious units of PHS. beca me part of
CDC in 1967. followed by the long-established nutrition
program and the National I nsriwte for Oc cupational Safety
and Hea lth.

On e of C D C's grea test accomplishments, the worldwide

eradi cation of smallpox, was launched in 1966. The
Smallpox Eradication Program aimed to eradicate smallpox
and co ntrol measles in 20 African countries and support
the worldwide efforts of the World Health Organization's
smallpox crusade. The disease had killed millions of people
over the centuries. 13y the late J 970s, just over a decade
later, CDC efforts helped eradicate smallpox from th e
world. CDC also achieved notable success at hOlTle track -
ing new emerging infections such as Legionnaire's disease,
toxic-s hoc k syndrome and hantavirus. More import:lntly,
[he MM WR published the first report of a new :lnd f;ml
di sease, acquired irlll11utlodefic iency syndrome (AIDS), in Dr. Slali FOSler, EIS
the June 5, 1981, issue. DUfmg the 1990s and early 20005, officer, ai/millis/aiIlS
CDC broadened its focLls to address chroni c disease slIIallpo.\" vlIccinr /0
prevention and obesity. ,/ N igeriall II'PI/Jall
ill '1967.
As C D C's activities expan ded in scope far beyond
communicable diseases to include chronic disease control
and health promotion, its name had to be changed to
reflect a broader mission. In 1970, th e name beca me the
C enter for Disease Control. In 1981, after extellSive reor-
gani zatio n, "Center" became "Ce nters." In 1992, th e words
"a nd Prevention" were added, but by law, CDC retained
its well- kno wn three-letter abbrev iation. a
 ??"
--=>
MII~s'onc,· Ch"p,n 11· U.::.. l'"hh( I kohh ll1f"b'''K' ''r~· VI!(ncl!~

Vignette
Surgeon General's Report of 1964
More than 40 years ago on January 11, 1964, Luther L. Terry, M D,
Surgeon Gem: ral of the U.S. Publi c Health Service, released the
report of the Surgeon General's Advisory Commi ttee on Smoking
and Health. This landmark document, now referred to as th e first
5urgeol/ GCI/I'ra/'s Rcport Oil 51110kill}; alit! I-lea/rll, had a tremendous
impact on pllblic attitudes and policy for three important reasons.
First , an official U.S. agency recognized for the first time that cigarette
smokin g caused cancer and other seriOllS diseases. Second , it prompt-
ed a series of public health actions reflecting changes in societal
att itudes toward the health hazards of tobacco usc. Third, the Surgeon
General's report was the fir st to rece ive widespread media and public
attention. Although evidence that smoking caused harm had acculllu -
lated since the 19305, official so urces did not recognize the ill effects
at rhe time. E pidemiolog ists used statistics and large-scale, long-term
case control surveys [Q link the increase in hmg cancer mortality to
smoking. Pathologists and laboratory scientists confir med the statisti-
cal relationship of smoking to lung cancer as well as to other serious
diseases, such as bronc hitis, emphysema and coronary heart di sease. In
1957, then- Surgeon General Leroy E.13urney declared as the official
position of the U.S. Publi c Health Service dut smoki ng caused
lu ng cancer.

The impulse for an official report 011 smoking and health did not
come until 1961, however, pushed by an alliance of pro min ent private
health organizations. Th e American Cancer Society, the American
Heart Association , rh e National Tuberculosis ASSOC iation, and the
Amer ican Public Health Association called for a national comm ission
on smoking In a letter addressed to President John F. Kennedy. Th e
letter sought a commission dedicated to "seeking a solution to this
health problem that would interfere least with the freedom of indlls-
try o r rhe happiness of individuals."

The Kennedy administration responded the following year. In 1962,

recently appointed Surgeon General Luther L. Terry announced that
he would convene a co mmittee of experts to conduct a comprehen-
sive review of the scientific lite rature on the smoking question. Terry
invited representatives of the fOllT voluntary medical organizations
who had first proposed the commission, as well as the Food and
Drug Administration , th e Federal Trade Commission, the American
Medical Association , and the Tobacco Institute (the lobbying arm
of the tobacco industry) to nominate ten commission members.
226 M!I~jlOll~I' Cl"'I"~r 11· U.S, Publoc l'k~lth J"r"!lr"cu,,~' Vlgue·nc·

From November 1962 through January 1964, the committee

reviewed more th:m 7,000 scientific articles with the help of more
than 150 consul tants. T he advisory committee concl uded that ciga-
rerre smoking caused both lung cancer and chronic bronchitis. The
commi ttee recognized for the first time, officially, t hat "cigarette
smoking is a health hazard of sufficient importan ce in the United
States to warrant approp riate remedial action."

