The Monarch of Public Health
Regina Benjamin took her place in front of dark velvet curtains, set her smile, and waited.
The scene was a bit like "Pictures with Santa" at a busy shopping mall on the Saturday before Christmas. More than 150 people patiently stood in line to have their photo taken with Benjamin, some with emotions akin to the awe of a child about to meet St. Nicholas. They craned their necks to see her up ahead; some were even a little giggly. Benjamin's helpers, wearing uniforms like hers, managed the crowd.
But the similarities stopped there. This was weeks after the holiday (January 11, 2010, to be exact). These were adults standing in line. The venue was the foyer of a federal building in downtown Washington, D.C. And this wasn't Kris Kringle they were waiting to see; it was the new U.S. surgeon general.
Minutes earlier, in a packed, 625-seat auditorium, Benjamin had been formally sworn in as the nation's eighteenth surgeon general. It had been an unusually florid affair, even by Washington's standards. Rows of federal health officials dressed in the formal, militaristic uniforms of the Commissioned Corps of the U.S. Public Health Service. Some formed a saluting gantlet that Benjamin passed through at the end. A passerby might have mistaken the event for some kind of war-hero homage.
Benjamin had many supporters there that day, and they were thrilled.
"It's wonderful to know that someone whose values you respect is in such a position of leadership," said Brenda Smith, an American University law professor standing in line with a group of friends.
"This is a great day for our state. For the world," said Betty Ruth Speir, an elderly gynecologist who, like Benjamin, was from Alabama.
Was it, though?
The surgeon general is indeed a public health celebrity, a post rooted in a rich history and automatically held in high esteem. Surgeon general reports remain hallmark documents in our society, cited in everything from student term papers to legislative policy debates. Surgeon general warnings are fixtures on magazine liquor ads and cigarette packaging. Polls assessing the surgeon general's credibility award the position higher marks than most other government health officials. Indeed, the surgeon general is commonly perceived (or, rather, misperceived) to be the government official responsible for the health and well-being of the general public. The surgeon general stars in public service announcement commercials and speaks frequently at university commencements and national conferences. The uniform and title still conjure importance and wisdom, and-for some Americans-a belief that there is still such a thing as a government health official who will level with the public when other bureaucrats won't.
Some of that aura comes from dewy memories of the surgeon general's power, independence, and integrity as it was many decades ago (when the federal health bureaucracy was much smaller). "He did not have to kowtow to the administration," said Daniel Whiteside, a dentist who served for years in the Public Health Service. "He could say, 'I don't care what the administration's policy is on any health issue. I'm going to tell you what is in the best interest of the American public, so far as a health issue is concerned. I don't care who likes it. I don't care who doesn't like it. I'm here for four years and you can't touch me.' And we had Surgeon Generals who did that; I mean, who went up against the administration and said 'Kiss off.'"
Whiteside was speaking mainly about the men who held the position in the early twentieth century-the long-ago kings of U.S. public health who served multiple terms while presidents came and went. But the perception that surgeons general are science-above-politics monarchs, acting as the uncensored health consciences of the nation, occasionally has resurfaced. Jesse Steinfeld, who held the job in the early 1970s, angered Nixon administration officials by attacking the cigarette and television industries. C. Everett Koop, in place through most of the 1980s, led a benevolent education campaign on the emerging AIDS epidemic when some Reagan White House officials disdainfully considered it a gay disease. Joycelyn Elders, surgeon general in the early 1990s, dismayed the Clinton administration with her frank remarks about whether to legalize marijuana or teach kids to masturbate.
But in truth, tolerance for outspoken surgeons general has always been limited. Elders was fired. Steinfeld was forced to resign early. Even the powerful surgeons general of old were careful not to cross certain political overlords. An example: Hugh Cumming, who held the job from 1920 to 1936, was considered one of the most powerful surgeons general of all time. In 1925, after a rash of industrial worker poisonings tied to leaded gasoline, Cumming was publicly pressured to look into it. But he declined to take any action until he first discussed it with Secretary of the Treasury Andrew Mellon-whose family had financial interests in the oil industry. (Mellon, to his credit, recused himself and told Cumming to use his own judgment.)
