clifford d. brown, o.d., mph, faao capt/usphs...

Optometric Care with the Public Health Community © 2010 Old Post Publishing 1455 Hardscrabble Rd. Cadyville, NY 12918

The Silent War by Clifford D. Brown

THE SILENT WAR: HISTORY AND IMPACT OF THE UNITED STATES PUBLIC HEALTH SERVICE

Clifford D. Brown, O.D., MPH, FAAO CAPT/USPHS Chapter Overview Silent wars, as internal spies and underground revolutionaries, attack a country from across and within its borders. More Native American Indians died of Small Pox introduced unknowingly by European colonists than by their overt acts of conquest with guns and horses. To combat such invasions or rebellions, a country needs a public health army. In the United States it is the Public Health Service (PHS). What follows is brief history of the founding of this army and reports of several battles, some successful, some not, against the microbes, toxins, and other opportunists looking to infect our society. Objectives On completion of this chapter, the reader should be able to:

1. List the founding dates of the specific agencies tasked with over sight, and the early facilities constructed for the Marine Hospital Service.

2. Discuss the evolution of the relational challenges between health care programs/providers of the Marine Hospital Service, the PHS, military health services, and U.S. Immigration or Homeland Security.

3. Compare and contrast the Surgeon General’s position as a Public Health Officer from within the Service versus an appointed position under the pleasure of the President.

4. Detail who influenced the military style structure of the PHS and how this has helped or detracted from its mission.

5. Give an example of PHS workings in a local or national crisis. Invasions of a nation by those powers which would destroy and/or usurp control are generally acknowledged to constitute a threat to the sovereign integrity of the nation. While most of the world’s population at least fundamentally comprehends armed aggression as a source of just such an attack, far fewer would understand the more silent threats posed by bacteria, viruses, drug addiction, radioactive fallout, contamination of food and water supplies, systemic disease, obesity and mental health-related disabilities, and debilitation of primary sense organs. Competent national leaders have actively accepted as fact the potential capacity for effective compromise and even destruction of the national infrastructure implicit within these insidious killers. Today the individual nations and collective national regions of the world increasingly rely upon international trade, support, and commerce to provide for their national populations. International travel and transport increase daily, as does the demand for goods and services by the world populace. The



acceleration of demand for this globalistic exchange of goods and services has shown no sign of abatement. It is only tempered to some degree by a modicum of restraint enacted when protectionism is used as leverage in trade disputes or when nations continue in general choose to control the transport of everything from people to commodities across their borders. So, more than ever the potential has increased for both national and international invasion and destruction of any nation by invisible, alien armies of microbes or toxins capable of effectively waging compromise-and-control warfare. An American Perspective Wisdom and an active awareness of national defense principles established in such leading European countries as Great Britain was demonstrated by John Adams and the Congress on July 16, 1798 when, together they began the march toward the establishment of the present day Public Health Service of the United States1. By signing an act which provided “for the relief of sick and disabled seamen” President Adams established the original Treasury Department administered Marine Hospital Fund2. Though part of its raison d’être was to keep potentially contagious foreigners out of the country through quarantine and deportation it was an important first step in public health in the U.S. And so began the fight against invasion by destructive alien entities and the formation of a public health-based department to fight covert, invisible entities much as George Washington’s militia had done militarily against a more visible enemy in the War of Independence a few years previous. For a struggling young country, the funding for such an operation posed a challenge. Each potential user of the service, namely the seamen, the Treasury Department’s Revenue Marine Division (later to become the National Guard), and the Navy funded the establishment of this chain of seaport hospitals by contributing twenty cents per month from their pay toward this neo-typical health maintenance organization. This collaboration was to last until the Navy began construction of their service-specific hospital system in 18173. Progression and Development of the Marine Hospital Service From its 1799 humble beginnings in a converted Army barracks on Castle Island in the Boston Harbor and a newly constructed hospital in Boston in 1804, a total of 27 Marine hospitals opened at sites along the Eastern seaboard and across to the Great Lakes, along the inland waterways, and in the major ports of the Gulf and the West coasts4. The devastating War Between the States left only eight units operational, prompting a study by the Secretary of the Treasury in 1869 that resulted in a reorganization of the service. The opportunity to be of service almost always fosters the careers of those who manipulate sincere public support into self-aggrandizement and enrichment. In the mid-1800's, during the time many would have us believe was more honest, noble and innocent in our nation, unbridled management of public funds by those who were not providing the care resulted predictably in unsatisfactory service



quality. Operating in a dearth of organization and control, care of the merchant seamen (many of whom were being treated for venereal diseases) failed to meet even the most minimal of standards. Hospitals were generally "managed" by customs collectors and politicians. As such, these institutions were staffed poorly and serviced by contractors who provided incomplete and low-quality medical care. With public funding in general at a minimum, those who would profit from the founding of a town quickly seized upon the realization that the location of a marine hospital almost guaranteed success5. This report found in Treasury Department documents (1855) was punctuated with references to an observed plethora of substandard surgeons, stewards, matrons, and nurses, all of whom were being fed by salaries from the public trough.

Without profit-driven incentives to produce quality service, organizational systems in place, and staffing by competent management personnel, the Marine hospital system failed to fulfill its mission. Dr. John Billings and Dr. W. D. Stewart were sent out to survey the situation by Treasury Secretary, George Boutwell6. Armed with the information gathered, Boutwell successfully proposed legislation in 1870 that created central command and control in a "Supervising Surgeon" (later the Surgeon General) for the Marine hospital service, and thereby establishing an element of knowledgeable national management and oversight of the abuse inflicted by so many politicians. Nonetheless, the struggle to remain autonomous, rather than to be fettered by the personal aspirations and individual philosophies of whatever politicians happened to be in power, continued to plague those who desired the most effective and quality-driven provision of health care to those who so desperately needed it.

As long as those with minimal training in health care continue to make crucial health-care-governing decisions, based upon their educational backgrounds of law and economics this struggle will predictably persist at high levels. Noteworthy for students of the future (and therefore, students of history), there remains no real escaping the agenda-driven machinations of politics and business upon all aspects of life, which directly effect day to day aspects of life in these United States ranging from health care to the sale of shoes, research to religious practice, “news” reporting to public educational curricula. This is not to say that that there have been no brief glimpses of freedom from this domination of politics and profit taking, but that those glimpses, when they occurred were most likely provided by the profound exposure of insightful research and the accompanying vision of exciting new breakthroughs into what had previously remained a mystery.

In just such a penetrating movement Robert Koch and Louis Pasteur7 led what might be titled the “bacterial revolution,” a leap of science that identified by discovery causal agents of many specific illnesses, carrier states, and vectors that had remained hidden from view and understanding until that time. Over a relatively short period, over 30 million Americans who had been living in poverty-driven squalor were, for the first time in history, brought within reach of at least a few of the benefits previously enjoyed only by the few, who, numbering about 150,000, controlled about 60% of the wealth8. Almost overnight, progressive



aspirations began to remold politics into the image -dream (of liberty and justice for more than just a few) held by America's constitutional fathers and the impoverished Europeans, Asian and African masses: The Establishment and Expansion of the Health Care Service Under 1870 reorganization legislation, John Maynard Woodworth was appointed in 1871 as the first Supervising General of the Marine Hospital Service (MHS), a department headquartered in Washington, DC. With the powers of central command and control over the service being directly vested in him, Dr. Maynard drew upon his experience as a military surgeon to create a functional organization, utilizing the tried and true operational structure and discipline of the military as a guide for his department’s medical staff. As is the intent of all well-designed military maneuvers, the initial action led directly to future accomplishment. The resulting entrance examinations, mandatory Service uniforms, and Service appointments (with assignments to postings) not only foundationally gifted the Service with need-dictated mobility and service orientation9, but also opened the door to the creation of the Commissioned Corps in 1889.