Th e 1964 Surgeon General's repon became the first of a series

of steps to reduce the impact of tobacco lise on the health of the
Am eri can people. The circumstances surrollnding the release of
the first report 111 ! 964 were peculiar. Surgeon General Terry Issued
the commiss ion 's report on a Saturday, a strategy meant to minimize
the effect on the stock market and maximize coverage in the Sunday
papers. "This sttategy succeeded,"Terry remcmbered two decades
later, "because the report hit the coumry like a bombshell. It was
front-page news and a lead s[Qry on eve ry radio :l.Ild television
station in the United States and many abroad."

Among the steps that followed the report were banning tobacco
advertising on broadcast media, placing mandatory health warnings
all cigarette packages and developing effective treatments for tobacco
dependence. The Office of the Surgeon General has issued 27 subse-
quent reports on tobacco lise, cove rin g su ch topics as environmental
(i.e., secondh and) tobacco smoke. These reports helped lead the way
to smo ke-free public places, restaurants and bars .

The widespread media and public attention led to significa nt changes

in public attitudes toward smoking. A Gallup survey conducted in
1958 found that only 44 percent of Americans believed smoking
caused cancer; that figure grew to 78 percent by 1968. l3 etween 1965
and 2002, adult smoking rates have been cut from 42.4 perce nt to
22.5 percent, nearly in half, and per-capita consumption of tobacco
produccs has fallen from 4,345 cigarettes in 1963 to 1,979 ciga rettes
in 2002, marc than half.

Th e 1964 Surgeon General's report was significant because it marked

the first of a series of authoritative scientific statements by the
Surgeon General that helped shape the debate on th e responsibility of
government, physicians and individual citizens for the nation's health.
Indeed, Surgeon General's reports since 1964 have addressed a br03d
range of he3lth issues. Th ese include secondhand smoke, maternal and
child health, nutrition and physical exercise, mental health, an d issues
th:\( he outside medicine. stich as suicide and gun viole nce, that are
studied for how they affect public health. 0
 .".,~. . - ."~"~-~' -r •• , ~ • -." . ,- ,. •• .,. •
M,I~,wllc, ('h31'l<'r II U S I'ubh~ H~3lfh l"frJ'truCfurc Look",!: Ahead 227
.
.- . .'. '-. ' . .

Looking Ahead
Public Health - A 21st Century
Perspective
The: 21 st century prt'st'llts a new set of challenges to the
nation's health. Whether confronting bioterrorism attacks,
emerging infccrions, lifestyle bch:tvlOrs, disparities in he:thh
status, or increases in chrOllic disease and injury ratcs, th e

, public hc:tlth COrllllltHlity now more than ever needs ;l.

strengthened infrastrucrure. .. Pu blic 1l{':J.lth needs to
gain capacity:J.s it prepares to respond to :J.cmc and chronic
Public health thn.·:J.ts to the nation's health, not all now known. Only :J.
needs to gain plrblic hcalth systcm supported by politic:J.1 will, plrblic :J.nd
capacity as it private partnerships, and other financial resources can meet
prepares to ongoing and new health challenges.
respond to acute
and chronic As Dr. W illi:J.m Keck of the Depannlent of COmlllUllity
threats to the Health Sc iences at the Northeastern Ohio Uniwrsities
nation's health .... College of Medicine points alit. .. A contimrally expanding
public health ;'Igenda in an era of shrinking governmental
resources diminishes the :lb ility of many local health depart-
ments to meet b:J.sic community health needs, let alone lift
their cornrmrnities to the highest levels of he:Jlth possible.
The successful public heald1 department' ofche futme wil!
develop multiple funding sources. :JdvOC;'lte effectively for
resources to meet cornrmrn ity needs, and build Strollg coll:1b-
or:ltive linbges with other community health agencies and
the illness ca rc system. It will otherwisc be impossible to
cnsure that each citizen h:J.s access to a seamless web of serv-
ices th:lt promote health, prevent illness and injury, diagnosl'
disease early :J.nd provide disease treatment th:lt is efficient
:J.nd eOective."

