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Surgeons General: Defenders Of Public Health

The New Physician January-February 2001
For a surgeon general, taking a stand on important public health issues frequently means defying politics, shocking the
public and risking being fired by the president of the United States. Still, for the past 131 years most surgeons general have been willing to take these risks in order to improve the health of all Americans.



Surgeon General Joycelyn Elders counted 30 microphones on her podium as she spoke at the United Nations’ headquarters in New York City during a teleconference for World AIDS Day in 1994. The whole world was listening as a psychiatrist asked Elders if children should be taught about masturbation. Safe sex is one way to avoid HIV/AIDS, and masturbation is part of practicing safe sex, Elders responded. Surgeon general says teach children to masturbate, Newsweek reported. Two days after the Newsweek article appeared, President Bill Clinton asked Elders to resign after serving only 15 months of her four-year term.


Once upon a time, most Americans wondered if the surgeon general is a real person or whether he’s a marketing image like Betty Crocker or Uncle Sam. Today, however, the surgeon general is frequently in the news—making headlines with provocative reports or comments. What’s going on? Has the role of the surgeon general really changed from when it was first established in the late 1800s? Not really. The Office of the Surgeon General has historically focused on critical and often unsettling public health issues, upsetting presidents, the public and Congress in the process. In fact, some of the most effective surgeons general have been the most controversial—speaking out for the better of public health. If earlier generations of Americans were confused, that’s only because modern media outlets weren’t around to spread news of the surgeon general across the nation and around the world.



THE FIRST PUBLIC HEALTH REVOLUTION


In 1877, state leaders attacked the first surgeon general, John Woodworth (1871–1879), when he pressed for a national quarantine system after a yellow fever epidemic quickly spread up the Mississippi River from New Orleans. State quarantine regulations were inconsistent and, therefore, ineffective, but state authorities didn’t like the federal government telling them what to do. Nevertheless, in 1878 Woodworth succeeded in getting a national quarantine act passed, which gave the surgeon general and what is now called the Public Health Service (PHS) full responsibility for quarantines, curbing the spread of infectious diseases.


States’ rights were again the issue during the “privy campaigns” in the early 1900s when Walter Wyman (1891–1911) was surgeon general. Most Americans had no concept of the germ theory of disease, which had just been developed in the 1880s. Ignorant of the risks, people built wells next to poorly constructed and maintained outhouses. In response to this public health threat, Wyman launched a nationwide public education campaign that included pamphlets, articles and diagrams about proper privy construction, care and maintenance. The campaign met public embarrassment and derision, but Wyman persisted and so did the PHS Commissioned Corps, and they transformed rural hygiene throughout America. “Wyman butted heads with state and local authorities who didn’t like the federal government telling them how to sink wells and build outhouses,” says John Parascandola, a PHS historian. “It may seem silly to us now, but the privy campaigns controlled infectious diseases and the spread of parasites like hookworms.”


Historians consider the first 20 years of the last century to be “the first public health revolution,” one of the most progressive periods public health has ever seen. Wyman and his successor, Rupert Blue (1912–1920), were national leaders in the “Sanitary Reform Movement” that helped control the most contagious diseases and greatly increased Americans’ life spans.


When bubonic plague invaded San Francisco in 1900, city leaders denied they had a problem, fearing bad press would hurt business. When they refused to abide by federal quarantine and immunization protocols, Wyman threatened to quarantine the entire state of California. By 1903, the plague was so bad that an emergency conference in Washington, D.C., recommended all travel into and out of California be stopped unless the state allowed PHS physicians to start an eradication campaign. San Francisco finally agreed.


When Blue succeeded Wyman in 1912, he would become the only surgeon general to also serve as president of the American Medical Association (AMA); Blue was elected president of the AMA in 1916. These were good times for public health and marked the beginnings of many modern-day government public health agencies. The Pure Food Act of 1906 was a precursor to the Food and Drug Administration. Disease control through quarantine and immigrant health screening eventually evolved into the Centers for Disease Control (CDC). And the Hygienic Lab on Staten Island, New York, grew and became the National Institutes of Health.


During Blue’s tenure, the AMA supported a system of universal health care, and there was strong public support for it, too. But before this system could be established, World War I enveloped national interests, and after the war, the vision and organizational support for universal health care had vanished. Conservative Warren Harding became president of the United States, and the next surgeon general, Hugh Smith Cumming (1920– 1936), maintained a relatively low profile. As the PHS retreated somewhat from its efforts at the state and local levels, the first public health revolution came to an end.