The role of the MHS was rightfully expanded in 1878 when yellow fever invaded the Mississippi River drainage and in so doing displayed the necessity for the adoption of a national approach to disease. Quarantines10 had to be initiated and enforced not only within the boundaries of a single state, but on a regional basis, and therefore by an agency with inter-state powers, such as that of the federal government. Owing to the pre-positioned MHS facilities located throughout the infected region, organization and coordination of quarantine measures were assigned to the MHS by the National Quarantine Act of 1878. This was not, however, the only area in which a federal approach was needed.

Some of the “poor (and) tired masses yearning to be free” often also carried old world disease and conditions, the costs of which our nation’s leaders knew we could ill afford to assume. Immigrants often oppressed and/or poor, desire freedom, but, then as now, those already living as citizens of the destination country also desire and deserve to be protected from “loathsome or dangerous contagious diseases” and those with other conditions likely to burden the state. In a fiscally responsible and public health-oriented move (based upon the Immigration Act of 1891) the MHS was delegated the responsibility to perform physical and mental

11inspections of immigrants arriving on American

shores. New York’s famous Ellis Island became one of many depots where thousands of immigrants were screened daily by MHS physicians for trachoma and other medical and mental maladies. HISTORICAL NOTE: Citing national interests and the need for a unified front, Congress organized its forces under leading doctors such as Rosenau, Kinyoun, and Welch, passing laws designating the Service as responsible for the medical inspection of all arriving immigrants and the Surgeon General as the final authority for quarantine reinforcement. And so, in 1902, mental



illness/retardation and trachoma (then a blinding disease), along with cholera, yellow fever, plague, smallpox and typhus became high-level targets for some of the 100 uniformed immigration investigators. The famous (infamous to some) Ellis Island "line" included stair-climbing (during which immigrants were screened based upon posture, gait, shortness of breath, and debility), a visual inspection of the appearance of the scalp, face, neck and hands, and finally an examination for signs of trachoma12. Other famous debarkation sites included San Francisco's Angel Island13 and the New Orleans Inspection Station. As knowledge of microbials grew in the latter 19th century, the MHS was in an excellent position to support much needed research in this area of study. In 1887, the Staten Island Hospital was chosen to be the site of a new bacteriological laboratory. Eventually this facility was to become the Hygienic Laboratory, renowned for its biochemical research and moved to Washington, D.C. in 1891. Today we know this research facility as the National Institutes of Health14. The Umbrella Opens Further Early in the 20th century (1902) the MHS became the Public Health and Marine Hospital Service (PHMHS). The Supervising General became the Surgeon General, vital statistics were published in the Public Health Reports, and the Biologics Control Act gave the PHMHS controlling authority over the nation’s vaccines, serums, and other biological products. Along with this expanded authority came expanded federal cooperation and consultation with state health authorities. In Washington State, rural public sanitation campaigns were initiated15. Across the southeastern states debilitating hookworm infestations were largely alleviated. In Louisiana, yellow fever was successfully controlled17, and in California, authorities eventually joined forces with federal public health officials in a campaign (unsuccessful) to eradicate plague. HISTORICAL NOTES: Charles Stiles successfully brought the light of scientific discovery to the hookworm infestation common to the southern States. Enduring snide comments from the press and the medical profession's public stand against an epidemic they had failed to diagnose, Dr. Stiles succeeded not only in reducing the incidence of this condition through widespread education and the establishment of more sanitary privies, but in the development of Departments of Health in the southeastern States16. Under the strong and visionary leadership of Surgeons General John Hamilton and Walter Wyman, investigative activities in the hygienic laboratory - later to become the National Institutes of Health- increasingly influenced America's healthy, but brought the Public Health Service into direct conflict with high-ranking politicians and their supporting constituencies. Dr. Joseph Kinyoun, the



first director of Staten Island's hygienic laboratory, was sent out by Surgeon General Wyman to San Francisco (and the officer in charge of San Francisco's quarantine duties was brought to Washington to replace him) to lead the battle against plague in San Francisco's Chinatown. California's Governor, Henry Gage, chose to side with his political base, the Asian leaders of Chinatown, claiming Kinyoun's diagnosis to be solely a statement of racial prejudice. Gage's vehement and vilifying attacks against Kinyoun -both personally and professionally- were extreme, but an independent commission verified Kinyoun's diagnosis and the State of California, after a full year of opposition, agreed to cooperate with Kinyoun's plan of quarantine and containment if Kinyoun agreed to leave the state. By that time, however, plague had not only spread, but had become endemic throughout the rodent population of the western United States18, adding yet another chapter in History's text of social sacrifice for political gain. These successes were used to support the need for the formation of county health departments within and throughout each state and expand the war against infectious disease. Deepening involvement and authoritative management by the PHMHS in the public health sector across the country resulted in yet another name change, this time dropping the “Marine Hospital” component and maintaining the Public Health Service (PHS) as the complete title. HISTORICAL NOTE: In 1912, the Public Health and Marine Hospital Service officially became the Public Health Service. Although only allopathic physicians were still at that time allowed to be commissioned, "the diseases of man and the conditions influencing the propagation and spread thereof…19" were designated as under PHS authority, assigning the Public Health Service open authority for the first time. Surgeon General Blue, the only Surgeon General to ever hold the office of AMA President20, proposed in 1916 "…an adequate health insurance system," an action which the advent of the First World War effectively brought to a halt. A Reign of Disease is Defined as the War Within With a new title (and a national recognition that waterways were not the only avenue for potential invasion by forces threatening the public health) came another expansion of the Public Health Service (PHS) mission. Legislation was adopted that defined21 the PHS as the organization whose obligation it was not only to “investigate the diseases of man…” but also the “conditions influencing the propagation and spread thereof, including sanitation and sewage and the pollution either directly or indirectly of the navigable streams and lakes of the United States.” This wording both declared war on disease and on conditions promoting disease and named the PHS as the homeland defender. When World War I involved the United States, the defender of the homeland was given a three-fold tasking:



1. Defend the regions surrounding prisoner of war camps from disease; 2. Secure the country against venereal disease; and 3. Enhance industrial hygiene, guarding against efforts by foreign powers to

pollute our water supplies. Care for the returning veterans was also assumed by the PHS until an independent Veterans Bureau was created in 1921 (see the chapter in Section 3, Public Health and the DVA by Dr. Meyers).

In many areas of life, awareness of need determines the actions taken. The life of the PHS was certainly no exception to the rule. In the interim between the first and second world wars, the PHS continued to grow as public officials began to better understand the war against disease and the public cry for protection mounted. It is no surprise then that during the 20th Century the public experienced an expanded awareness of the immensity and complexity inherent in disease processes. This led to a call for providers and support staff specialized in the preventive, curative, and palliative care needed to affect an increase in public health. The Corps professional cadre grew accordingly to include not only the medical (allopathic) physician but the complete spectrum of primary care physicians(medical, osteopathic, optometric, dental, podiatric, and PhD level clinical psychologists) and mid-level providers and licensed support staff professionals as well (pharmacists, registered nurses, nurse practitioners, physicians assistants, physical therapists, medical lab technicians, hospital administrators, engineers, dieticians, respiratory therapists, etc.). HISTORICAL NOTE: Under the duress of WWI, Congress finally opened commissioning to dentists, pharmacists and sanitary engineers as reserve officers, but in the year 1925, only 182 regular Corps Commissioned officers and 68 reserves out of 4,672 PHS staff had been commissioned. With the advent of WWII, the PHS Act of 1944 initiated the commissioning of physical therapists, dieticians, nurses, scientists and sanitarians (sanitarians being divided into health service officers and sanitarians). Veterinarians soon joined the ranks. Post-WWII, the Commissioned Corps had grown from a prewar total of 625 officers to 2,600, two-thirds of these being reserve officers and one half being non-allopathic physicians. Specialized care/research centers and agencies also were established, such as the facility located in Carville, LA which became the national site for research and treatment of leprosy

22,23.

