Federal employee health program

The Federal employee health program is administered by the Division of Hospitals. It was authorized by Public Law 658, 79th Congress, as amended, which was permissive legislation authorizing the heads of departments and agencies, within the limits of appropriations available, to provide health services for their employees.

Health services authorized are treatment of on-the-job illness requiring emergency attention; preemployment and other examinations; referral of employees to private physicians and dentists; preventive programs relating to health. Under the law, the PHS has two primary functions and responsibilities:

(1) When requested, the PHS reviews the health service program conducted by a Federal department or agency and submits comments and recommendations. Consideration is given by the departments to these recommendations. Most agencies which have sought advice have considered it very valuable.

(2) The PHS operates 39 health units for 189 participating agencies on a contractual and reimbursable basis, serving about 60,000 Federal employees. More than 250,000 visits are made to the health units each year. There have been 3,800 thorough physical examinations of employees 40 years old and older. Fifty percent of those examined were found to have conditions necessitating, in the great majority of cases, referral to a physician. Immunization and disease detection are also included in the program. Although thousands of Federal employees have available some kind of health service or program under Public Law 658, there are also many thousands throughout the country who have no employee health services at all even though the permissive legislation in effect for the past 17 years allows these services. There have been particular problems encountered in fully implementing the provisions of the legislation that authorize establishment of preventive health programs for Federal employees.

THE FOREIGN QUARANTINE SERVICE

In August 1962, the Division of Foreign Quarantine received a call from a Canadian health official reporting that a 15-year-old boy who had recently passed through New York City en route to Canada was ill with smallpox. The boy had arrived at Idlewild International Airport aboard a plane from Brazil and had taken a train out of New York City for Toronto. U.S. quarantine officials began a search for the other passengers aboard the plane. The New York City Health Department set up vaccination centers and urged all possible contacts to be immunized. About 10,000 persons received vaccination. Most of the plane passengers were located and vaccinated. No additional cases developed.

In March 1963, typhoid fever was reported in Zermatt, Switzerland, a major ski resort. More than 250 cases developed, including 10 in the United_States. Any travelers who were ill when they arrived in this country from the Zermatt area were detained by the U.S. Quarantine Service for medical observation. The Quarantine Service notified local health officials of the name and U.S. address of any person arriving from the Zermatt area, and urged that all possible measures be taken to prevent the spread of typhoid fever.

Milestones in history of Division of Foreign Quarantine

Both the quarantine inspection of persons entering the United States and the medical examination of aliens are old, established functions of the Public Health Service. By acts of 1878 and 1893, Congress authorized the Public Health Service, then known as the Marine Hospital Service, to begin operation of a Federal quarantine system. The Immigration Act of 1891 assigned to the Service the responsibility of performing medical examinations of aliens at ports of entry.

Changes in emphasis since World War II

The expansion in international travel since World War II, and in particular the increase in the volume and speed of air travel, have intensified quarantine problems. In addition, medical inspections of aliens entering the United States have increased since the 1940's as a result of expanded tourism, new exchange programs, increased immigration from unrestricted areas, and immigration under special legislation such as that covering refugees and escapees.

Advancement of new health knowledge

The entomology program of the Division of Foreign Quarantine, which is conducted in international traffic areas and at farm placement program examination

centers, includes research to detect insecticide resistance in mosquitoes and lice and to improve insect survey methods and control techniques. New information is made available to scientists, the World Health Organization, airlines, and other interested persons and organizations.

Extension of health services for the public

The Division designates and supervises yellow fever vaccination centers throughout the country. These centers provide shots for persons who plan to travel to areas infected with yellow fever.

Control of, or protection against, particular health hazards

Quarantine.-The Division is on guard at 380 seaports, airports, and land border ports of entry in the United States, its possessions, and Puerto Rico. It applies health controls to international sea, air, and land traffic in order to prevent the introduction into the United States of: (1) Quarantinable diseases: namely, smallpox, cholera, plague, yellow fever, louse-borne typhus, and louseborn relapsing fever-which are prevalent in many parts of the world; (2) rabies and other human diseases transmitted by dogs, cats, and monkeys; (3) psittacosis, through restrictions on the importation of parrot-family birds; (4) anthrax, through laboratory check on imported lather brushes; (5) other serious communicable diseases, through controls applied in cooperation with local health departments; (6) disease-transmitting insects, by spraying of airplanes and ships and by entomological surveillance of airport and seaport areas; (7) unauthorized shipments of disease organisms or transmitting agents.

The Division also applies measures to prevent the immediate spread of quarantinable and other dangerous communicable diseases in the event they are introduced into the country. These measures are: (1) Application of health controls, including vaccination, surveillance, or isolation, to travelers; (2) stimulation of immunization of persons working in and around ports of entry who come into contact with international travelers; (3) insect vector control in international traffic areas; and (4) rodent control on ships and in dock areas.