SIGNALING THE START OF MODERN TIMES


Thomas Parran Jr. (1936–1948) is considered the first of the modern surgeons general because he spent at least as much time educating the public as he did administering the PHS. An outspoken public health activist, Parran was lucky to be serving during the years of President Franklin D. Roosevelt’s New Deal, when the public was more accepting of government’s involvement in their lives. Parran advocated universal health care, which again was widely supported—mainly because of the Depression’s devastating impact on the nation. But again the country’s involvement in a war prevented this from happening.


Although Parran helped found the World Health Organization, he is probably best known for his national campaign to eradicate venereal disease, a crisis which blossomed first among U.S. troops during World War I. Before he became surgeon general, Parran headed the PHS’s Venereal Disease Division from 1926 until 1930, and in 1934, while serving as New York State’s health commissioner, he canceled a nationally broadcasted radio interview because network brass refused to let him say “syphilis” on the air. Calling a press conference, he announced to the nation that he’d been censored, giving his campaign far more publicity than the radio show would have provided.


When Roosevelt appointed Parran surgeon general in 1936, it was still taboo to talk about venereal disease in the media. Parran ignored this, however, and had the PHS produce posters, films and pamphlets as part of his controversial public education campaign. His book on venereal disease, Shadow on the Land, discussed sexually transmitted disease explicitly and thoroughly, and it became a national best seller. His efforts led to the enactment of the Venereal Disease Control Act of 1938, which lowered the incidence of venereal disease by increasing funding for sex education campaigns and for research into venereal disease diagnoses and treatment. The increased funding also allowed PHS personnel to become more involved in disease control.


Few recognize the name Luther Terry (1961–1965), but many of us have heard of the “Surgeon General’s Report on Smoking and Health” that Terry released in 1964. This report led to the mandate requiring surgeon general’s warnings to be placed on all cigarette packs, and it prompted a dramatic decline in smoking, especially among men. “It made the surgeon general a household name,” Parascandola says. “The smoking report was the first surgeon general report to have a huge impact on the public. From then on, a surgeon general’s report carried more weight—it wasn’t just shelved or circulated internally.”


Terry’s report identified smoking as a cause of lung cancer and chronic bronchitis, but he wasn’t the first surgeon general to attack tobacco. Terry’s predecessor, Leroy Burney (1956–1961), issued warnings about smoking in 1957 and 1959, after the first definitive research showed cigarette smoking caused heart disease and lung cancer. But Terry’s report had more credibility, partly because more evidence had accumulated and because his advisory committee was composed of scientists and physicians who had never taken a public stance on tobacco. He also gave both sides—Big Tobacco and anti-smoking activists—the opportunity to veto any proposed committee member.


“Terry’s report was certainly a departure from mainstream thinking,” says Dr. Fitzhugh Mullan, a former assistant surgeon general, a PHS historian and an author. Terry announced the report’s results at a Saturday press conference that was held behind closed doors at the State Department in order to minimize the report’s effects on the stock market and to ensure wide coverage in Sunday newspapers. “The report hit the country like a bombshell,” Terry told PHS historian Parascandola. “It was front page news and the lead story on every radio and television station in the United States.”


Two things happened in the late 1960s that forever changed the surgeon general’s job. First, in 1968, the surgeon general was no longer responsible for managing a huge bureaucracy—the PHS. That job went to the newly created assistant secretary for health (and was given to the secretary of health and human services in 1995). This meant the surgeon general had less control over budgets and policies, but it also meant he could spend more time exercising his tremendous podium power. A surgeon general’s management skills were suddenly less important than his communication skills.


Second, the creation of Medicare and Medicaid during the 1960s politicized health care like never before. “Health issues were no longer just a matter of scientific debate but of huge budget allocations,” Parascandola says. Debates on birth control pills, family planning and abortion further politicized health care. In this highly charged climate, the surgeon general was bound to upset someone—no matter his message.


