# Centers for Disease Control and Prevention (CDC): History, Overview of Domestic Programs, and Selected Issues > Briefs, arguments, decisions, and more. URL: https://www.frixlaw.com/law-library/documents/crs%3AR47981 ## Record - **Collection:** Congressional research report - **Document type:** CRS Report - **Published:** March 22, 2024 - **Citation:** R47981 ## Text Centers for Disease Control and Prevention (CDC): History, Overview of Domestic Programs, and Selected Issues March 22, 2024 Congressional Research Service https://crsreports.congress.gov R47981 SUMMARY Centers for Disease Control and Prevention (CDC): History, Overview of Domestic Programs, and Selected Issues R47981 March 22, 2024 Kavya Sekar Analyst in Health Policy The Coronavirus Disease 2019 (COVID-19) pandemic shined a spotlight on the Centers for Disease Control and Prevention (CDC), one of nine Public Health Service (PHS) agencies in the Department of Health and Human Services (HHS). CDC’s role in and response to the pandemic have been the subject of numerous congressional hearings and oversight investigations. History CDC began as the Communicable Disease Center in 1946 focused on assisting states and localities in controlling communicable disease outbreaks. CDC’s role has expanded over the decades to include programs aimed at disease prevention and health promotion more broadly. In 1980, when CDC was renamed the Centers for Disease Control (after two prior name changes), its official mission was to serve as HHS’s “focus for developing and applying disease prevention and control, environmental health, and health promotion and health education activities designed to improve the health of the people of the United States.” Over time, CDC evolved in response to an epidemiologic transition that occurred throughout the 20th century, in which the leading causes of death in the United States shifted from infectious diseases to chronic diseases and injuries. CDC also evolved as the field of epidemiology developed and scientists identified the preventable causes of a wide range of health challenges. Within the context of these developments, CDC was positioned to study preventable health challenges and to support programs to address them. CDC retains a dual responsibility for responding to emerging health threats, such as disease outbreaks, and for supporting ongoing disease prevention and health promotion efforts. Organization and Programs In FY2023, CDC and the Agency for Toxic Substances and Disease Registry had a program level of $14.5 billion, consisting of $9.3 billion for core public health programs and $5.2 billion for other programs funded by mandatory budget authorities such as the Vaccines for Children program and the World Trade Center Health Program. CDC currently comprises 23 centers, institutes, and offices (CIOs). Some of these CIOs focus on specific health areas (e.g., immunization and respiratory diseases), whereas others focus on specific functions and capabilities (e.g., laboratory science and safety). Within these CIOs, CDC’s domestic public health activities generally fall within three categories: (1) support to state, local, tribal, and territorial (SLTT) health agencies, including assistance in investigating health threats and grant funding for health programs; (2) science and data, including CDC support for networks of laboratories and surveillance systems to monitor health threats and changes; and (3) health education and guidance. These activities cover a wide range of health topics, including infectious diseases, chronic diseases, injury, disability, occupational health, environmental health, and public health emergency preparedness and response. This CRS report does not focus on CDC’s global health programs. Authorization CDC does not have a single, overarching statute that defines its overall mission, structure, and programs. Congress in 2022 codified the position of the CDC Director and its responsibilities through the PREVENT Pandemics Act (P.L. 117-238, Division FF, Title II). CDC as an agency has been shaped by reorganizations carried out under HHS departmental reorganization authorities. Many CDC programs cite general program authorizations in the Public Health Service Act (PHSA) as their statutory basis. Congress has often shaped CDC’s programmatic focus areas through the annual appropriations process, in which CDC has received its funding through disease and program-specific accounts and line items. Some CDC programs are explicitly authorized in law, mostly in the PHSA. CDC also administers some federal public health regulations, though it is not primarily a regulatory agency. In addition, the CDC Director oversees the Agency for Toxic Substances and Disease Registry (ATSDR), a separate HHS operating division. Congressional Research Service Centers for Disease Control and Prevention (CDC): History, Overview, and Issues Reorganization and Reform CDC has recently undertaken its own reorganization and reform effort through the Moving Forward initiative. Committee members in both the House and the Senate have solicited input on potential CDC reform. If Congress considers further legislative reform, Congress may contemplate the appropriate scope of the agency’s mission and activities. Congress faces many policy options for CDC reform, including (1) awaiting results from the Moving Forward initiative, (2) establishing a process for CDC reform, and (3) further codifying the agency in statute. Congressional Research Service Centers for Disease Control and Prevention (CDC): History, Overview, and Issues Contents History and Context......................................................................................................................... 3 Brief History.............................................................................................................................. 3 Public Health Service Act of 1944 ...................................................................................... 4 1946-1950: Establishment and Initial Years ....................................................................... 5 1950s-1960s: Expansion in Epidemiology, Communicable Disease, and Vaccination Programs ...................................................................................................... 6 1970s: Becoming the Center for Disease Control and Expanding Scope ........................... 8 1980s: The Centers for Disease Control, Lead Disease Prevention Agency, and the HIV/AIDS Epidemic................................................................................................ 10 1992-Present: Centers for Disease Control and Prevention .............................................. 12 Current Status: The COVID-19 Pandemic and CDC’s Moving Forward Initiative ......... 15 CDC’s Evolution in Context ................................................................................................... 17 Congress’s Role in Shaping CDC ........................................................................................... 19 Appropriations .................................................................................................................. 19 Authorizing Legislation: Case Studies.............................................................................. 20 Agency Overview Today ............................................................................................................... 22 Mission .................................................................................................................................... 22 Organization ............................................................................................................................ 23 Statutory Authorizations.......................................................................................................... 25 CDC Director Authorization ............................................................................................. 25 General Program Authorizations....................................................................................... 25 Program-Specific Authorizations ...................................................................................... 27 Appropriations......................................................................................................................... 29 Activities ................................................................................................................................. 29 Support to SLTT Public Health Agencies ......................................................................... 29 Science and Data ............................................................................................................... 34 Health Education and Guidance........................................................................................ 39 Regulations.............................................................................................................................. 40 Mandatory Health Services Programs ..................................................................................... 41 Vaccines for Children ........................................................................................................ 41 World Trade Center Health Program ................................................................................ 42 Considerations and Options for Reform ........................................................................................ 43 Defining the Mission ............................................................................................................... 43 Scoping CDC by Disease and Health Area ....................................................................... 43 Scoping CDC by Function ................................................................................................ 44 Scoping CDC by Role....................................................................................................... 45 Selected Policy Options .......................................................................................................... 45 Await Results from the Moving Forward Initiative .......................................................... 45 Establish a CDC Reform Process ..................................................................................... 46 Further Authorize CDC ..................................................................................................... 47 Figures Figure 1. CDC Organizational History: A Timeline ...................................................................... 17 Congressional Research Service Centers for Disease Control and Prevention (CDC): History, Overview, and Issues Figure 2. How Congress Shapes CDC Programs Through Appropriations: Illustrative Example ................................................................................................................... 20 Figure 3. CDC Organization Chart ................................................................................................ 24 Tables Table 1. Selected CDC Program Authorizations ........................................................................... 28 Table 2. Top 10 CDC Grant Programs, by Funding Amount in FY2022 ...................................... 31 Table 3. Selected CDC Surveillance Systems ............................................................................... 36 Table 4. Selected CDC Surveys..................................................................................................... 38 Contacts Author Information........................................................................................................................ 48 Congressional Research Service Centers for Disease Control and Prevention (CDC): History, Overview, and Issues T he Coronavirus Disease 2019 (COVID-19) pandemic shined a spotlight on the Centers for Disease Control and Prevention (CDC), one of nine Public Health Service (PHS) agencies in the Department of Health and Human Services (HHS). CDC’s role in and response to the pandemic have been the subject of numerous congressional hearings and oversight investigations. With CDC the nation’s lead agency for disease prevention and health promotion, CDC’s primary domestic activities include providing support to state, local, tribal, and territorial (SLTT) health agencies, which are often at the forefront of public health. CDC also supports public health research, investigation, and data collection and provides public health education, guidance, and outreach to various audiences, including the general public, clinicians, and public health practitioners. These activities cover a wide range of health topics, including infectious diseases, chronic diseases, injury, disability, occupational health, environmental health, and public health emergency preparedness and response. In addition, the agency exercises regulatory authority in a few limited areas, such as in federal quarantine and inspection and occupational health and safety. CDC also administers a few mandatory health services programs, such as the Vaccine for Children program. Through its global health programs, CDC provides public health assistance to foreign governments (these activities are not a focus of this report). Initially established in 1946 as a small center focused on controlling malaria and other vectorborne diseases, CDC evolved into the federal government’s lead agency for disease prevention and health promotion in 1980. The agency grew through acquisition when many other preexisting federal public health programs, such as programs for tuberculosis and vital statistics, were transferred to CDC. In addition, Congress shaped CDC by enacting legislation aimed at strengthening its programs in certain areas, such as in injury prevention and control and public health emergency preparedness and response. Throughout CDC’s history, CDC Directors have undertaken comprehensive reviews of the agency that informed subsequent reorganizations, for example in the late 1970s and most recently through the Moving Forward initiative, which began in 2022.1 All of this occurred against the backdrop of changing health concerns and a growing health prevention science field. Throughout the 20th century, an epidemiologic transition occurred in which the leading causes of death in the United States shifted from mostly infectious diseases to mostly chronic diseases and injuries. Epidemiologists adapted the methods developed for controlling communicable diseases to learn the preventable causes of a wide range of diseases and health problems. At the beginning of the 20th century, most diseases were viewed as a matter of fate. By the end of the 20th century, it was widely understood that many health problems could be prevented, whether through vaccines, bug spray, seatbelts, helmets, condoms, diet, exercise, or other measures. CDC positioned itself to study how to prevent health problems and to support prevention and control programs to address such challenges.2 During the 118th Congress, some Members of Congress have contemplated legislative reform of CDC following the agency’s perceived performance during the COVID-19 pandemic.3 In particular, CDC has received scrutiny for its development and distribution of an initial laboratory 1 See Brief History section of this report. 