Biotcrrorisl11

Dr. IVillimll K('(/.: 13ioterrorism is deflned as the unlawful release of biologic

oj Norlllt'IISlt'W O/rio
Unir'ersilies CIIIII:!;t'
t!f .\It'{ficiut'.
agents or toxins to kill or sicke n people, animals or pl:1nts
with the intent to intimidate o r coe rce a governm ellt or
civi li:J.n popul:1tion. A bioterroriSIll :J.ttack would represem a
rl1:ljor public he:J.lth thn,':Jt in the United St:J.tes. C DC, the
government agency in charge of responding to public Ill'alth
eme rgencies for decades. lllust now prepare for bioter-ror-ism
:J.ttacks.
CDC and public health authorities became aware of the
threat of domestic bioterrorism after several small acts of
focused bacteriologic criminal assault in the United States.
These acts included th e intentional comamin:nioll of salad
bars with Sfdmo"ellil organ isms in 1984 in Oregon and of
muffins and pastr ies with Shigella organisms in Texas in 1996.
As a result, the United States government decided to revisit
and update a national plan for bioterrorism preparedness and
response. In 1999, as part of this strategy, C DC collaborated
with th e Association of Public Health Laboratories and the
Federal 13ureau of Investigation to establish the Laboratory
Response Network. This network deve lop ~ local, state and
federal publ ic he:tlth laboratory capacity to respond to
bioterrorisl11 events.

AII/hm.\' was spread Ihrm/.r:/1 IIII' pos/1I1 sys/rlll i/l Ihe fall (12 00 I.

Only in the f:111 of 200 I were CDC's bioterrorism plans

put imo action, in response to an anthrax atta ck in the U.S.
At a time of hei ghtened tension due to the events of Sep-
tember II, letters co ntaining anthrax powder spread thi s
infectious disease deliberately through the postal system;
22 people were infected and five people died.

Lifesty le an d Be h avior C h an ge
While this ce ntury's medica l advances and publi c health
efforts have dramatically reduced the threat of infectiollS
disease in the U.S., poor hC:llth due to lifestyle behaviors
remains a threat co public health. Poor lifestyle behaviors
arc linked to chronic diseases, the heaviest burden on the
 '. . ' 229
. . . .,. .

health care systelll today. These behaviors involve tobacco

tlse. alcohol and drllg abuse, lack ofheahhy diet :ll1d exercise,
and risky sexual practices. [n p:micular, poor Ilutrition and a
sedentary lifestyle arc considered by some experts to be "the
21st century plague" as they lead to obesity and diabetes,
now considered national epidemics. They also contribute to
a host of other serious medical problems, such as heart dis-
ease and cancer - the two leading causes of death in the U.S.

Public health professionals know that promoting healthy

behaviors is one of the best ways to prevent disease and
disability. Conseq uently, many public health activities are
designed to help individuals and communities acbieve and
maintain a healthy lifestyle at ally age. For example, CDC
launched a campaign called VERB (to connote action) in
2002 to fight childhood obesity, encouraging young people
ages nine to 13 to be physically active every day. The calll-
paign combines paid advertising, marketing strategies and
partnership efforts to reach the distinct audiences of tweens
and adul t~linf111t::ncers. As CDC Director Dr. Julie L.
Gerberding said. "The VE RU camp:lign Ius sllrp:lssed
expectations and is responsible for improving physic;!1
activity levels alllong youth." In February 2004, C DC
released the results or a tdephone smvcy that indicate that
physical activity aillong the nation's youth is increasing as
a result of the VEIU3 campaign.

CDC /)ire(/ur C hroni c-Di sease Prevention and Con t ro l

Julie L. Grrbadillg Chronic diseases. such as heart disease, stroke, diabetes and
cancer, cause 70 percent of a[[ deaths in the Uni ted States
each year. A la rgt:: number or these deaths are preventabl e.
People with chronic conditions are the largest, most costl y
and f..1stest-growing grou p in health care, and their numbt::rs
are expected to swell in the 21 St century.

From specific laboratory measures to morc complex studi es

of behaviors and risk ractors, CDC's efforts arc design cd to
understand the causes and consequences of chronic disc:lses
and to place the powerful cools of prevention within reach
of more people every day. Moreover, CDC works to ensure
th at :ldvances in basic scientific and be h:lVioral research are
put into practice to benefil all Americans. As p:lrt or its mis-
sion, C DC works with states to develop comp rehensive, sus-
tainable prcvcmion programs that target the leading causes of
death and disability in our soc iety and the ir risk factors. [n
addition, numerous efforts to manage chronic disease, along
with social marketing campaigns, changes in food (such as
removal of trans f..1tS) and a new food pyramid have gained
an increasing role ill ch roni c-disease prevention. New
approaches to prevention afe cruc ial to fight chronic diseases
in th is century.

Infecti o u s Diseases and E m e rg in g Threats

D espite incredible gains in combating infectious diseases,
they remain a public hea lth concern in the 21sr century.
In fectious diseases are the third leading cause of death in
the United States and still predominate worldwide, with
acute lower respiratory tract infections, 1-1 IV / AIDS, diarrheal
chseases, tuberculosis and malaria as the major threats.

