Episode 90: The Surgeon General

On today's episode: Who is the Surgeon General and what powers do they have? When a public health crisis strikes, what can the Surgeon General do? What influence did Surgeons General have on issues like smoking and HIV/AIDS? We sit down with Fitzhugh Mullan, professor of Health Policy and Management at George Washington University. 

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Civics 101

Episode 90: The Surgeon General


Virginia Prescott: [00:00:23] I'm Virginia Prescott and this is Civics 101, the podcast refresher course on the basics of how our democracy works. You've probably heard the name surgeon general, maybe seen it on the scary warning labels on cigarette packs or liquor bottles. But who exactly is the person behind the stickers and what kind of power do they have? Well we're finding out today with Fitzhugh Mullan. He's author of Plagues and Politics: the Story of the United States Public Health Service.


[00:00:50] Thank you so much for joining us.


Fitzhugh Mullan: [00:00:51] My pleasure.


Virginia Prescott: [00:00:52] So first of all who is the surgeon general and what do they do?


Fitzhugh Mullan: [00:00:56] Surgeon General is the head of the U.S. Public Health Service. That is the uniform wearing part of Health and Human Services. Part of the federal agency that protects our health as Americans. There are about 6000 commissioned officers who are commissioned in the U.S. Public Health Service. And the surgeon general is the senior officer appointed by the president to head up that corps and play really a more important role as a spokesperson about health for the country.


Virginia Prescott: [00:01:28] So the surgeon general is actually a general.


Fitzhugh Mullan: [00:01:33] Surgeon general in fact has always been a physician who is distinguished in their role as a public health leader and expert and carries the rank of general officer equivalent to a general in the army or an admiral in the Navy.


Virginia Prescott: [00:01:50] Let's get a sense of what kind of powers the surgeon general has. Do they influence policy or legislation?


Fitzhugh Mullan: [00:01:56] The surgeon general in today's arrangement actually comes to office with very little power, high visibility, and high levels of respect at least if you asked the population about the person. The reason they have not a great deal of power is that they have neither a large budget nor a large role in the bureaucracy of managing the government or public health as an individual.


[00:02:23] The individuals in the public health services 6000 commissioned officers all of them are health professionals and play important roles in agencies like the NIH and the CDC and the FDA. But the surgeon general him or herself is typically in charge of them but he doesn't run their programs day to day.


[00:02:45] However the surgeon general by dint of being a leading health professional or leading public health advocate by dint of being appointed by the President and confirmed by the Senate by dint of wearing this historic uniform that is highly noticeable and has had many people wear it with great respect of the country really has a pulpit a bully pulpit as it were for talking about the nation's health and what we as a country and we as individuals can do to lead healthier lives and create a healthier society.


Virginia Prescott: [00:03:20] So do they have the ear of the president?


Fitzhugh Mullan: [00:03:24] They do depending upon the particular arrangement. The most famous earlier surgeon general was a man named Thomas Parran and this was in the 1930s. He was the public health commissioner in the state of New York when the governor was a man named Franklin Roosevelt. And when Franklin Roosevelt became president Dr. Parran came to Washington as his surgeon general.


[00:03:49] In that case he was close to and many of the things he was able to do were facilitated by the president. In other cases and generally today the surgeon general is not a close confidant of the president but certainly is within the presidential scheme of appointments an important appointment because presidents want people who are highly credible highly respected both within the profession and with the public as a whole.


Virginia Prescott: [00:04:18] I can't hear Parran's name without acknowledging that he was in charge of the Public Health Service during the Tuskegee experiments. Now this was a decades long study of syphilis conducted unknowingly on African-American men in Alabama under Parran's watch, right?


Fitzhugh Mullan: [00:04:34] The Tuskegee syphilis experiment took place before during and after Parran's tenure. But yes that was certainly a problem situation for the public health service and for the country for medical ethics. And the surgeon general in charge certainly bears some responsibility. I don't want to dismiss that at all. On the other hand Parran did many things were very important.


Virginia Prescott: [00:05:00] Let's talk about another famous surgeon general. One who may be one of the reasons that we know about the surgeon general we see the labels on cigarette packages and advertisements for cigarettes that say Surgeon General's warning which started with Luther Terry. Now what did he do?


Fitzhugh Mullan: [00:05:16] Luther Terry was surgeon general in the 1960s. He was a chest surgeon himself a physician himself. And he was actually in office at the time that the research all came together to prove beyond doubt that tobacco was associated smoking in particular tobacco in general with a number of diseases most importantly lung cancer.


[00:05:40] It was not his research and it was not even particularly research done at that moment. There had been earlier reports implicating the same connection. But Dr. Terry assembled a group of notable scientists and public health experts who reviewed all the data and declared definitively that there was no doubt tobacco was causative in lung cancer and a variety of other diseases. And for that he's given great credit. It is from that point on that the anti-smoking campaign has been a particular resident factor on the surgeon general's desk when he or she comes to office and every surgeon general since that time has remained quite vocal and quite active in the tobacco control efforts of us as a country.


Virginia Prescott: [00:06:30] Let's talk about another public health crisis that the surgeon general engaged with, the HIV/AIDS crisis. Tell us about C. Everett Koop.


