It may be time to reconsider the role of the surgeon general.
In an email to her staff Wednesday, Vice Admiral Regina Benjamin, the 18th surgeon general of the United States, announced her resignation from the post she held for 4 years.
“My goal was to create a grassroots movement, to change our health care system from one focused on sickness and disease to a system focused on wellness and prevention. With your help, that movement has begun,” Benjamin wrote in her email.
In a follow-up email, U.S. Secretary of Health and Human Services Kathleen Sebelius suggested that Benjamin should be “proud of her many achievements.”
“Regina has served as America’s doctor since 2009 and has impacted the health and lives of Americans across the country. I am deeply grateful for her leadership and service,” Sebelius wrote. “The Surgeon General’s road to prevention has touched the lives of millions of Americans and has had a positive impact on the health of this Nation.”
“Regina has been passionate about changing our healthcare system from one focused on sickness and disease to a system focused on wellness and prevention,” Sebelius continued.
Benjamin is the founder and former CEO of the Bayou La Batre Rural Health Center in Alabama and was the first Black woman to serve on the American Medical Association’s Board of Trustees. As surgeon general, she promoted wellness and preventative treatment.
All of this, however, does not mitigate the fact that Benjamin’s resignation notice is the first time many Americans have been introduced to this surgeon general. A rudimentary Google search on Benjamin’s tenure as surgeon general reveals a scattering of public appearances promote physical fitness. According to the surgeon general’s homepage, Benjamin only had two “calls to action” — a 2009 initiative to promote healthy homes and a 2011 initiative to support breastfeeding.
The invisible surgeon general
Mark Bittman, a columnist for the New York Times and food writer for the New York Times Magazine, has emerged as a critic of the surgeon general. In a February 20 opinion piece, Bittman lamented about the “invisibility” of the post.
“Rarely, surgeons general have risen to the occasion,” Bittman wrote. “In 1957, Leroy E. Burney announced that there was a causal relationship between smoking and lung cancer. In 1964 his successor, Luther L. Terry, published the critically important report that gave the anti-tobacco movement the power it needed to save countless tens of millions of lives in the half-century since then. Koop — inexplicably and wonderfully backed by Reagan — brought the truth about AIDS into the light of day, mailing information about the syndrome to every household in the country.
“But since his term ended, the best-known surgeon general has been Joycelyn Elders, who held office for about a year (1993-4) before being fired for suggesting that masturbation be taught in order to help young people refrain from unsafe sex,” Bittman continued. “Carmona took flak for his positions in favor of abortion rights and was “told to stand down” when he wanted to take a scientific approach to stem-cell research. Those are the recent exceptions. Benjamin, like most of her predecessors, is virtually invisible.”
A changing role
Benjamin’s tenure may be reflective of a role that is ill-defined and may be — at its core — obsolete. Traditionally, the surgeon general — or chief surgeon — of the United States is the head of the U.S. Public Health Service Commissioned Corps.
The USPHS is one of the seven uniformed militarized services of the United States, along with the Army, the Navy, the Air Force, the Coast Guard, the Marine Corps and the National Oceanic and Atmospheric Administration Commissioned Corps. It is charged with national emergency response and medical assistance in areas with extreme medical need and in times of national crisis. In the course of fulfilling these roles, the USPHS is involved in medical research, public health advocacy and eradication of infectious diseases.
In 1968, however, organizational restructuring of the Department of Health, Education and Welfare — now the Department of Health and Human Services — transferred oversight of the USPHS to the Assistant Secretary of Health, with the deputy surgeon general serving as service chief executive officer. The Office of the Surgeon General was absorbed into the Office of the Assistant Secretary of Health, and the role of surgeon general became that of an advisor to the assistant secretary and spokesperson for the nation’s health policies.
Under the Affordable Care Act, the surgeon general was named the chair of the National Prevention, Health Prevention, and Public Health Council. This council is charged with developing a strategy to improve access to care. Given that the surgeon general is specifically tasked with developing and promoting one of the most prominent items in the Obama administration’s agenda, the absence of the surgeon general is puzzling.
Why wasn’t the surgeon general seen promoting the Affordable Care Act? Why was there no news coverage of the surgeon general’s proposal to the president about improving access to health care in remote and disenfranchised areas? Why wasn’t the surgeon general’s opinion heard on other public health issues, such as gun control?
The “last” surgeon general
The last surgeon general who can honestly be said to live up to the expectations of the office was C. Everett Koop, who — after a tumultuous Senate confirmation and repeated threats that he’d be fired for putting science before politics — became an advocate for HIV and AIDS research, stood up to the all-powerful tobacco lobby, ordered that health warnings be placed on all cigarette packages, and pushed to separate policymakers’ concerns about homosexuality from the efforts to find a cure for HIV.
At a presentation at San Francisco General Hospital, Koop argued, “I am the surgeon general of the heterosexuals and homosexuals, of the young and the old, of the moral and immoral, the married and unmarried. I don’t have the luxury to decide what side I want to be on.”
In 2007, Koop joined former surgeons general David Satcher and Richard Carmona to testify before Congress about the need to avoid politicizing science and the role of surgeon general. One of only two surgeons general who were actually surgeons — Carmona is the other — Koop understood that there was no training regimen and no set expectations for a surgeon general. One must — on their own volition — rise to the level of the office.
However, in such a position, it is easy to be swept up in the ebb and flow of executive branch politics, especially considering that the surgeon general has permanent access to the bully pulpit. While the surgeon general has no real executive power in the government, the opinion of the surgeon general carries weight — although public presence has been sorely lacking among recent holders of the office. As Bittman pointed out, Benjamin was wasting an opportunity by carrying on a health policy the first lady sponsored with more conviction.
“[Her] most public work, the 2010 document called ‘The Surgeon General’s Vision for a Healthy and Fit Nation,’ has a decidedly mild Michelle Obama-ish tone,” Bittman argued. “In discussing the obesity crisis, it lays the blame squarely at the feet of … the victims: ‘In addition to consuming too many calories and not getting enough physical activity, genes, metabolism, behavior, environment, and culture can also play a role in causing people to be overweight and obese.’”
“Instead of talk about curbing the marketing of junk to children, we get a discussion of ‘limiting television viewing’; instead of banning soda from schools, we get ‘Make sure water is available throughout the school setting.’ In short, instead of criticizing the industry for peddling and profiting from poison, it criticizes us for falling prey to it,” Bittman continued.
It may be time to reconsider the role of the surgeon general.
“I’m all for the surgeon general promoting exercise, especially at a time when the obesity debate has skewed towards focusing on ‘calories in’ without enough attention to ‘calories out,’” policy expert Jeff Stier wrote for the National Center Blog. “But at a time when we have a wide range of serious health problems in need of innovative solutions, this just strikes me as odd…If this is the best the surgeon general can do, it makes me wonder whether the office ought to exist in the first place.”
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