Surgeon General's Warning is a brief history of the office that includes the proud moments and the despicable ones, the perception and realities, the heroes and the scoundrels. The book explains how the surgeon general became the most powerful and influential public health officer in the country and how those powers were later stripped away. It discusses the unique bully pulpit role the post retained, and the prowess of some surgeons general in that pulpit and the meekness of others. It examines how the Office of the Surgeon General reached its current nadir. And it concludes that it no longer makes sense to have a surgeon general.
"What Is It?"
In January 2009, just weeks before President Barack Obama's inauguration, the media buzzed with reports that the president-elect was considering CNN medical journalist Sanjay Gupta for surgeon general. The telegenic Gupta, a young Atlanta-based neurosurgeon, had once been voted one of People magazine's "Sexiest People" and was a television superstar. He promised to be the kind of head-turning persona not seen since the days of Koop and Elders. The Daily Show, the popular late-night comedy/news program, took note with an exchange between host Jon Stewart and Indian American correspondent Aasif Mandvi.
In the segment, Mandvi crowed about the prospect of Gupta taking the job, and how it would mean Indian Americans would have as prominent a place in the new Cabinet as Chinese Americans and other ethnic groups.
Stewart interrupted, "Aasif, surgeon general is technically not a Cabinet position."
"It's not?" Mandvi said, surprised.
"Oh. What is it?"
"It's the head of the Public Health Service. It's a lot of informal duties and-"
"So it's beneath the Cabinet," Mandvi said, a look of disgust erupting on his face.
"Well those are your words, Aasif. It's a very high level . . ."
Mandvi, however, acted devastated. Such a position was not worthy of an accomplished physician representing a talented and proud people, he lamented. Looking at the camera, addressing Gupta, he cried; "Surgeon General? You should be ashamed of yourself!"
The bit was dead-on. Yes, the office is esteemed. And yes, many people don't really know what the surgeon general does.
During the flurry of attention over Gupta, the Harris Poll surveyed 2,848 U.S. adults about the surgeon general and 14 federal agencies. Participants were asked if they understood each entity's role. The surgeon general ranked near the bottom of the list-only the workings of the National Institutes of Health and Securities and Exchange Commission were bigger mysteries. Yet in the same survey, the surgeon general came out near the top of the list when participants were asked which entities were doing a good job.
So what does the surgeon general do?
At one time, he oversaw nearly all of the federal government's civilian health agencies. It was a surgeon general in the 1870s who resurrected the first federal hospital system. His successors instituted quarantines to fight deadly yellow fever and cholera epidemics and calmed the nation during the deadly Spanish flu epidemic of 1918-1919. They handled the medical care of hundreds of thousands of veterans at the end of World War I, and spearheaded the desegregation of U.S. hospitals in the 1960s. They also issued warnings to the public about health dangers ranging from unpasteurized milk to laundry detergent. Perhaps most famously, Surgeon General Luther Terry in 1964 released the report that finally settled the question of whether smoking causes lung cancer. Arguably, no government official has had a greater personal influence on the public's health than the U.S. surgeon general.
Such activities caused politicians and journalists to gradually start referring to the surgeon general as "the nation's doctor." The position retains a tremendous cachet today. If imitation is the sincerest form of flattery, note that since 2003, three states-Michigan, Arkansas and Florida-have created surgeon general positions to revitalize public health efforts. The job descriptions differed somewhat, but each state surgeon general official has been expected to give accurate and objective reports and benefits from a title that confers a kind of instant credibility. "The name 'surgeon general' conveys a certain respect," said Arkansas surgeon general Joe Thompson.