2 See CDC’s Evolution in Context section of this report. 3 See for example, Representative Mariannette Miller-Meeks, “Miller-Meeks Seeks Stakeholder Feedback to Reform CDC Following Years of Consistent Failures and Broken Trust,” press release, April 5, 2023, https://millermeeks.house.gov/media/press-releases/miller-meeks-seeks-stakeholder-feedback-reform-cdc-followingyears-consistent. Congressional Research Service 1 Centers for Disease Control and Prevention (CDC): History, Overview, and Issues test for COVID-19, as well as for its COVID-19 related health guidance, which critics perceived as confusing or favorable to certain interest groups.4 Some have asserted that CDC has lost public trust, citing polls showing declining favorable public views of CDC and other public health agencies.5 One independent investigative report characterized CDC’s culture as academic and slow to respond to the urgent and changing emergency health situation posed by the pandemic.6 CDC has acknowledged some of these challenges in its own internal Moving Forward evaluation, and has since begun an internal reform process.7 There are many current views and proposals regarding potential CDC reform. Some have called for Congress to formally authorize CDC in statute.8 Although Congress shapes CDC’s funded programs through appropriations each year, CDC does not currently have a single, overarching statute that defines the agency’s mission, structure, and programs. As Representative Guthrie, chair of House Energy and Commerce Health Subcommittee (committee of jurisdiction for CDC) put it, “Congress has never, in a single voice, told the CDC what its mission is and is not.”9 Others have called for Congress to establish a more formal process for considering potential CDC reform, for example, by establishing an external advisory group to evaluate the agency and propose reforms.10 Still others have called for patience, arguing that Congress should allow CDC to continue with its Moving Forward reform effort before considering any major legislative reform.11 This CRS report (1) provides an overview of CDC and presents selected issues for potential legislative reform; (2) describes CDC’s history and contextualizes its evolution into the agency it 4 See, for example, HHS Office of the Inspector General, CDC’s Internal Control Weaknesses Led to Its Initial COVID-19 Test Kit Failure But CDC Ultimately Created a Working Test Kit, A-04-20-02027, October 2023, https://oig.hhs.gov/oas/reports/region4/42002027.pdf; and U.S. Congress, House Committee on Oversight and Accountability, Oversight of CDC Policies and Decisions During the COVID-19 Pandemic, 118th Cong., 1st sess., June 7, 2023. 5 J. Stephen Morrison and Tom Inglesby, Building the CDC the Country Needs, Center for Strategic and International Studies, January 2023, https://csis-website-prod.s3.amazonaws.com/s3fs-public/publication/ 230112_Morrison_Building_CDC.pdf?VersionId=kTKB3urWn1bfZpXuCqixfxzHfT8AUcIM. 6 The COVID Crisis Group, Lessons from the COVID War: An Investigative Report (New York, NY: PublicAffairs, 2023), pp. 64, 166. 7 CDC, “CDC Moving Forward Summary Report,” September 2022, https://www.cdc.gov/about/organization/cdcmoving-forward-summary-report.html. 8 Dr. Joel M. Zinberg and Drew Keyes, Unauthorized and Unprepared: Refocusing the CDC After COVID-19, Paragon Health Institute, July 2023, https://paragoninstitute.org/wp-content/uploads/2023/07/Unauthorized-and-UnpreparedRefocusing-the-CDC-after-COVID-19_Zinberg-Keyes_FOR-RELEASE_V1.pdf and Letter from Academy of General Dentistry ( to The Honorable Mariannette Miller-Meeks, M.D., Representative, House Committee on Energy and Commerce, April 23, 2023, https://www.agd.org/docs/default-source/advocacy-papers/agd-miller-meeks-letterheadcdc-rfi_.pdf?sfvrsn=1904d33c_0. 9 U.S. Congress, House Committee on Energy and Commerce, Subcommittee on Oversight and Investigations, Looking Back Before Moving Forward: Assessing CDC’s Failures in Fulfilling its Mission, 118th Cong., 1st sess., June 7, 2023. 10 J. Stephen Morrison and Tom Inglesby, Building the CDC the Country Needs, Center for Strategic and International Studies, January 2023, https://csis-website-prod.s3.amazonaws.com/s3fs-public/publication/ 230112_Morrison_Building_CDC.pdf?VersionId=kTKB3urWn1bfZpXuCqixfxzHfT8AUcIM and Brian J. Miller, Niraj Gowda, and Padmini Ranasinghe, et al., “A Vision for Supporting and Reforming The CDC,” Health Affairs, June 10, 2022. 11 American Public Health Association, Testimony of Georges C. Benjamin, Executive Director at Looking Back Before Moving Forward: Assessing CDC’s Failures in Fulfilling its Mission, House Energy and Commerce Committee, Subcommittee on Oversight and Investigations, June 7, 2023, p. 32 and Letter from Michael R. Fraser, CEO, Association of State and Territorial Health Officials to Senator Bill Cassidy, Ranking Member, Senate Committee on Health, Education, Labor, and Pensions, October 20, 2023, https://www.astho.org/globalassets/pdf/government-affairs/ astho-responds-to-senate-help-rfi-on-cdc-reform-october-2023.pdf. Congressional Research Service 2 Centers for Disease Control and Prevention (CDC): History, Overview, and Issues is today, including a discussion of Congress’s role in that evolution; and (3) outlines the CDC’s current mission, organization, statutory authorizations, appropriations, and major domestic programs and activities. Information on the Agency for Toxic Substances and Disease Registry (ATSDR)—a separate HHS operating division authorized by Comprehensive Environmental Response, Compensation, and Liability Act of 1980 (CERCLA)—is included within the overall discussion of CDC programs.12 This CRS report does not focus on CDC’s international programs and activities. What Is “Public Health”? In 1920, professor C.-E.A. Winslow defined the nascent concept of public health as [t]he science and art of preventing disease, prolonging life, and promoting physical health and efficiency through organized community efforts for the sanitation of the environment, the control of community infections, the education of the individual in the principles of personal hygiene, the organization of medical and nursing services for the early diagnosis and preventive treatment of disease, and the development of social machinery which will ensure to every individual in the community a standard of living adequate for the maintenance of health. CDC still uses this quote in its online Public Health 101 course today. Other definitions of public health are similarly broad. For example, in 1988, the Institute of Medicine (today the National Academy of Medicine) defined public health as “fulfilling society’s interest in assuring people can be healthy.” There are two key themes to definitions and ideas about public health. One is that public health focuses on preventing adverse health outcomes and promoting health more generally. Health promotion seeks to achieve an optimal state of wellness. The second is that public health focuses on efforts to improve health on a population and community-wide basis rather than on an individualized basis. Sources: CDC, “Introduction to Public Health,” https://www.cdc.gov/training/publichealth101/public-health.html, and C.-E.A. Winslow, “The Untilled Fields of Public Health,” 1920, Science, vol. 51, no. 1306, pp. 23-33. History and Context Brief History The public health system in the United States grew out of the sanitary reform movement of the 19th century, which was premised on the view that disease was caused by environmental conditions and lack of sanitation.13 Throughout the 1880s, states and cities established Boards of Health, often with broad powers to protect their residents’ health.14 These boards generally focused on tackling potential sources of disease in the physical environment. They conducted surveys on the health conditions of their populations, performed inspections, investigated outbreaks, and disinfected possessions and locations thought to cause disease. By the end of the 19th century, 40 of the 45 states then in existence and many localities had established health departments. In the late 19th century, as scientific understanding of the germ theory of disease developed, many of these health departments established laboratories to identify and investigate the germs that caused disease. State and local public health agencies then expanded their roles, 12 42 U.S.C. §§9601 et seq., at §9604(i) 13 Institute of Medicine, Chapter 3: A History of the Public Health System, The Future of Public Health., 1988, https://www.ncbi.nlm.nih.gov/books/NBK218224/; and Bernard J. Turnock, “Chapter 1: What is Public Health?” in Public Health: What it is and How it Works, 5th ed. (Jones and Bartlett Learning, LLC, 2012), p. 5. 14 Bernard J. Turnock, “Chapter 1: What is Public Health?” in Public Health: What it is and How it Works, 5th ed. (Jones and Bartlett Learning, LLC, 2012), p. 6. Congressional Research Service 3 Centers for Disease Control and Prevention (CDC): History, Overview, and Issues moving into surveillance (i.e., disease data reporting and monitoring), clinical care, and health education.15 Some trace the federal government’s role in public health to the Marine Hospital Service (MHS), a system of federally run hospitals for merchant seamen first established in 1798.16 By the late 1800s the MHS began to play a role in preventing the introduction and spread of infectious diseases into the United States by ship—including smallpox, yellow fever, and cholera. In 1878, Congress enacted the first federal quarantine law to prevent and control the introduction of infectious diseases into the United States.17 The MHS’s role then expanded to include public health activities, for example, federal quarantine, vaccination efforts, epidemic investigations, and medical examinations of immigrants.18 MHS was renamed the Public Health and Marine Hospital Service in 1902 and then the Public Health Service in 1912.19 Public Health Service Act of 1944 Even before CDC existed, Congress enacted the Public Health Service Act of 1944 (PHSA), which established the general set of federal public health authorities that, as amended, remain the basis of many CDC programs and regulations today.20 The PHSA consolidated and revised all preexisting federal laws pertaining to the U.S. Public Health Service (PHS), which had become part of the Federal Security Agency.21 As explained below in the “Statutory Authorizations” section, Title III of PHSA established a general set of federal public health authorities, including the authority to engage in research and investigations, to regularly publish health statistics and reports, and to assist states in preventing and controlling diseases.22 PHSA Title III also established the federal legal authorities for foreign and interstate quarantine and isolation to control communicable diseases. At the outset, the Surgeon General envisioned the federal government’s role in public health as focused primarily on assisting the states with implementation of their public health programs. According to the statement of the Surgeon General, then head of the PHS, after its enactment: [T]he new law will facilitate the smooth operation of the Federal-State public health programs and will make it possible to expand State and local health services to the people. With a minimum of Federal administrative control to insure efficient and economical 15 Institute of Medicine, Chapter 3: A History of the Public Health System, The Future of Public Health., 1988, https://www.ncbi.nlm.nih.gov/books/NBK218224/. 16 “An Act for the Relief of Disabled Seamen,” 5th Congress, https://memory.loc.gov/cgi-bin/ampage?collId=llsl& fileName=001/llsl001.db&recNum=728, and National Library of Medicine (NLM), “History of the Public Health Service: Disease Control and Prevention- Health Care for Seamen,” https://www.nlm.nih.gov/exhibition/phs_history/ seamen.html. 17 National Quarantine Act of 1878, P.L. 45-66. See Centers for Disease Control and Prevention (CDC), “History of Quarantine (Port Health),” https://www.cdc.gov/quarantine/historyquarantine.html. 18 National Library of Medicine, “History of the Public Health Service: Disease Control and Prevention- Fighting the Epidemic Spread of Disease,” https://www.nlm.nih.gov/exhibition/phs_history/seamen.html. 19 National Library of Medicine, “History of the Public Health Service: Two Centuries of Health Promotion,” https://www.nlm.nih.gov/exhibition/phs_history/seamen.html, and CDC, “The Roots of Public Health and CDC,” https://www.cdc.gov/museum/online/story-of-cdc/roots/index.html. 20 P.L. 78-184. 21 The Federal Security Agency was established by Reorganization Plan No. 1 of 1939. In addition to the U.S. Public Health Service, it included as subunits the Social Security Board, the U.S. Employment Service, the Office of Education, and other public welfare-related entities. The Federal Security Agency later became the Department of Health, Education, and Welfare, which in turn became the Department of Health and Human Services. 22 Alanson W. Willcox, “The Public Health Service Act, 1944,” Public Health Service, Federal Security Agency Bulletin, August 1944. Congressional Research Service 4 Centers for Disease Control and Prevention (CDC): History, Overview, and Issues expenditure of Federal funds, State health authorities develop, organize, and administer their own programs; but on technical problems, planning and administration of comprehensive programs, and training of personnel they look to the Public Health Service for leadership and expert advice. 23 1946-1950: Establishment and Initial Years The modern-day CDC began as the Communicable Disease Center in 1946.24 The center grew out of the Office of Malaria Control in War Areas (MCWA), which had been established in 1942 to prevent and control the spread of malaria around military training centers in the U.S. South.25 MCWA had been headquartered in Atlanta, GA, and CDC has been headquartered there since. By 1946, most of the military training centers had closed, but federal officials saw value in maintaining the expertise and capabilities of the office to prevent and control communicable diseases in the United States more generally.26 CDC was established administratively within the U.S. Public Health Service. Congress subsequently provided an appropriation in support of the new center.27 Initially, CDC was focused on vector-borne communicable diseases such as malaria.28 (Vectorborne diseases are caused by “vectors” such as mosquitoes, ticks, and fleas.29) In the following years, CDC’s role expanded to assist states in addressing other outbreaks and health threats, including diarrheal diseases and polio.30 By 1949, the center had become a division of the Bureau of State Services within the PHS and had the following responsibilities: 23 Alanson W. Willcox, “The Public Health Service Act, 1944,” Public Health Service, Federal Security Agency Bulletin, August 1944. 