Medical examination of aliens.-The Division examines aliens at major U.S. consulates and at ports of entry to detect excludable conditions specified in immigration law. These include: (1) Dangerous communicable diseases; (2) feeblemindedness, insanity, psychopathic personality, epilepsy, narcotic drug addiction, chronic alocholism, and other mental defects; and (3) physical defects that may limit the alien's ability to earn a living.

Sanitation.-Division personnel inspect foreign-flag passenger liners to insure that the vessels have adequate rat and insect control, that their food sanitation is satisfactory, and that their water supply and waste disposal systems do not present any hazard to health. Water samples are collected for analysis as a part of the inspection. The Division has asked the World Health Organization to establish international standards of sanitation for ships.

Health education and information.-The Division serves as the official source in the United States of health information for international travel. To inform the traveling public about health hazards and immunization requirements, the Division issues leaflets, booklets, and other publications, and disseminates information to transportation companies; to travel agencies; to newspapers and magazines; to other Federal agencies, such as the Defense Department, the Passport Division of the State Department, and the U.S. Travel Service of the Commerce Department; to local and State health departments; to the national health departments of other governments; and to the World Health Organization and its regional offices.

Recruitment and training

The Division recruits and trains inspectors for duty at quarantine stations throughout the country. After appointment, recruits receive a year of trainin in the details of quarantine inspection. The training program includes 2 months of instruction and 10 months of field experience under close supervision.

Collection and dissemination of health statistics

The Division collects, analyzes, and disseminates international epidemiological information on quarantinable and other dangerous communicable diseases. Particular attention is paid to endemic and epidemic occurrences of the quarantinable diseases in any country. Such occurrences are followed closely from day to day to determine their prevalence and incidence, their geographical dis

tribution, and the chances of their being brought into the United States by travelers. The flow of epidemiological intelligence is shown in the attached chart.

International health functions

The Division implements the international sanitary regulations issued by the World Health Organization. It also furnishes other governments with technical assistance in the development of quarantine programs and the training of quarantine personnel. The Chief of the Division serves on the Committee on International Quarantine of the World Health Organization, and is a member of the WHO Expert Advisory Panel on International Quarantine. In addition, headquarters and field personnel participate in international conferences dealing with the control of quarantinable diseases, the facilitation of international travel, and related matters.

The foreign quarantine operation of the Public Health Service has been marked in recent years by the following shifts: (1) Increased emphasis on quarantine inspection of aircraft and aircraft passengers, without any decrease in maritime inspections; (2) initiation of preclearance of conveyances and passengers outside the United States, such as in Bermuda and on the St. Lawrance Seaway; (3) shift to use of quarantine inspectors who are not physicians; (4) introduction of a fee for alien medical examinations; (5) trial at some Mexican border stations of joint use of personnel of four inspectional agencies (Quarantine, Customs, Immigration, and Agriculture) which clear persons crossing into the United States; and (6) increased use of worldwide epidemiological intelligence in the application of quarantine measures.

In fiscal year 1962, Division quarantine officers inspected 32,980 ships, 65,187 aircraft, and 16,782,531 travelers, including 10,670,199 local Mexican border

crossers.

HEALTH SERVICES FOR INDIANS AND ALASKA NATIVES

An emergency radio call to the Public Health Service Alaska native hospital in Anchorage startled even the most seasoned members of the Indian health

staff. A bush pilot 4,000 feet over the frozen land was calling for help because a baby was about to be born on the plane. He asked Dr. Gloria Park at the hospital what to do.

Dr. Park quickly gave instructions. The pilot carried them out, at the same time flying his plane. When the baby arrived, the air waves crackled with this bulletin: "He's kicking around and doing great."

Medical advice by radio has been increasing in Alaska as the Division of Indian Health, in cooperation with the State health department, continues to improve health services in the hundreds of remote villages.

Responsibility for the health needs of American Indians and Alaska natives has provided the Public Health Service with a unique opportunity of being the only agency in this country responsible for planning and implementing a complete, comprehensive community health care program.

The more than 380,000 beneficiaries receive the widest range of health services in an integrated system of hospitals and clinics, public health and environmental health services.

Sanitation facilities and water supply systems are constructed, and the Indian families and communities are trained to use and maintain them and ultimately assume full responsibility for operating them.

Methods developed in the Indian health program will prove of value to nonIndian communities in achieving the most sufficient use of available health

resources.