Although the U.S. surgeon general's stature has endured, the office's powers are long gone. Federal reorganizations in the 1960s stripped away most of the job's responsibilities and gave them to people appointed by whoever was in the White House at the time. "It was really the politicization of the Public Health Service," said the late David Sencer, who was director of the federal Center for Disease Control when the most substantial reorganizations took place. The surgeon general, meanwhile, became a bench-riding bureaucrat and glorified health educator. As early as 1973, the political scientist Eric Redman likened the position to a once-powerful European king who had been reduced to a figurehead, "a pathetic shadow of authority who traveled around the country lecturing high school students on the hazards of smoking."
Today, those speeches are the surgeon general's main job, at least as far as the public is concerned. Interestingly, not all the men and women who have held the job enjoyed public speaking, but most have seen it as an important duty. Key to that duty, several have said, is being a guardian of scientific truth and steering clear of ideology and propaganda. "The surgeon general's responsibility is to communicate directly with the American people based on the best available science," said David Satcher, who held the job in the late 1990s and early 2000s.
(Interestingly, there is no requirement that a surgeon general be a medical doctor of any kind, much less a surgeon. Federal law dictates that the main requirement for anyone aspiring to the job is that they have specialized training or experience in public health. And even that requirement has been repeatedly ignored-three of the eighteen surgeons general did not come from public health backgrounds, including Dr. Benjamin.)
The surgeon general also has some supervisory duties over the Commissioned Corps, that subgroup of uniformed health professionals within the U.S. Department of Health and Human Services. The Corps-a quasi-military subgroup of roughly 6,800 within a department of 65,000 mostly civilian employees-is a remarkable collection of doctors, nurses, and other health professionals trained to be deployed to disease outbreaks, disaster sites, and other emergencies. The Corps is most apparently modeled after the navy, and the surgeon general is treated as a three-star admiral and the organization's ceremonial leader. But most of the actual decisions about deployment are made by others, including the surgeon general's boss, the HHS assistant secretary of health (or ASH, in the parlance of the federal health bureaucracy). The ASH holds the rank of four-star admiral, but doesn't bother to wear the uniform.
In other words, the surgeon general is more a symbol than a job. To some, it's also been an irritation.
Some politicos and commentators have accused surgeons general of being "nanny" figures whose reports and lectures about appropriate health behaviors amount to a taxpayer-funded annoyance. "I've been flipping through my copy of the Constitution, and I can't find the part where the federal government is charged with making our kids eat better," wrote the libertarian writer Michael D. Tanner in 2007.Critics find it vexing that the position hasbuilt-in gravitas and a travel budget, and there have been a number of legislative attempts to eliminate the surgeon general or the Commissioned Corps, or both. Some presidents opted to just leave the job unfilled, sometimes for stretches as long as four years. "The last thing we wanted was a surgeon general to deal with; we had enough problems," groused Charles Edwards, a top Nixon health official, explaining why the job was left vacant after Steinfeld was tricked into resigning.
Indeed, no presidential administration has been at ease with a freewheeling, press-garnering surgeon general. Even Josiah Bartlet felt that way. Recall that Bartlet was the idealized chief executive on the once popular television drama The West Wing. In an episode that aired in February 2001, President Bartlet called for the resignation of a surgeon general whom he admired but who caused a political headache by discussing the legalization of marijuana. (A storyline inspired by Bill Clinton's termination of Joycelyn Elders less than seven years earlier.)
"If a surgeon general is doing the job correctly, they will eventually fall out of favor with the administration that appointed them, because they develop an allegiance to the science first," said David Rutstein, a former deputy surgeon general who resigned his job in frustration in 2010.
Crusaders No More
The genesis of this book was a class discussion among public health doctoral students at the University of North Carolina in the fall of 2005. The topic was something to the effect of "What is the story of public health these days, and who are its protagonists?" One student said the president was sometimes a leader on public health matters. Another said the Institute of Medicine had an influential voice. Someone opined that trial lawyers had done a great deal to shape public health discourse. A fourth ventured that the rock singer Bono could qualify as a hero, for his work drawing attention to AIDS in the developing world.