HISTORICAL NOTE: Hansen's Disease, or leprosy, a disease whose destruction and social stigma dates from early Biblical times, was challenged in Hawaii and Louisiana by the PHS crusaders, and it was in Carville, Louisiana that Dr. Faget, using sulfone therapy, first exacted a revolutionary control. Today, the National Hansen's Disease Center houses residents until their conditions are controlled and they can be released on medication to their communities.



The need for officers to oversee and direct Indian health efforts finally received recognition, and in 1928 a PHS officer was appointed as the Director of Health for the Bureau of Indian Affairs of the Department of the Interior24. HISTORICAL NOTE : Though it would be 27 years before the PHS actually assumed full responsibility for health care provision to the American Indians and Alaskan Natives, the entry of the PHS into this world-within-a- world was the opening through which optometric physicians would finally gain inclusion into the national war effort against homeland disease. A short year later PHS officers were assigned by law to provide medical and psychiatric care to the Bureau of Prisons, followed by the opening of two PHS hospitals, one in Lexington, KY and another in Fort Worth, TX, to specifically treat substance abusers25,26. The Social Security Act of 1935 formalized the designation of the PHS as the agency in charge of constructing a national framework (that extended from Washington D. C. to the local level) of health departments. This same act coupled all levels of government by providing federal funding for states to train public health personnel and to perform research on all aspects of human health25.

The appointment of Thomas Parran in 193625 added fuel to the PHS’s already burning determination for public health enhancement to be realized at all levels. Dr. Parran brought the issue of venereal disease out of the closet and into the view of the public. His focus on the control of the spread of this disease and its effects on human life were nowhere more effectively elucidated than in his 1937 book “Shadow on the Land.” In this book Dr. Parran minimalized morality issues by placing them in perspective to the human tragedy that effectively removed so many from receiving the care that would stop the advance of the disease. Much to his credit, Dr. Parran saw the passage of the National Venereal Disease Control Act of 1938 which provided federal dollars to support treatment and research into the prevention of these diseases. In recognition of improved management gained by consolidation of similar agencies under a more unified structure, a general re-organization of government in 1939 included the shifting of the PHS to join with the Social Security Board and others under the Federal Security Agency. Under this new agency PHS officers were detailed to the military services when American involvement in World War II began. Since that time nine PHS officers have given their lives in service to the United States while serving in the United Nation’s refugee camps in Europe and the Middle East, the most recent casualty in the war on terror being a PHS Social Worker in Iraq.



HISTORICAL NOTE: Among the five first PHS martyrs in the war on disease was Dr. Thomas McClintic, who in 1911 was sent to Montana from the Hygienic Laboratory to investigate a deadly disease called "black measles", later to be called Rocky Mountain Spotted Fever. He contracted the disease just as he was finishing his investigation and treatment/control program, and died shortly after returning to see his wife in Washington D.C.28

Over 124,000 nurses25 were trained during the war under the assistance of the PHS-administered Nurse Training Act of 1943 in an attempt to answer the shortage of nurses experienced during the war. The Cadet Nurse Corps marked the beginning of direct PHS involvement of large scale education of health care professionals.

By 1943 the PHS had reached 16,000 employees, with program divisions including the Office of the Surgeon General, The National Institutes of Health, the Bureau of Medical Services, and the Bureaus of State Services. The 1944 Public Health Services Act strengthened the Office of the Surgeon General and provided grant monies in terms of grants for medical research. Simultaneously the success of the PHS in controlling malaria and other communicable diseases (i.e. typhus, typhoid fever, and dengue) during WWII resulted in the conversion of the program in 1946 to the permanent program known as the Communicable Disease Center (CDC)29. In 1970 it was renamed the Center for Disease Control, in 1981 the Centers for Disease Control, and in 1992 the Centers for Disease Control and Prevention, though the CDC acronym was retained.

The PHS was given the right to grant funds to states for surveying their hospitals and public health centers and planning construction of additional facilities under the Hill-Burton Act (or, Hospital Survey and Construction Act) of 1946. Three years later, in 1949 the PHS was directly involved in the establishment of the National Institute for Mental Health. This continual expansion of federal level health care program management was significantly boosted with the transfer to the PHS of responsibility for Indian Health in 1955. At this point the Division of Indian Health (presently known as the Indian Health Service) was established to administer these programs. A year later the National Library of Medicine was transferred from the military and also made a part of the PHS. A House Divides The 1960’s saw the important inclusion of the Food and Drug Administration into the PHS fold, but the public took even more notice of a Surgeon General with a striking silver beard named Dr. C. Evert Koop when he published his famous report “Smoking and Health.” This report clearly enunciated and defined for the American public the dangers of smoking30 and tied the risk of cancer to tobacco use. From this report came the eventual warning that is now standard on the cigarette package: “WARNING:…hazardous to your health.” For the first time many Americans realized that there was a U.S. Surgeon General and a Public



Health Service. The political fall-out, though, of this very bold and medically correct stance would soon be realized. In 1970, after 58 years of monitoring, educating, and researching for the American public in the area of water safety standards, environmental pollution, industrial waste, and sanitation, the responsibility for water and environment were split off from the PHS and a new agency was created called the Environmental Protection Agency. This led to a loss of positions and programs, along with influence in political decision-making. When politicians in the late 60’s found the PHS officials to be less than fully sensitive to their political agendas, a major reorganization of the PHS was effected, dramatically changing the leadership structure. No longer was the Surgeon General appointed from the Commissioned Corps as had been done since the origins of the Corps.

The 1968 reorganization assigned the direction of the Surgeon General to a political appointee, the Assistant Secretary for Health. Heads of PHS agencies were no longer PHS officers, but again, only appointees. The Surgeon General was removed from his direction of the PHS and functioned largely as an advisor and spokesperson on public matters. The fallout? Most recently an extremely popular and innovative Surgeon General was removed from office when he refused to accept as major priorities those espoused by the governing administration. Previously, other Surgeon Generals who advocated widely disputed policy positions were removed when public pressure for their removal was brought to bear. History of Eye Care in the PHS With a seven-year Ellis Island experience serving as his training school, Dr. John McMullen's trachoma survey findings resulted in specific direction being given by the 1913 Federal Appropriations Act to the PHS to treat trachoma. Traveling by mule, he established and manned personally a dozen temporary trachoma hospitals and clinics without the benefits of antibiotics31. Effective July 1, 1955, the Transfer Act of 1954 transferred control over the programs governing American Indian Health from the Bureau of Indian Affairs (BIA) to the Public Health Service (PHS, this new component, the Indian Health Service (IHS), bringing with it 2,500 staff, 48 hospitals, 13 school infirmaries…and the health care responsibility for over 497,000 American Indians and Alaskan Natives (AI/AN). The resulting significance to the Indian population can easily be attested to by the fact that within five years time the Indian infant mortality rate had decreased by 25 percent and the rate of death from tuberculosis by 50 percent. The O.D. Quiets the Western Front Two wars, one with guns and one without, influenced eye care specifically during the mid-60's. Vietnam grabbed national press attention and, inevitably, the attention of the public. The demand for division-level eye care skyrocketed in the