24 CDC, “Our History-Our Story,” https://www.cdc.gov/museum/history/our-story.html. In a 1946 supplement to the Code of Federal Regulations, CDC was listed as a field station of the States Relations Division within the Bureau of State Services of the U.S. Public Health Service. (U.S. National Archives, Division of the Federal Register, 1946 Supplement to the Code of Federal Regulations of the United States of America [Washington: GPO, 1947], p. 61496153.) 25 Federal Security Agency, U.S. Public Health Service, Development of the Communicable Disease Center, 1946, https://globalhealthchronicles.org/files/original/151a6159652008b3bf2ce2f158a5cdc1.pdf. 26 Federal Security Agency, U.S. Public Health Service, Development of the Communicable Disease Center, 1946, https://globalhealthchronicles.org/files/original/151a6159652008b3bf2ce2f158a5cdc1.pdf; Helen Neff, “The Center for Disease Control—1946-1976,” Connecticut Medicine, 1979; and William Foege, “Centers for Disease Control,” Journal of Public Health Policy, 1981. 27 Elizabeth W. Etheridge, “Chapter 1: War and the Mosquito,” in Sentinel for Health: A History of the Centers for Disease Control and Prevention (University of California Press, 1992), pp. 16-17. According to the book, “the U.S. Public Health Service had all the authority it needed to set up the new center, however, it needed funding from Congress.” FY1946 appropriations (P.L. 79-124) for the Public Health Service included a new line item for “communicable diseases” with a funding level of $1.04 million (the FY1945 appropriations law [P.L. 78-373] did not include a similar line item.) For examples of discussions of related appropriations, see U.S. Congress, House Committee on Appropriations, Subcommittee on Labor Department and Federal Security Appropriations, Department of Labor—Federal Security Agency Appropriation Bill for 1946, hearings, 79th Cong., 1st sess., April 19, 1945 (Washington: GPO, 1945), pp. 335-341; U.S. Congress, House Committee on Appropriations, Subcommittee on Labor Department and Federal Security Appropriations, Department of Labor—Federal Security Agency Appropriation Bill for 1947, hearings, 79th Cong., 2nd sess., April 15, 1946 (Washington: GPO, 1946), pp. 230-237; and U.S. Congress, House Appropriations, Labor Department and Federal Security Appropriations, Department of Labor—Federal Security Agency Appropriations Bill for 1948, hearings, 80th Cong., 1st sess., February 7 and 18, 1947 (Washington: GPO, 1947), pp. 273 and 368-377. 28. Federal Security Agency, U.S. Public Health Service, Development of the Communicable Disease Center, 1946, https://globalhealthchronicles.org/files/original/151a6159652008b3bf2ce2f158a5cdc1.pdf. 29 CDC, “About the Division of Vector-Borne Diseases,” https://www.cdc.gov/ncezid/dvbd/index.html. 30 Elizabeth W. Etheridge, “Chapter 2: The Lengthened Shadow of a Man,” in Sentinel for Health: A History of the (continued...) Congressional Research Service 5 Centers for Disease Control and Prevention (CDC): History, Overview, and Issues This center … provides through the regional offices to State and local health agencies consultation and training in the development and operation of communicable disease control programs and public health laboratory practices. It plans, directs and evaluates in cooperation with State and local health agencies programs for the control of selected communicable disease; provides professional leadership, and makes available the latest professional techniques in connection therewith. The center conducts and evaluates studies and investigations in the development of new and improved procedural techniques for the prevention, detection, diagnosis, control and treatment of communicable disease, and enforces the medical aspects of the interstate quarantine regulations. 31 1950s-1960s: Expansion in Epidemiology, Communicable Disease, and Vaccination Programs In its early years, CDC became known for the Epidemic Intelligence Service (EIS), which was established in 1951 to respond to the threat of potential biological warfare.32 EIS remains a core CDC program today.33 In the early 1950s, EIS was composed of early-career medical professionals who were trained by CDC to use epidemiology to control communicable diseases. Epidemiology uses statistical methods to study how often diseases occur in specific groups of people and to help trace the factors that contribute to disease. Epidemiology commonly relies on surveillance, or systematic and ongoing disease tracking and analysis. After training, EIS officers were available on-call to assist states with controlling communicable disease outbreaks. From the beginning, CDC received frequent requests for EIS assistance and the center became known for its ability to use applied epidemiology to help control disease spread.34 Reorganization Plan No. 1 of 1953 dissolved the Federal Security Agency and established the Department of Health, Education, and Welfare (HEW) in its stead (see textbox below). CDC was transferred to the new department. Throughout the early decades of its existence, CDC absorbed other programs and divisions within the PHS, for example, the Venereal Disease Division in 1957, the Tuberculosis program in 1960, the Morbidity and Mortality Weekly Report in 1961, and the Quarantine Service in 1967.35 As the Venereal Disease Division was absorbed into CDC, along with it came the public health advisors (PHAs), a cadre of early career health workers assigned to states who investigated sexually transmitted disease (STD) cases (then known as venereal disease). These young professionals implemented mass testing programs, interviewed Centers for Disease Control and Prevention (University of California Press, 1992), p. 35; and John Parascandola, “From MCWA to CDC—The Origins of the Centers for Disease Control and Prevention,” Public Health Reports, vol. 111 (November 1996), pp. 549-551. 31 Federal Security Agency, “Public Health Service: Organization and Delegations of Authority,” 14 Federal Register 2667, at 2672, May 20, 1949. 32 Elizabeth W. Etheridge, “Historical Perspectives: History of CDC,” Morbidity and Mortality Weekly Report, vol. 45 (June 1996), pp. 526-30; and Helen Neff, “The Center for Disease Control—1946-1976,” Connecticut Medicine, 1979. 33 CDC, “Epidemic Intelligence Service,” September 2023, https://www.cdc.gov/eis/index.html. 34 Elizabeth W. Etheridge, “Chapter 3: The Disease Detectives,” in Sentinel for Health: A History of The Centers for Disease Control, ed. University of California Press (1992), pp. 36-66; and Jeffrey Koplan and Stephen B. Thacker, “Fifty Years of Epidemiology at the Centers for Disease Control and Prevention: Significant and Consequential,” American Journal of Epidemiology, vol. 154, no. 11 (2001). 35 CDC, “CDC Timeline 1940s-1970s,” https://www.cdc.gov/museum/timeline/1940-1970.html; and Elizabeth W. Etheridge, “Chapter 8: Call to Arms,” in Sentinel for Health: A History of The Centers for Disease Control, ed. University of California Press (1992), p. 115. Congressional Research Service 6 Centers for Disease Control and Prevention (CDC): History, Overview, and Issues patients, and traced patients’ contacts—functions that remain core parts of public health programs today.36 In 1955, CDC responded to its first national health crisis. After the Salk polio vaccine became available, the PHS began to receive reports of polio cases among children who received the vaccine. CDC established a surveillance unit to monitor and investigate the cases and provide regular summaries of findings to state health officers and others involved in disease control. CDC eventually learned that 80% of the reported cases were associated with one product that constituted 10% of the total vaccine supply. A manufacturing issue was found and the product was pulled from the market. This incident, often called “the Cutter incident” (attributed to vaccine producer Cutter Laboratories), set a precedent for CDC to take a leadership role in national response during future emerging health threats and outbreaks, especially by leading national disease tracking and surveillance.37 CDC subsequently played a similar role in coordinating U.S. national disease tracking during the 1957-1958 Asian influenza pandemic, which caused several U.S. outbreaks.38 In the 1960s, CDC began to play a key role in federal immunization programs. Following the licensure of the Sabin oral polio vaccine in 1961, Congress enacted the Vaccination Assistance Act of 1962,39 which established the first federal grant program focused on immunization.40 The law added a new PHSA Section 317, which authorized a state grant program for intensive community vaccination programs against polio, diphtheria, whooping cough, and tetanus—a program that remains in place today and is commonly known as the “Section 317 Immunization Program.”41 CDC became responsible for administering the new grant program. The agency provided funding and vaccines to states, and PHAs helped with program implementation. As the measles and rubella vaccines were licensed in 1963 and 1969, respectively, the two types of vaccines were integrated into the program. Incidence of vaccine-preventable disease fell throughout the 1960s.42 In the late 1950s, CDC began to provide public health assistance to other countries. At first, CDC provided periodic assistance during disease outbreaks. During the global Asian influenza pandemic in 1957-1958, CDC helped distribute testing supplies throughout the world, informed global laboratory practices, and tracked and summarized disease cases.43 In 1966, an international 36 Elizabeth W. Etheridge, “Chapter 6: Building the Temple,” in Sentinel for Health: A History of The Centers for Disease Control, ed. University of California Press (1992), pp. 89-91. 37 Helen Neff, “The Center for Disease Control—1946-1976,” Connecticut Medicine, 1979; Elizabeth W Etheridge, “Historical Perspectives: History of CDC,” Morbidity and Mortality Weekly Report, vol. 45 (June 1996), pp. 526-30; and D.A. Henderson, “The Development of Surveillance Systems,” American Journal of Epidemiology, vol. 183, no. 5 (February 26, 2016), pp. 381-386. 38 D.A. Henderson, “The Development of Surveillance Systems,” American Journal of Epidemiology, vol. 183, no. 5 (February 26, 2016), pp. 381-386. 39 P.L. 87-868. 40 R. Hinman, Walter A. Orenstein, and Anne Shuchat, “Vaccine-Preventable Diseases, Immunizations, and MMWR— 1961—2011,” Morbidity and Mortality Weekly Report, vol. 60, no. 4 (October 7, 2011), pp. 49-57. Prior to enactment of this law, vaccines were administered in private medical practices or by state and local health departments, generally using state and local funds with some support from the Maternal and Child Health Block grant program. 41 Paul Jarris and Virginia Dolen, “Section 317 Immunization Program: Protecting a National Asset,” Public Health Reports, vol. 128, no. 2 (March 2013), pp. 96-98. 42 Alan R. Hinman, Walter A. Orenstein, and Anne Shuchat, “Vaccine-Preventable Diseases, Immunizations, and MMWR—1961—2011,” Morbidity and Mortality Weekly Report, vol. 60, no. 4 (October 7, 2011), pp. 49-57. 43 Helen Neff, “The Center for Disease Control—1946-1976,” Connecticut Medicine, 1979, and David J. Sencer, “CDC’s 60th Anniversary: Director’s Perspective—David J. Sencer, M.D., M.P.H., 1966-1977,” Morbidity and Mortality Weekly Report, vol. 55, no. 27 (July 14, 2006), pp. 745-49. Congressional Research Service 7 Centers for Disease Control and Prevention (CDC): History, Overview, and Issues malaria eradication program was transferred from the Agency for International Development to CDC. CDC’s international work subsequently expanded to include a smallpox eradication program and a famine relief initiative.44 CDC was briefly renamed the National Communicable Disease Center in 1967.45 By 1968, it became a center within the broader Health Services and Mental Health Administration agency. Its responsibilities were to support “a national program for the prevention and control of communicable and other preventable diseases.”46 Reorganization Plans in 1953 and 1966 Both CDC and the U.S. Public Health Service (PHS) underwent several major reorganizations in the 1960s and 1970s. These reorganizations were underpinned by two federal reorganization plans submitted to Congress in accordance with the Reorganization Act of 1949: • April 1953: Reorganization Plan No. 1 of 1953 (67 Stat. 631) created the Department of Health, Education, and Welfare and transferred all functions and agencies of the Federal Security Agency, including the PHS and its CDC subunit, to the new department. At the time of the reorganization, the Surgeon General oversaw the PHS agencies. The plan also stated, “The [HEW] Secretary may from time to time make such provisions as the Secretary deems appropriate authorizing the performance of any of the functions of the Secretary by any other officer, or by any agency or employee, of the Department.” • June 1966: Reorganization Plan No. 3 of 1966 (80 Stat. 1610) transferred the PHS from under the Surgeon General to the HHS Secretary. The plan “transferred to the Secretary of Health, Education, and Welfare … all functions of the Public Health Service, of the Surgeon General of the Public Health Service, and of all other officers and employees of the Public Health Service, and all functions of all agencies of or in the Public Health Service.” It provided further that the Secretary “may from time to time make such provisions as he shall deem appropriate authorizing the performance of any of the functions transferred to him by the provisions of this reorganization plan by any officer, employee, or agency of the Public Health Service or of the Department of Health, Education, and Welfare.” The plan abolished several PHS subunits, including the Bureau of State Services, which had been the home of the Communicable Disease Service since 1946. With regard to implementation of these abolishments, the plan stated that the “Secretary shall make such provisions as he shall deem necessary respecting the winding up of any outstanding affairs of the agencies abolished.” Following the Supreme Court ruling in INS v. Chadha, which cast doubt over the validity of reorganization plans, Congress enacted P.L. 98-532, which stated, “Congress hereby ratifies and affirms as law each reorganization plan that has, prior to the date of enactment of this Act, been implemented pursuant to the provisions of chapter 9 of title 5, United States Code, or any predecessor Federal reorganization statute.” Thus, the 1953 and 1966 reorganization plans and the authorities they provided were ratified as law (42 U.S.C. §3501 and 42 U.S.C. §202, note, respectively) at that time. These authorities remain in place today. 