I was one of those students, and as I sat listening, a thought began to nag me: why aren't they talking about the surgeon general? As someone who grew up in the 1980s, I had clear memories of Surgeon General C. Everett Koop, with a prophet's beard and an admiral's uniform, shaking his finger at tobacco companies and leading a compassionate public education campaign on AIDS at a time when the fear and stigma about the disease was at its worst. Koop was perhaps the closest thing to a hero in that field I'd ever seen, but he and his successors apparently were nowhere on my classmates' radar. What happened to the surgeon general?
This book will offer an answer.
Surgeon General's Warning shows that the Office of the Surgeon General was always a bit of an anomaly within the federal government, and that odd status provided a unique potential for influencing the public health. Specifically, it afforded surgeons general the ability to speak more candidly and powerfully about the nation's problems than other health officials. But that potential was realized only occasionally. When it occurred, it was the result of a confluence of factors, including the determination and savvy of the surgeon general, the support of his or her political bosses, and a lack of competition for the bully pulpit regarding key issues of the day.
But the equation that could produce a Koop or Elders or Thomas Parran seems to have irrevocably changed. And that is to the public's detriment.
Surgeons general have always had to take orders from their political bosses. What's changed is that other federal health officials-like the HHS secretary and the CDC director-have developed an enduring taste for the bully pulpit, and have come to see surgeons general as unworthy competitors for it. They have a point: some surgeons general have been quota-filling, just-happy-to-be-here appointees with little expertise in influenza or some of the myriad other topics they were expected to speak about to a worried public. That was as much a failing of the surgeon general selection process as of the people who held the office.
In the past decade, in both Republican and Democratic administrations, surgeons general have become essentially invisible. Benjamin's predecessor, Richard Carmona, was repeatedly muzzled by the George W. Bush administration, and important reports he worked on were never allowed to see the light of day. Benjamin had an even lower profile, partly because of how she was controlled by her bosses and partly because of her own diffidence. "The general public, if you said Dr. Regina Benjamin, they wouldn't even know who you're talking about," said Laurence Grummer-Strawn, a federal expert on breast-feeding who has worked with Benjamin's office. "The surgeon general could have much more influence on the health of the nation if people were paying attention to her."
There's no longer a realistic expectation that lawmakers or executive branch officials will restore the Office of the Surgeon General to its past status. In an era of perennial government budget shortfalls, when local public health departments have eliminated tens of thousands of jobs-including care-providing nurses and outbreak-controlling epidemiologists-an invisible surgeon general is an indefensible waste of money.
But it is also the purpose of this book to mourn what has happened. The weakening of the office has led to a vacuum in health policy leadership. The federal bureaucrats who have taken the surgeon general's place in the spotlight have tended to walk a politically correct line and to steer clear of controversies that might trigger "Nanny state" complaints that the government is meddling in the lives of individuals. They almost refuse to openly acknowledge a central tenet of public health-that the state's responsibility is to look after the health of everyone, which sometimes means guiding or restricting people's choices. Their aversion to risk and confrontation has allowed a parade of misinformed talkers to fill the airwaves and Internet with wrongheaded theories that, left unchallenged, lead to the detriment of public health. Rantings about vaccines as a cause of autism have contributed to a resurgence of measles and other infectious diseases in areas where vaccination rates have been low.Manufacturers of sugary and fatty foods and beverages have persisted in marketing campaigns that propel the nation's obesity problem. And gun makers and their enthusiastic customers have so far cowed every substantial attempt to limit the purchase of firearms and ammunition, as U.S. gun-related deaths continue to surpass 30,000 each year.
A Koop or Elders would have said something about such shenanigans, and their strong words would undoubtedly have emboldened some lawmakers and policymakers to take action. But the last couple of surgeons general were wimps. In recent years the bold, speak-truth-to-power public health figures in government have resided at the local level. Take former New York City mayor Michael Bloomberg and his city health commissioners, for example, who pushed for complete smoking bans, limitations on serving sizes of sugary sodas, and a variety of other measures irritating to libertarians and certain corporate interests.