face of exploding mines, gas, booby-traps and shrapnel wounding from grenades and mortars. In response, two optometrists were imbedded with each Army division and assigned to provide emergency and restorative care to troops on the battlefield of rice paddies and jungles. In the civilian world of America the demand for optometry at the federal level was presented in a world that remained largely ignored by the press and society in general, namely, the reservation-confined Indian nations. Dr. Isao Hoshiwara, the Chief of Ophthalmology and Eye Care Services, had allocated funds from a trachoma grant to create an optometry position within the IHS. This action occurred 62 years after the Ellis Island stand against trachoma had begun and 41 years after Dr. McMullen finally retired from his itinerant treatment of trachoma in the hills of Kentucky. Though this advent of optometry did not even merit a mention in most of the articles written to document the course of PHS history, those of the public most highly at risk for this blinding disease often associated with childhood infection would see relief within one generation from the devastation of the associated blindness in large part due to the care provided by early PHS optometric physicians. HISTORICAL NOTE: During the 1920's, a Boston physician, Dr. Kennedy, traveled west to view the awe-inspiring grandeur that we know today as Glacier National Park. Stopping along Highway 2's roadside at the old Blackfeet Indian Agency, he noticed the tell-tale corneal opacitification of trachoma in the Peigan children. A few moments and several children later, Dr. Kennedy reportedly exclaimed, "I know what that disease is, and I can cure it!" Good to his word, Dr. Kennedy not only returned personally, but he brought several of his medical colleagues with him so that he could treat the tribal population of about 7,000 (down from an original 85,000 as a result of both the intentional introduction of smallpox, then tuberculosis and coupled with starvation offered as deserved fare by unscrupulous Indian agents). Many elders of the Piegan, Blood, and Picuni tribes (known to us simply as the Blackfeet Indians) have recounted their recollections from that time, for indelibly etched into their memories are the scenes of children being ushered out of their classes at the boarding school (first Jesuit, and then a Federal Academy with forced attendance) into a room where they were forcibly restrained while their lids and corneas were manually scraped. As might be expected, without anesthetic, the trauma and pain were remarkable. Children who were waiting could hear the screams, and many ran to hide, some running for 80 miles across the prairies to get home, only to have riders locate them in their teepees and return them under restraint to undergo the surgical procedure. Dr. Kennedy and his team were generally successful in bringing to this disease under control on the Blackfeet and the Pine Ridge reservations, but many reservations remained unassisted and there the disease ran rampant. Years later, with the advent of antibiotics, trachoma's ravages could be readily contained if the process was stopped early in its destructive stage. The corneal scarring resulting from a lack of treatment remains even through today in a significant portion of the surviving elder population on many reservations32.)



Soon after Dr. Hoshiwara brought Dr. Paul Owens, the first PHS optometrist, into the IHS in 1966, others were added, and, by 1968 when Dr. Lester Caplan was appointed as the first optometric consultant to the IHS director33, there were already five optometry positions designated, though two were vacant. Positions outside of the Southwest were opened in Alaska by the mid-1970's, and the expansion, both in the ranks of the PHS Commissioned Corps and in the Civil Service, continued over the next 20 years until in 1994 there were 93 commissioned officers in the PHS, including 86 in the IHS, three, in the FDA, two in the Bureau of Prisons, and one apiece in the Division of Commissioned Personnel and the Coast Guard31.

By the early 90's, through the combined efforts of PHS Optometry and Ophthalmology Services, trachoma had been essentially eliminated within the Indian population, much of the credit going to the inclusion of optometry within the PHS/IHS and the tireless efforts of first Dr. Carl Szuter, ophthalmologist, and then others. If results comprise the primary measure of success, the decision of Dr. Hoshiwara and the Director of the IHS, Dr. Emery Johnson, to include optometry paid off nicely. Optometry had proven itself a worthy contributor in America’s national war on disease, and the PHS had furnished the opportunity for the first national recognition of professional optometry in the civilian world.

Based upon this seized opportunity, optometry would go on to assume its rightful position as a profession nationally (under Medicare law) and direct involvement in the war against disease and disability. Running Before the Wind

During the 70's and 80's, political considerations and approaches changed, affecting many professional organizations. The National Institute of Occupational Safety and Health (NIOSH) and the Occupational Safety and Health Administration (OSHA), created by law in 1970, combined with the initiation of professional standards review organizations (PSROs). These seeming improvements for the PHS were balanced by the shift to fiscal restraint in the Omnibus Budget Reconciliation Act (OBRA) of 1981. For the first time in 180 years, the eight remaining National Health Service hospitals, commonly called the Bureau of Medical Services Hospitals (which, as you may recall, had been originally established to serve merchant seamen), closed their doors, as did the 27 associated clinics. Optometry positions in Seattle, New Orleans, Boston, and Staten Island closed with them. Without its primary service mission, the PHS was forced to shift philosophically. Many programs, such as the migrant health program, were left intact, but others, like the Health Resources Administration (HRA) were forced to consolidate. The "leaner and meaner" organization34, under Dr. Everett Rhodes, saw the IHS elevated to Agency status commensurate with the expansion of the Indian Nations tribal and self-governance programs. Within the PHS the rise of optometry’s status in the eyes of the rest of PHS professions also occurred. This and other professional successes lead to optometrists participating on FDA



advisory committees, NIH review committees, the CDC, and in other federal agencies. Optometry transitioned from a relatively unknown provider of eyeglasses relegated to “office” space in cloakrooms, boiler rooms, basements and hallways, to having nation-wide recognition and acceptance professionally as full members of hospital Active Medical Staffs. While the quality and quantity of technical support still varies widely, the general elevation of inter-professional trust and respect has enabled most PHS optometrists to practice at or close to their level of training, particularly as the rest of the medical staff have been confronted with more knowledge and appreciation of the training and capabilities of the optometrist. Founding Leadership in PHS Optometry Following Dr. Caplan’s pioneering contributions as the “Father of Optometry for the IHS” in his role as the original civilian consultant, Dr. Hamilton established the office of the IHS Chief of Optometry, and CAPTAIN Siu Wong, in addition to clinical practice, developed program structures and quality assurance mechanisms, providing insightful and nationally recognized leadership throughout all branches of Federal Service Optometry. These optometrists set the foundation for a major decision in 1994 by Dr. Trujillo, the National IHS Director for two decades, who named then IHS Optometry Consultant CAPTAIN Gary Pabolis, the IHS Optometry Consultant, to be the first Senior Consultant of PHS eye care. A year later, IHS Optometry and Ophthalmology agreed to create the IHS Eye Care Coordination Committee, consisting of two O.D.'s, two M.D.'s and a chairperson, the first being CAPTAIN Pabolis. A third O.D. committee position was then included; however, this representative of tribal eye care was not a voting member.