1970s: Becoming the Center for Disease Control and Expanding Scope In 1970, CDC was renamed the Center for Disease Control. CDC’s official responsibilities had widened to encompass “a national program for the prevention and control of communicable and vector-borne diseases and other preventable conditions, including those related to malnutrition.”47 At the time, CDC’s program areas consisted of (1) ecological investigations, (2) epidemiology, 44 Elizabeth W. Etheridge, “Chapter 13: Over Oceans and Into Space,” and “Chapter 14: The Crusade Against Smallpox,” in Sentinel for Health: A History of The Centers for Disease Control, ed. University of California Press (1992), pp. 178-187 and 188-210; and William Foege, “Centers for Disease Control,” Journal of Public Health Policy, 1981. 45 CDC, “CDC Timeline 1940s-1970s,” https://www.cdc.gov/museum/timeline/1940-1970.html. 46 Public Health Service, “Health Services and Mental Health Administration: Statement of Organizations, Functions, and Delegations of Authority,” 33 Federal Register 15957, October 30, 1968. 47 Public Health Service, “Health Services and Mental Health Administration: Statement of Organizations, Functions, and Delegations of Authority,” 35 Federal Register 10797, July 1, 1970. Congressional Research Service 8 Centers for Disease Control and Prevention (CDC): History, Overview, and Issues (3) foreign quarantine, (4) malaria, (5) nutrition, (6) small pox eradication, (6) training, (7) laboratory, and (8) state and community services (including those related to tuberculosis, other respiratory diseases, and STDs).48 This marked the first time that CDC’s official responsibilities included noncommunicable health conditions. However, even before this change—as early as the 1950s—the CDC Director had assigned staff to study the epidemiology of noncommunicable health issues, such as cancer, malnutrition, and family planning.49 In 1973, after a series of PHS reorganizations, CDC officially became one of the service’s five main agencies (instead of a division within a larger program).50 Throughout the 1970s, the scope of CDC’s work expanded as the agency established programs in the areas of nutrition, environmental health (e.g., lead exposure), smoking tobacco and health, occupational safety and health, oral health, cancer, health education, family planning, and birth defects.51 CDC acquired the PHS nutrition survey in 1971 (today known as the National Health and Nutrition Examination Survey, NHANES), the National Clearinghouse on Smoking and Health in 1972, and the National Institute for Occupational Safety and Health, along with lead paint poisoning prevention and urban rat control programs, in 1973.52 During the 1970s, CDC was credited with some public health successes. With assistance from CDC’s global smallpox program, which relied on a strategy of surveillance and containment, smallpox was announced officially eradicated from the globe in 1979.53 By the end of the decade, the last human case of wild poliovirus (rather than vaccine-induced) was reported in the United States. Using NHANES data, CDC’s environmental services division helped determine that blood lead levels were associated with lead concentration in gasoline, which led to regulations that decreased the amount of lead in gasoline and subsequently reduced blood lead levels in the population.54 CDC also faced scrutiny in the 1970s. In 1972, CDC was criticized for the so-called Tuskegee study begun in 1932 that left untreated syphilis in Black male patients for decades, even when 48 Public Health Service, “Health Services and Mental Health Administration: Statement of Organizations, Functions, and Delegations of Authority,” 35 Federal Register 10797, July 1, 1970. 49 Jeffrey Koplan and Stephen B. Thacker, “Fifty Years of Epidemiology at the Centers for Disease Control and Prevention: Significant and Consequential,” American Journal of Epidemiology, vol. 154, no. 11 (2001); Stephen B. Thacker, “Epidemiology and Public Health at CDC,” MMWR, vol. 55, no. SUP02 (December 22, 2006), pp. 3-4; Elizabeth W. Etheridge, “Chapter 3: The Disease Detectives,” and “Chapter 9: The Candidate for Surgeon General,” in Sentinel for Health: A History of The Centers for Disease Control, ed. University of California Press (1992), pp. 47 and 135-136; and David J. Sencer, “CDC’s 60th Anniversary: Director’s Perspective—David J. Sencer, M.D., M.P.H., 1966-1977,” Morbidity and Mortality Weekly Report, vol. 55, no. 27 (July 14, 2006), pp. 745-49. 50 At the time, the U.S. Public Health Service consisted of (1) the Center for Disease Control, (2) the Food and Drug Administration, (3) the Health Resources Administration, (4) the Health Services Administration, and (5) the National Institutes of Health. Public Health Service, “Reorganization Order,” 38 Federal Register 18261, July 9, 1973; and William Foege, “Centers for Disease Control,” Journal of Public Health Policy, 1981. 51 CDC, “CDC Timeline 1940s-1970s,” https://www.cdc.gov/museum/timeline/1940-1970.html; William Foege, “Centers for Disease Control,” Journal of Public Health Policy, 1981; and Helen Neff, “The Center for Disease Control—1946-1976,” Connecticut Medicine, 1979. 52 Elizabeth W. Etheridge, “Chapter 16: Acquisitions,” in Sentinel for Health: A History of The Centers for Disease Control, ed. University of California Press (1992), pp. 224-234. 53 Elizabeth W. Etheridge, “Chapter 14: The Crusade Against Smallpox,” in Sentinel for Health: A History of The Centers for Disease Control, ed. University of California Press (1992), pp. 188-210; Elizabeth W Etheridge, “Historical Perspectives: History of CDC,” Morbidity and Mortality Weekly Report, vol. 45 (June 1996), pp. 526-30; D.A. Henderson, “Smallpox Eradication,” Public Health Reports, vol. 95, no. 5 (September 1980), pp. 423-426; and D.A. Henderson, “The Development of Surveillance Systems,” American Journal of Epidemiology, vol. 183, no. 5 (February 26, 2016), pp. 381-386. 54 CDC, “CDC Timeline 1940s-1970s,” https://www.cdc.gov/museum/timeline/1940-1970.html; and Karen K. Steinberg, “Laboratory Science and Public Health at CDC,” MMWR, vol. 55, no. SUP02 (December 22, 2006), pp. 5-6. Congressional Research Service 9 Centers for Disease Control and Prevention (CDC): History, Overview, and Issues treatment became available, in order to study progression of the disease. The agency had inherited the study with the transfer of the Venereal Diseases Division in 1957.55 CDC was also criticized for taking years to determine the cause of Legionnaires’ disease, a severe form of pneumonia that caused several deadly outbreaks at the time. In addition, a 1976 mass immunization campaign to protect against a potential swine flu epidemic was suspended early when no influenza outbreak occurred and the vaccines were found to be associated with a rare but increased risk of GuillainBarre syndrome, a severe neurological disorder.56 A subsequent review at the government’s request found that the “program was marked by controversy, delay, administrative troubles, legal complications, unforeseen side effects and a progressive loss of credibility for public health authorities,” and the review implicated the CDC Director in many of the challenges faced.57 Some have since defended the CDC Director’s decisions, arguing that he made the right decisions based on available information.58 1980s: The Centers for Disease Control, Lead Disease Prevention Agency, and the HIV/AIDS Epidemic In the late 1970s, CDC Director William Foege sought to shape CDC’s future direction by soliciting public input and convening an advisory committee of outside experts and members of the public.59 The committee published a report in 1978 that identified the highest priority preventable health problems at the time, recommended strategies to address those problems, and made recommendations regarding CDC’s role. The report recommended that CDC become the lead federal agency for disease prevention to address the full range of health problems facing the nation and the globe.60 The following year, the Surgeon General, with input from CDC, published the first Healthy People report, which laid out the major preventable health challenges facing the country and marked a national commitment to prevention.61 This report also set the stage for CDC to take a holistic approach to disease prevention and health promotion in the 1980s. The Department of Education Organization Act,62 enacted in 1979, created the Department of Education as a separate department and renamed the Department of Health, Education, and Welfare as the Department of Health and Human Services. The following year, CDC was reorganized and renamed the Centers for Disease Control (with the “s” added) and its official mission (which remains in place today) became as follows: 55 Elizabeth W. Etheridge, “History of CDC,” Morbidity and Mortality Weekly Report, vol. 45 (June 1996), pp. 526-30. In 1997, the President offered an apology for the study conducted in Tuskegee to its survivors, and the wives, family members, children, and grandchildren of the men subjected to the government’s research (https://clintonwhitehouse4.archives.gov/textonly/New/Remarks/Fri/19970516-898.html). 56 Elizabeth W. Etheridge, “Chapter 18: 1976,” and “Chapter 19: Aftermath,” in Sentinel for Health: A History of The Centers for Disease Control, ed. University of California Press (1992), pp. 247-275. 57 Richard E. Neustadt and Harvey V. Fineberg, The Swine Flu Affair: Decision Making on a Slippery Disease, 1978, https://nap.nationalacademies.org/catalog/12660/the-swine-flu-affair-decision-making-on-a-slippery-disease. 58 Rita Rubin, “US CDC Celebrates 70 Years,” The Lancet, vol. 388, no. 10057 (November 5, 2016), pp. 2224-2225. 59 William Foege, “Centers for Disease Control,” Journal of Public Health Policy, 1981. 60 CDC Programs and Policies Advisory Committee, Recommendations for a National Strategy for Disease Prevention, Atlanta, GA, June 30, 1978, https://stacks.cdc.gov/view/cdc/131521. 61 United States Public Health Service, Healthy People: The Surgeon General’s Report on Health Promotion and Disease Prevention, 1979, https://profiles.nlm.nih.gov/spotlight/nn/catalog/nlm:nlmuid-101584932X94-doc; and William Foege, “Centers for Disease Control,” Journal of Public Health Policy, 1981. 62 P.L. 96-88. Congressional Research Service 10 Centers for Disease Control and Prevention (CDC): History, Overview, and Issues The Centers for Disease Control (CDC) serves as the Department’s focus for developing and applying disease prevention and control, environmental health, and health promotion and health education activities designed to improve the health of the people of the United States. 63 At the time, CDC consisted of programs and offices focused on (1) epidemiology, (2) biosafety, (3) international health, (4) laboratory improvement, (5) prevention services, (6) environmental health, (7) occupational safety and health, (8) health promotion and education, (9) professional development and training, and (10) infectious diseases.64 The key new additions included the Center for Health Promotion and Education and Center for Environmental Health, both of which incorporated preexisting CDC programs.65 Most prominently, the 1980s were marked by the HIV/AIDS epidemic.66 CDC first received reports of the new disease in 1981 and then conducted further epidemiologic and laboratory investigations. CDC quickly learned that the disease spread primarily among men who had sex with men and was likely caused by a blood-borne virus. CDC formed a taskforce on the disease and warned that it could become a major health issue.67 Budgetary constraints of the early 1980s limited CDC’s ability to direct resources to the problem.68 By the mid to late 1980s, as the disease spread more widely, Congress had begun to dedicate more resources to HIV/AIDS programs. CDC’s HIV prevention budget grew from $200 thousand in FY1981 to over $300 million in FY1988 (not inflation adjusted).69 CDC used its established methods of assessing risks and developing preventive programs in its efforts to control the epidemic. Throughout the 1980s, CDC established several new grant programs to fund HIV/AIDS prevention and control programs at the state and local level and spearheaded several informational campaigns on the disease.70 By FY1991, HIV/AIDS funding represented 37% of the agency’s budget.71 Defining Public Health in America: Public Health in America Statement, 1994 In 1988, an Institute of Medicine report on the U.S. public health system found that it had fallen into “disarray.” The report found general lack of agreement within the field on public health’s mission and appropriate role. While 63 Public Health Service, “Center for Disease Control; Office of the Assistant Secretary for Health Statement of Organization, Functions and Delegations of Authority,” 45 Federal Register 67772, October 8, 1980. For the current official mission statement, see CDC, “Immediate Office of the Director (IOD): Mission Statement,” https://www.cdc.gov/about/organization/cio-orgcharts/iod.html. 64 Public Health Service, “Center for Disease Control; Office of the Assistant Secretary for Health Statement of Organization, Functions and Delegations of Authority,” 45 Federal Register 67772, October 8, 1980. 65 Elizabeth W. Etheridge, “Chapter 23: Toward the 21 st Century,” in Sentinel for Health: A History of The Centers for Disease Control, ed. University of California Press (1992), pp. 314-315. 66 CDC, “CDC Timeline 1980s,” https://www.cdc.gov/museum/timeline/1980.html. 67 Elizabeth W. Etheridge, “Chapter 24: Discovery of the AIDS Epidemic,” in Sentinel for Health: A History of The Centers for Disease Control, ed. University of California Press (1992), pp. 321-340. 68 Elizabeth W. Etheridge, “Chapter 24: Discovery of the AIDS Epidemic,” in Sentinel for Health: A History of The Centers for Disease Control, ed. University of California Press (1992), pp. 321-340; and U.S. Congress, House Committee on Government Operations, The Federal Response to AIDS, committee print, 98th Cong., 1st sess., November 30, 1983, H. Rept. 98-582. 69 Gary R. Noble, William C. Parra, and Priscilla B. Holman, “Organizational Structure and Resources of CDC’s HIVAIDS Prevention Program,” Public Health Reports, vol. 106, no. 6 (November 1991), pp. 664-667. 70 Bernard J. Turnock, “Chapter 4: Law, Government, and Public Health,” in Public Health: What it is and How it Works, 5th ed. (Jones and Barlett Learning, 2012), pp. 206-207. 