It was William Stewart, the ill-fated surgeon general of the late 1960s, who perhaps best described the historical standard for true public health leaders. "From the 1880s onward," he once said, "the public health movement always included rebels: men and women ready to strike out with new approaches at the roots of evil; crusaders who never lost faith that the movement possessed the breadth of vision, as well as the spirit and competence to meet the health needs of a growing and changing society."Surgeons general have played that crusader role better and more often than any other national public health figure. Absent such a crusader, the public's health is prey to the misinformation and self-interest of tobacco companies, snake-oil salesmen, and other malefactors. There are other heroes at work, to be sure, some with substantial resources and policymaking powers. But the true, traditional leader is missing, and the fight has suffered as a result.
I was struck by how much the role of surgeon general has deteriorated during a 2008 interview with Anthony Fauci, a potently articulate federal scientist with a job most people have never heard of-director of the National Institute of Allergy and Infectious Diseases. For decades, Fauci has been a de facto surgeon general, educating the public and speaking to the press about a range of health issues. Several people I interviewed said that if anyone had the smarts, passion, and oratorical skills to be a great surgeon general, it's Tony Fauci.
But when asked if he would ever want the job of surgeon general, he did not pause in answering no. He sees himself as a scientist who has maintained a high degree of prominence by being apolitical. Surgeons general talk about being apolitical, too, he said, but that's now more an aspiration than a reality. Surgeons general are too subject to the push and pull of the people in the White House and in the nearby Humphrey Building, where the HHS secretary and other top politically appointed health officials work.
"I love my job, and I'm more visible, and better known," he said. "Why would I want to be surgeon general?"
Rise, Fall, and Struggle
This book traces the story of the surgeon general through the stories of the eighteen individuals who have held the post.
The Office of the U.S. Surgeon General was created simply as a house-cleaning administrator for a beleaguered string of marine hospitals. But the first surgeon general, John Woodworth, was an ambitious Civil War veteran with bigger plans. Intent on becoming the sole leader of a nascent federal bureaucracy with authority over sanitation and epidemic control, he died while vying for power against a gang of the great public health leaders of his era. The second man to hold the office, John Hamilton, was a nasty political fighter who picked up the sword and defeated Woodworth's competitors. He and his successor, Walter Wyman, cemented the surgeon general's position as the federal doctor in charge of the nation's health.
The surgeon general and his staff came to be heroes. Dressed in military uniforms, the doctors and sanitarians of the U.S. Public Health Service battled yellow fever, cholera, and other nineteenth-century scourges, some of them losing their lives to disease in the line of duty. In the early decades of the twentieth century, books and articles were written about their wisdom and valor. Burnishing that reputation was the fourth surgeon general, a mustache-twirling amateur boxer named Rupert Blue, who entered the office revered for his role in beating back plague in San Francisco. Blue was an instinctively quiet man who nevertheless built up the surgeon general's bully pulpit, leading health education campaigns and speaking out on the need for national health insurance. His eventual replacement, Hugh Cumming, reigned for an astonishing sixteen years through careful alliances and personal friendships with presidents and other power brokers.
Cumming was succeeded by Thomas Parran, who for many years afterward was regarded as the greatest surgeon general of all time. Parran worked the bully pulpit like no one before him, reaching celebrity status in the 1930s and 1940s as he forcefully worked to change social mores and stop the spread of sexually transmitted diseases. He wrote a best-selling book, graced the cover of Time magazine, and starred in radio broadcasts-all in his attempts to address a public health problem that even ham-fisted reporters had deemed too coarse a topic for polite company.