CAPTAIN Pabalis was also the first to chair the Association of Military Surgeons Optometry Section, followed by two years of service by Dr. Terry Bolen. Dr. Clifford Brown then led the Section for 18 years, during which time he became the first PHS optometrist to successfully test into Diplomate status in the American academy of Optometry and joined the ranks of PHS optometrists Pabolis, Wong, and Schleisman by receiving the coveted AMSUS Optometrist of the Year Award. CAPTAIN Pabolis initiated the Biennial IHS eye care meetings during this same time frame to directly address both the complex level of eye care and the cultural issues specific to the IHS-based practice and in support of the perpetually under-staffed clinical mission of the IHS he tasked CAPTAIN Brown to establish the deployment of National Guard health care providers to reservation hospitals, a congressionally sanctioned national program now widely used by all professions33. Dr. Pabalis also set up the first Memorandum of Agreement with an optometry school, opening the door to the IHS-based training of literally thousands of optometry student externs and residents. In today's Public Health Service, the opportunities available to the optometrist are limited only by one's interest and training. From working in the FDA with device testing to remote IHS sites accessible by small plane, snowmobile or mule, to research, management, or educational positions in



metropolitan areas, opportunities exist for those who are willing to think past the clinical walls. A few examples follow: A previous optometry consultant, CAPTAIN Wong spent years managing program development and quality assessment. She has traveled throughout the world to various military and federal service sites, reviewing programs and conducting peer review. Even after her retirement from the PHS, she continues to organize and assess quality and improvement measures, organize professional groups to meet the specific needs of female officers, and provide leadership and consulting for various national health organizations (such as the APHA). For her work she has received multiple awards, at the national and regional level, as well as local recognition from across the Federal and civilian spectrum. Several optometry officers have served in the Division of Commissioned Personnel and in the FDA. These officers manage officer assignments in headquarters positions. Optometrists have involved themselves in a combination of clinical and administration duties within hospital systems. Research (clinical) opportunities exist for most PHS optometrists

Purely clinical practice is common, but the clinical mix of patients is usually broader than that of general optometric practice. Most clinical practice is hospital based, so the optometrists provide primary eye care and many specialties while also working as a part of a multidisciplinary health care team. National and local disaster preparedness training is provided for multiple levels of service and in a variety of sections, some of which include operations, planning, logistics, demobilization, safety, team leadership, liaison, and information technology.

Available to many PHS optometrists are clinical deployments aboard Navy hospital ships as well as other overseas assignments. Some optometrists have served as team leaders for medical teams deployed on disaster relief missions and have been chosen to work in high level command positions, serving alongside the Department of Homeland Security (DHS) and Federal Emergency Management Association (FEMA) officials in large national disaster response organizations. The Bureau of Prisons’ Directorship of Optical Fabrication Laboratories is yet another position open to an optometrist. Civilian positions (filled by professionals not commissioned as PHS officers) exist both within the IHS and tribal programs. Instructor/manager positions of optometric internships and residency programs are among many other positions open to the O.D. officer. Memorandums of Agreement (MOA) exist between most of the schools and colleges of optometry and the area offices of the PHS enabling optometrists to mentor students that are interested in studying onsite. Advanced degree educational programs are frequently available to PHS officers, often in the form of advanced civilian education. Opportunities exist for direct involvement in the Armed Forces Optometric Society (AFOS), the American Academy of Optometry (AAO), the American Public Health Association (APHA), the American Optometric Association (AOA), state and/or local associations and societies, the Association of Military Surgeons of the United States (AMSUS), etc. For any



who aspire to Diplomate status within the American Academy of Optometry's Public Health and Environmental Vision Section as uniformed or civilian members of the PHS, assistance is currently provided throughout the entire two-year testing and research process. Marching into the Future Post-9/11, the Department of Homeland Security was established by the President to increase interagency coordination and cooperation. At that time, the longstanding desire by the USPHS Surgeons General was put into action under the dynamic leadership of a Vietnam veteran, VICE ADMIRAL Richard Carmona. Under his leadership, the transformation process into a "new Corps" was born, including, among other things, increased emergency training for disaster response on a national level. The daily wear of the USPHS uniform was instituted, changing forever the one-day-per-week uniform wear of most officers. Military-style physical testing began, along with a mandatory completion of all immunizations and vaccinations. Some officials from each site were put through anthrax immunization procedures, and all officers were required to register for one of four levels of deployment. Those who failed to pass these basic readiness requirements were flagged and denied promotion. An extensive list of courses was presented online as required study. After completing this entry level of coursework and testing, more advanced coursework was required for those who wanted to serve at higher levels of responsibility (command positions). Service in the Time of Need: Natural Disasters When Hurricane Katrina made landfall in 2005 on the Gulfport beaches of Mississippi, the forces of FEMA, PHS, and DHS combined to respond in the emergency relief effort. Within days and then over the next several months, optometrists were deployed at various sites as liaison officers, some at management levels and one as a team leader for the Mississippi Hospital Augmentation Team, the first team fielded to ground zero (Gulfport). The mission of this group was to provide teams of health care providers, the composition of each team being custom-selected by the team leadership to match the specific need presented by the State's request for assistance. While the challenges were numerous, transportation through demolished neighborhoods (guarded by homeowners sporting firearms to ward off would-be looters) and over roads which lacked both signage and traffic lights proved to be one of the most significant obstacles encountered. Indeed, the witnessing by the deployed PHS officers of an at-gunpoint, mid-day, carjacking of a motor home parked alongside the PHS bus at a gas station demonstrated the desperation of the time. Those left without transportation, clothing, housing, water, medical care, and food frequently ignore laws and rules of behavior that they otherwise observe routinely.



A short time later, Hurricane Rita struck, compounding the devastation by adding rain to sections of the New Orleans and the surrounding parishes already flooded the from Katrina’s storm surge . One optometrist was redeployed and numerous others were deployed for the first time in response to this new catastrophe. The experience gained in the re-establishment of Mississippi and the city of New Orleans was invaluable, and demonstrated the flexibility of many optometry officers (as managers, state liaisons, and medical team leaders) to perform outside of their usual scope of practice at a high level under austere and highly stressful conditions. CASE STUDY: A USPHS Officer’s Deployment During National Disaster Deployed as a Clinical Supervisor, I brought along my white lab coat, complete with monogrammed name label. From that point onward, the process continued with surprises served up daily. I had no orders or point of contact, just a plane ticket promised by the official government travel agent. Even the original E-ticket told me that I should be flying out of Norfolk, VA...in two minutes from the time I first received it. While this in itself might not seem highly irregular, I was at the time stationed and physically positioned in Montana. After phoning the agent, he quickly changed my ticket, allowing me to fly out of Billings, MT (sans the 47 hour drive to Norfolk, VA) and on to Mississippi. I recount this situation for you to illustrate the point that you may not have, during deployment, all of the paperwork in order and points of contact defined prior to your departure. This was to be the situation throughout the entire deployment, with missions blurred and momentarily changing at all times of the day and night. PUBLIC HEALTH QUESTIONS FOR CASE STUDY

What are the public health needs in a natural disaster?

How can a public health care professional, whether optometrist or other provider prepare for:

o Practicing their profession in a natural disaster whether in their own location or deployed

o Providing other health or emergency relief services not a part of their routine practice.

Where can one obtain training that will enhance their preparedness to provide emergency relief service?

Bottom line: you are not deployed for your own comfort or convenience, but, instead, to remain constantly ready to be used in whatever capacity you are needed. Whether waiting or moving out to a mission site you are fulfilling your purpose as an actively-ready response team member. You do not feel ready for the role assigned? Disasters at this level frequently do not detail their time and date of arrival, much less their location or type of destruction.



