The demise of the surgeon general

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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 (Jan. 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 18th surgeon general. It had been an unusually florid affair, even by Washington’s standards. Rows of federal health officials were dressed in the formal, militaristic uniforms of the commissioned Corps of the U.S. Public Health Service. Some formed a saluting gauntlet 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 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 20th 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 using 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.

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 1918-19. 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.

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.

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.