But the end of Parran's tenure also saw the first signs of an eclipse of the Office of the Surgeon General. He was attacked in a congressional hearing for supporting President Truman's health reform-an assault that had the long-term effect of discouraging Public Health Service leaders from taking on certain controversial topics. Despite his many accomplishments and near-celebrity status, Parran was ushered out of office following a petty disagreement with a hot-tempered political boss.
So began a decline that continues to this day.
The seventh and eighth surgeons general-Leonard Scheele and Leroy Burney-started to lose power in the 1950s, following the creation of a cabinet-level federal health department during the Eisenhower administration. They also blundered in dealing with cigarette smoking, problematic vaccines, and rival bureaucrats.
The early 1960s saw the office's pinnacle moment, when Surgeon General Luther Terry released a report that would cause a turnabout in the American public's regard for the dangers of smoking. But even as Terry changed the lives of generations of Americans, his power too was slipping away. The erosion of the once vaunted surgeon general's powers became complete during the term of Terry's successor, William Stewart. Those powers would never come back.
In the 1970s, two very different personalities-the feisty Jesse Steinfeld and the more accommodating Julius Richmond-served as surgeon general. Both endured political bosses who tried to push them upstage or offstage, but succeeded in making important contributions to public health. Steinfeld ignited a movement to ban smoking in public places, and Richmond set new societal goals for healthy living.
The surgeon general experienced a resurgence with Richmond's successor-C. Everett Koop, easily the most famous surgeon general of the past half-century. An outsized personality who managed to surprise nearly everyone in Washington, D.C., Koop elevated a moribund position into superstar status. He was the Reagan era's sage and unwavering voice of public health, educating and influencing the public on matters ranging from AIDS to zoonoses, and so good at it that he could not be hushed by the assorted political, business, and religious interests that disagreed with him. If Parran's reign was a golden age, Koop's represented the silver-a glorious era that suffered in comparison only because Koop was never given the administrative powers that were the standard in Parran's time.
However, Koop succeeded through a rare alignment of events and personalities that unfortunately would not be seen again.
His replacement-Antonia Novello, the first woman appointed to the position-was a just-happy-to-be-here team player who was a disappointment as surgeon general and a figure of ignominy years later. Then came Joycelyn Elders, perhaps the most inspiring public speaker to hold the office, but tone deaf to the political fallout from her confrontational candor about controversial topics like the teaching of masturbation or the legalization of marijuana. Elders's meteoric tenure ended after barely a year-the shortest ever for a surgeon general-after President Bill Clinton deemed her too much of a political liability. Her firing (by a liberal chief executive, no less) seemed to permanently brand the position as expendable, and cast a pall over it that cowed some of Elders's successors.
Elders was followed by David Satcher, the last important surgeon general. Borrowing a trick from Julius Richmond, the low-key Satcher secured a second appointment within HHS, which afforded him resources that bolstered his work as surgeon general. With subtle determination, he produced groundbreaking and agenda-setting reports on obesity, sexual health, mental health, suicide, and a range of other topics. He restored dignity, visibility, and influence to the office. People who were turned off either by Novello or by Elders were again listening to the surgeon general.
It's been downhill ever since. Richard Carmona was a brash former war hero who as surgeon general followed orders to dissolve into the woodwork. Even more discouraging is the story of the most recent officeholder, Regina Benjamin. In an earlier life, Benjamin was likened to a living saint, overcoming fire and hurricanes to serve poor patients in an Alabama fishing village. But she was ill-equipped for life in Washington, and has become the most underachieving surgeon general to date. The blame for her failings rests as much with the system that selected and suppressed her as with Regina Benjamin herself. A few legislators have ventured proposals to fix that system-good proposals that could work. However, there has been no political will to enact them. Federal power brokers occupied with constituent demands, political fights, and personal peccadillos tend to have little time or interest in the surgeon general's problems.
This book analyzes and celebrates the importance of Benjamin and her predecessors in the nation's public health history. But it comes with a warning of its own: Unless something changes, we can expect-and, frankly, should expect-the surgeon general's demise.