71 Gary R. Noble, William C. Parra, and Priscilla B. Holman, “Organizational Structure and Resources of CDC’s HIVAIDS Prevention Program,” Public Health Reports, vol. 106, no. 6 (November 1991), pp. 664-667. Congressional Research Service 11 Centers for Disease Control and Prevention (CDC): History, Overview, and Issues the report made some initial recommendations, federal public health agencies then worked to further define public health’s mission and scope. In 1994, the CDC Director and the Deputy Assistant Secretary for Disease Prevention and Health Promotion led a working group of PHS agency representatives and outside stakeholders to develop a consensus list of essential public health services. Ultimately, in fall 1994, HHS leadership and U.S. public health organizations adopted a Public Health in America statement that drew from the list, shown below. This framework, revised since 1994, has continued to serve as a basic foundation for public health practice in the United States. Public Health in America Statement: Vision: Healthy people in healthy communities Mission: Promote physical and mental health and prevent disease, injury, and disability Public Health: • Prevents epidemics and the spread of disease • Protects against environmental hazards • Prevents injuries • Promotes and encourages healthy behaviors • Responds to disasters and assists communities in recovery • Assures the quality and accessibility of health services Essential Public Health Services: • Monitor health status to identify community health problems • Diagnose and investigate health problems and health hazards in the community • Inform, educate, and empower people about health issues • Mobilize community partnerships to identify and solve health problems • Develop policies and plans that support individual and community health efforts • Enforce laws and regulations that protect health and ensure safety • Link people to needed personal health services and assure the provision of health care when otherwise available • Assure a competent public health and personal health care workforce • Evaluate effectiveness, accessibility, and quality of personal and population-based health services • Research for new insights and innovative solutions to health problems Sources: Institute of Medicine Committee for the Study of the Future of Public Health, The Future of Public Health, 1988, https://www.ncbi.nlm.nih.gov/books/NBK218215/; James A. Harrell and Edward L. Baker, “The Essential Services of Public Health,” Leadership in Public Health, vol. 3, no. 3 (1994), pp. 27-30; The Public Health National Center for Innovations and the de Beaumont Foundation, Defining Public Health Practice: 25 Years of the 10 Essential Public Health Services, August 2019, https://www.astdd.org/docs/defining-public-health-practice-25-years-of-the-10essential-public-health-services.pdf; and Bernard J. Turnock, "Chapter 5: Core Functions and Public Health Practice,” in Public Health: What it is and How it Works, 5th ed. (Jones and Bartlett Learning, 2012), pp. 217-264. 1992-Present: Centers for Disease Control and Prevention The Preventive Health Amendments of 1992 changed all statutory references to CDC in law to “Centers for Disease Control and Prevention,” the name of the agency today.72 Since the early 1990s, CDC’s programs have continued to evolve. As shown in the textbox above, discussions about the appropriate role and scope of public health in the late 1980s and early 1990s set the stage for issues on which CDC would focus in the following decades. This section discusses some of the agency’s major areas of focus. Vaccines for Children and other immunization programs. Following a measles epidemic from 1989 to 1991, where half of all cases occurred among unvaccinated preschool children, the 72 P.L. 102-531. Congressional Research Service 12 Centers for Disease Control and Prevention (CDC): History, Overview, and Issues Omnibus Budget Reconciliation Act of 199373 established the Vaccines for Children (VFC) program in Section 1928 of the Social Security Act.74 Through this Medicaid-financed program, CDC purchases recommended childhood vaccines in bulk at a federally negotiated discounted rate and distributes them to SLTT agencies to allow participating providers to furnish them at no cost to eligible children (see the “Vaccines for Children” section). Together with the longstanding PHSA Section 317 immunization program (see the “1950s-1960s” section), the VFC program helped expand CDC’s role in supporting the infrastructure for immunization safety-net programs across the country. Starting in the 1990s, CDC also began to expand other immunization programs; for example, it invested in the nation’s network of Immunization Information Systems, population-based data systems that help record and track immunizations received.75 Chronic disease. Since the 1990s, CDC’s chronic disease prevention and control programs have expanded. In the early 1990s, Congress enacted several laws authorizing cancer programs at CDC. For example, in 1992, Congress enacted the Cancer Registries Amendment Act,76 which established the National Program of Cancer Registries—state-based systems to collect and track data on cancer.77 In addition, in 1990, Congress enacted the Breast and Cervical Cancer Mortality Prevention Act of 1990,78 which established a CDC state grant program to fund cancer screening among uninsured and underinsured women, the National Breast and Cervical Cancer Early Detection Program (NBCCEDP). More recently, starting in 2008, CDC also funded heart disease and stroke risk factor screenings for the population served by NBCCEDP, known as the WISEWOMAN program.79 In FY2023, CDC’s Chronic Disease Prevention and Health Promotion program funded 30 separate grant programs.80 Firearm injury and mortality prevention research and the “Dickey amendment”: In the mid1990’s, some concerns arose surrounding perceived political biases of CDC research related to firearms and violence.81 Starting in FY1997, Congress added a new appropriations limitation that, at the time read, “none of the funds made available for injury prevention and control at the Centers for Disease Control and Prevention may be used to advocate or promote gun control.”82 A version of this amendment, commonly known as the “Dickey amendment,” has been included in annual appropriations every year since FY1997.83 While the language does not specifically 73 P.L. 103-66. 74 42 U.S.C. §1396s. 75 CRS Report R47024, Immunization Information Systems: Overview and Current Issues. 76 P.L. 102-515. 77 See CDC, “National Program of Cancer Registries,” cdc.gov/cancer/npcr/index.htm. 78 P.L. 101-354. 79 CDC, “WISEWOMAN Frequently Asked Questions (FAQs),” cdc.gov/wisewoman/faqs.htm. The program’s name is an acronym for “Well-Integrated Screening and Evaluation for WOMen Across the Nation.” 80 CDC, “National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP): Our Budget,” https://www.cdc.gov/chronicdisease/programs-impact/budget/index.htm. 81 See statements made at 1996 hearing: S. Congress, House Committee on Appropriations, Subcommittee on Labor, Health and Human Services, and Education, Hearing on Centers for Disease Control and Prevention Budget, 104 th Cong., 2nd sess., May 1, 1996, H.Hrg 24-955 (Washington: GPO, 1996), pp. 111-392. 82 P.L. 104-208. 83 Found in the annual Departments of Labor, Health and Human Services, and Education, and Related Agencies (LHHS) appropriations bill. In FY2023 (P.L. 117-328), the provision read, “None of the funds made available in this title may be used, in whole or in part, to advocate or promote gun control.” The title refers to the entire title that provides HHS appropriations in the LHHS law. The limitation has applied to all of HHS appropriations in the LHHS act since FY2012. Although the amendment is commonly referred to as the “Dickey amendment,” Representative Jay (continued...) Congressional Research Service 13 Centers for Disease Control and Prevention (CDC): History, Overview, and Issues mention research, CDC responded to the amendment and the surrounding political controversy by limiting its research related to firearms and violence.84 Some studies have found that since the limitation has been in effect, firearm-related violence has been underfunded and understudied relative to other leading causes of death based on mortality rates.85 Starting in FY2020 (P.L. 116-94), following several high-profile mass shootings, Congress has provided $12.5 million annually to CDC for “firearm injury and mortality prevention research.” These amounts have been directed in appropriations report language for each of FY2020 through FY2023.86 During a 2019 House Appropriations subcommittee hearing, some Members of both parties expressed support for keeping the Dickey amendment in place as a “guardrail,” while funding CDC research related to firearms and violence.87 Public health emergency and bioterrorism. In 1999, CDC established several new major public health emergency programs. For example, CDC launched the National Pharmaceutical Stockpile, now known as the Strategic National Stockpile (SNS), a federal stockpile of drugs, vaccines, and other medical products intended for emergency responses (SNS is now housed at the Administration for Strategic Preparedness and Response).88 In the same year, CDC established the Laboratory Response Network, a coordinated network of laboratories at the federal, state, and local level with specialized capabilities to detect biological, chemical, and other health threats.89 As discussed in greater detail in the “Example 3: Public Health Emergency Activities” section, Congress has enacted a series of statutes since 2000 that have likewise expanded CDC’s role and programs in public health emergency management and response. Major infectious disease outbreaks and epidemics. Since the early 2000s, CDC has responded to several major global and domestic infectious disease outbreaks. These have included the severe acute respiratory syndrome outbreak (SARS; 2003), H5N1 avian influenza (2005), H1N1 pandemic influenza (2009), Ebola virus (2014-2015 and 2018-present), Zika virus (2016), the Coronavirus Disease 2019 pandemic (COVID-19; 2020-2023), and mpox outbreak (2022). In particular, concerns about a potential avian influenza pandemic in 2005 prompted many congressional hearings, plans, and policy assessments on national preparedness for a pandemic Dickey did not introduce the amendment. Representative Dickey proposed a different amendment that did not pass in committee markup. See CQ Almanac, 104th Congr., 2nd Sess., 1997, 52nd ed., 10-59-10-66., http://library.cqpress.com/ cqalmanac/cqal96-841-24596-1091627. 84 From a 2017 GAO report, “CDC officials said that after the restriction was enacted, the agency interpreted it as a prohibition of activities related to gun control advocacy, but not as a restriction of activities that supported firearm injury-related data collection and scientific research. However, CDC officials added that the agency has limited its firearm-related research over time because, in 1997, its budget was reduced by an amount equal to what the agency had spent on such research, and because it learned that further reductions were possible if the research continued.” See GAO, Personal Firearms: Programs that Promote Safe Storage and Research on their Effectiveness, GAO-17-665, September 2017, p. 20, https://www.gao.gov/assets/690/687239.pdf. 85The appropriations limitation has applied to all HHS research since FY2012, therefore some of the studies examine effects on National Institutes of Health (NIH), CDC, and other HHS health research. David E. Stark and Nigam H. Shah, “Funding and Publication of Research on Gun Violence and Other Leading Causes of Death,” Journal of the American Medical Association, vol. 317, no. 1 (January 3, 2017), pp. 84-85 and Joseph A. Ladapo, Benjamin A. Rodwin, and Andrew M. Ryan, “Scientific Publications on Firearms in Youth Before and After Congressional Action Prohibiting Federal Research Funding,” Journal of the American Medical Association, vol. 310, no. 5 (August 7, 2013), pp. 532-34. 86 CRS review of appropriations reports accessible from the CRS Appropriations Status table. 87 House Subcommittee on LHHS Appropriations, Addressing the Public Health Emergency of Gun Violence, 116th Cong., 1st sess., March 7, 2019. 88 See CRS Report R47400, The Strategic National Stockpile: Overview and Issues for Congress. 89 CDC, “CDC Timeline 1990s,” https://www.cdc.gov/museum/timeline/1990.html. Congressional Research Service 14 Centers for Disease Control and Prevention (CDC): History, Overview, and Issues that informed CDC’s subsequent responses.90 Many of these infectious disease responses— especially the COVID-19 pandemic—have tested CDC’s role as a lead public health agency with expertise in infectious disease control and response, as explained further in the next section. The Affordable Care Act and public health programs. The Patient Protection and Affordable Care Act (ACA91), enacted in 2010, was landmark health policy legislation that made many changes across federal health policy areas, including public health prevention and health promotion programs. The ACA authorized several new programs at CDC and codified several existing programs, including programs related to infectious diseases, diabetes prevention, and oral health.92 The ACA established a new mandatory budget authority for public health, the Prevention and Public Health Fund, “to provide for expanded and sustained national investment in prevention and public health programs to improve health and help restrain the rate of growth in private and public sector health care costs.”93 That ACA section has appropriated funding annually, and as directed through annual appropriations, CDC has received the majority of this funding in recent years (e.g., $903 million to CDC in FY2023 out of $943 million total). This PPHF, combined with annual discretionary appropriations, serves as one of CDC’s main sources of budget authority for public health programs.94 Current Status: The COVID-19 Pandemic and CDC’s Moving Forward Initiative During the COVID-19 pandemic, CDC took a highly visible role in educating the public about the virus and disease, collecting and tracking COVID-19 data, informing COVID-19 research and science, and issuing health guidance aimed at prevention and control. CDC also advised and coordinated many national public health programs, for example, testing, contact tracing, and vaccination efforts.95 The agency also used its regulatory authorities to issue public health orders during the pandemic, for example, an order requiring vaccination for international travelers to the United States and an order restricting the entry of certain noncitizens into the United States, commonly known as the “Title 42” entry restrictions.96 90 The COVID Crisis Group, Lessons from the COVID War: An Investigative Report (New York: Public Affairs, 2023), pp. 73-74. See, for example, U.S. Congress, House Committee on Government Reform, The National Pandemic Influenza Preparedness and Response Plan: Is the United States Ready for Avian Flu? 109th Cong., 1st sess., November 4, 2005, 109-94; and CDC, “National Pandemic Strategy,” https://www.cdc.gov/flu/pandemic-resources/nationalstrategy/index.html. 91 P.L. 111-148, as amended. 