Surgeon General Jesse Steinfeld (1969–1973) infuriated President Richard Nixon so much that the president fired him. “You can’t fire me,” Steinfeld told Nixon. “I’ve got a four-year term.” So Nixon took away Steinfeld’s office, his secretary and his parking place. At the beginning of Nixon’s second term, the surgeon general quit. Steinfeld once told The New York Times that although his departure was part of an overall Nixon housecleaning, he believes he lost his job because he raised concerns about second-hand smoke and television violence. Steinfeld and Elders are the only two surgeons general forced to resign.


The Office of the Surgeon General was essentially mothballed from 1973 to 1977, a time when Congress and the Nixon and Ford administrations tried to eliminate the position but failed. When President Jimmy Carter appointed Julius Richmond (1977–1981) as surgeon general, the physician said he’d take the weakened position only if it was combined with the assistant secretary for health. “I felt this would restore stature and power to the surgeon general,” says Richmond, who is now professor emeritus of health policy in the department of social medicine at Harvard Medical School. Carter agreed. So once again, the surgeon general managed the entire PHS, though no surgeon general after Richmond would do so until David Satcher was appointed surgeon general in 1998.


THE SECOND PUBLIC HEALTH REVOLUTION


A pediatrician, Richmond had served as the founding director of Project Head Start, a program for economically disadvantaged preschool children. As surgeon general, he pushed for adequate access to mental health care and health care for the underserved, and he aggressively assigned physicians in the Commissioned Corps to work in disadvantaged regions.


Richmond says the most challenging part of his job was “making sure the urgent doesn’t take precedence over the important.” He considered preventive medicine important. “You, the individual, can do more for your own health and well-being than any doctor, hospital, drug or exotic medical device,” Richmond said in his preventive health-care report—the government’s first official wake-up call to consumers about taking personal responsibility for their health.


Richmond began what Mullan and others refer to as the “second public health revolution”—educating the public on how lifestyle choices raise or lower risks for early death. This meant changing how Americans think about medicine, letting them know that it doesn’t just fix problems but prevents them, too.


Richmond’s 1979 “Healthy People” campaign, the first of its kind, set measurable long-term goals for reducing infant mortality and deaths from heart attack, stroke and cancer—all indicators of public health. Every 10 years since then, surgeons general have updated those objectives. “As a nation, we’ve actually met or exceeded many of those goals,” Richmond says.


KOOP D'ETAT


Richmond may have de-mothballed the office, but C. Everett Koop (1981–1989) gave it celebrity status.


As a pediatric surgeon, Koop tackled cases other surgeons wouldn’t touch—like separating several sets of Siamese twins—and made remarkable advancements in his field. As surgeon general, the outspoken Koop waged war against Big Tobacco and dared to talk about AIDS and condoms every chance he got. He once said: “As a physician, it has always been my passion to be a crusader, as well as a pioneer. I take on difficult issues and problems regardless of the opinions of others.”


Koop became such an icon for the surgeon general that some people think he still has the job. “Koop told the truth in ways people could understand,” says Dr. Mohammad Akhter, executive director of the American Public Health Association. “That’s what Americans want their doctor[s] to do.”
“Koop was indisputably terrific,” Mullan says. “He took a moribund backstage job and by force of personality transformed it.”


Sporting his trademark Captain Ahab beard and dressed in his starched white shirt and double-breasted navy blue suit with shiny brass buttons, Koop looked more like a 19th century ship’s sawbones than a pediatrician from New Hampshire. He was a physician Uncle Sam, his finger wagging and his voice booming in precise sentences.


Koop’s grueling confirmation hearings took a record 11 months. For years, he’d spoken out against abortion rights. He’d gone so far as to appear in an anti-abortion film that presented him standing on an island in the Dead Sea, a thousand dolls floating in the salty water around him. During the confirmation period, pro-choice supporters used the clip to unfairly portray Koop as a religious zealot. Meanwhile, social conservatives salivated.


Once in office, Koop was asked by Reagan staffers to issue a report about abortion’s negative health effects on women. The administration believed that surely the report would prompt the Supreme Court to overturn Roe v. Wade, which legalized abortion. They were wrong. Koop instead told Reagan that “scientific studies do not provide conclusive data about the health effects of abortion.”


“It was clear to me,” Koop says, “the Reagan administration saw the surgeon general’s job primarily as a means of promoting their social agenda—especially pro-life and family issues.”


“Koop’s politics changed,” Mullan says. “Once in office, he set aside his personal beliefs and became a humane and thoughtful figure who spoke out with enormous common sense and passion.”