Detailed preparation for the tasks required of you may not be allowed. As a matter of fact, we frequently had no warning or opportunity for preparation allotted to us. Decisions often must be made quickly and correctly and without any extensive planning by people not trained to do this specific job. You are "just" an eye doc, so how in the world do you make the transition into this world of death and destruction from your familiar, stable, quiet, relatively secure world of ophthalmic examination? How do you prepare emotionally and intellectually? You cannot completely prepare for any national disaster. The simple fact is that the other health care providers serving with you are likely no more prepared than you for this task. On any deployment, but particularly that precipitated by a national disaster, you never know or have to understand what will be required of you; you just must be ready constantly to do whatever the mission demands and to do it with your best effort. Deployment mission demands are widely varied in complexity, venue, and length. Your personal parameters will most likely be stretched substantially, at least mine were, but as a health care professional you will do your job. Are you concerned that you are too specialized to serve in this capacity? Consider the ophthalmologist and pediatrician, the ob-gyn and pharmacists on my team. They felt stretched, but they did what needed to be done when called upon to do so. These were not less specialized than I, nor were the nurses who had not worked in clinical settings for years. We all did our job. The Command Team was composed of a psych nurse, a medical doctor, a nurse, a biochemical engineer, and me. The diversity served us well, as these different training specialties all brought expertise to the table that proved useful. My experience in the Air Force and Army came in very handy, but the problem-solving techniques we all practice daily within the confines of our offices were equally beneficial. Just as we assist patients every day to provide health-related solutions to their particular situations, so you too work through problem solving by identifying what resources are available and how they may best be managed to obtain the desired goal. No one person or group has all the answers, but as a team you can accomplish substantial amounts of work in a very limited amount of time even under adverse conditions if you keep in mind the fact that you are there to take care of your people. Long hours of waiting, sweltering heat, and humidity without relief, the stench lofting in from many sources, little or no sleep at night, frantic preparation for missions only to have them cancelled at the last minute, all could have resulted in mutinous mind-sets within team members. How was the staff able to keep the group functioning for the two weeks we were there? By breeding loyalty into the whole organizational structure. Leadership is not accomplished by tyranny, but simply by service. While approaches to leadership vary considerably, true leadership ignores the annoyances and plans in every way imaginable for all of the problems that your team might encounter when you send them out. Sitting down with your team members one on one to get a feel for how they are doing, what constitutes their



comfort zone (professionally and physically, spiritually and emotionally) is necessary before you start handing out assignments. Supporting of individual team members may include any or all of the following: encouragement and expressions of relief that they returned safely from a mission, remaining in regularly scheduled contact with the teams while they are out on assignment, debriefing them upon return from each task, helping them to understand how what they have done supports and enables the overall mission, and listening while they vent their emotional responses. Such support produces within your team members the conviction that you can be trusted, that they are not abandoned, and that their efforts are appreciated. When you sacrifice your own comfort, when you go out of your way to support your team members, they know it. When the time comes for them to put in long hours their obligation to you will almost invariably lead them to give that last bit of effort for you and for the mission. In Vietnam, this often spelled the difference between fragging and heroism among the soldiers. The take-home message? Take care of your troops, and they will take care of you. On the other hand, you may well not agree with all of the decisions made by your command. You must respect the right of the commander, however, to make those decisions, preparing ways in your own mind to calm the storm that you know will come when the commander's message is delivered to the troops. This means of course that you must resist the temptation to instigate, foment, and support dissension within the ranks for your own purposes. Your respectful disagreements must be voiced within the confines of the command staff meetings and remain out of the general troop arena. After-action reports often are the only vent for these disagreements. Often by then you have cooled down, and may even understand the wisdom of that command decision. Respect at all times for the position is necessary, as it is the only thing that separates you from chaos. As the command staff became increasingly fatigued it was easy to start second-guessing the "old man." Our efforts had to remain focused and supportive or the mission would fail. None of us were there for glory or promotion. All were there to support the mission of bringing help to those who so desperately needed it. The strain and fatigue could easily have led to command staff breakdown. So what kept it from happening? PUBLIC HEALTH IMPLICATIONS OF CASE STUDY The Importance of Command and Control Many criticize the drudgery of military training and the rigors and requirements of rank structure. All of us can personally testify to abuse often associated with authority; the actions of certain professors or police officers may come to mind, for instance. This same training and rank structure, though, was developed to bring a chaotic mess involving masses of people into a working, functional unit capable of directing a defined effort in one direction and in so doing



accomplishing what otherwise could not have been done. Unified command structure, then, can morph an effective effort out of chaos. Individual identity and concerns must often be compromised in this system, but generally speaking, the importance of egocentric interests within such a structure does not allow for sacrifice of the whole. Should conflict arise between individuals, those at higher command levels evaluate the decisions of any commanding officer and adjudicate if necessary, usually in the same manner as in any large organization. It is not, then, up to the individual to lead a crusade against a commanding officer because of a perceived slight. Considerations of this type do not glorify or romanticize war or other disasters with graphic depictions detailing first hand accounts of harrowing experiences. Leadership considerations do not describe the heightened mental awareness apparent in each of the team members packed into cars and vans as we picked our way through the back streets clogged with debris, as we crept past hand-painted (in red) signs nailed to trees stating "We AIM to please" that festooned the intersections of what once had been neighborhood thoroughfares. Pontifications on the advantages (and disadvantages) of command structure fail to introduce you to the overbearing stench of rotted human and animal remains distorted by prolonged exposure to southern-fried heat and water. The sights of limbs three feet thick now supporting only dry-brown vestiges of what had for centuries provided green evidence of the tenacity of live oaks and the stone steps leading to nowhere are not found in the above comments. In this type of situation your personal struggles most often are placed into a proper perspective (minimalized) by a shift of focus onto those you have come to serve, particularly by those who have labored so significantly just to stay alive. I think of the 70 year-old man who, when trapped inside by the sudden swell of the hurricane surge, tore ceiling vents open in their kitchens so that they could catch a gulp of air, only to be crushed against the ceiling by the refrigerator which had suddenly broken free of the floor below and bobbed to the surface. Knowing that certain death awaited him if he did not pry his body away from the refrigerator (and his air source), he finally was able to do so. With a last gulp of air tanked into his lungs, this elderly man left his vent hole to dive down, smash out and squirt through a window, snagging a second story railing upon breaking the surface, where he hung for hours before being rescued. This account parallels that of the wheel-chair bound man who, to escape drowning during the surge, broke out a window with his floating chair and pulled himself through. Somehow he managed throughout this desperate ordeal to maintain his hold on the wheelchair with the one hand on which he had fingers and to hook a post with the fingerless arm to keep from being swept away to his death. Survivors and the remains of those less successful told stories of terrifying destruction and detailed not only the fight of so many to survive but the very reason for our presence and the rigors of our training.

While our armed forces give all they have to protect us from armed aggressors, the US Constitution provides the USPHS with an opportunity to directly serve her citizens who are mentally, spiritually, and/or physically injured,



to do it effectively, and to make your chosen profession, the Commissioned Corps, and your nation proud of you. Lest the clinical importance of optometric practice be ignored here, I must include a telling request made to me personally during an interview and assessment I conducted of a New Orleans physician who staffed the New Orleans children’s hospital in the wake of Hurricane Rita: "We have everything we need in the way of supplies, but what we really need is someone to treat all of the red, chemically-burned, irritated eyes and to replace prescriptions for lost glasses and contacts." Note: Armed with this information, the first deployment role for a clinical optometrist was developed and established in the PHS, complete with a cache of deployable instruments organized by CAPTAIN Lawrence Zubel, a leading PHS optometry officer. The load of supplies contained within the cache trucks, which were themselves developed for the whole PHS deployment to disaster-stricken regions, was also in part designed by CAPTAIN Brown and his expert team of ready responders. In 2008, when Hurricanes Gustav and then Ike struck, multiple optometry officers were once again deployed, but this time an optometrist (Dr. Brown) was chosen to be the first Deputy Commander of the Incident Response Coordinating Team, the team assigned direct federal command and control over all federal response efforts and materials within the disaster area. This same optometry officer, initially chosen by headquarters to be Team Leader of the Regional Incident Support Team (RIST-8), was then promoted into the Team Lead position for one of the five National Incident Service Teams (NIST-C), the teams called upon to direct our national federal response to any large scale disaster that might occur. The organization, deployment, and structure of this PHS emergency/disaster response force, then, continues to evolve as new threats develop, but optometry officers within the PHS have served in the past as integral players on these teams and look forward to new opportunities to serve our country in this manner. PUBLIC HEALTH CASE STUDY QUESTIONS ADDRESSED

Too numerous to list, the initial dangers are physical injury, dehydration, hypothermia or hyperthermia, mass panic and violence. Later, dysentery, starvation, pollution, and biohazards present. Finally, refuge situations, over crowding, looting, and other social problems during rebuilding occur.