92 See CRS Report R41278, Public Health, Workforce, Quality, and Related Provisions in ACA: Summary and Timeline. 93 P.L. 111-148, §4002. 94 For more information, see CRS Report R47895, Prevention and Public Health Fund: In Brief. 95 CDC, “CDC in Action: Working 24/7 to Stop the Threat of COVID-19,” February 4, 2021, https://www.cdc.gov/ budget/documents/covid-19/CDC-247-Response-to-COVID-19-fact-sheet.pdf. 96 CDC, “Amended Order Implementing Presidential Proclamation on Advancing the Safe Resumption of Global Travel During the COVID-19 Pandemic,” https://www.cdc.gov/quarantine/cruise/pdf/Vax-Order-10-30-21-p.pdf, and CRS Legal Sidebar LSB10874, COVID-Related Restrictions on Entry into the United States Under Title 42: Litigation and Legal Considerations. CDC also issued other public health orders, such as an eviction moratorium and a transportation mask mandate, that were subject to litigation and enjoined by courts. See CRS Legal Sidebar LSB10638, Supreme Court Blocks Enforcement of the CDC’s Eviction Moratorium, by David H. Carpenter, and CRS Legal Sidebar LSB10589, Legal Issues Related to Transportation Mask-Wearing Mandates, by Bryan L. Adkins. Congressional Research Service 15 Centers for Disease Control and Prevention (CDC): History, Overview, and Issues CDC and its actions during the pandemic have been the subject of numerous congressional hearings, oversight reports, and independent evaluations. In particular, CDC received scrutiny for its development and distribution of an initial laboratory test for COVID-19, as well as for its COVID-19 related health guidance, which critics perceived as confusing or favorable to certain interest groups.97 Some have asserted that CDC has lost public trust, citing polls showing declining favorable public views of the agency.98 One independent investigative report characterized CDC’s culture as academic and slow to respond to the urgent and changing emergency health situation posed by the pandemic.99 Some have argued that the challenges CDC faced during the pandemic are attributable to a general lack of funding and capacity at CDC and, more broadly, in the public health system.100 In April 2022, CDC’s leadership began a review and reform process, entitled Moving Forward, aimed at modernizing the agency to better achieve its mission. The initial review consisted of two components: a scientific and programmatic review and an organizational structure review. Broadly, the structural review found that CDC’s academic approach sometimes hindered its ability to rapidly respond to an evolving threat such as the COVID-19 pandemic. In particular, the review found that the agency’s incentive structures rewarded scientific publications over impact and actions. The review also found that the agency could benefit from becoming more flexible and less siloed by health area or program.101 In February 2023, CDC finalized an agency reorganization following recommendations from the evaluations (see the “Organization” section for more details).102 The agency stated that, as a result of the initiative, it was working through 160 reform actions targeted to be completed by January 2024. These included, for example, website changes, laboratory capacity reforms, CDC-wide response training, and data modernization.103 97 See, for example, HHS Office of the Inspector General, CDC’s Internal Control Weaknesses Led to Its Initial COVID-19 Test Kit Failure But CDC Ultimately Created a Working Test Kit, A-04-20-02027, October 2023, https://oig.hhs.gov/oas/reports/region4/42002027.pdf; and U.S. Congress, House Committee on Oversight and Accountability, Oversight of CDC Policies and Decisions During the COVID-19 Pandemic, 118th Cong., 1st sess., June 7, 2023. 98 J. Stephen Morrison and Tom Inglesby, Building the CDC the Country Needs, Center for Strategic and International Studies, January 2023, https://csis-website-prod.s3.amazonaws.com/s3fs-public/publication/ 230112_Morrison_Building_CDC.pdf?VersionId=kTKB3urWn1bfZpXuCqixfxzHfT8AUcIM. 99 The COVID Crisis Group, Lessons from the COVID War: An Investigative Report (New York, NY: PublicAffairs, 2023), pp. 64, 166. 100 American Public Health Association, Testimony of Georges C. Benjamin, Executive Director at Looking Back Before Moving Forward: Assessing CDC’s Failures in Fulfilling its Mission, House Energy and Commerce Committee, Subcommittee on Oversight and Investigations, June 7, 2023; Letter from Association of American Medical Colleges to The Honorable Mariannette Jane Miller-Meeks, M.D., House Representative, April 21, 2023, https://www.aamc.org/ media/66591/download?attachment; and Richard Besser, Comments from Richard Besser, MD on Ways to Support and Strengthen the Centers for Disease Control and Prevention, Robert Wood Johnson Foundation, April 10, 2023, https://www.rwjf.org/en/insights/advocacy-and-policy/regulatory-comments/2023/04/comments-from-richard-besseron-ways-to-support-and-strengthen-the-cdc.html. 101 CDC, “CDC Moving Forward Summary Report,” September 2022, https://www.cdc.gov/about/organization/cdcmoving-forward-summary-report.html. 102 CDC, “CDC Moving Forward Reorganization,” 88 Federal Register 9290-9291, February 13, 2023. 103 CDC, “CDC Moving Forward,” https://www.cdc.gov/about/organization/cdc-moving-forward.html. Congressional Research Service 16 Centers for Disease Control and Prevention (CDC): History, Overview, and Issues Figure 1. CDC Organizational History: A Timeline Source: See the sources in the “History and Context” section of this report. CDC’s Evolution in Context As shown in CDC’s organizational history in Figure 1, the scope of the agency has greatly expanded since it was first established. CDC evolved and grew as an agency as the fields of public health and prevention science grew. In the first half of the 20th century, a greater scientific understanding of the germ theory of disease helped facilitate the communicable disease control science and methods for which CDC became known.104 CDC cultivated specialized expertise 104 Nancy Krieger, “Epidemiology Expands: Germs, Genes and the (Social) Environment (1900-1950),” in Epidemiology and the People’s Health: Theory and Context (Oxford University Press, 2011), pp. 95-101; and Mervyn Susser, “Epidemiology in the United States After World War II,” Epidemiologic Reviews, vol. 7 (1985), pp. 147-173. Congressional Research Service 17 Centers for Disease Control and Prevention (CDC): History, Overview, and Issues within the federal government in disease control, specifically in the developing fields of epidemiology and surveillance.105 Throughout the 20th century, the field of public health became more specialized, and distinguished itself from the field of medicine. Public health grew to encompass research into the social, environmental, and biological determinants of health, broadly, along with the practice of addressing those determinants.106 The 20th century also saw a shift in the burden—or overall health impact—of diseases. In the early 1900s, infectious diseases were the major causes of death in the United States. By midcentury—including by the time CDC was established in 1946— chronic conditions such as cancer and heart disease became the leading causes of death (often called the epidemiologic transition). Throughout the 20th century, even after 1946, mortality rates from infectious diseases fell, except during epidemics such as the HIV/AIDS epidemic and the COVID-19 pandemic. 107 As the major health concerns changed, so too did the field of public health and its focus areas. 108 In particular, evolution in the field of epidemiology—in which CDC cultivated distinct expertise—helped expand the scope of public health.109 Throughout the 20th century, epidemiologists learned to apply the scientific methods developed for communicable diseases to a wide range of diseases and conditions, including chronic diseases and injuries. Epidemiologists helped scientifically determine the risk factors that led to poor health; for example, the scientific relationships between smoking tobacco and lung cancer, folic acid intake and birth defects, and seat belt use and motor vehicle fatalities.110 This scientific understanding could then be used to develop public health interventions to address risk factors, such as health education and promotion campaigns.111 CDC was in a position to support both the data collection and research into risk factors, as well as some of the programmatic interventions to address them. Within this context, CDC expanded in scope as an agency. As recounted in the brief history here, CDC sometimes expanded through acquiring existing programs and through departmental reorganizations. CDC fit these diverse programs under the broad umbrella of public health such that by the 1980 reorganization, CDC became HHS’s focus for developing and applying disease 105 Jeffrey Koplan and Stephen B. Thacker, “Fifty Years of Epidemiology at the Centers for Disease Control and Prevention: Significant and Consequential,” American Journal of Epidemiology, vol. 154, no. 11 (2001); and Stephen B. Thacker, “Epidemiology and Public Health at CDC,” MMWR, vol. 55, no. SUP02 (December 22, 2006). 106 Allan M. Brandt and Martha Gardner, “Antagonism and Accommodation: Interpreting the Relationship Between Public Health and Medicine in the United States During the 20 th Century,” American Journal of Public Health, vol. 90, no. 5 (May 2000), pp. 707-715. 107 David S. Jones, Scott H. Podolsky, and Jeremy A. Greene, “The Burden of Disease and the Changing Task of Medicine,” New England Journal of Medicine, vol. 366 (2012), pp. 2333-2338, and CDC National Center for Health Statistics, “Leading Causes of Death,” https://www.cdc.gov/nchs/fastats/leading-causes-of-death.htm. 108 Mervyn Susser, “Epidemiology in the United States After World War II,” Epidemiologic Reviews, vol. 7 (1985), pp. 147-173. 109 Jeffrey Koplan and Stephen B. Thacker, “Fifty Years of Epidemiology at the Centers for Disease Control and Prevention: Significant and Consequential,” American Journal of Epidemiology, vol. 154, no. 11 (2001). 110 Allan M. Brandt and Martha Gardner, “Antagonism and Accommodation: Interpreting the Relationship Between Public Health and Medicine in the United States During the 20 th Century,” American Journal of Public Health, vol. 90, no. 5 (May 2000), pp. 707-715. Krista S. Crider, Yan Ping Qi, Lorraine F. Yeung, et al., “Folic Acid and the Prevention of Birth Defects: 30 Years of Opportunity and Controversies,” Annual Review of Nutrition, vol. 42 (August 22, 2023), pp. 423-452; and CDC National Center for Injury Prevention and Control, “Achievements in Public Health, 1900-1999 Motor-Vehicle Safety: A 20th Century Public Health Achievement,” Morbidity and Mortality Weekly Report, vol. 48, no. 18, (May 14, 1999), https://www.cdc.gov/mmwr/preview/mmwrhtml/mm4818a1.htm. 111 Mervyn Susser, “Epidemiology in the United States After World War II,” Epidemiologic Reviews, vol. 7 (1985), pp. 147-173; Safety: A 20th Century Public Health Achievement,” Morbidity and Mortality Weekly Report, vol. 48, no. 18 (May 14, 1999). Congressional Research Service 18 Centers for Disease Control and Prevention (CDC): History, Overview, and Issues prevention and control and for promoting health more broadly.112 The 1980 reorganization was also preceded by a broader reassessment of CDC’s role in addressing preventable health challenges. In addition, as illustrated in the next section, Congress has at times facilitated new or enhanced programs and roles for CDC through both the authorizations and the appropriations process. Congress’s Role in Shaping CDC As noted above, CDC has been substantially shaped by a series of administrative reorganizations throughout the 20th century. Congress has also played a role in shaping the agency. Much of this role has been to provide the agency with annual appropriations, often through disease- or program-specific accounts and budget lines, that have shaped CDC’s programmatic focus areas.113 In addition, Congress has at times enacted authorizing legislation aimed at shaping CDC’s programs and functions. Examples of each of these methods of shaping CDC are included below. Most recently, Congress formally authorized the position of the CDC Director and required agency-wide strategic planning through the PREVENT Pandemics Act.114 Appropriations Congress has provided annual appropriations for CDC programs since the agency was first established (see the “1946-1950: Establishment and Initial Years” section). Through this process, Congress has often appropriated funding based on certain health or program areas. Earlier in its history, the entire U.S. Public Health Service received appropriations for specific public health functions; the appropriations laws did not specify the specific operating divisions or units to carry out such activities. For example, in the appropriations act for FY1960,115 the Public Health Service received appropriations for “Assistance to States,” “Control of Venereal Diseases,” “Control of Tuberculosis and Communicable Disease Activities,” among other purposes. In 1974, after CDC became one of five main PHS agencies, appropriations laws began to appropriate funds to CDC more directly.116 In recent decades, Congress has appropriated funds to specific accounts within CDC aligned with certain broad health areas (e.g., immunization) or activity areas (e.g., epidemic services). Within these accounts, Congress often specifies funding for particular programs through appropriations report language (see Figure 2). The number and specificity of CDC’s programmatic budget lines within accounts have grown over the past several decades. To illustrate, in FY1990, the conference report accompanying CDC appropriations specified funding levels for 18 programs within CDC accounts.117 In FY2023, the explanatory statement accompanying CDC appropriations specified funding levels for more than 140 lineitems within CDC accounts (in both accompanying tables and text).118 112 Public Health Service, “Center for Disease Control; Office of the Assistant Secretary for Health Statement of Organization, Functions and Delegations of Authority,” 45 Federal Register 67772, October 8, 1980. 113 For a general discussion of the interplay between congressional appropriations and administrative reorganizations, see “Appropriations as a Tool of Reorganization” and “Congressional Responses to Particular Agency Head Actions” in CRS Report R44909, Executive Branch Reorganization, by Henry B. Hogue. 114 P.L. 117-328, Division FF, Title II; 136 Stat. 5706; 42 U.S.C. §242c. 115 P.L. 86-158. 116 See P.L. 93-517. 117 U.S. Congress, House Committee on Appropriations, Conference Report to Accompany H.R. 29909, 101st Cong., 1st sess., October 6, 1989, pp. 18-19. 