Parascandola says it was a gutsy change for Koop. “He disappointed many conservatives who supported his appointment. They felt betrayed,” he says.


Koop never changed his views on abortion, though. He simply felt abortion was a moral issue, not a medical issue. “I maintained my [pro-life] support,” Koop says, “but removed myself from their tactics.” He says he was frustrated by “the sleazy tactics, lack of integrity and absence of scholarship on both sides [of the issue]” and was constantly caught in the crossfire. When asked about the ribbons of rank on his uniform, he often replied, “one row is for what the liberals did to me; the other row is for what the conservatives did to me.”


Koop instead aimed his cross hairs at Big Tobacco, against whom he used a new strategy. “I didn’t just talk about how they peddle a product that kills when used as directed,” Koop says. “I spoke out about the devious ways cigarette companies lead you down the garden path to addiction. Changing the tenor of the attack set the stage for today’s state and federal class action suits.”


Almost single-handedly, Koop got smoking banned from airplanes. Brandishing research conducted in Canada (because U.S. airlines refused to cooperate), Koop showed that a person flying on a plane allowing smoking inhaled the same amount of carcinogens no matter where she sat. The research also showed that flight attendants were inhaling the equivalent of three cigarettes per day—even if they didn’t smoke —and that nicotine metabolites linger in non-smokers longer than they do in smokers. Today’s smoke-free offices, shopping malls and restaurants are a direct legacy of Koop’s efforts.


So Koop had already distinguished himself as surgeon general when the AIDS epidemic came along in the early 1980s. Because AIDS was a highly politicized disease, Koop frequently butted heads with Reagan staffers, who chose to ignore the dire health problem. “No one in the Public Health Service bureaucracy wanted to deal with it,” Koop recalls. “So I stepped into a vacuum and became the government’s spokesman for AIDS. Essentially I said, ‘Mr. Reagan, you’re wrong.’ Most government employees don’t do that.”


Besides talking about AIDS to teens, parents, teachers and physicians, he defied Reagan by mailing a controversial pamphlet to every home in America that plainly explained the facts of the disease and debunked the myths. “History will probably say that we would have taken a lot longer to get to where we are with AIDS education if I hadn’t done what I did,” Koop says.


SURVIVING THE KOOP LEGACY


When Antonia Novello (1990–1993) took office after Koop, she had big shoes to fill. She was outspoken, but not controversial. As the first woman and first Hispanic to hold the office, she did so with effectiveness and tact during the first Bush administration. Unlike her most recent predecessors, Novello, a pediatrician, rose to the position through the ranks of the Commissioned Corps. Like Koop, she spoke out against Big Tobacco. She got Joe Camel banned from advertisements and shamed the alcoholic beverage industry for ads targeting young people.


Novello’s childhood vaccination campaign increased the number of school-aged children being vaccinated from 65 percent to 80 percent. She brought AIDS education to high-risk migrant populations and fought to increase health-care access for Hispanics. Every chance she got, she delivered the get-real message that “we need to start mingling with the world and become socially and culturally aware of the needs of different people who make up this country.”


In 1993 Clinton appointed Joycelyn Elders (1993–1994) to the position. The first African-American surgeon general and the second woman, Elders was also the second to be fired, or “asked to resign” as it’s politely put. “You bet I was fired,” says Elders, from her home in Little Rock, Arkansas, where she is professor emeritus at the University of Arkansas for Medical Sciences. “The job was pretty much what I thought it would be until the very end. I thought it was supposed to be apolitical. You’re not supposed to serve at the wishes of the president. You’re supposed to do what’s good for public health. That’s how I approached the job.”


Elders believes she might have survived the masturbation episode had Newt Gingrich’s conservative Contract With America coalition not been calling the shots in Congress. “Bill Clinton agreed with what I said, but he had too much on his plate and couldn’t afford the political heat,” she says. It is widely understood that Elders’ comments were misinterpreted and twisted for political gain, and she was surprised when Clinton asked her to resign.


Elders also might have been able to serve out her term had she not already set hairs on end while speaking publicly about AIDS and adolescent sexuality. “We’ve taught high school students what to do in the front seat,” she once said, referring to driver’s education. “Now we need to teach them what to do in the back seat.”


“Joycelyn Elders had a wonderful knack for putting her foot in her mouth,” Parascandola says. “It’s not what she said, but how she said it that made it easy for the press and public to misinterpret.”


