Effect Measure

For some years I have been playfully asking students and colleagues (all active health professionals or professionals to be) if they could tell me the name of the Surgeon General of the United States. Few could. In fact, last night the current Acting Surgeon General’s name was mentioned and I had not only forgotten who it was, but I actually know the guy (Steve Galson). If you ask public health professionals to name any SG, however, they all can. Most often it’s C. Everett Koop but might also be David Satcher, Joycelyn Elders or (for some of us older folk) the late Julius Richmond (Julie used to complain about how hard it was stamping those warnings on all the cigarette packs every day).

The SG is the head of the uniformed services of the United States Public Health Service, wears a Navy uniform and holds a rank equivalent to a Vice Admiral. If this makes you think the Surgeon General is a powerful position, you’d be half right. Whatever power the SG has comes from your thinking he or she (and there have been a number of women SGs in recent years) is powerful. The SG has a very small staff and even less real power to do anything — except look and sound powerful. The SG is the public face of the USPHS and to some extent federal public health (although the Director of CDC is much more visible and genuinely powerful and shares that public perception). The Office of the Surgeon General’s also issues reports, some of which have been very influential in highlighting important public health problems. One of the most famous in recent history was the 1964 Smoking and Health Report which established cigarettes as an officially recognized cause of heart and lung disease. More recently Reports on sexuality and ethnic disparities have also been useful contributions to advancing health policy in the US. Pretty much the importance of the SG comes from the fact that it is a tall platform to stand on. C. Everett Koop made effective use of this bully pulpit to promote a variety of important public health ideas. However under the Bush administration, the Surgeon General has been pretty much invisible (see posts here, here, here, here and here). If you don’t care about public health, you surely don’t care about the Surgeon General. But if you do care about public health, you might want someone who can again be its public face, “the nation’s doctor.” So who will serve in that position next is of some interest.

Yesterday the Obama administration let slip a name they were considering for the post. It took many people by surprise. It is CNN’s medical reporter and practicing neurosurgeon, Dr. Sanjay Gupta. Last night I saw progressive health policy analyst Ezra Klein (American Prospect) say on MSNBC he thought it was a shrewd choice. He may be right, although I am less confident. But his reasoning is sound. Klein noted that the main (and possibly only) real function of the SG these days is to communicate to the nation about public health. He reasoned that choosing a professional communicator and already high profile doctor for the post was a savvy move by Obama and signaled both his understanding of the potential for the post and his determination to give his health policy the best chance of success by going directly to the public with it.

It’s hard to know what Gupta’s own views are. At CNN he had to appear “objective,” which sometimes meant he had to distort reality to accommodate powerful interests in health care. Michael Moore pretty much eviscerated him over Gupta’s review of Moore’s film, Sicko, but Gupta took the push back fairly graciously. I think he will dependably represent the Obama administration’s position, whatever it happens to be. My only real hesitation has to do with whether he has that indefinable thing called gravitas. That might be because he’s a lot younger than I am (and older than Ezra Klein).

It’s a Presidential appointment (term of four years) and requires Senate confirmation (which should be trouble free).

Addendum (2 pm, 1/7/09): My sources within CNN tell me this isn’t a done deal. Gupta is still working out the personal side of it. I also wonder if he will be able to continue to practice (a major issue for a surgeon who needs to keep his skills limber) and of course there will almost certainly be a big time pay cut. So it wouldn’t surprise me if this didn’t go through.


  1. #1 Frank Mirer
    January 7, 2009

    Does anyone know what’s up with CDC Director? Does anyone know what’s up with the search for NIOSH Director, or is there even a search?

  2. #2 revere
    January 7, 2009

    Frank: I live in fear Obama will reappoint her but I don’t think it’s likely. No one I know has any info about her departure. The sooner the better as far as I am concerned. Same for NIOSH. Those are Secretary appointments, though, so we’ll probably have to wait.

  3. #3 David
    January 7, 2009

    I hear Oprah was pushing Obama to nominate Dr. Oz… Just kidding… I just couldn’t resist!

  4. #4 Lea
    January 7, 2009

    CNN’s Sanjay Gupta is anti-pot. The selection of CNN’s Sanjay Gupta as Surgeon General by President-elect Obama does not bode well for recreational marijuana smokers. In 2006, the well-known surgeon wrote a column in Time, “Why I Would Vote No on Pot.” At the time, Nevada and Alaska had tax-and-regulate initiatives on the ballot.

    Here are excerpts from Gupta’s column:

    “Maybe it’s because I was born a couple of months after Woodstock and wasn’t around when marijuana was as common as iPods are today, but I’m constantly amazed that after all these years – and all the wars on drugs and all the public-service announcements – nearly 15 million Americans still use marijuana at least once a month…

    “…marijuana isn’t really very good for you. True, there are health benefits for some patients. Several recent studies, including a new one from the Scripps Research Institute, show that THC, the chemical in marijuana responsible for the high, can help slow the progress of Alzheimer’s disease. (In fact, it seems to block the formation of disease-causing plaques better than several mainstream drugs.) Other studies have shown THC to be a very effective anti-nausea treatment for people – cancer patients undergoing chemotherapy, for example -for whom conventional medications aren’t working. And medical cannabis has shown promise relieving pain in patients with multiple sclerosis and reducing intraocular pressure in glaucoma patients.