Check lists are as important in emergency situations as in the operating room. Develop check lists of personal equipment similar to a survival camping trip (water purification systems, emergency food, first aid kits, hygiene kits, medications, sleeping gear, clothing to protect against severe weather, flashlights/headlamps, waterproof matches, emergency blankets, etc. Determine communication methods: cell phone, walkie-talkie, blackberry, radio, etc. Determine your life lines: who do you call if you are



in danger. Have an exit plan. Know what is and is not available for transportation of your self or injured persons.

Prepare team supplies and clinic supplies that are portable. Bring information references or ways to communicate with supervisors or those trained in jobs outside your expertise.

Know where and be effectively prepared to direct people looking for others lost during the disaster.

Training sources: FEMA, fire departments, Red Cross, public health departments, hospitals, EMT classes, Coast Guard, MPH in Disaster Management.

Current Health Warfare in the Arena of Public Health Optometry Exciting new opportunities and organizational entities are being developed across the scope of the public health scene as we speak. Public health is increasingly at the foremost tip of the spear in terms of national planning and training. Students of all disciplines are taking a closer look at service in public health as both a profession and as a model approach to all health care. Schools of public health nation-wide are flooded with applicants as awareness of the trends and world-wide need escalates. Health care can no longer be viewed accurately in terms of a single nation; the global community must now be addressed with active and due consideration. While politics will continue to play a role in the provision of care, an increasing number of leaders are realizing the necessity of international efforts in the control and treatment of disease and the support of health as a way of life.

Cardiovascular and hypertensive disease and its effects upon diabetic vasculature, smoking, methamphetamine use, traumatic brain injury, domestic violence, infant mortality, suicide, and depression all constitute challenges for PHS research and clinical forces, to say nothing of Post Traumatic Stress Disorder and Auto-Immune Deficiency Syndrome. REAR ADMIRAL Hallidy, who serves as the IHS Dental Consultant to the US Surgeon General, has teamed with CAPTAIN Brown, optometrist, and CAPTAIN Carolyn Aoyama Chief of IHS Women’s Wellness in presenting to international and inter-professional audiences newly-established facts tying domestic violence and mild traumatic brain injury (mTBI), audiences that have included the U.S. Surgeon General and many other Admirals of the U.S. and Great Britain, the Association of Military Surgeons of the United States, the American Academy of Optometry, the National Combined Councils, and the IHS Women’s Wellness Grantee Council. Since trauma-related changes to the limbic system have been identified as causal factors affecting emotional behavior and personality change, both military and civilian personnel are being united in the definition by this pioneering effort in training providers to better define, detect, and treat this full-spectrum social pathology. Action advocacy, then, is being supported by scientific data that redefines mTBI disruption and the resulting frustration that so frequently leads not only to self-inflicted violence but violence against others. Large scale studies have firmly established maxillofacial injuries as the major delineating sign of



domestic violence as well as TBI/mTBI. It is fitting, then, that a dentist and an optometrist bring this message to our own professions and then to the world.

This is an example of leadership, which, if it is to survive and flourish, demands responsible action. As optometry assumes increasingly visible roles of leadership within the scientific sector of the professional community, the mindset of the new optometrist must dichotomously expand to encompass the presenting scientific advances and the development of a closely directed march into creative application and proactive expansion far beyond the service restriction into which we have bound ourselves in the past. While the professional and socio-political minefields inherent within such advancement are truly multitudinous, the potential rewards made subsequently available to creative, astute leadership and society as a whole far outstrip the risks. Health Ship Diplomacy: Its Concepts and Practice National leaders have realized that health care diplomacy has done more to build bridges of communication, trust, and constructive interaction than has the might of the military. The socially destructive ravages of war offer only a possibility for a solution to a nation’s troubles, an answer that might be successful. The PHS and military strategists have designed a plan to facilitate just such a deliberate, hands-on message of goodwill.

In a reunification of the US Navy and the PHS health care forces, hospital ships armed with a ready barrage of Naval and PHS health care professionals have deployed around the world, bringing a life of improved health to thousands of people previously enslaved by disease and handicapping, incapacitating degenerative conditions. Whether due to weather-related or geologically determined disaster or due simply to indigenous disease, the life thus established or returned to people who have no other sources of aid turn them almost unanimously in gratitude toward the US forces providing the relief.

Health care coupled with basic education and supported by military force used judiciously stand as an easy match against the terror-dominated regimes, for families function much more freely when allowed to finally develop fully, to realize their individual and collective aspirations. In the war against hate-mongering for the hearts and minds of the world’s people a logical place to begin is found within the battle for new beginnings located in the maternity wards of the Middle East hospitals. PHS officers have been sent to Iraq and Afghanistan birthing centers for as many as a dozen short tours. There they train the indigenous health care workers and provide life-giving care to the women and their babies. A lack of prenatal care had resulted in up to 50% mortality rates in newborns, not to mention those of the mothers. Literally thousands of infants and mothers are now thriving as a direct result of this PHS-driven team effort.

For our part within the ranks of health care providers, PHS optometrists often lead the way into expansions of research-based knowledge and adaptive clinical approaches, while remaining active advocates in educational circles (our professional training/teaching institutions) for early recognition of, emphasis on,



and treatment of the subtle signs and symptoms of diabetes, mild traumatic brain injury, domestic violence, and forensic neurooptometry. All students, but particularly those interested in a career in the PHS must be acquainted with the concept of uniting as members of a health care team and ready to assume a multi-factorial approach to the practice of prevention. The view of care must be holistic, rather than seen as an opportunity to simply treat individual disease entities as if they were somehow isolated or mono-systemic occurrences within the human body. Looking beyond the specific and into the generalized support of an elected government struggling to provide basic goods and services to its people, the PHS has assigned health care professionals as attaches within the current theater of military operations. These PHS officers assist in the design and establishment of the nation’s health care systems. From the acquisition and management of the medical supplies to the creation of sanitation and potable water and on into the care for the pediatric, adult, and geriatric injured and ill, our PHS providers are standing along side our military as they battle aggression and terrorism. As in any war, there have been and will continue to be casualties. Noncombatant PHS officers are targeted by terrorists because we are Americans, just as Americans throughout the world have been in the past, both on the fighting fields and military posts/bases and in our major cities. Having counted the cost and found it worthwhile, thousands of health care professionals from all specialties are choosing to spend their lives providing care within the PHS.