Fitzhugh Mullan: [00:06:40] So C. Everett Koop was a pediatric surgeon of great note. He was an early pioneer in the field of pediatric surgery. He was appointed by President Reagan in 1980 as surgeon general with no public health background to speak of the public health establishment in general was arrayed against him. Feeling this was a person who did not have qualifications and experience. And he withstood a nine month confirmation period that he described as the worst in his life. While his name and reputation was hit around batted around Washington eventually he was confirmed.


[00:07:18] And he sat quietly for a few years in the middle of what was then the developing AIDS crisis in 1985. He was asked by the president to write a report on AIDS. And he took that charge very seriously ran hard with it and produced the first surgeon general's report on AIDS which was a document noted for its comprehensiveness, its explicitness and its humanism in terms of embracing everybody who had AIDS removing or laboring to remove the stigma that was associated then and afterward with HIV and AIDS.


[00:07:59] Koop set a high standard as a physician as a healer and asked the country to come with him effectively. He was saluted for it. He became enormously well respected and liked. He traveled the country thereafter really campaigning on protection against AIDS. Supporting early research to learn more about what the virus was and became. Some said the second most well-known face in Washington after President Reagan himself.


Virginia Prescott: [00:08:32] It did help in being so recognizable that he had a very distinctive Abraham Lincoln like beard didn't he?


Fitzhugh Mullan: [00:08:41] Yeah he had an Ahab like quality, Lincoln like quality.


[00:08:46] He was a religious man although he didn't practice that as a surgeon general but he definitely had a sort of biblical sense about him which didn't hurt in his political campaigning.


Virginia Prescott: [00:09:07] How did the public health service get its start?


Fitzhugh Mullan: [00:09:10] In the developing republic called the United States in the mid 19th century, there was in fact a Marine Hospital Service. This was by act of Congress a service that took care of sailors in port cities who arrived and were sick. And as was the habit in the days were essentially dumped in the port cities. At that point most medical care was custodial it was home care and if you didn't happen to live in the city nobody was going to care for you and you were a problem for the city. So port cities arranged through the federal government to set up a service that would provide care for sailors, Marine employees in coastal cities.


[00:09:55] In the 1970s it was decided this needed much more organization and it was established as the Marine Hospital Service of the U.S. government and the first commanding officer who was a civil war soldier had been a civil war medical officer put his physicians in uniform gave them merit appointments as opposed to patronage appointments and moved them around from city to city so they didn't become stuck in one place but had loyalty to the service.


[00:10:26] It worked very well, in 1888 that was written into law as a Marine Hospital Service eventually the public health service of the U.S. government and as public health and the United States grew that service began to take on more and more activities. Early research that today is the NIH, Disease Control that today is the Centers for Disease Control, the quality and safety of drugs today's Food and Drug Administration, the Indian Health Service, the health services and resources administration. These are all key agencies of HHS Health and Human Services at the national federal level the public health service was at the center of that growth and development that historic growth in development over the 19th and 20th centuries.


Virginia Prescott: [00:11:14] Now the public health service is very busy though not always in the spotlight. So what are some of the main threats that the public health service is fighting right now?


Fitzhugh Mullan: [00:11:25] Well there's one important reality of public health work. The better you do the work the less you will be known for it. In other words people in public health are in the business of preventing things from happening. So that the the most successful work in public health results in non events you don't have an epidemic, you don't have bad water. You don't have dirty air. You don't have people dying or suffering.


[00:11:54] So it's a part of professional life and certainly the health professions that is undramatic when it's successful.


[00:12:03] So the issues we have before us today there is clearly a whole set of problems around access to care and equity and access. Last century the 20th century Americans entered that century dying at roughly 45 years of age. We left the century with Americans living about 75 years we put almost 30 years on the lifespan of the American population. On the other hand that was not equal. Some populations live longer some shorter, between ethnic groups between rural and urban between insured and uninsured, so hugely unequal as even amidst our success.


[00:12:42] So developing a fairer health system where everybody gets equal benefit or at least good benefit from it. Very important challenge we're struggling with that as a country. And then plenty of challenges from antibiotic resistance to the opportunities of new technologies of artificial intelligence in medicine and health. That isn't going to make great differences in the future but we must keep in mind equity isn't just about leaping ahead to have the best moonshots in healthcare. We need a good solid platform that all Americans can benefit from.


Virginia Prescott: [00:13:17] You're talking about systemic problems and there are challenges in infrastructure, take the drinking water in Flint Michigan. But you know a lot of public health is about policy about infrastructure but it's also about behavior like smoking like addiction like unprotected sex. What role does a surgeon general have in those kind of behavioral challenges?


Fitzhugh Mullan: [00:13:41] The surgeon general has an extraordinary opportunity. It is a pulpit where you get to climb the steps into the pulpit, frequently the surgeon general's reports, there are conferences convened by the surgeon general and there are multiple platforms on which he or she can speak and write for an individual job it probably has about as much potential leverage over health and health thinking as any job you can imagine. Certainly than any other in the United States and surgeons general have been good about using that and it becomes a challenge for anyone coming to that office to be very strategic.


[00:14:19] This goes beyond the policy obviously you need the support of the administration and particularly the president in terms of the directions you want to go. But once you know that you're within those bounds your abilities and particularly with the range of media that we have available to us today the way to enter the consciousness of the American person in terms of their health are manifold and that is the old surgeon general in both traditional ways like articles and speeches as well as social media, podcast, what have you, which surgeons general are using these days increasingly.



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