“My mouth was my greatest asset,” Elders says. “I admit to everything I said because I don’t regret a word of it. Obviously I never said we should teach children to masturbate. They already masturbate. God taught them how.”


The “condom queen,” as critics called her, helped increase the number of high schools with primary preventive health clinics from 30 in the entire country when she took office to 1,100 four years later. “Pediatricians were opposed to it at the time,” she says. “They were afraid the clinics would steal their patients. School-based clinics have actually increased patients for pediatricians—so now they’re all for it.”


Pointing to some statistics—teen pregnancy rates among African Americans dropping 30 percent from 1991 to 1997; condom use among teens rising from 25 percent in 1991 to 60 percent today—Elders says her outspoken style contributed to improved public health. “Much of this is due to the willingness of me and others to speak out,” Elders says.


After Elders, it seemed it would have been hard to confirm even a monk to be the surgeon general. Could anyone be effective in a political environment in which proven ways to control sexually transmitted disease offended those who touted “traditional family values”?


Henry Foster Jr., an obstetrician –gynecologist, was named to succeed Elders, but his nomination failed after he acknowledged having performed abortions. By 1996, four bills had been submitted in Congress to eliminate the position of the surgeon general. “I think it’s rather pathetic,” Koop says, “that Congress, not liking Clinton’s last two designations, decided the way to settle the problem is to get rid of the office. It’s really an insanity.” The surgeon general’s office sat empty for three years until 1998, when Clinton appointed David Satcher (1998–2002).


Clinton thought he’d found the Elders antidote in Satcher. An African-American family practitioner and the son of poor farmers in rural Alabama, Satcher had a soft-spoken style and an impeccable record. The confirmation should go through without a hitch—or so Clinton thought. The confirmation hearings mired when Satcher supported Clinton’s refusal to ban late-term abortions. He was also attacked for research he supported as director of the CDC in which HIV-infected pregnant African women were used as a control group and given placebos instead of experimental medicine. And social conservatives protested Satcher’s support of needle-exchange programs. But unlike Foster, Satcher had the medical establishment’s backing and bipartisan support in Congress.


A cautious consensus-builder who nevertheless says what he feels needs to be said, Satcher still supports needle-exchange programs, saying research shows they reduce the spread of AIDS and don’t encourage drug abuse. His top issues include encouraging pregnant women to get good prenatal care, eliminating racial disparities in disease and giving mental health the same priority as physical health. He started the nation’s first campaign to combat suicide, the eighth leading cause of death in the United States. And most recently, Satcher has shifted his focus to bioterrorism threats.


Satcher has drawn the most criticism for his report calling for schools to teach safe sex. Most schools only educate their students about abstinence-until-marriage as a way to prevent pregnancy and sexually transmitted disease. The report says that no scientific studies have shown talking about sex in the classroom encourages teenagers to have sex, and it says that several studies have shown sexually active teens are more likely to use protection if they’ve had more comprehensive sex education. Moreover, Satcher’s report says that sexual orientation cannot be altered by force of will.


The church-based Focus on the Family organization says the report “calls severely into question the surgeon general’s ability to remain the chief medical officer of the United States.” The Bush administration distanced itself from the report without attacking it. Satcher says sex education is the most controversial and sensitive issue he’s faced as surgeon general.


It seems that sex bedevils every surgeon general. “Some people just don’t like to talk about sex,” says Dr. David Sundwall, who served as assistant surgeon general during the Reagan administration. “They don’t like to acknowledge that sexuality is a normal human function. Satcher is demonstrating that you can talk about it in biological terms, not just moral terms.”


Satcher’s term ends in February. President Bush has not asked him to stay on. Satcher has said even if he were asked to stay on, he wouldn’t. At press time, no one could tell The New Physician whom to expect as the next surgeon general. The only name that keeps coming up is Kenneth Cooper, the 71-year-old Texan and friend of Bush’s who’s groundbreaking 1968 book, Aerobics, sparked an exercise boom. Cooper has lots of ideas, many of which are already stirring controversy, including giving federal tax deductions of up to $1,000 for Americans who stay healthy. But no matter who is selected for the position, only one thing’s for sure: If he wants to take a stand on public health issues, the surgeon general is bound to make someone unhappy.
Howard Bell is a New Physician contributing editor.