Based upon a long-established set of Corps values (found within the ranks of the only federal service specifically formed for the purpose of health care provision) the PHS must lead the way into expansions of research-based knowledge and adaptive clinical approaches, all the while remaining an active advocate within educational circles for recognition of and response to the earliest and most subtle signs and symptoms of environmental, social, spiritual, and physical pathologies that infect our world’s population. Using the training already provided by the U.S. schools and colleges of optometry, optometric physicians can indeed furnish leadership in this conquest, contributing positively to the advancement of so much more than the diagnosis and treatment of ocular and systemic disease. One could readily cite, as has been done, the examples of the work of optometric physicians in the early diagnosis of mTBI and its ties to domestic violence, of fellowship trained retinal researchers, of national disaster team leaders, or of the excellent work in forensics (such as that done by Drs Jack Richmond and Bob Bertolli), to demonstrate this point. “Alternative" medicine, so long disparaged by so many, is just now gaining conceptual acceptance within allopathic circles, overcoming many long-entrenched academic barriers. The opportunities for the development of new, more effective and less physiologically challenging strategies of care are exciting, requiring creativity of thought and approach, much of which is being forcefully driven by genetic research. The time for mere routine and complacency, so often providing security to yesterday’s provider within the walls of a clinical setting is



fast passing away. As these walls sink, however, the horizons expand and the level of service demanded by the population served rises exponentially. Nowhere is the challenge and stimulation greater than within the Public Health Service, for the demand for primary care is expanding, while the supply of providers is shrinking. The immunologically supportive approach will necessitate an increase in a collaborative clinical approach. Technologies to enhance vision and systemic disability must be made more available. The need of the child to heighten their visual and general health for maximum educational achievement has been accepted across virtually all groups and geographies. Because the nation and the world are closer, providers such as those in the PHS can bridge those gaps. So…to the brave, I say “Welcome to the USPHS, the new world of health care;” to the others, all I can say is “Wish you were here.” Take Home Conclusions

The U.S. Public Health Service was originated as the Marine Hospital Service. Its purpose was to protect the country from diseases brought in by seaman and to provide treatment to the seaman.

The PHS includes seven agencies, some of which are the Centers for Disease Prevention and Control, Food and Drug Administration, National Institutes of Health, the Indian Health Service, Coast Guard, Bureau of Prisons, and Bureau of Immigration.

PHS optometry includes clinical practice such as in the Indian health Service, research, administration, and international work.

A military structure adopted in the 19th century has gifted the PHS with the discipline and mobility needed to serve in natural and man-made disasters and wars.

Study Questions

1. Which President signed into law funding by the Department of Treasury to establish the Marine Hospital Fund?

2. Who restructured the Marine Hospital Service based on a military model and why was this helpful?

3. What does it mean to be a commissioned officer in the PHS? 4. Compare the PHS with the Department of Veterans Affairs as

described in another chapter. Would you consider the advancements of optometry as a profession to have a similar course or a different course? Support your answer.

5. Make a check list of personal and professional items you would need for deployment on a medical team to an area hit by a severe earthquake.



REFERENCES

1. Ralph C. Williams, The United States Public Health Service, 1798-1950 [Washington, D.C.: The Commissioned Officers Association of the United States Public Health Service (1951)], p. 26.

2. An Act for the Relief of Sick and Disabled Seamen. July16, 1798 (I Stat. L., 605-606).

3. Robert Strauss, Medical Care for Seamen: The Origin of Public Medical Service in the United States (New Haven: Yale University Press, 1950), pp. 32-60.

4. John Parascandola, PhD, A Historical Guide to the U. S. Government.(Oxford University Press, 1998), pp. 487, 7, 490.

5. William M. Gouge, “Report on Marine Hospitals,” Senate Executive Documents, 34th Congress, 1st Session, 1855, Vol. 5, Number 53, pp. 246-7.

6. 35. Fitzhugh Mullin, MD, Plagues and Politics, Basic Books, Inc. (1989), pp.19-20, 58-60, 65, 40, 139, 197, 203.

7. Victoria Harden, A Historical Guide to the U.S. Government, National Institutes of Health, Oxford University Press, 1998, pp. 408-414.

8. Fitzhugh Mullin, MD, Plagues and Politics, Basic Books, Inc. (1989), p. 32. 9. John Parascandola, PhD, From Marine Hospital to the Public Health

Service, Medicina, Nei Secol Arta E Scienza, 11/1 (1999), pp. 202. 10. John Parascandola, PhD, From Marine Hospital to the Public Health

Service, Medicina, Nei Secol Arta E Scienza, 11/1 (1999), p. 203. 11. John Parascandola, PhD, Doctors at the Gates: The Development of

Mental Tests at Ellis Island, SAMHSA NEWS, Winter 1997, p. 9. 12. Fitzhugh Mullin, MD, Plagues and Politics, Basic Books, Inc., (1989) pp.

45-51. 13. Luigi F. Luciccini, The Public Health Service on Angel Island, Jan/Feb

1996, Vol. III, Public Health Reports, p. 92. 14. John Parascandola, PhD, From Marine Hospital to the Public Health

Service, Medicina, Nei Secol Arta E Scienza, 11/1 (1999), p. 204. 15. Leslie Lumsden, The Causation and Prevention of Typhoid Fever with

special reference to conditions observed in Yakima County, Washington, 1911.

16. Fitzhugh Mullin, MD, Plagues and Politics, Basic Books, Inc., (1989) pp.63-64.

17. Fitzhugh Mullin, MD, Plagues and Politics, Basic Books, Inc., (1989) pp. 61-63.

18. Fitzhugh Mullin, MD, Plagues and Politics, Basic Books, Inc., (1989) pp. 39-40.

19. Annual Report of the Surgeon General of the Pubic Health Service, 1912, p. 9.

20. Fitzhugh Mullin, MD, Plagues and Politics, Basic Books, Inc., (1989) p. 58.



21. Victoria Harden, A Historical Guide to the U.S. Government, National Institutes of Health, Oxford University Press, 1998, p 410.

22. John Parascandola, PhD, A Historical Guide to the U. S. Government, Public Health Service, (Oxford University Press, 1998), p. 489.

23. John Parascandola, PhD, The Gillis W. Long Hansen’s Disease Center at Carville, Public Health Reports, November-December, 1994, Vol. 109, No. 6, P. 728.

24. Fitzhugh Mullin, MD, Plagues and Politics, Basic Books, Inc., (1989) p. 139.

25. John Parascandola, PhD, A Historical Guide to the U. S. Government, Public Health Service, (Oxford University Press, 1998), p.490.

26. Fitzhugh Mullin, MD, Plagues and Politics, Basic Books, Inc., (1989) p. 96. 27. Fitzhugh Mullin, MD, Plagues and Politics, Basic Books, Inc., (1989) p.

115. 28. Fitzhugh Mullin, MD, Plagues and Politics, Basic Books, Inc., (1989) p. 65. 29. John Parascandoal, PhD, From MCWA to CDC_Origins of the Centers for

Disease Control and Prevention, PHS Chronicles/Public Health Reports, Nov/Dec 1996, Vol.III, p. 549.

30. Fitzhugh Mullin, MD, Plagues and Politics, Basic Books, Inc. (1989), pp. 197-203.

31. Lester Caplan, OD, Lecture on the Presentation of the First Lester Caplan Award, May 7, 2006, Southern College of Optometry, Indian Health Service Biennial Eye Care Meeting .

32. Duane Gillum, , Personal Communication, Blackfeet Community Hospital, 1994.

33. Gary Pabolis, OD, Personal Communication, March, 2009 34. John Parascandola, PhD, A Historical Guide to the U. S. Government,

Public Health Service, (Oxford University Press, 1998), p. 492.

In appreciation

A special word of thanks must go to the following individuals:

Dr John Parascandola, the retired archivist for the USPHS who freely shared with me such a plethora of information and some of his many articles;

CAPTAIN Steve Leiman, one of the many talented officers with whom I served in Gulfport, MS, kindly gifted me with a copy of Mullin’s Plagues and Politics, a classic resource;

CAPTAIN Gary Pabolis and Dr Les Caplan for their leadership and unselfish sharing of their historical knowledge of PHS optometric history;

CAPTAIN Sui Wong, for her editing and service to Federal Service Optometry.