Early Days
    of  PHAs

  PHA Tales

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  Future of 
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  Task Force
    2010

  Watsonian

CDC & ATSDR Public Health Advisor Series

The Public Health Advisor (PHA) concept originated during World War II to address the upsurge of venereal diseases that historically accompanies war; however, the actual PHA series did not begin until shortly after WW II when six college graduates with social science backgrounds were hired by the USPHS to work on Maryland's Eastern Shore. In 1948, Dr. Johannes Stuart, an economist in the VD division, came up with a pragmatic solution to a difficult problem. The division had trouble hiring health workers, since the civil service lists were filled with people who could not do this special work. Stuart persuaded his boss, Lida J. Usilton, that bright college graduates could be trained to interview venereal disease patients, track down their sexual contacts, and persuade them to get treatment. In the summer of 1948 six young men just out of college were hired on an experimental basis. This pilot project was designed to demonstrate the potential value of using young, highly motivated college graduates in carrying out venereal disease control activities. These individuals were called "co-ops" because they were assigned to state health departments under a cooperative agreement between the state health department and the federal government. One of the first six hires was William C. (Bill) Watson, Jr., who made his career in public health along with two others from the original six.

The PHAs were in keeping with an idea of Joseph Mountin, Director of the Public Health Services State Services Division. Mountin called attention to the need for auxiliary workers to perform many routine operations in the country, and who could be relied upon to provide services in less highly developed countries. The work was not easy, but there was esprit de corps, and once in, a person became a member of the club.  Eventually the venereal disease control effort was transferred to CDC in 1957.

The Maryland success led to expanded use of PHAs in other states. The result was a cadre of individuals, reasonably well grounded in the principles of epidemiology, with demonstrated program management skills. As CDC expanded into programs for vaccine preventable diseases (1963) tuberculosis (1964), and later to chronic diseases, accident prevention, etc., the contribution that PHAs could make to managing health programs was recognized, and many were recruited into other public health programs. A large expansion of the CDC system took place as part of the syphilis eradication program, and as a result, of grant-funded initiatives in childhood immunization and tuberculosis control. CDC PHAs, now numbering several hundred, were the vanguard for seeing that the elements of the eradication model were implemented nationwide. Most of the field workers, supervisors, and managers of the syphilis eradication programs in the states were CDC assignees. Similarly, most state project coordinators in immunization and tuberculosis control were CDC assignees, and virtually all of them were recruited from the VD program. Some states continued to hire small numbers of VD field workers, although most worked exclusively with gonorrhea patients, and none had access to a career system within their state.

Several other federal programs experimented with the use of public health advisors in state assignments, including health mobilization, the urban rat control program, and the chronic disease program. (The health mobilization and chronic disease programs were discontinued. The rat control program was transferred to CDC as a result of a reorganization in the early 70's. At that time there were fewer than 10 rat control field assignees.)

Recruitment of women and members of racial and ethnic minority groups occurred sporadically during the first few years of the PHA program. An explicit policy of accelerating recruitment among such under-represented groups was developed in the 1960s (racial and  ethnic minorities) and 1970s (women).

The size of the PHA field staff fluctuated considerably over the years, consistent with the vagaries of Federal funding. Experienced PHAs were often recruited from the syphilis program for management assignments at CDC headquarters, regional offices, and state and local health departments, to facilitate implementation of nationwide public health programs, such as controlling vaccine preventable diseases and tuberculosis.

In 1969, a review of the CDC assignee program was conducted by Health Services and Mental Health Administration in connection with an overall review of Federal health staffing issues. The study report praised the assignee program as a valuable resource.

In June of 1987, CDC conducted a management study of its PHA field staff in order to assess current effectiveness and the future role of PHAs. State and local health agencies voiced strong support for continued placement of PHAs to 

1) assist in fulfilling their public health mission; 
2) serve as links between CDC headquarters and state and localities for technology transfer, and 
3) respond rapidly to deal with public health crises. 

Similarly, CDC headquarters staff generally regarded the PHA field staff experience as very useful background to succeed in headquarters positions.

CDC recruited from 100 to 150 entry level PHAs from 1988 through 1992; that number was reduced to 65 during 1993. Also in 1993, the first cohort of 15 TB PHAs was hired and assigned to the New York City Department of Health. By the end of 1993, recruitment of STD and TB Public Health Associates was suspended as part of CDC's overall downsizing effort.

In 1994, an Office of the Inspector General (OIG) review of CDC staff assignments to state and local governments concluded that "CDC's staff assignments to State and local governments are authorized by the Public Health Service Act, are designed to assist CDC in achieving its mission, and are governed by comprehensive written policies and procedures."

In 1994, an internal CDC Workgroup was formed to look at the future role of CDC assignees to the states, particularly PHA assignees. Given the current interest in reinventing government, the changing needs of State and local constituents, and the evolving priorities of CDC, the Workgroup focused on identifying strengths and weaknesses of the current field staff system, and the effects on the system due to changes in technology, program strategy, health care policy, and Federal-State relationships.

In 1995, CDC convened a meeting on "The Future Role of CDC Field Assignees" involving input from representatives of state and local health departments, national public health organizations, CDC components, and field staff. The discussion focused on the role of CDC field assignees, training and recruitment of new field assignees, and transition of existing field assignees. The PHA Watsonian Society summarized the value and service of all PHAs in testimony before the committee. That testimony stated, "in CDC's long and illustrious history, field trained PHAs have assumed management positions and have contributed greatly to the mission, vision, and product of CDC. Without reservation, most former CDC directors, as well as most former CIO directors will tell you that without the field trained PHA managers, CDC would not have become the most prominent public health agency in the world. Although recruitment for the PHA series of CDC may need to be modified in today's world, and individuals may be required to have master degrees, the multiple-State field training that has worked so well in the past should not be vacated."

There is no actual count of the number of persons recruited by CDC to become Public Health Advisors, but the number probably exceeds 5,000. As they developed, they gained valuable knowledge and experience of what makes local, state, and national programs operate effectively. Public Health Advisors are willing to do what it takes to get a job done. These qualities have been and are one of the major factors that sets CDC apart from other agencies.

Read More about the Early Days

Tales from Today's Public Health Advisors