118 Congressional Record, vol. 168, no. 198, book II, December 20, 2022, pp. S8877-S8881. See also CDC Operating Plan FY2023 for a summary. Congressional Research Service 19 Centers for Disease Control and Prevention (CDC): History, Overview, and Issues Figure 2. How Congress Shapes CDC Programs Through Appropriations: Illustrative Example Source: CRS analysis of CDC appropriations. Authorizing Legislation: Case Studies At times, Congress has enacted legislation that has created new programs or changed CDC’s authorities and functions. Three illustrative examples are explained in the following case studies. In the first example (injury prevention and control), Congress authorized a specific type of activity at CDC. In the second example (the National Center on Birth Defects and Developmental Disabilities), Congress explicitly established a new center at CDC by statute. In the third example (public health emergency activities), Congress established and shaped CDC’s roles and programs in public health emergency preparedness and response through a series of laws that have been periodically reauthorized since 2000. Example 1: Injury Prevention and Control A 1985 report requested by Congress, Injury in America: A Continuing Public Health Problem, called for addressing injuries—including traffic-related injuries, falls, drowning, poisoning, violence, and other injuries—as public health problems, including by increasing research into the causes of injuries and the means to prevent them. The report recommended that a Center for Injury Control be established within CDC.119 Congress then enacted the Injury Prevention Act of 1986,120 which formally authorized CDC injury prevention and control activities in the Public 119 Institute of Medicine and National Research Council, Injury in America: A Continuing Public Health Problem, 1985, https://nap.nationalacademies.org/catalog/609/injury-in-america-a-continuing-public-health-problem. See especially page 116. 120 P.L. 99-649. Congressional Research Service 20 Centers for Disease Control and Prevention (CDC): History, Overview, and Issues Health Service Act.121 CDC’s budget for injury prevention and control grew from $10 million in 1985 to $49.2 million in 1997 (not inflation adjusted). CDC established the National Center for Injury Prevention and Control in 1992.122 Example 2: National Center on Birth Defects and Developmental Disabilities The Children’s Health Act of 2000123 amended the PHSA to establish, in statute, the National Center on Birth Defects and Developmental Disabilities (NCBDDD) within CDC.124 According to CDC, the center was created in response to “strong advocacy efforts by external organizations whose view was that children’s health issues were not being adequately addressed by CDC.”125 In 2001, CDC moved the staff and resources of the preexisting Division of Birth Defects and Developmental Disabilities out of the National Center for Environmental Health, where it had been located for over 30 years, to become the new NCBDDD.126 Example 3: Public Health Emergency Activities Beginning in 2000, Congress enacted a series of laws aimed at strengthening public health emergency capabilities within CDC and other HHS agencies. The Public Health Threats and Emergencies Act, enacted in 2000, included several provisions that required assessments of national public health emergency capacity and needs.127 The law also authorized grants to support state and local capacity to address health threats. In addition, the law authorized CDC to improve its laboratories and other facilities to support public health emergency capacity. It included a section that stated, Congress finds that the Centers for Disease Control and Prevention have an essential role in defending against and combatting public health threats of the 21 st century and requires secure and modern facilities that are sufficient to enable such Centers to conduct this important mission.128 The committee report accompanying the Senate bill expressed concern that many state and local health departments would not be able to rapidly and effectively respond to a major outbreak in their communities. The report also noted that federal agencies, such as CDC, needed updated laboratories, facilities, and technologies for public health emergency response. In particular, many buildings at CDC had not been updated since just after World War II, and many of CDC’s laboratories lacked capabilities required for research with dangerous infectious agents.129 121 See Title III, Part J. 122 David A. Sleet, Grant Baldwin, and Angela Marr, “History of Injury and Violence as Public Health Problems and Emergence of the National Center for Injury Prevention and Control at CDC,” Journal of Safety Research, vol. 43, no. 4 (September 2012), pp. 233-47. 123 P.L. 106-310. 124 PHSA §317C. 125 CDC, “CDC’s National Center on Birth Defects and Developmental Disabilities Strategic Plan,” February 2011, https://stacks.cdc.gov/view/cdc/11701. 126 CDC, “Statement of Organization, Functions, and Delegations of Authority,” 66 Federal Register 20148, April 19, 2001. 127 P.L. 106-505, Title I. 128 P.L. 106-505, §102. In 2001, anthrax spores were deliberately released through U.S. postal mail. In total, 22 people got sick and, of these, five died. See CDC, “History of Anthrax,” 2020, https://www.cdc.gov/anthrax/basics/anthraxhistory.html. 129 S.Rept. 106-505. Congressional Research Service 21 Centers for Disease Control and Prevention (CDC): History, Overview, and Issues Following the 9/11 terrorist attacks and the anthrax incident of 2001, Congress enacted the Public Health Security and Bioterrorism Preparedness and Response Act of 2002,130 which sought to further enhance public health emergency capacity. The law enhanced CDC’s authorities to improve its laboratory facilities and surveillance networks to respond to public health threats. The law also authorized CDC’s Public Health Emergency Preparedness (PHEP) cooperative agreement program in PHSA Section 319C-1, a grant program that funds public health emergency preparedness and response capacity in state and local health departments. This law set the stage for the Pandemic and All Hazards Act of 2006 (PAHPA),131 which reauthorized and further amended the CDC provisions enacted in 2002. PAHPA has since been reauthorized twice, in 2013132 and 2019,133 and both times included additional provisions that addressed CDC programs related to public health threats. The programs authorized by these laws have helped develop the field of public health emergency preparedness and response across the country. CDC has established 15 foundational capabilities that SLTT health agencies should have in order to prevent, protect against, respond to, and recover from public health emergencies such as infectious disease outbreaks and chemical, biological, nuclear, and radiological threats.134 These include functions such as emergency coordination, public health laboratory testing, and medical countermeasure (e.g., vaccines, treatments) dispensing and administration. SLTT health agencies are required to invest in these capabilities as a condition of receiving CDC PHEP grants. These programs have brought frameworks from the emergency management field into public health responses to various health threats, such as infectious diseases. Much of the evolution in the field of public health emergency management was driven by legislation enacted by Congress.135 Agency Overview Today The following sections provide an overview of CDC as an agency today, including its mission, organization, authorizations, funding, and key activities. Mission Like several other agencies established by executive action, CDC does not have an overall mission or purpose defined in statute. In 2022, Congress articulated the breadth of the agency’s work in the PREVENT Pandemics Act.136 The act codified the position of the CDC Director and provided that the Director is to implement responsibilities and authorities that are related to the investigation, detection, identification, prevention, or control of diseases or conditions to preserve and improve public health domestically and globally and address injuries and occupational and environmental hazards, as appropriate.137 130 P.L. 107-188. 131 P.L. 106-417. 132 P.L. 113-5. 133 P.L. 116-22. 134 CDC, “Public Health Emergency Preparedness and Response Capabilities: National Standards for State, Local, Tribal, and Territorial Public Health,” https://www.cdc.gov/orr/readiness/capabilities/index.htm. 135 Dale A. Rose, Shivani Murthy, and Jennifer Brooks, “The Evolution of Public Health Emergency Management as a Field of Practice,” American Journal of Public Health, vol. 107, no. 2 (September 2017), pp. S126-S133. 136 P.L. 117-328; Division FF, Title II. 137 Public Health Service Act Section 305(b)(1); 42 U.S.C. §242c(b)(1). Congressional Research Service 22 Centers for Disease Control and Prevention (CDC): History, Overview, and Issues As established in Federal Register notices, CDC’s official mission statement is as follows:138 The Centers for Disease Control and Prevention (CDC) serves as the national focus for developing and applying disease prevention and control, environmental health, and health promotion and health education activities designed to improve the health of the people of the United States. In addition, CDC’s stated mission on its website is as follows: CDC works 24/7 to protect America from health, safety and security threats, both foreign and in the U.S. Whether diseases start at home or abroad, are chronic or acute, curable or preventable, human error or deliberate attack, CDC fights disease and supports communities and citizens to do the same. CDC increases the health security of our nation. As the nation’s health protection agency, CDC saves lives and protects people from health threats. To accomplish our mission, CDC conducts critical science and provides health information that protects our nation against expensive and dangerous health threats, and responds when these arise.139 CDC’s mission statements comprise two predominant themes. First, the agency is responsible for overall health promotion and disease prevention. Second, the agency is responsible for health security and response to specific health threats. Organization As shown in Figure 3, CDC is organized into many centers, institutes, and offices (CIOs). Some of these CIOs focus on specific public health challenges (e.g., injury prevention and control), while others focus on general public health capabilities (e.g., state, tribal, local, and territorial public health infrastructure and workforce). 138 CDC, “Immediate Office of the Director (IOD): Mission Statement,” https://www.cdc.gov/about/organization/cio- orgcharts/iod.html. For Federal Register notices, see for example, Public Health Service, “Center for Disease Control; Office of the Assistant Secretary for Health Statement of Organization, Functions and Delegations of Authority,” 45 Federal Register 67772. 139 CDC, “Mission, Role and Pledge,” https://www.cdc.gov/about/organization/mission.htm. Congressional Research Service 23 Centers for Disease Control and Prevention (CDC): History, Overview, and Issues Figure 3. CDC Organization Chart Source: Adapted by CRS from CDC, “CDC Organization Chart,” https://www.cdc.gov/about/pdf/organization/ cdc-org-chart.pdf, updated as of February 23, 2023. Notes: HIV = Human Immunodeficiency Virus; STD = Sexually Transmitted Disease; TB = Tuberculosis. CDC most recently underwent a reorganization in 2023 as a part of its Moving Forward initiative.140 According to CDC, the reorganization was informed by feedback from staff and partners on how CDC could change its structure to better respond to public health challenges. The reorganization included the following key changes:141 140 For more on this initiative, see “Current Status: The COVID-19 Pandemic and CDC’s Moving Forward Initiative.” 141 CDC, “CDC Moving Forward,” https://www.cdc.gov/about/organization/cdc-moving-forward.html. Congressional Research Service 24 Centers for Disease Control and Prevention (CDC): History, Overview, and Issues • • CDC created the new National Center for State, Tribal, Local, and Territorial Public Health Infrastructure and Workforce, intended to improve collaboration with local health departments and public health partners. To align with its “core capabilities,” CDC established new offices within the Office of the Director: the Office of Health Equity; the Office of Public Health Data, Surveillance, and Technology; the Office of Laboratory Science and Safety; and the Office of Readiness and Response. Statutory Authorizations As discussed above, CDC is an administratively established agency that has been shaped by congressional appropriations and some program authorization statutes. Congress has mostly shaped CDC’s programs through specifying and directing funding through the annual appropriations process. The agency, like several other agencies established by executive action, does not have a single, overarching statute that defines its overall mission, structure, or programs.142 CDC’s programs are authorized by general and program-specific laws, mostly in the PHSA. The position of the CDC Director and its responsibilities were codified into law in December 2022.143 CDC Director Authorization Authorized in PHSA Section 305,144 added in December 2022, the CDC Director is responsible for the overall direction of CDC and the Agency for Toxic Substances and Disease Registry, as well as the management and operation of its programs.145 This law made the CDC Director a presidentially appointed and Senate-confirmed position, effective January 20, 2025. The authorization does not define the specific programs for which the CDC Director is responsible; instead, the law defines the general scope of the Director’s authorities and responsibilities (see the “Mission” section). PHSA Section 305 also requires the CDC Director to develop a strategic plan every four years to identify overall priorities and objectives for the agency. General Program Authorizations The general public health authorities of the Public Health Service Act, many of which were established in 1944, have long underpinned CDC’s activities (see the “Public Health Service Act of 1944” section). CDC’s current programs and structure evolved from a series of reorganizations and acquisitions, as discussed in the “Brief History” section. Many CDC programs across a wide range of health areas cite general and permanent PHSA Title III authorities of the HHS Secretary as their statutory basis, including the following: PHSA Section 301 (42 U.S.C. §241): Research and Investigation. This section allows PHS agencies, including CDC and the National Institutes of Health (NIH), to conduct, coordinate, and 142 According to one analysis by political science scholars, 40% of federal agencies established from 1946 through 1995 were established by executive action rather than legislation; see William G. Howell and David E. Lewis, “Agencies by Presidential Design,” The University of Chicago Press Journals, vol. 64, no. 4 (November 2002), pp. 1095-1114. 