Plight of the Surgeon General

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Science  12 Oct 2007:
Vol. 318, Issue 5848, pp. 169
DOI: 10.1126/science.1149333

On 10 July 2007, three former U.S. surgeons general sat before the House Committee on Oversight and Government Reform and detailed a rising tide of political interference in the conduct of the office in which they had served. Richard Carmona, who resigned the position last year, told of being blocked from speaking out on issues such as stem cell research and emergency contraception, and of instructions to reference President Bush three times on every page of any speech he gave. David Satcher of the Clinton Administration recounted interference with his report on sexuality and public health, in part because of the Monica Lewinsky affair. And C. Everett Koop described attempts of the Reagan political staff to thwart his AIDS campaign.

CREDIT: LUC NOVOVITCH/REUTERS

The hearing raised questions not just about political interference with science but about the Surgeon Generalship itself—a position that has had a mercurial ride through U.S. political history. Legislation in 1889 established the position of Surgeon General of the Marine Hospital Service, a minor government agency that evolved rapidly during the 20th century into the U.S. Public Health Service (PHS). By the 1960s, the Surgeon General, always an appointee from the ranks of PHS career officers, was in charge of a small empire of federal health programs, including the National Institutes of Health, the Food and Drug Administration, and the Indian Health Service. In 1967, a politically appointed Assistant Secretary for Health in the Department of Health, Education, and Welfare supplanted the Surgeon General as the line manager of the PHS, and the Surgeon Generalship became ceremonial. Nixon left the job empty from 1972 to 1976, and Carter designated his Assistant Secretary for Health as Surgeon General as an afterthought.

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 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.

Legislation is needed to do three things: provide an independent budget for the currently mendicant position; mandate an annual Surgeon General's Report on the state of the nation's health; and, essential to all else, insulate the Surgeon General from political interference. Political shielding for key government officials (such as departmental inspectors general) has precedent, and similar measures should be adapted for the Surgeon General. It is Congress that needs to rescue the office of Surgeon General and give it, once and for all, the support and protection it needs to advance the public's health.

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