Strengthening the Surgeon General

In an editorial in the October 12th issue of Science, former Assistant Surgeon General Fitzhugh Mullan highlights the challenges inherent in the position of Surgeon General. Mullan recounts a July hearing held by the House Committee on Oversight and Government Reform, which featured testimony from former Surgeons Generals from the Reagan, Clinton, and Bush administrations: Drs. C. Everett Koop, David Satcher, and Richard Carmona. 

In his opening statement, Chairman Henry Waxman noted that the hearing was one in a series asking âwhy federal agencies that were once admired as the finest in the world, like the Food and Drug Administration, are failing to meet the publicâs expectationsâ and seeking ways to ârestore these troubled agencies to models of excellence that will help our nation meet the challenges ahead.â With regards to the Office of the Surgeon General specifically, Waxman expressed this concern:

Political interference is compromising the independence of the Office of the Surgeon General. On key public health issues, the Surgeon General has been muzzled. The Surgeon Generalâs greatest resource â his or her ability to speak honestly and credibly to the nation about public health â is in grave jeopardy.

In his story on the hearing, the New York Timesâ Gardiner Harris emphasized the strictures that Carmona reported facing while working for the Bush administration. Carmona testified that he was not allowed to speak or issue reports on issues ranging from stem cells, emergency contraception, and sex education to prison, mental, and global health issues. Officials tried to water down and delay a report on secondhand smoke, which concluded that even brief exposure to cigarette smoke could cause immediate harm. Carmona said he was also told to mention President Bush repeatedly in his speeches and ask, and asked to make speeches to support Republican political candidates. (For more on the political forces at work, see this Washington Post article and my earlier blog post on Carmona.)

White House pressure to downplay sensitive reports is not confined to the Bush administration â Satcher said that the Clinton administration discouraged him from issuing a report on the effectiveness of needle-exchange program, and Koop reported pressure from Reagan-administration officials to refrain from discussing AIDS; both went public with the information, anyway. As in so many other areas of science (global warming, reproductive health, endangered species, etc.), the Bush administration has taken political interference with science to new lows.

Yet Mullanâs editorial reminds us that the serious public-health consequences of White House interference are not the only lesson to draw from the hearing on the Office of the Surgeon General. The Surgeon Generalship began as a minor government agency and became more prominent during the 20th century, yet Nixon and Carter seemed to place little importance on filling it. Koop boosted the officeâs prominence and influence, but Surgeons Generals still face challenges that make it hard for them to live up to public expectations, Mullan reports:

In 1981, President Reagan nominated C. Everett Koop for the job, a physician with little public health experience, who withstood a bruising confirmation marathon and then reinvented the position of Surgeon General. At a time when most public officials were distancing themselves from AIDS, he tackled the exploding epidemic. His willingness to speak frankly, embrace those suffering with the disease, and disregard the apparent preferences of his political overlords was welcomed by both scientists and the public. The president remained silent but supportive, according to Koop, while others in the Administration schemed to oust him. His name and his office gained wide recognition and helped propel his campaigns in other areas such as smoking, child health, and nutrition. Internally, he revitalized the PHS [Public Health Service] Commissioned Corps, generating a pride in the mission of public health that had been absent for many years.

The force of Koop's personality, the happenstance of the AIDS epidemic, and a hands-off president resulted in an extraordinary moment of power and effectiveness for the Surgeon General. But this alignment of events is rare, and Surgeons General since Koop have struggled to achieve the independence and visibility that he enjoyed. The Surgeon General remains a respected figure, but the job is ill-defined, budgetless, and subject to the whims of political appointees at the Department of Health and Human Services and the White House.

The Surgeon General is widely considered to be the doctor for the nation and an ombudsman for the public's health. But in reality, modern holders of the office are tightly constrained by the increasingly politicized environment of Washington. It is difficult to imagine a modern Congress creating the office of Surgeon General. Politics wouldn't allow it to happen. Fortunately, and to our nation's great benefit, the position and the tradition already exist. But the job needs help.

Mullan recommends legislative solutions, which are similar to those that the House committee reported receiving during the hearing:

All three witnesses urged Congress to strengthen the Office of the Surgeon General by giving it budgetary independence and the staffing it needs to carry out its vital mission. They believe that future Surgeons General must be empowered to communicate vital health information, based on the best available science, directly to the American people. Chairman Waxman has drafted the Surgeon Generalâs Independence Act to implement these recommendations and protect future Surgeons General from political interference.

Perhaps in the future weâll be able to rely on the Surgeon General to give us the most up-to-date information about the pressing public health issues we face. In the meantime, weâll have to continue wondering what important knowledge isnât getting through.