143 The PREVENT Pandemics Act, P.L. 117-238, Division FF, Title II. 144 42 U.S.C. §242c. 145 The PREVENT Pandemics Act, P.L. 117-238, Division FF, Title II. Prior to the enactment of this statute, the CDC Director was an administratively established position. Congressional Research Service 25 Centers for Disease Control and Prevention (CDC): History, Overview, and Issues fund research and investigations “relating to the causes, diagnosis, treatment, control, and prevention of physical and mental diseases and impairments of man.” Under this authorization, PHS agencies may award grants and contracts for research, publish studies and research-based health information, and make available PHS facilities for research, among other research activities. CDC cites PHSA Section 301 as one authorizing statute for all of its CIOs and accounts.146 PHSA Section 307 (42 U.S.C. §242l): International Cooperation. This section authorizes the HHS Secretary to engage in international cooperation in health research, health statistics, health care technology, health care services, and other activities, especially for HIV/AIDs, tuberculosis, malaria, and other preventable infectious diseases. The section authorizes participation in international meetings, the award of grants, and the exchange of scientists and other fellows with other countries, among other cooperative activities. CDC cites PHSA Section 307 as one authorizing statute for all of its CIOs and accounts.147 PHSA Section 310 (42 U.S.C. §242o): Health Conferences and Health Education Information. This section requires the HHS Secretary to call annually a conference among state health authorities. The section also authorizes the Secretary to periodically issue information related to public health and requires the Secretary to publish weekly reports on the health conditions in the United States and other countries and other health information. CDC cites PHSA Section 310 as one authorizing statute for all of its CIOs and accounts.148 PHSA Section 311 (42 U.S.C. §243): Federal-State Cooperation in Communicable Disease Control and Public Health Matters. This section authorizes the HHS Secretary to provide and accept assistance in enforcing quarantine and other health authorities at the federal and state level, and to assist states (and their political subdivisions) in controlling communicable diseases and in other public health matters. The Secretary may provide related assistance and training to states, and may make available resources, such as personnel and medical supplies, to the states that “may be effectively used to control epidemics of any disease or condition and to meet other health emergencies or problems.” CDC cites PHSA Section 311 as one authorizing statute for all of its CIOs and accounts, except “Public Health Scientific Services” and “Global Health.”149 PHSA Section 317 (42 U.S.C. §247b): Project Grants for Preventive Health Services. This section allows the HHS Secretary to award grants for preventive health service programs to states, their political subdivisions, and other public health entities. Recipients may receive supplies, including vaccines and other preventive agents, in lieu of grant funds. Subsection (k)(1) specifically authorizes vaccination grant programs. Subsection (k)(2) authorizes grant programs for the prevention and control of diseases and conditions more broadly, including for research, demonstration projects, public information and education programs, and other programs aimed at health professionals. Subsection (l) provides authority to purchase recommended adult vaccines at a negotiated rate, to be provided in lieu of grant funds at the recipient’s request. CDC cites PHSA 146 CDC, “Authorizing Legislation,” Congressional Justification: FY2025, pp. 49-56, https://www.cdc.gov/budget/ documents/fy2025/FY-2025-CDC-congressional-justification.pdf. 147 CDC, “Authorizing Legislation,” Congressional Justification: FY2025, pp. 49-56, https://www.cdc.gov/budget/ documents/fy2025/FY-2025-CDC-congressional-justification.pdf. 148 CDC, “Authorizing Legislation,” Congressional Justification: FY2025, pp. 49-56, https://www.cdc.gov/budget/ documents/fy2025/FY-2025-CDC-congressional-justification.pdf. 149 CDC, “Authorizing Legislation,” Congressional Justification: FY2025, pp. 49-56, https://www.cdc.gov/budget/ documents/fy2025/FY-2025-CDC-congressional-justification.pdf. Congressional Research Service 26 Centers for Disease Control and Prevention (CDC): History, Overview, and Issues Section 317 as one authorizing statute for all of its CIOs and accounts, except “Global Health” and “Public Health Preparedness and Response.”150 Program-Specific Authorizations Three CDC centers and institutes and ATSDR are explicitly authorized in law: • • • • National Institute for Occupational Safety and Health (NIOSH), authorized by the Occupational Safety and Health Act of 1970 (29 U.S.C. §§651 et seq.). National Center on Birth Defects and Developmental Disabilities (NCBDD), established in PHSA Section 317C (42 U.S.C. §247b-4). National Center for Health Statistics (NCHS), established in PHSA Section 306 (42 U.S.C. §242k). ATSDR, established by the Comprehensive Environmental Response, Compensation and Liability Act of 1980 (CERCLA; 42 U.S.C. §§9601 et seq., at §9604(i)).151 Some of these components were initially established separately from CDC—NIOSH and NCHS, in particular—and were then later transferred to CDC (see the “History and Context” section). Some CDC offices, such as the Office of Women’s Health (PHSA Section 310A152), are also authorized in law. CDC also administers program-specific statutes throughout the PHSA and other laws.153 Some of these statutes are directed at CDC, for example, the authorization for the Epidemiology and Laboratory Capacity grant program in PHSA Section 2821.154 Others are directed at the HHS Secretary but carried out by CDC by delegation, for example, an authorization for activities related to the prevention and control of sexually transmitted diseases in PHSA Section 318.155 The program-specific authorizations that CDC administers vary in terms of specificity, as illustrated in Table 1. Some, such as PHSA Section 318, authorize a general set of public health activities (e.g., research, demonstration projects, and education) with respect to a certain health area (e.g., sexually transmitted diseases). Others authorize and delineate a specific program to be administered by CDC, such as the authorization for the Public Health Emergency Preparedness cooperative agreement in PHSA Section 319C-1, which sets forth eligible awardees, a program funding formula, and other requirements for the grant program. Many of CDC’s specific program authorizations have expired authorizations of appropriations. CDC’s FY2025 Congressional Budget Justification lists 29 programs with authorizations of 150 CDC, “Authorizing Legislation,” Congressional Justification: FY2025, pp. 49-56, https://www.cdc.gov/budget/ documents/fy2025/FY-2025-CDC-congressional-justification.pdf. 151 HHS initially established ATSDR to be headed by an Administrator who reported directly to the Assistant Secretary for Health on April 25, 1983 (42 FR 17652). On May 12, 1983, the then CDC Director became the first Administrator of ATSDR following litigation that compelled the federal government to carry out certain provisions of the Comprehensive Environmental Response, Compensation and Liability Act of 1980. See Richard G. Stoll, “Resolution of EDF/CMA Suit to Promote Government Health Studies,” National Resources Law Newsletter (1983). 152 42 U.S.C. §242s 153 For a full list of current CDC authorizations, see CDC, “Authorizing Legislation,” Congressional Justification: FY2025, pp. 49-56, https://www.cdc.gov/budget/documents/fy2025/FY-2025-CDC-congressional-justification.pdf. 154 42 U.S.C. §300hh–31. 155 42 U.S.C. §247c. Congressional Research Service 27 Centers for Disease Control and Prevention (CDC): History, Overview, and Issues appropriations that have expired in FY2023 or earlier.156 In general, when Congress appropriates funds for a program whose funding authorization has expired, that appropriation provides sufficient legal basis to continue the program during that period of availability absent indication of congressional intent to terminate the program.157 Table 1. Selected CDC Program Authorizations Title Projects and programs for the prevention and control of sexually transmitted diseases PHSA and U.S. Code Section PHSA §318; 42 U.S.C. §247c Epidemiology-laboratory capacity grants PHSA §2821; 42 U.S.C. §300hh-31 Oral health promotion and disease prevention PHSA §317M; 42 U.S.C. §247b–14 Compilation of data on asthma PHSA §317I; 42 U.S.C. §247b-10 Improving state and local public health security PHSA §319C-1; 42 U.S.C. 247d-3a Summary Allows the HHS Secretary to conduct many activities related to the prevention and control of sexually transmitted diseases, including, among others, technical assistance and training; research and demonstration grants; prevention and control program grants; and fostering innovative interdisciplinary approaches. Requires the CDC Director to establish an Epidemiology and Laboratory Capacity Grant Program for state, local, and tribal health departments to strengthen epidemiologic and laboratory capacity for response to infectious diseases and other conditions of public health importance. Authorizes CDC grants to states and tribes for oral health purposes, including community water fluoridation, school-based dental sealant programs, and oral health program leadership and data collection. Requires CDC to conduct surveillance activities to collect and publish data related to asthma’s health impact and clinical management. Authorization for the Public Health Emergency Preparedness cooperative agreement program. Authorizes CDC to award cooperative agreements to state and local jurisdictions for public health emergency preparedness and response. Requires awardees to submit preparedness and response plans, report annually on progress against health security goals, and to conduct certain activities, such as drills and trainings for staff. Specifies a funding formula and requires states to maintain public health security expenditures. Source: Selected from CDC, “Authorizing Legislation,” Congressional Justification: FY2024, pp. 54-61, https://www.cdc.gov/budget/documents/fy2024/FY-2024-CDC-congressional-justification.pdf. Note: CRS selected a sample of CDC program authorizations to provide an illustrative view of how the agency’s programs are authorized. 156 CDC, “Appropriations not Authorized by Law,” Congressional Justification: FY2025, pp. 58-59, https://www.cdc.gov/budget/documents/fy2025/FY-2025-CDC-congressional-justification.pdf. 157 CRS Report R46497, Authorizations and the Appropriations Process Congressional Research Service 28 Centers for Disease Control and Prevention (CDC): History, Overview, and Issues Appropriations In FY2023, CDC/ATSDR had a total program level of $14.5 billion, consisting of $9.3 billion in core public health program funding for CDC and ATSDR and an estimated $5.2 billion for other mandatory spending programs.158 CDC receives most of its core program funding through the annual Departments of Labor, HHS, and Education, and Related Agencies (LHHS) Appropriations Act. CDC receives LHHS appropriations through accounts that align mostly with the titles of its CIOs. ATSDR is funded by the Departments of the Interior, Environment, and Related Agencies Appropriations Act. CDC also administers several programs that are funded by mandatory spending authorities, such as the Vaccines for Children program and the World Trade Center Health Program (see the “Mandatory Health Services Programs” section). Congress has also provided CDC with supplemental emergency funding during public health emergencies and other incidents. Given that many CDC programs are based in general authorities, Congress often uses the appropriations process to inform CDC’s programs. Appropriations reports accompanying CDC annual appropriations usually specify programmatic funding levels within CDC accounts, though to varying levels of detail depending on the program and account. For more information on CDC funding, see CRS Report R47207, Centers for Disease Control and Prevention (CDC) Funding Overview. Activities CDC uses its general and specific program authorizations, as well as the appropriated funds it receives, to administer programs focused on a wide array of health topics, including infectious diseases, chronic diseases, injury, disability, occupational health, environmental health, and public health emergency preparedness and response. Most of CDC’s domestic programs fall within three main categories: (1) support to SLTT health agencies; (2) science and data; and (3) health education and guidance. The discussion below is not exhaustive of all CDC programs but is intended to provide an illustrative view of CDC programs and their scope. CDC also provides assistance to international governments and organizations through its global health programs, which are not a focus of this report. For more information on CDC global health programs, see CRS In Focus IF11758, U.S. Global Health Funding: FY2020-FY2023 Appropriations. Support to SLTT Public Health Agencies Since CDC’s inception, one of its primary functions has been to support public health agencies at the SLTT levels. CDC supports these agencies in all areas of public health through technical assistance, guidance, leadership, convenings, funding (primarily through grants, as discussed in the next section), and other material assistance. CDC staff can provide support during outbreaks and other emergencies, including by investigating and responding to threats. For example, through CDC’s Epidemiologic Assistance program, SLTT public health agencies can request that EIS officers help investigate public health problems such as “infectious and noninfectious disease outbreaks, unexplained illnesses, or natural or manmade disasters.”159 CDC also administers 158 CDC, “FY2024 President’s Budget Detail Table,” https://www.cdc.gov/budget/documents/fy2024/FY-2024-CDC- Budget-Detail.pdf. 159 CDC, “Epidemiologic Assistance,” https://www.cdc.gov/eis/request-services/epiaids.html. Congressional Research Service 29 Centers for Disease Control and Prevention (CDC): History, Overview, and Issues several fellowship and workforce programs to fund staff at SLTT agencies. CDC staff may also take temporary placement positions within SLTT agencies. Major Grant and Assistance Programs CDC administers numerous programs that provide funding or other assistance to SLTT [Text truncated at 120,000 characters. The full text is on the page linked above.] --- Source: Frix Law Library, https://www.frixlaw.com/law-library/documents/crs%3AR47981. Public record. Not legal advice.