    “But I suspect that most of the people eager to vote yes on the new ballot measures aren’t suffering from glaucoma, Alzheimer’s or chemo-induced nausea. Many of them just want to get stoned legally…

    Bull-shit, bull-shit, bull-shit. Lying sack of ___

  5. #5 Lea
    January 7, 2009

    Dr. Sanjay Gupta, a pro-vaccine pusher with ties to Merck.

    Dr. Sanjay Gupta is a strong proponent of the Gardasil HPV vaccine, and the television show he once hosted (“Accent Health”) was primarily sponsored by Merck, makers of Gardasil.

    Gupta is intelligent and healthy, but dishonest, misinformed, a fake and arrogant.

    Then again, Dr. Gupta is, indeed, a bonafide brain surgeon. That might come in handy in Washington, come to think of it. Maybe he can perform a little brain surgery on his fellow Washingtonian bureaucrats and find a way to restore the common sense they all apparently lost when they got elected.

  6. #6 revere
    January 7, 2009

    Lea: I am neither pro-Gupta nor anti-pot. I think we should decriminalize it. But I don’t see anything wrong with what he said. Unless you have a medical indication, it isn’t very good for you (like cigarettes aren’t good for you). And you refer to recreational pot smokers. They are people who just want to get stoned or buzzed, like recreational drinkers. I don’t think that’s a criminal act. But I don’t see any untruths in what you quoted.

    As for gardasil or any HPV vaccine, I would advise my daughter to get it if she were the right age. I don’t think it should be mandatory given the very thin experience we have with it and I am no friend of Merck. But again, I don’t seen anything particularly wrong with his position. Most doctors are pro vaccine. I am. That doesn’t make me pro Big Pharma. You know I am not. But I am separating the science from the politics and economics. Vaccines save lives, should be used wisely and appropriately but trashing them indiscriminately is dangerous.

    The SG is not a bureaucrat. He has no bureau worth speaking of to control.

  7. #7 Lea
    January 7, 2009

    You’re definitely out of the loop my dear revere as many are when it comes to cannabis, and absolutely no disrespect meant by that. It’s been a successful anti-pot campaign waged by the government, I’ll give ’em that much.
    There are other ways to “smoke” cannabis now other than through the rolled joint. Vaporizers for one.
    And please, let me decide what I want to do with my body, not the government.

    And yes, I’d rather have a joint in the evening than alcohol.

    Obama has a tough road to tow and quite honestly I don’t see any real changes at this point in time manifesting.
    It sickens me when I see the politicans smiling on the television and pretending like everything is going to be alright.

  8. #8 Lea
    January 7, 2009

    I’ll add this revere and then shut up.

    In the largest study of its kind, UCLA’s Dr. Donald Tashkin has concluded that smoking marijuana, even regularly and heavily, does not lead to lung cancer.

    Dr. Tashkin noted in the Washington Post that the new findings “were against our expectations. We hypothesized that there would be a positive association between marijuana use and lung cancer, and that the association would be more positive with heavier use. What we found instead was no association at all, and even a suggestion of some protective effect.”
    Presentation – Marijuana Use and Lung Cancer

    Donald P. Tashkin, M.D. et al. presented the study “Marijuana Use and Lung Cancer: Results of a Case-Control Study” at the American Thoracic Society International Conference on 5/24/06. The study was funded by the National Institute on Drug Abuse (NIDA), and involved 1,200 people in Los Angeles who had lung, neck or head cancer and an additional 1,040 people without cancer matched by age, sex and neighborhood. The study’s abstract reported:

    “Marijuana smoke contains several known carcinogens, heavy habitual use can produce accelerated malignant change in lung explants [removed living tissue]….

    We therefore assessed possible associations between MJ use — including heavy long-term use — and the risk of lung cancer in middle-aged adults living in Los Angeles County….

    Personal interviews were completed in 611 lung cancer cases & 1040 controls. Data were collected on lifetime use of marijuana, tobacco, alcohol & other drugs, SES, diet, occupation & family history of cancer. Logistic regression was used to estimate the effect of MJ use on lung cancer risk, adjusting for age, gender, race/ethnicity, education & cumulative tobacco smoking & alcohol use.

    Conclusion: We did not observe a positive association of MJ use — even heavy long-term use — with lung cancer, controlling for tobacco smoking and other potential confounders.” 5/24/06 Donald Tashkin

  9. #9 Joe Correl
    January 8, 2009

    Dr. Phil Leveque is by far the more qualified physician to fill the post of Surgeon General. Dr. Gupta by comparison has affiliations which seem to be more ties to the political/pharma industrial complex.