Although the combination of improved hygiene and sanita-

tion, v:lccinations and antibiotics has helped turn the tide
:lgainst infectious dise:lses in this country, new diseases :lnd
the resurgence of old ones make infectious diseases a con-
stant concern. Emerging lIlfections are those that h:lYC
not been previously recognized. .. The AIDS p:lnde mic ,
is an eX:lmple of:l truly new and emerging infectiollS d isease
The AIDS pan-
whose public health impact had not been previously exper i-
demic is all exam-
enced . On the other hand, infections that have been ple of a truly new
experienced previously reappear in a more virulent form and emerging
01" in a new epidemiological setting. The influenza type A
infectious disease
pandemics of 1918,1957 and 1968 are examples of this. whose public
Global air travel, now widely available and affordable, health impact had
introduces infected travelers to the U.S. with diseases that not been previ-
ol1ce might have stayed overseas. For example, severe acute ously experienced.
respiratory syndrome (SA R S) was first reponed in AS!:l in
February 2003. Over th e next few months, due to global air
travel, the illness sp read to more than two dozen countries in
Nonh America, South America, Europe :lnd Asia. According
to the World H ealth Organization (WHO), a total of 8,098
people worldwide became SIck with SARS during the 2003
outbreak. Of t hese, 774 died. In the United States, only eight
people had laboratOry evidence of SA RS infection and all of
them had been traveling in other coumries where SAlt.S had
been identified. Fortunately, C D C worked closely with the
W H O and other partners in a global effort to address the

•
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•
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... " < '"
, )
•
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 Paramedics duri'I.~ Ihe SA RS oil/break ill 7(mmlo.

SARS outbreak of2003, preventing SARS frolll spread in g

more widely in the United States.

, ~ CDC continues its work of increasing the c:lpaci ry of

laboratories and surveillance systems hert' and abroad to
CDC continues its detect :Hld mOnitor ch:ll1ges in disease patterns and to serve
work of increasi ng as an early-warning system . For example, stlrveill:1l1ce centers
the capacity of in both the U.S. and Asia monitor the ever-present threat
laboratories and of inf1t1cnza pandemics. CDC also continues to work with
survei !l,m ce sys- public and private panners to c h:lll ge the way a ntibiotics are
tems here and prescribed and used in hospitals and other settings. CDC
abroad to detect helps form working teams that link epidellliolob'Y, partner-
and monitor ships, edu cation of health care providers and patie nts, and
changes in disease vector control to counter the spread of specific infectious
patterns and to disea$l' threats. These threats range from sexuall y rransJllirred
serve as :tn C3rly- diseases, like syphilis and chlamydia, to bloodborne threats,
warning system. like hepatitis C. The teams help control existing infectious
disease threat.~ and prepare the nation for new o nes.

Meeting the challenges of infectious d iseases in the 21 st

century means that the scientific and technological advances
that forllJ the foundation of a public health respollSc must
evolVl' quickly an d continu:tlly. As former C D C director Dr.
Jeffrey Kaplan observed in the 2002 [O M R.eport, "We are
o nly as prepared as the least prepared among us." []

•
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232 M,le.!o"" Ch.'plef 11 US Puhhc H".dth lufn'!ructu ....'

Pho to " , ediU

I'~se 213:John Adams. court<~y l,bn, y dCong .....~s, I'rum ~nd I'hot~raphs
I1,VI<lOIiIlC-USZ62-3'J'}2I.
1'3g,· 213:Joh" M~}'"ord Woodworth. (I I'ictu'e 1-lls[o,y.
PJS" 21-1: Yellow fl',""r, Q U,'ttmalln/CORlllS.
Page 215: FDR "g"IIIg Social S,'cu",y Act. CO""",), the Soc,,1 Secll'''Y
Ad""""r •.• r,o, •. w,vw,',a'b'<lv.
Pag" 222: CDC fo"m(.-r Dr. Joseph Mnu"tln and CDC sratTi'r!, <'o"rle,y of the
CDC Pub]'c ~Ic-~lth Image l.brary.
I',S<' 223: Dr. Ak"""k. l,ng"""', courtc.y Thc Al,n Ma",,, Chc",,'y /IIkd",1
Al"<"h,v,,' of,h" John, Hopkin. M"dic.lln<til\uiou<.
Pos<' 223: Au E(S offin·r. enunc's}, of ,il,' CDC I'ublie I-kalth Image ltbr:try.
1'.lgc 22-1: Dr. Sun l'o'lcr, COllrtl"Y or thl' C DC I'ubllc Health II11.ge LIbrary.
I"s" 228: Anthrax .1,"1, (I M,ke Sloek.'/COIUI IS SYGMA.
Pas" 229: Dr.Juh" l. (;crbrrdmg. cnn,I<"Y <)f ,he CDC I'"b)ie Health ImaS"
l,hrlrY·
Pasc 231: I'oramed,c<, 0 Rc\l[c .... /CORIlIS.