A Doctor, But Whose?

Published August 27, 2007

National Review Vol. LIX, No. 15

This has been a summer of surgeon-general headaches for the Bush administration. In July, former surgeon general Richard Carmona, who served from 2002 to 2006, appeared before a congressional committee to criticize his former employers, claiming he had been muzzled for political reasons.

“The reality is that the nation’s doctor has been marginalized and relegated to a position with no independent budget, and with supervisors who are political appointees with partisan agendas,” Carmona, himself a political appointee, told the committee. His specific claims ranged from the benign (that his speeches, like those of all political appointees, were put through a staff-review process) to the peculiar (that he was invited to meetings about global warming) to the utterly implausible (that he was told not to participate in a Special Olympics event because of the Kennedy family’s role in the project). But all were music to the ears of Rep. Henry Waxman (D., Calif.), chairman of the House Oversight and Government Reform Committee. Carmona’s allegations doubtlessly will resurface whenever the question of Republicans and science reemerges in the coming years.

Meanwhile, the administration’s new nominee for surgeon general, James Holsinger, has managed to upset both liberals and conservatives. A paper he wrote for the United Methodist Church in 1991, in which he argued that homosexuality is unhealthy, has drawn the ire of Democratic senators; and his support for human cloning for biomedical research has angered some Republicans.

The Bush administration has not been unique in its surgeon-general troubles. In the Clinton years, Joycelyn Elders got into hot water for recommending masturbation as a public-health measure, and her successor David Satcher sought to promote needle exchange over drug-treatment programs, but was held back by his superiors in the Department of Health and Human Services.

The theatrics and hand-wringing surrounding these scandals have tended to avoid a simple question: What is the surgeon general’s purpose and role? Carmona’s description of the job as “the nation’s doctor” is a very common one, but it hardly offers an answer: What does a “nation’s doctor” do?

When the post was created in 1871, the surgeon general was head of the Marine Hospital Service, which cared for American merchant sailors. Under the first surgeon general, John Maynard Woodworth, the MHS took the form of a uniformed pseudo-military service, and was assigned some crucial public-health responsibilities, most notably the maintenance of quarantines. In 1889, the larger U.S. Public Health Service was created, and the surgeon general was made its head. The MHS, meanwhile, was folded into the PHS and became its Commissioned Corps, a uniformed service assigned to help prevent the spread of disease and bring medical care to areas in need. Today, it continues to perform these functions through its roughly 6,000 doctors, nurses, pharmacists, engineers, and other uniformed officers.

The surgeon general’s duties, in short, fit the grandeur of his title. But since 1953, when another reorganization created the cabinet-level office now known as the Department of Health and Human Services, the surgeon general’s duties have gradually contracted. In 1968, the responsibility for running the PHS was moved to the assistant secretary for health, to whom the surgeon general now reports.

With very few practical administrative responsibilities, the surgeon general’s office has become increasingly symbolic. Its website lists the following as first among the surgeon general’s duties:

To protect and advance the health of the Nation through educating the public; advocating for effective disease prevention and health promotion programs and activities; and, provide a highly recognized symbol of national commitment to protecting and improving the public’s health.

Today’s surgeon general, in other words, is a public-health spokesman and brand. But a spokesman for whom? The controversy over supposed political control of the office suggests that many in the Left do not think the surgeon general should speak for the president who appointed him, but rather for the science of public health.

This field, however, has become radically politicized over the past several decades, serving on one hand as a Trojan horse for some of the most extreme cultural theories of the Left, and on the other as an excuse for paternalistic restrictions on individual behavior. Some of the surgeons general in Democratic administrations, such Elders and Satcher, have been most concerned to advance the Left’s cultural agenda, but most, including Carmona, have exemplified the paternalistic tendency.

The surgeon general today is little more than a finger-wagging preacher calling on the public to give up unhealthy habits. Earlier this year, the surgeon general’s office released a report on teen drinking, and last year Carmona released one on second-hand smoke — the latest in a long line of reports on tobacco use, which has been the favorite subject of assorted surgeons general since the 1960s. In recent years, the office has published a report on the role of culture, race, and ethnicity in mental health, and another on youth violence — neither of them a public-health issue under any but the broadest definition.

These reports — which are generally just compilations of government statistics produced not by the surgeon general or his staff, but by bureaucrats in other agencies — routinely fall into exaggeration and excess. In 2006, Carmona described obesity in America as “a terror within” comparable to Islamic fundamentalism, and claimed it takes the lives of almost half a million Americans a year — a figure the Centers for Disease Control later had to acknowledge was unfounded.

The tone of surgeon-general reports makes for a telling case study in the way health has usurped the place of virtue in America’s public vocabulary. Public health is the only remaining language in which to speak of vice — an old-fashioned word that once would have been the obvious way to refer to, say, smoking and drinking. The self-righteousness that colors the crusade against obesity, smoking, and other modern sins is as near as the Left gets to religion, and the surgeon general fills the role of oracle.

That is precisely why Democrats are so worked up about the latest surgeon-general troubles. Responding to concerns about political control of the office, Sen. Ted Kennedy introduced a bill to give the surgeon general an independent budget and to constrain the president’s authority to select surgeons general by forcing him to pick from a short list prepared by the Institute of Medicine, an arm of the National Academy of Sciences.

This approach is exactly backward. The surgeon general should be more, not less, integrated into the administration The Kennedy bill, with its ideal of scientific independence from the petty concerns of democracy, is a recipe for unrestricted public-health activism in the name of the executive branch, but without its approval or control. As the office is currently constituted, the surgeon general simply does not serve a legitimate public purpose. In Republican administrations, it is little more than a source of internal strife; in Democratic ones, it is an arm of the radical Left. Far from keeping politics out of science, the office has relentlessly politicized public health, and has done remarkably little of practical use. The Kennedy bill would only make matters worse.

The Bush administration, or its successor, has two good options for reform. It could eliminate the office outright, and absorb its few practical responsibilities into existing public-health agencies, especially the Centers for Disease Control. Or, as is more likely given the political cost of doing away with the surgeon general’s “brand,” the assistant secretary for health, who is already charged with overseeing all those public-health agencies, could simply assume the title of surgeon general, endowing the post with serious responsibilities and leaving little time for mischief.

In that case, the surgeon general would be a senior political appointee, more closely linked to the aims and priorities of the president. His reconstituted office would have a serious role in running the Department of Health and Human Services and its public-health agencies, rather than being a publicity gambit founded on outbursts and exaggerations. Such a surgeon general could thus truly speak for the country’s public-health bureaucracy and serve as a symbol of the government’s efforts to prevent the spread of disease. But he would not need to be a voice for ideological alarmism or political extremism.

The surgeon general is not the nation’s doctor. Doctors examine and heal, advise and consult. The surgeon general just preaches. His gospel, the good news of public health, does not benefit from reckless activism. And his title and status, in their current form, lead only to confusion about the proper (and properly limited) role of science in governing a democracy.

Mr. Levin is a fellow at the Ethics and Public Policy Center and a senior editor of The New Atlantis magazine.

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