    January 9, 2009

    As someone who’s been dealing w/the insidious disease,multiple sclerosis,(MS), since 1993, but neurologists say I’ve had it since 1978,but w/ minimal symptoms so that it went undetected, I’m now at the point where I want to at least be able to try it t see if it does ease the spasticity and relieve the pain which now has become an issue esp. when it comes to getting a good night’s sleep. Not until last yr. has pain been much of a problem but no I’m taking VICODIN (sp)? and that’s not so great either. I’m convinced that the “powers that be” i.e. “BIG PHARMA” will lobby and do all in their power to keep marijuana from becoming legal even for medicinal purposes because once people realize that marijuana can relieve many symptoms of many diseases, this will cut into their profits, BIG TIME. i hope you all will find it within your hearts to at least educate yourselves as to the real benefits people w/these diseases would receive if marijuana/cannabis werelegal for medicinal purposes. THANK-YOU IN ADVANCE. L. STRECKER

  11. #11 g336
    January 20, 2009

    On one hand, smoking too much pot can make you stupid. On the other hand, so can watching too much television.

    The relevant principles in a rational society are personal liberty and personal responsibility. Whether with regard to marijuana or anything else.

    And thus a modest proposal. This assumes a national health care system, which sooner or later is a foregone conclusion.

    First of all do away with “sin” taxes. Government has no more right to be in the business of determining “sin” than determining “sanctity.” (And for anyone who wants to argue that the term “sin tax” is merely a colloquialism, I offer the counterpoint that language is determinitive of meaning.)

    Second, institute “health risk taxes” that are based on the empirical costs of treating the ill effects of the use of various products and services. These taxes would be applied to the relevant products and services, across the board. Where a risk is at first underestimated, or where a risk increases over time, government runs a brief deficit while the tax is increased in a manner that will pay it off within, say, 20 years.

    By “empirical” I also mean “detailed.”

    For example the risks of cigarettes are much higher than those of pipe tobacco and cigars; the tax on each would reflect that fact. The health implications of wine, beer, and distilled spirits, all differ, and the tax on each would reflect that fact.

    For marijuana the risk may not be cancer but something else (and the issue of people smoking themselves into stupidity is irrelevant here: stupidity by itself is not a medical condition that incurs health care costs).

    For food products, taxes on corn syrup would offset its cost advantages; same case for transfats and other cheepskate shortcuts that infest our food supply. Taxing the ingredients themselves is far preferable to taxing the finished product (after all, it’s not the “cookie” that’s bad for you, it’s the crap that goes into a crappy cookie compared to a good one), and the tax gets passed through to the buyer as a higher cost for the product itself.

    Taxes would also apply to equipment and services used in extreme (hazardous) sports: such items as mountain climbing gear, skydiving gear and services, and so on: covering the costs associated with activities that often result in expensive search & rescue (or “scrape up the splat”) missions.

    The health cost impact of automobile (and motorcycle) accidents is already covered by automobile insurance, as it should be; and this also deals with accidents between motor vehicle and pedestrians or bicyclists.

    The health cost impact of various types of employment may already be covered in the various insurances that employers have to maintain for their workplaces and employees.

    Health impact costs may also be assessed against home entertainment equipment that is found to contribute to a couch-potato lifestyle.

    Objectivity and empiricism in assessing taxes of these kinds will alleviate entirely the problem of “some people” paying for “other peoples” lifestyle choices: everyone pays their own way. Everyone is free to make their own choices and pay the costs associated with the risks of those choices.

    The only new casualty in this picture, will be the peculiar species of busybody moralist who gains unique satisfaction from sticking their nose into others’ business and inflating their ego with a smug sense of superiority over others. But as for them, I say goodbye and good riddance.

  12. #12 Luke
    February 1, 2009

    I’m sure Mr. Gupta would also say it’s not good for you to stick your fingers in your ears, drink water from an untreated river, breathe bus exhaust, or eat quadruple bacon burgers, but would he “vote no” on (i.e. criminalize) these things? If so he has no place in the U.S. government. We can only hope that this greater responsibility gives him better judgment in civic matters.

    But the truth is, Surgeon General is a low-level position (In regards to actual policy). The people who can truly effect drug policy are in the Justice Dept. and the DEA. The Justice picks appear to be a mixed lot on Cannabis, and the DEA appts. are not known yet.

    Please Obama, do the right thing here.

  13. I don’t have enough information to know if he would have been a good Surgeon General. What I do know is that, the person that is in that position now (and if my memory doesn’t fail I think is Dr Regina M. Benjamin) has to urgently take care of the childhood overweight issue this country is going through right now. In the United States over 17% of the children between 2 and 19 years old are overweight that means 12.5 million children. That implies future and grave health problems. We need to do something now!

  14. I don’t have enough information to know if he would have been a good Surgeon General. What I do know is that, the person that is in that position now (and if my memory doesn’t fail I think is Dr Regina M. Benjamin) has to urgently take care of the childhood overweight issue this country is going through right now. In the United States over 17% of the children between 2 and 19 years old are overweight that means 12.5 million children. That implies future and grave health problems. We need to do something now!

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