In this post, I will review the history of Dr. Carmona's service as Surgeon General, outline the controversy, and end with a discussion of of some recent criticism of the controversy.
Born and raised in New York City, Dr. Carmona dropped out of high school and enlisted in the U.S. Army in 1967. While enlisted he received his Army General Equivalency Diploma, joined the Army's Special Forces, ultimately becoming a combat-decorated Vietnam veteran, and began his career in medicine.
After leaving active duty, Dr. Carmona attended Bronx Community College, of the City University of New York, where he earned his associate of arts degree. He later attended and graduated from the University of California, San Francisco, with a bachelor of science degree (1977) and medical degree (1979). At the University of California Medical School, Dr. Carmona was awarded the prestigious gold headed cane as the top graduate. He has also earned a masters of public health from the University of Arizona (1998).
He was appointed to the post of Surgeon General by George W. Bush in 2002, for a four year term. His term ended in 2006, and he was not reappointed. At the time, it was not clear why.
Dr. Carmona still has not been replaced. President Bush has nominated a replacement, Dr. James Holsinger, who is awaiting Senate confirmation. (Holsinger has generated some controversy himself; it still is not clear how that will play out.)
During Congressional hearings prior to the consideration of Holsinger's confirmation, Dr. Carmona was invited to testify. He testified -- with ample, credible evidence -- that the Bush administration systematically repressed his efforts to advance the cause of public health. That was on July 10, 2007.
In the public testimony, he did not name names, but he agreed to provide specifics in a closed-door session...
On July 29, 2007, the Washington Post published an article about one of the specific instances of suppression. They linked to the report (The Surgeon General’s Call to Action on Global Health 2006), and provided some background information and some analysis.
The interviewed three individuals, who stated that the report had been suppressed by William R. Steiger. Steiger has been in the news before, for similar antics. For example, see this article by Chris Mooney. (More on Steiger here and here.)
The Blogospheric response was immediate, with nearly-universal condemnation of the actions of the Administration. As of this moment, WaPo notes 156 blog posts on the subject. That includes four here at ScienceBlogs: Now this is why political appointees shouldn't have a say in science, More from Carmona, Small Minds Thinking Tiny Things Depatment, and Bush Aide Blocked Report.
I mentioned that the response was almost a consensus that the suppression had been inappropriate. Over the time span from the original testimony (July 10) and the WaPo article about Steiger's role (July 29), there were a few posts that expressed the opinion that the Administration had acted within reasonable limits in suppressing the report. (1 2 3 4) Some viewed the whole thing as irrelevant, and called for the abolition of the position of the Surgeon General. Others insisted that Carmona's experience was not significantly different from that of previous Surgeons General (1 2). That indicates, to me, that hey did not read the reports carefully. Carmona and the prior Surgeons General were very clear that Carmona was subject to much more political pressure than his predecessors.
Those that argued that the Administration had acted within reasonable limits in suppressing the report seemed to buy into the concept of the unitary executive: that the President has complete control over everything that is done within the Executive Branch. The corollary of that is that there is no role for Congressional oversight, and that the President is free to interpret law as he sees fit.
Another point arose in the responses to the controversy. Some mentioned the opinion that the controversy has been cited wrongly as an example of the politicization of science.
From the Volokh Conspiracy:
My point here is not to defend the Bush Administration, nor is it to suggest that the report should have been withheld. Rather it is that many cases of "science politicization" are in fact policy disputes. The Post's subhead reads "Global Health Draft In 2006 Rejected for Not Being Political," yet the report itself was an inherently political document. The dispute between Carmona and Bush officials was about the extent to which a policy report should reflect, endorse, or promote Bush Administration policy. It was not an instance of politics or ideology trumping science. If the Administration is to be criticized for blocking the release of The Surgeon's General Call to Action on Global Health, it should be criticized on policy grounds — for opposing particular public health measures and refusing to support others — rather than for allegedly censoring scientific expertise.
UPDATE: Here is a good example of how this story is (wrongly) placed in the traditional narrative of science politicization. Contrary to Mark Hoofnagle's claim, this episode has little to do with "scientific integrity." Nonetheless, he terms it "despicable."
The Volokh post, while thoughtful, misses an important point. To understand this, it is necessary to draw a distinction between a broad, general kind of politics, and the more specific category of partisan politics.
It the broadest sense, politics could be defined as "the set of arts and sciences directed toward the goal of getting other people to do what you want them to do."
In that definition, most medical interventions could be termed political. That is because health professionals must enlist the cooperation of their patients in order to have a positive impact. By the broad definition, a doctor trying to get a patient to quit smoking is engaging in politics. However, this obviously would not be partisan politics.
With that in mind, let's look at the assertion that Carmona's report was a policy document, as opposed to a scientific document. In a broad sense, it is true. That is evident from the title: ...Call to Action...". Carmona was trying to influence behavior. That is natural; it is what every physician does, as an integral part of medical practice.
In this conceptual framework, it is apparent that what Stieger was trying to do was to take a science-based nonpartisan policy document, and turn it into a ideology-based partisan policy document. So instead of referring to to this as an instance of the politicization of science, perhaps it would be more accurate to call it an instance of partisanization of nonpartisan policy.
This may be a subtle distinction, but it is an important one. To see more clearly what the implications are, it is helpful to look at a alternate draft document that Steiger prepared (or had someone else prepare). That can be seen here (PDF), as copied from a website put up for Henry Waxman. There is also a comparison of the two drafts, here (PDF).
To illustrate the point, here are comparable selections form Carmona's draft, and that of Steiger:
Carmona: Caring about the health of others is of strategic significance since health diplomacy, or working with other nations on shared health goals, promotes international cooperation, is critical to the long-term health and security of the American people. It is the way to protect, promote, and advance the health and safety of the nation...
Steiger: Health is a diplomatic tool to promote good relations and improve ties between the United States and other countries. When you think about it, promoting health cooperation with other countries is always a win-win situation. Strengthening health globally will strengthen security, including our own health security. But it also improves health in our partner countries. There’s no downside.
This is subtle. Carmona emphasizes the "strategic" and "security" implications of global health initiatives. This makes sense. There obviously is no point at all to spending five hundred billion dollars to combat a dubious terrorist threat, when spending just five hundred million on disease prevention could save more lives and have a greater positive economic benefit. This is not the line the Administration wants to promote.
In addition, Dr. Carmona devoted substantial attention to the issues of global poverty, and poverty in the USA. Steiger used the word poverty only twice, once in the context of international health, with no specific reference to the negative health impact of poverty in the USA. Carmona addresses obesity at length. But, consistent with Steiger's prior record of caving in to the influence of the US food industry, Steiger does not address obesity at all.
This illustrates that there was not only partisan political influence, but antiscientific corporate influence, as well. So far I have not seen that issue addressed by either side in this debate.
Comments
Very thorough. I think it's a stretch though to say that recommendations based on science are of necessity political though. The SG should be able to say, "X is unhealthy, and Y measures to fix it have shown Z" without being accused of being a political actor. Between that and requiring Carmona to be a cheerleader for the president seemed a bit twisted.
Also, no one seems to remember Koop got in trouble for suppressing information on the safety of abortion during his tenure and was similarly attacked for politicizing the office. I think there is a precedent for railing against suppression of relevant health information from the SG for political reasons.
Posted by: MarkH | August 1, 2007 9:39 AM