Provision of medical care for Indians

Public Law 568 of the 83d Congress states that "all functions, responsibilities, authorities, and duties *** relating to the maintenance and operation of hospital and health facilities for Indians, and the conservation of the health of the Indians are hereby transferred to, and shall be administered by, the Surgeon General of the U.S. Public Health Service *

In carrying out that responsibility, the Public Health Service provides a community-type health program for Indians and Alaska natives. This covers curative, preventive, and environmental aspects of health. Medical diagnostic and treatment services are provided for 380,000 Indians and Alaska natives in 50 hospitals, 26 health centers, 16 school health centers, and more than 200 parttime clinics. In addition, there are contracts with community hospitals and private physicians, dentists, and pharmacists. In the public health and the preventive aspects of medicine, the Service provides prenatal, postnatal, maternal and child health, school health, and immunization clinics at every health facility. In environmental health, the Service is steadily improving the water supply and sanitation facilities on the reservations and in Indian communities. Examples of the care and services provided are:

General medical and surgical hospitalization.

Tuberculosis case finding, hospitalization, and followup.

Medical and surgical outpatient clinics.

Specialty clinics:

Prenatal and postnatal.

Well baby and well child.
Immunization.

Dental.

Diabetic.

Environmental health:

Water.

Waste disposal.

Within the program for inpatients and outpatients:

Health education services.

Medical social services.

Pharmacy services.

Medical records.

Advancement of health knowledge

There are communicable diseases among the Indians that are practically nonexistent in the rest of the population of the United States. As a result the diagnosis and treatment of these diseases is mainly a textbook procedure except in the Indian health program.

An illustration is trachoma, a virus infection of the eye. It was thought that trachoma, which causes blindness if left untreated, was nonexistent in the United States; as a result it was not being properly diagnosed. When several

cases were properly diagnosed, Dr. Phillips Thygeson of the University of California was brought in to verify the diagnosis. He prepared a program to train physicians to diagnose and treat this infection. A manual describing trachoma, with pictures, was published. A vaccine against trachoma is being tested and studied among Indians in Arizona.

Many studies on the effectiveness of tuberculosis drugs have been made. In the Indian pueblos around Albuquerque, a study was made of the effectiveness of isoniazed as a prophylactic agent against tuberculosis.

Extension and improvement of health services for the public

To be close to the Indian population, most of the Indian hospitals are small; this makes for a large number of hospitals. Thus the program gives many physicians invaluable experience in administration of a hospital. Their experience will benefit the whole community if they return to private practice.

In the program, professional health workers learn first-hand the public health perspective of looking at community health as a whole as opposed to looking at individual health as an end in itself. This broader outlook is invaluable for those who return to private practice.

Dentists in the Indian health program are usually young men recently out of dental school. Since most dental schools do not teach students to utilize dental assistants effectively, the Division of Indian Heaith has a program for dentists and their assistants in which they are taught how dental assistants can be utilized to maximum effectiveness. This has been successful in increasing the productivity of dentists. Since most Division dentists eventually return to private practice, the training they have received enables them to serve more patients.

Professional health workers in the Division ofen receive short- or long-term training which upon their return to private life enables them to render better service to patients and community.

Nurses' aids are trained in the Division. Many later find employment in private hospitals.

The health of the Indians has been, and still is, inferior to that of other people in the United States. As long as this is true, the Indian community is a potential reservoir of infection. Immunization, health education, sanitation, rabies control, in addition to the more conventional medical programs, have as a corollary goal the elimination of any potential Indian reservoir of infection for the whole population.

The Division of Indian Health has always cooperated with other Government agencies and private institutions in research, if tribal councils agree. Knowledge gained from research projects has benefited the public at large as well as the Indian.

Emergency care on a reimbursable basis is available at DIH installations to all persons who need it, whether or not they are Indians. This is especially important in remote areas of the West and Alaska.

Control of and protection against health hazards

The Division of Indian Health provides a total preventive health program for Indian beneficiaries through its organization of areas and service units. The field units comprise medical, dental, nursing, sanitation, and health education components. The preventive health program includes field clinics, home visits, community demonstrations, promotional and educational activities, and construction of domestic water supply and other sanitation facilities.

There are three significant differences between this program and the usual preventive health programs. First, to meet staffing requirements in remote areas and to reckon with cultural factors, Indians have been employed in the preventive health units and trained to work as dental assistants, practical nurses, sanitarian aids, and community workers. Second, the program emphasizes a house-to-house and worker-to-family concept. Third, the actual design and construction of sanitation facilities needed to correct environmental deficiencies is undertaken by a public health agency.

Recruitment and training of professional health personnel

Personnel are recruited by the Division of Personnel, directly by DIH headquarters, by area offices, by area recruiting teams, and by the Bureau of Medical Services.

Turnover varies among the professions. The medical category averages between 40 and 50 percent; pharmacists, nutritionists, and dentists, about 30 percent; nurses 40 to 45 percent; medical record librarians 20 percent; health